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|---|---|---|---|---|---|---|
doctor: and just try i guess the best as possible to practice the proper sleep hygiene so you can get to sleep at night and and feel pretty rested patient: okay | D2N118 | 49 | [
"Discussion"
] | [
"Plan"
] | and just try i guess the best as possible to practice the proper sleep hygiene so you can get to sleep at night and and feel pretty rested | 3,000 |
doctor: alright patient: mm-hmm | D2N118 | 50 | [
"Chitchat"
] | [
"Null"
] | alright | 3,001 |
doctor: so do you have anything any other questions for me patient: no that's all | D2N118 | 51 | [
"Discussion"
] | [
"Plan"
] | so do you have anything any other questions for me | 3,002 |
doctor: alright so we will see you in three months patient: okay sounds good | D2N118 | 52 | [
"Follow-up"
] | [
"Plan"
] | alright so we will see you in three months | 3,003 |
doctor: alright patient: like | D2N118 | 53 | [
"Chitchat"
] | [
"Null"
] | alright | 3,004 |
doctor: hey betty how are you doing patient: i'm doing okay i just been really frustrated because with my asthma and it just seems like i can never catch a break never get better i'm always it seems like i'm always coughing and wheezing | D2N119 | 0 | [
"Greetings"
] | [
"Subjective"
] | hey betty how are you doing | 3,005 |
doctor: i'm sorry to hear that what normally triggers your asthma type symptoms patient: i find that it's really really when i get sick if i get sick with a cold i almost always know that my asthma is going to flare i did notice one time though that when i went to my aunt's house i i had a flare afterwards and i think ... | D2N119 | 1 | [
"Personal History"
] | [
"Subjective"
] | i'm sorry to hear that what normally triggers your asthma type symptoms | 3,006 |
doctor: okay so now you mentioned that that happens somewhat a lot how frequently does this occur that you have these breathing type problems patient: it seems like it happens really every month or every other month for the past six months i usually end up going to the urgent care a lot and get or my primary care docto... | D2N119 | 2 | [
"Personal History"
] | [
"Subjective"
] | okay so now you mentioned that that happens somewhat a lot how frequently does this occur that you have these breathing type problems | 3,007 |
doctor: wow that that can be a little bit scary so you mentioned that your primary care provider or the urgent care provider gave you medications what medications are you using for your asthma right now patient: i have two inhalers one but i really just use one of them it's a blue one that seems like the only inhaler t... | D2N119 | 3 | [
"Therapeutic History"
] | [
"Subjective"
] | wow that that can be a little bit scary so you mentioned that your primary care provider or the urgent care provider gave you medications what medications are you using for your asthma right now | 3,008 |
doctor: okay so do you think that's the albuterol inhaler is it do you remember the name like ventolin or patient: yes yes that's the name of it | D2N119 | 4 | [
"Therapeutic History"
] | [
"Subjective"
] | okay so do you think that's the albuterol inhaler is it do you remember the name like ventolin or | 3,009 |
doctor: is that it okay alright and then how often do you feel like you need to use that patient: i would say like almost everyday i feel like i'm using my inhaler because i'm always coughing and wheezing and a couple of times a night i'll wake up as a couple times a week i'll end up waking up needing to use my inhaler... | D2N119 | 5 | [
"Therapeutic History"
] | [
"Subjective"
] | is that it okay alright and then how often do you feel like you need to use that | 3,010 |
doctor: okay and then when you use it at that time does it help patient: it does | D2N119 | 6 | [
"Therapeutic History"
] | [
"Subjective"
] | okay and then when you use it at that time does it help | 3,011 |
doctor: okay and how many walk me through how you use that you just wake up and you take one puff or is it two puffs patient: yeah i take i usually take two puffs | D2N119 | 7 | [
"Therapeutic History"
] | [
"Subjective"
] | okay and how many walk me through how you use that you just wake up and you take one puff or is it two puffs | 3,012 |
doctor: okay but then you get enough relief that you can go back to sleep patient: yeah for the most part | D2N119 | 8 | [
"Therapeutic History"
] | [
"Subjective"
] | okay but then you get enough relief that you can go back to sleep | 3,013 |
doctor: okay now have you ever needed to be hospitalized due to your asthma symptoms you mentioned you've had to go to the er patient: yeah for only once i can think of when i was young i think like around eight years old i had to be hospitalized but nothing since then | D2N119 | 9 | [
"Personal History"
] | [
"Subjective"
] | okay now have you ever needed to be hospitalized due to your asthma symptoms you mentioned you've had to go to the er | 3,014 |
doctor: okay i do wan na take a little bit of a a deeper dive here into your er and urgent care visits can you tell me a little bit more about those patient: yeah i feel like i've had several i do n't remember the exact number but i've had several this past year they almost always have to start me on prednisone | D2N119 | 10 | [
"Personal History"
] | [
"Subjective"
] | okay i do wan na take a little bit of a a deeper dive here into your er and urgent care visits can you tell me a little bit more about those | 3,015 |
doctor: okay like a prednisone taper pack that type of thing patient: yeah yeah sometimes they'll just give me like like a like a large dose over five days | D2N119 | 11 | [
"Therapeutic History"
] | [
"Subjective"
] | okay like a prednisone taper pack that type of thing | 3,016 |
doctor: okay so both the dosepak and then also the high dose as well okay patient: yeah | D2N119 | 13 | [
"Therapeutic History"
] | [
"Subjective"
] | okay so both the dosepak and then also the high dose as well okay | 3,017 |
doctor: and then when was your last exacerbation patient: probably about a month ago | D2N119 | 14 | [
"Personal History"
] | [
"Subjective"
] | and then when was your last exacerbation | 3,018 |
doctor: okay so just out of curiosity you mentioned that you you have trouble when you go over to your aunt's house because of your cat now i see here that you really like to go outside and walk and do those type of things do you have any other type of issues whenever you you go outside any any seasonal allergies or an... | D2N119 | 15 | [
"Personal History"
] | [
"Subjective"
] | okay so just out of curiosity you mentioned that you you have trouble when you go over to your aunt's house because of your cat now i see here that you really like to go outside and walk and do those type of things do you have any other type of issues whenever you you go outside any any seasonal allergies or anything l... | 3,019 |
doctor: okay so you do n't have any history of seasonal allergies which is good so it looks like here that you put down that you enjoyed hiking so you do n't have any trouble getting out and going hiking and and have you tried the new trails there behind behind the wreck center patient: yeah i'm really excited to i mea... | D2N119 | 16 | [
"Personal History"
] | [
"Subjective"
] | okay so you do n't have any history of seasonal allergies which is good so it looks like here that you put down that you enjoyed hiking so you do n't have any trouble getting out and going hiking and and have you tried the new trails there behind behind the wreck center | 3,020 |
doctor: okay now i really need you to be truthful when you answer these next questions this is important for taking a good history do you smoke any type of cigarette or tobacco product and have you ever smoked or do you smoke marijuana on a regular basis patient: no i've never smoked and i do n't vape either or yeah i ... | D2N119 | 17 | [
"Drug History"
] | [
"Subjective"
] | okay now i really need you to be truthful when you answer these next questions this is important for taking a good history do you smoke any type of cigarette or tobacco product and have you ