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|---|---|---|---|---|---|---|
doctor: okay and so does the pain move anywhere like your upper back your shoulder patient: no it just stays on monday | D2N115 | 12 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and so does the pain move anywhere like your upper back your shoulder | 2,900 |
doctor: okay and then any kind of hearing any kind of hearing problems visual disturbances patient: no | D2N115 | 13 | [
"Vegetative History"
] | [
"Subjective"
] | okay and then any kind of hearing any kind of hearing problems visual disturbances | 2,901 |
doctor: okay have you do have you ever like played sports before or had like a sports accident before patient: yeah i played football | D2N115 | 14 | [
"Personal History"
] | [
"Subjective"
] | okay have you do have you ever like played sports before or had like a sports accident before | 2,902 |
doctor: okay and then when you got in the car accident did you end up going to the emergency room patient: no i mean i i know that going to the emergency room that like the english rides like five hundred bucks so i did n't want to do that | D2N115 | 16 | [
"Personal History"
] | [
"Subjective"
] | okay and then when you got in the car accident did you end up going to the emergency room | 2,903 |
doctor: i understand i understand okay was there any like swelling or bruising on your neck patient: not that i know about no other mag of my neck i really ca n't see that | D2N115 | 17 | [
"Personal History"
] | [
"Subjective"
] | i understand i understand okay was there any like swelling or bruising on your neck | 2,904 |
doctor: yeah okay no just checking okay so if you do n't mind i'm gon na go ahead and do my physical exam so when i press on here on the side of your neck does it hurt patient: yeah a little bit | D2N115 | 18 | [
"Physical Examination"
] | [
"Objective"
] | yeah okay no just checking okay so if you do n't mind i'm gon na go ahead and do my physical exam so when i press on here on the side of your neck does it hurt | 2,905 |
doctor: okay positive pain to palpation of the soft tissues of the neck what about when i press on your back or your shoulders patient: no that's fine | D2N115 | 19 | [
"Physical Examination"
] | [
"Objective"
] | okay positive pain to palpation of the soft tissues of the neck what about when i press on your back or your shoulders | 2,906 |
doctor: okay so when you flex your neck when you're touching your chin to your chest does that hurt patient: mm-hmm | D2N115 | 20 | [
"Physical Examination"
] | [
"Objective"
] | okay so when you flex your neck when you're touching your chin to your chest does that hurt | 2,907 |
doctor: alright positive pain with flexion what about when you move it back patient: yeah that hurts worse | D2N115 | 21 | [
"Physical Examination"
] | [
"Objective"
] | alright positive pain with flexion what about when you move it back | 2,908 |
doctor: okay okay severe positive pain to extension okay so can you turn your head from side to side does that hurt patient: yeah a little bit | D2N115 | 22 | [
"Physical Examination"
] | [
"Objective"
] | okay okay severe positive pain to extension okay so can you turn your head from side to side does that hurt | 2,909 |
doctor: okay positive pain with rotation and then can you touch your ear to your shoulders patient: no | D2N115 | 23 | [
"Physical Examination"
] | [
"Objective"
] | okay positive pain with rotation and then can you touch your ear to your shoulders | 2,910 |
doctor: okay alright so positive pain on lateral bending wow this is pretty this is pretty serious not serious necessarily sorry about that so i reviewed the results of your x-ray but the results show no signs of fracture or bony abnormalities but let's go ahead and talk about my assessment and plan for you i believe w... | D2N115 | 24 | [
"Discussion",
"Referral",
"Medication",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Assessment",
"Plan"
] | okay alright so positive pain on lateral bending wow this is pretty this is pretty serious not serious necessarily sorry about that so i reviewed the results of your x-ray but the results show no signs of fracture or bony abnormalities but let's go ahead and talk about my assessment and plan for you i believe what you ... | 2,911 |
doctor: i do understand that some people have like reservations about going to the chiropractor but you know we do have some good ones that have like longstanding histories and patients that have had positive results from the experience but if you if you do n't like the idea of that we can consider other options like t... | D2N115 | 25 | [
"Discussion",
"Referral"
] | [
"Plan"
] | i do understand that some people have like reservations about going to the chiropractor but you know we do have some good ones that have like longstanding histories and patients that have had positive results from the experience but if you if you do n't like the idea of that we can consider other options like that reha... | 2,912 |
doctor: alright any other questions patient: no | D2N115 | 26 | [
"Discussion"
] | [
"Plan"
] | alright any other questions | 2,913 |
doctor: alright thank you | D2N115 | 27 | [
"Chitchat"
] | [
"Null"
] | doctor: alright thank you | 2,914 |
doctor: hey hi bobby how are you doing patient: i'm doing good how are you | D2N116 | 0 | [
"Greetings"
] | [
"Subjective"
] | hey hi bobby how are you doing | 2,915 |
doctor: i'm doing fine so i understand you're here having some left or some right shoulder pain that you've had for a few weeks now patient: yeah it was i was doing some work in my backyard and a lot of different projects going on and you know i was obviously sore all over the next couple of days but my my right should... | D2N116 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | i'm doing fine so i understand you're here having some left or some right shoulder pain that you've had for a few weeks now | 2,916 |
doctor: okay so have you had ever had any pain in that shoulder before patient: a little bit i you know i i hurt that same shoulder because it's my my dominant hand my right hand i hurt it playing baseball when i was younger | D2N116 | 2 | [
"Personal History"
] | [
"Subjective"
] | okay so have you had ever had any pain in that shoulder before | 2,917 |
doctor: mm-hmm patient: so i've always had a little bit issues but this is it's does n't feel like it's in the rotator cuff it's it's kinda more on the outside and it's kinda like it's more tender on the outside when i raise my arm up so | D2N116 | 3 | [
"Personal History"
] | [
"Subjective"
] | mm-hmm | 2,918 |
doctor: okay yeah are you able to move your arm very well or not patient: yeah there is no restriction with my arm it just i definitely feel some pain on the outside of it | D2N116 | 4 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay yeah are you able to move your arm very well or not | 2,919 |
doctor: okay and are you having pain all the time or just or does it come and go patient: just whenever i move it if i'm sitting still i really do n't notice anything but whenever i move it then i can definitely feel some pain | D2N116 | 5 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and are you having pain all the time or just or does it come and go | 2,920 |
doctor: okay how about at night is it bothering you at night also patient: a little bit because i sleep on that side so | D2N116 | 6 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay how about at night is it bothering you at night also | 2,921 |
doctor: okay and i may miss did you say what have you been taking for pain for that patient: i just been taking some advil and then icing as much as i can so that's about it | D2N116 | 8 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay and i may miss did you say what have you been taking for pain for that | 2,922 |
doctor: okay and does that seem to help or patient: a little bit yeah a little bit i mean it's it's still like you know sore to touch but it definitely dulls it a little bit | D2N116 | 9 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay and does that seem to help or | 2,923 |
doctor: well sounds like you have quite a few projects going on what all what all are you doing for for your yard and patient: i well let's see i've been putting an outdoor shower in we're extending our patio putting making some flower boxes putting down some you know for stone and all the flower beds so my wife's real... | D2N116 | 10 | [
"Other Socials"
] | [
"Subjective"
] | well sounds like you have quite a few projects going on what all what all are you doing for for your yard and | 2,924 |
doctor: wow it sounds like a variety of projects but if you're putting down stone you're probably lifting those as well and then patient: yeah | D2N116 | 11 | [
"Other Socials"
] | [
"Subjective"
] | wow it sounds like a variety of projects but if you're putting down stone you're probably lifting those as well and then | 2,925 |
doctor: yeah i bet that is sore now tell me this have you experienced any numbness in your arm or your hands or patient: no not really no numbness that i can think of | D2N116 | 12 | [
"Vegetative History"
] | [
"Subjective"
] | yeah i bet that is sore now tell me this have you experienced any numbness in your arm or your hands or | 2,926 |
doctor: okay alright so see i'm gon na i'd like to do just a quick physical exam and i've reviewed your vitals those look good your no fever so that's good you're ninety seven . eight and your heart rate looks good at sixty two respirations sixteen your blood pressures one sixteen over eighty four that looks fine your ... | D2N116 | 13 | [
"Physical Examination",
"Discussion",
"Medication",
"Radiology Examination",
"Referral",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | okay alright so see i'm gon na i'd like to do just a quick physical exam and i've reviewed your vitals those look good your no fever so that's good you're ninety seven . eight and your heart rate looks good at sixty two respirations sixteen your blood pressures one sixteen over eighty four that looks fine your oxygen s... | 2,927 |
doctor: okay alright yeah a lot of patients it's very successful with the physical therapy so i really hope that will do it and so we'll just start there okay patient: sounds great | D2N116 | 14 | [
"Chitchat"
] | [
"Null"
] | okay alright yeah a lot of patients it's very successful with the physical therapy so i really hope that will do it and so we'll just start there okay | 2,928 |
doctor: okay thanks patient: thanks | D2N116 | 15 | [
"Chitchat"
] | [
"Null"
] | okay thanks | 2,929 |
doctor: did you have any other any other problems any other injuries that that went along with this or patient: my both my my feet are actually really sore too i obviously have been doing a lot of other yard work so you know it's kinda it's really stiff and stuff and they you know my ankle joints as well my wife seems ... | D2N116 | 16 | [
"Personal History"
] | [
"Subjective"
] | did you have any other any other problems any other injuries that that went along with this or | 2,930 |
doctor: yeah so if you do n't feel that you did anything to injure it we might start just maybe do some epsom salts have you tried soaking your feet in epsom salts that will tend to kinda pull out what's going on in there and just help your those muscles to relax and the soreness to to go away you might try that patien... | D2N116 | 17 | [
"Discussion",
"Medication"
] | [
"Plan"
] | yeah so if you do n't feel that you did anything to injure it we might start just maybe do some epsom salts have you tried soaking your feet in epsom salts that will tend to kinda pull out what's going on in there and just help your those muscles to relax and the soreness to to go away you might try that | 2,931 |
doctor: mister jackson is a 45 -year-old male who has a history of diabetes type two and mild intermittent asthma and he is here today with right elbow pain so hey there mark nice to see you again listen sorry you're having some elbow pain let's talk about it but i would like to record this conversation with this cool ... | D2N117 | 0 | [
"Acute Symptoms",
"Personal History",
"Greetings"
] | [
"Subjective"
] | mister jackson is a 45 -year-old male who has a history of diabetes type two and mild intermittent asthma and he is here today with right elbow pain so hey there mark nice to see you again listen sorry you're having some elbow pain let's talk about it but i would like to record this conversation with this cool app that... | 2,932 |
doctor: okay great so mark tell me about your right elbow pain what's been happening patient: so yeah i've been playing a lot of tennis recently buddy of mine you know you're always telling me to get off the couch and be more active so a buddy of mine asked me if i wanted to go play tennis he just joined a country club... | D2N117 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay great so mark tell me about your right elbow pain what's been happening | 2,933 |
doctor: okay alright and where in your elbow is it hurting patient: outside part | D2N117 | 2 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay alright and where in your elbow is it hurting | 2,934 |
doctor: hmmm okay does the pain radiate anywhere like down to your arm up to your shoulder or anywhere else patient: no it does n't | D2N117 | 3 | [
"Acute Symptoms"
] | [
"Subjective"
] | hmmm okay does the pain radiate anywhere like down to your arm up to your shoulder or anywhere else | 2,935 |
doctor: okay and what would you say the pain is you know on a scale of zero to ten patient: it's probably an eight when i'm just when i'm using it even if it's to get something out of the cupboard and it's a three when i'm just kinda resting | D2N117 | 4 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and what would you say the pain is you know on a scale of zero to ten | 2,936 |
doctor: hmmm okay and do you would you say it's a sharp pain stabbing pain aching throbbing how would you describe it patient: all of the above shooting stabbing very sharp | D2N117 | 5 | [
"Acute Symptoms"
] | [
"Subjective"
] | hmmm okay and do you would you say it's a sharp pain stabbing pain aching throbbing how would you describe it | 2,937 |
doctor: okay alright and you let's see other than the the tennis you know increase in tennis activity you have n't had any trauma recently falling on it or you know felt a pop anywhere or anything like that have you patient: not that i can recall | D2N117 | 6 | [
"Personal History",
"Other Socials"
] | [
"Subjective"
] | okay alright and you let's see other than the the tennis you know increase in tennis activity you have n't had any trauma recently falling on it or you know felt a pop anywhere or anything like that have you | 2,938 |
doctor: okay and and you said it's it's worse with movement better with rest is there anything else that makes it makes it worse or makes it better patient: i've taken some tylenol and ibuprofen but as soon as those wear off it it comes right back so they do n't really help | D2N117 | 7 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay and and you said it's it's worse with movement better with rest is there anything else that makes it makes it worse or makes it better | 2,939 |
doctor: okay okay alright yeah well i definitely i'm glad you're getting some exercise now that's good for your diabetes and all that and out there playing tennis kinda back back to the back to the old days for you right did do i recall that were n't you a big tennis player back in the day like state champ in high scho... | D2N117 | 9 | [
"Personal History",
"Other Socials"
] | [
"Subjective"
] | okay okay alright yeah well i definitely i'm glad you're getting some exercise now that's good for your diabetes and all that and out there playing tennis kinda back back to the back to the old days for you right did do i recall that were n't you a big tennis player back in the day like state champ in high school or so... | 2,940 |
doctor: i did i did yeah that was that was crazy that was a great tournament what a what a finish unbelievable patient: yeah hey did you see the masters i know you're a golfer | D2N117 | 11 | [
"Chitchat"
] | [
"Null"
] | i did i did yeah that was that was crazy that was a great tournament what a what a finish unbelievable | 2,941 |
doctor: yeah yeah yeah i do n't get out as often as i as as i like to but but the masters yeah that was that was amazing that was lot of fun to lot of fun did you catch it too patient: i did | D2N117 | 12 | [
"Chitchat"
] | [
"Null"
] | yeah yeah yeah i do n't get out as often as i as as i like to but but the masters yeah that was that was amazing that was lot of fun to lot of fun did you catch it too | 2,942 |
doctor: yep yep agreed agreed and so well listen we'll we'll hopefully get you feeling better here and get you back out on the court and out on the course and we'll talk about that but let's let me ask you about your diabetes a little bit a little bit here so how have your blood sugars been running mark have they been ... | D2N117 | 16 | [
"Personal History"
] | [
"Subjective"
] | yep yep agreed agreed and so well listen we'll we'll hopefully get you feeling better here and get you back out on the court and out on the course and we'll talk about that but let's let me ask you about your diabetes a little bit a little bit here so how have your blood sugars been running mark have they been what in ... | 2,943 |
doctor: hmmm okay yeah yeah understood so those cadboy eggs they'll get you every time too right patient: yes | D2N117 | 17 | [
"Chitchat"
] | [
"Null"
] | hmmm okay yeah yeah understood so those cadboy eggs they'll get you every time too right | 2,944 |
doctor: boy my gosh yeah those are the best so those are those are deadly do n't tell my cardiologist so okay so listen you know i see that we have you on metformin five hundred milligrams once a day no actually last visit we increased it so i've got you on metformin five hundred milligrams twice a day correct you're s... | D2N117 | 18 | [
"Therapeutic History"
] | [
"Subjective"
] | boy my gosh yeah those are the best so those are those are deadly do n't tell my cardiologist so okay so listen you know i see that we have you on metformin five hundred milligrams once a day no actually last visit we increased it so i've got you on metformin five hundred milligrams twice a day correct you're still tak... | 2,945 |
doctor: okay and but your blood sugars are a bit off you know maybe those the cadberry eggs so how about your asthma how has that been doing you know have you had any asthma attacks you're still taking flovent twice a day and the albuterol as needed patient: yeah knock on wood i my asthma is pretty much under control | D2N117 | 19 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | okay and but your blood sugars are a bit off you know maybe those the cadberry eggs so how about your asthma how has that been doing you know have you had any asthma attacks you're still taking flovent twice a day and the albuterol as needed | 2,946 |
doctor: okay excellent excellent alright and i recall you know just kinda review a few things i i think you've got an allergy to penicillin is that correct patient: that's correct yes | D2N117 | 20 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | okay excellent excellent alright and i recall you know just kinda review a few things i i think you've got an allergy to penicillin is that correct | 2,947 |
doctor: okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct patient: yes that's right | D2N117 | 21 | [
"Personal History"
] | [
"Subjective"
] | okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct | 2,948 |
doctor: okay and then let's go ahead and examine you alright so mark your exam is pretty much you know for the most part normal with a few exceptions on your heart exam you still have a grade three out of six systolic ejection murmur and that's unchanged from prior exam we're watching that and so that just means i hear... | D2N117 | 22 | [
"Physical Examination"
] | [
"Objective"
] | okay and then let's go ahead and examine you alright so mark your exam is pretty much you know for the most part normal with a few exceptions on your heart exam you still have a grade three out of six systolic ejection murmur and that's unchanged from prior exam we're watching that and so that just means i hear some so... | 2,949 |
doctor: okay sorry about that so you've got moderate pain with passive range of motion of the right elbow there is no palpable joint effusion and now what if i press against your wrist like so does that hurt you patient: yeah it hurts a little bit | D2N117 | 23 | [
"Physical Examination"
] | [
"Objective"
] | okay sorry about that so you've got moderate pain with passive range of motion of the right elbow there is no palpable joint effusion and now what if i press against your wrist like so does that hurt you | 2,950 |
doctor: okay alright sorry so that's you have mild pain with resisted extension of the right wrist as well okay otherwise normal unremarkable exam and let's talk about your results now so your right elbow x-ray today shows no acute fracture or other bony abnormality so that's good there's no malalignment or sign of joi... | D2N117 | 24 | [
"Personal History",
"Radiology Examination",
"Vegetative History"
] | [
"Subjective",
"Objective"
] | okay alright sorry so that's you have mild pain with resisted extension of the right wrist as well okay otherwise normal unremarkable exam and let's talk about your results now so your right elbow x-ray today shows no acute fracture or other bony abnormality so that's good there's no malalignment or sign of joint effus... | 2,951 |
doctor: okay great excellent alright so tell you what let's let's talk about my assessment and your plan here so for your first problem my assessment is is that you have acute lateral epicondylitis of your right elbow and this is also known as tennis elbow go figure right so this is due to overuse likely the increase i... | D2N117 | 25 | [
"Discussion",
"Follow-up",
"Medication",
"Referral",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Assessment",
"Plan"
] | okay great excellent alright so tell you what let's let's talk about my assessment and your plan here so for your first problem my assessment is is that you have acute lateral epicondylitis of your right elbow and this is also known as tennis elbow go figure right so this is due to overuse likely the increase in your y... | 2,952 |
doctor: yeah yeah well patient: i'm not i'm not young anymore | D2N117 | 26 | [
"Chitchat"
] | [
"Null"
] | yeah yeah well | 2,953 |
doctor: yeah well let's let's keep you active but take a break for a bit and let's ease back into it okay so it's great to see you and i'll see you back in four weeks let me know if you have other problems in the meantime patient: okay | D2N117 | 27 | [
"Follow-up"
] | [
"Plan"
] | yeah well let's let's keep you active but take a break for a bit and let's ease back into it okay so it's great to see you and i'll see you back in four weeks let me know if you have other problems in the meantime | 2,954 |
doctor: alright so how're you doing today angela patient: i'm doing pretty well | D2N118 | 0 | [
"Greetings"
] | [
"Subjective"
] | alright so how're you doing today angela | 2,955 |
doctor: alright so looking here at your appointment notes it says you're you're here you think you have a kidney stone you had some in the past so we're gon na take a look at that and then you also have a past medical history of hypertension and diabetes we want to take a look at those as well so first thing what's goi... | D2N118 | 1 | [
"Personal History"
] | [
"Subjective"
] | alright so looking here at your appointment notes it says you're you're here you think you have a kidney stone you had some in the past so we're gon na take a look at that and then you also have a past medical history of hypertension and diabetes we want to take a look at those as well so first thing what's going on wi... | 2,956 |
doctor: okay so the case of kidney stones so have you had you said you've had them in the past and how often would you say patient: i do n't know i this is probably like my seventh or eighth kidney stone | D2N118 | 2 | [
"Personal History"
] | [
"Subjective"
] | okay so the case of kidney stones so have you had you said you've had them in the past and how often would you say | 2,957 |
doctor: seven or eight kidney stones so do you think you passed it yet or is it still in the patient: i think this one passed yeah | D2N118 | 3 | [
"Personal History"
] | [
"Subjective"
] | seven or eight kidney stones so do you think you passed it yet or is it still in the | 2,958 |
doctor: this one passed how long would you say it took to patient: well i went last week and then i think it passed about three days ago | D2N118 | 4 | [
"Personal History"
] | [
"Subjective"
] | this one passed how long would you say it took to | 2,959 |
doctor: okay so are you still noticing any blood in your urine patient: no no more blood | D2N118 | 5 | [
"Vegetative History"
] | [
"Subjective"
] | okay so are you still noticing any blood in your urine | 2,960 |
doctor: alright are you still having pain patient: nope | D2N118 | 6 | [
"Acute Symptoms"
] | [
"Subjective"
] | alright are you still having pain | 2,961 |
doctor: okay that that's that's that's really good did they do anything for you at the hospital giving you any medications patient: they gave me some pain medicine | D2N118 | 8 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | okay that that's that's that's really good did they do anything for you at the hospital giving you any medications | 2,962 |
doctor: okay do you remember what it was patient: i think it was percocet | D2N118 | 9 | [
"Therapeutic History"
] | [
"Subjective"
] | okay do you remember what it was | 2,963 |
doctor: okay well that's good i'm very glad to see that you were able to pass that stone have you seen a urologist before about this patient: i have n't seen one in a while but yes i saw someone maybe a year ago | D2N118 | 10 | [
"Personal History"
] | [
"Subjective"
] | okay well that's good i'm very glad to see that you were able to pass that stone have you seen a urologist before about this | 2,964 |
doctor: okay so yeah i know you keep having these recurrent kidney stones so i definitely think we can get you a referral to urology just to check up on that and also wan na do some labs as well patient: okay | D2N118 | 11 | [
"Referral",
"Diagnostic Testing"
] | [
"Plan"
] | okay so yeah i know you keep having these recurrent kidney stones so i definitely think we can get you a referral to urology just to check up on that and also wan na do some labs as well | 2,965 |
doctor: so i also see you're here for you have a past medical history of of hypertension and when you came in today your blood pressure was a little bit high it was a one fifty over ninety i'm reading here in your chart you're on two point five of norvasc patient: hmmm | D2N118 | 12 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | so i also see you're here for you have a past medical history of of hypertension and when you came in today your blood pressure was a little bit high it was a one fifty over ninety i'm reading here in your chart you're on two point five of norvasc | 2,966 |
doctor: now have you been taking that regularly patient: i have but at home my blood pressure is always great | D2N118 | 13 | [
"Therapeutic History"
] | [
"Subjective"
] | now have you been taking that regularly | 2,967 |
doctor: okay maybe you have a little white coat syndrome some of my patients do have it i have it myself and i'm a provider so i definitely understand yeah i know we we talked about last time you getting a blood pressure cuff and taking those about two to three times a week so what have those readings been i'm usually ... | D2N118 | 14 | [
"Chitchat"
] | [
"Null"
] | okay maybe you have a little white coat syndrome some of my patients do have it i have it myself and i'm a provider so i definitely understand yeah i know we we talked about last time you getting a blood pressure cuff and taking those about two to three times a week so what have those readings been i'm usually like one... | 2,968 |
doctor: that's that's that's not too bad i think when you first came in you were around like one eighty so it seems to be that that norvasc is is working for you how about your diet i know you were having a little issue eating some fast food and and cakes and cookies and have you been able to get that under control pat... | D2N118 | 15 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | that's that's that's not too bad i think when you first came in you were around like one eighty so it seems to be that that norvasc is is working for you how about your diet i know you were having a little issue eating some fast food and and cakes and cookies and have you been able to get that under control | 2,969 |
doctor: okay so do you think you would be able to get that under control by yourself or would you do you think you would need help with that maybe a dietitian be able to help you out patient: yeah i do n't know i do n't know if i can make another appointment i just add to the extra | D2N118 | 16 | [
"Discussion",
"Other Treatments"
] | [
"Plan"
] | okay so do you think you would be able to get that under control by yourself or would you do you think you would need help with that maybe a dietitian be able to help you out | 2,970 |
doctor: yeah yeah definitely understand patient: mm-hmm | D2N118 | 18 | [
"Chitchat"
] | [
"Null"
] | yeah yeah definitely understand | 2,971 |
doctor: alright yeah so i mean that's one thing we just got ta work one is your diet we try to keep you at least just twenty three hundred milligrams or less of sodium per day i know that's hard for a lot of salads and stuff i know it's hard for lot of people especially with all like the the prepackage foods we have ar... | D2N118 | 19 | [
"Other Treatments"
] | [
"Plan"
] | alright yeah so i mean that's one thing we just got ta work one is your diet we try to keep you at least just twenty three hundred milligrams or less of sodium per day i know that's hard for a lot of salads and stuff i know it's hard for lot of people especially with all like the the prepackage foods we have around tod... | 2,972 |
doctor: so let's also look here you have a history of diabetes and so you're on that five hundred milligrams of metformin daily now have you been taking that as well patient: yeah i take my metformin | D2N118 | 20 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | so let's also look here you have a history of diabetes and so you're on that five hundred milligrams of metformin daily now have you been taking that as well | 2,973 |
doctor: so what have your blood sugars been running daily patient: well i do n't check it very often | D2N118 | 22 | [
"Personal History"
] | [
"Subjective"
] | so what have your blood sugars been running daily | 2,974 |
doctor: okay so i'm looking here i think last after your last visit you got a1c now was six . seven so it's a little bit high it's gone down a little bit since you were first diagnosed with the type two diabetes a year ago so i'm glad we're making progress with that as well alright so i'm just gon na do a quick physica... | D2N118 | 24 | [
"Physical Examination"
] | [
"Objective"
] | okay so i'm looking here i think last after your last visit you got a1c now was six . seven so it's a little bit high it's gone down a little bit since you were first diagnosed with the type two diabetes a year ago so i'm glad we're making progress with that as well alright so i'm just gon na do a quick physical exam o... | 2,975 |
doctor: alright any any belly pain patient: no | D2N118 | 25 | [
"Physical Examination"
] | [
"Objective"
] | alright any any belly pain | 2,976 |
doctor: alright so i'm gon na listen to your lungs your lungs are clear bilaterally i do n't hear any crackles listen to your heart so on your heart exam i do hear that grade two out of six systolic ejection murmur and we already knew about that previously so it has n't gotten any worse so that's good so i'm gon na jus... | D2N118 | 26 | [
"Physical Examination"
] | [
"Objective"
] | alright so i'm gon na listen to your lungs your lungs are clear bilaterally i do n't hear any crackles listen to your heart so on your heart exam i do hear that grade two out of six systolic ejection murmur and we already knew about that previously so it has n't gotten any worse so that's good so i'm gon na just press ... | 2,977 |
doctor: alright i'm gon na press here on your back patient: no pain | D2N118 | 27 | [
"Physical Examination"
] | [
"Objective"
] | alright i'm gon na press here on your back | 2,978 |
doctor: okay so on your abdomen exam of your abdomen i'm showing no tenderness to palpation of the abdomen or tenderness of the the cva either on the right side so that that's good i think that's pretty much cleared up so let's we'll talk a little bit about my assessment and plan for you and so my assessment you you di... | D2N118 | 28 | [
"Physical Examination",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | okay so on your abdomen exam of your abdomen i'm showing no tenderness to palpation of the abdomen or tenderness of the the cva either on the right side so that that's good i think that's pretty much cleared up so let's we'll talk a little bit about my assessment and plan for you and so my assessment you you did have t... | 2,979 |
doctor: alright we'll get a urine culture just to make sure everything is is cleared up i also want to give you a referral to referral referral to urology patient: okay | D2N118 | 29 | [
"Referral",
"Diagnostic Testing"
] | [
"Plan"
] | alright we'll get a urine culture just to make sure everything is is cleared up i also want to give you a referral to referral referral to urology | 2,980 |
doctor: because you do keep having these all the time and so maybe there's something else going wrong and so they can help get that under control patient: can i see doctor harris | D2N118 | 30 | [
"Discussion",
"Referral"
] | [
"Plan"
] | because you do keep having these all the time and so maybe there's something else going wrong and so they can help get that under control | 2,981 |
doctor: of course yeah we can we can get you that road to doctor harris and patient: he's not like | D2N118 | 31 | [
"Discussion",
"Referral"
] | [
"Plan"
] | of course yeah we can we can get you that road to doctor harris and | 2,982 |
doctor: he's great he's he's he he he's great i've heard he does really good work so that'll be good so for the hypertension you seem to be doing well on the two . five of norvasc so we are not gon na make any changes to that do you need any refills right now patient: no usually the pharmacy just sends them through whe... | D2N118 | 32 | [
"Medication",
"Other Treatments",
"Reassessment"
] | [
"Assessment",
"Plan"
] | he's great he's he's he he he's great i've heard he does really good work so that'll be good so for the hypertension you seem to be doing well on the two . five of norvasc so we are not gon na make any changes to that do you need any refills right now | 2,983 |
doctor: okay great so we we wo n't we gave you refills with that i do wan na give you a consult to nutrition patient: okay | D2N118 | 33 | [
"Referral"
] | [
"Plan"
] | okay great so we we wo n't we gave you refills with that i do wan na give you a consult to nutrition | 2,984 |
doctor: just to help you with that diet patient: okay | D2N118 | 34 | [
"Discussion",
"Referral",
"Other Treatments"
] | [
"Plan"
] | just to help you with that diet | 2,985 |
doctor: because i think that's a major factor of us eventually getting you off of all medications patient: hmmm | D2N118 | 35 | [
"Discussion",
"Other Treatments"
] | [
"Plan"
] | because i think that's a major factor of us eventually getting you off of all medications | 2,986 |
doctor: and then for your diabetes i'm just keep you on that on that five hundred of metformin okay i think you're doing well with that as well also but i do want you to start taking your blood sugars if you can take them before every meal patient: okay | D2N118 | 36 | [
"Discussion",
"Reassessment"
] | [
"Assessment",
"Plan"
] | and then for your diabetes i'm just keep you on that on that five hundred of metformin okay i think you're doing well with that as well also but i do want you to start taking your blood sugars if you can take them before every meal | 2,987 |
doctor: just to gauge where you are so you can tell how much food you should actually be be eating patient: okay | D2N118 | 37 | [
"Discussion",
"Other Treatments"
] | [
"Plan"
] | just to gauge where you are so you can tell how much food you should actually be be eating | 2,988 |
doctor: alright patient: i can try that | D2N118 | 38 | [
"Chitchat"
] | [
"Null"
] | alright | 2,989 |
doctor: so how does that that sound patient: that sounds like a plan when should i come back and see you | D2N118 | 39 | [
"Discussion"
] | [
"Plan"
] | so how does that that sound | 2,990 |
doctor: so you can you can come back in three months and we'll check up again i forgot you did tell me last time that you were having some issues with insomnia patient: hmmm | D2N118 | 40 | [
"Follow-up",
"Personal History"
] | [
"Subjective",
"Plan"
] | so you can you can come back in three months and we'll check up again i forgot you did tell me last time that you were having some issues with insomnia | 2,991 |
doctor: how is that going for you is it still happening patient: i mean sometimes i stay awake just kinda worrying about things but but i've tried some meditation apps and that helps | D2N118 | 41 | [
"Vegetative History"
] | [
"Subjective"
] | how is that going for you is it still happening | 2,992 |
doctor: okay alright and i know we talked a little bit before about practicing proper sleep hygiene you know just making sure that all of your electronics are off you know dark room patient: yeah | D2N118 | 42 | [
"Vegetative History"
] | [
"Subjective"
] | okay alright and i know we talked a little bit before about practicing proper sleep hygiene you know just making sure that all of your electronics are off you know dark room | 2,993 |
doctor: cool room have you been doing that patient: well i do like to sleep with the tv on and my phone is right by my bed because i never know if someone's gon na call me you know | D2N118 | 43 | [
"Vegetative History"
] | [
"Subjective"
] | cool room have you been doing that | 2,994 |
doctor: yeah i i know i'm like apple i do n't know if you have an iphone or not but i know apple has this the the sleep mode now do that disturbance so you put that on patient: it's a good idea | D2N118 | 44 | [
"Referral"
] | [
"Plan"
] | yeah i i know i'm like apple i do n't know if you have an iphone or not but i know apple has this the the sleep mode now do that disturbance so you put that on | 2,995 |
doctor: interrupt you patient: yeah | D2N118 | 45 | [
"Chitchat"
] | [
"Null"
] | interrupt you | 2,996 |
doctor: okay have you tried taking melatonin to sleep patient: i used it a couple times but but it did n't seem to help that much | D2N118 | 46 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | okay have you tried taking melatonin to sleep | 2,997 |
doctor: okay how about i do n't think i've prescribed you anything yet do you think you would need anything patient: hmmm i do n't really wan na take any sleeping pills | D2N118 | 47 | [
"Discussion",
"Medication"
] | [
"Plan"
] | okay how about i do n't think i've prescribed you anything yet do you think you would need anything | 2,998 |
doctor: okay that's understandable alright so for the last issue for the insomnia i'm just gon na have you take ten milligrams of melatonin as needed patient: okay | D2N118 | 48 | [
"Medication",
"Reassessment"
] | [
"Assessment",
"Plan"
] | okay that's understandable alright so for the last issue for the insomnia i'm just gon na have you take ten milligrams of melatonin as needed | 2,999 |
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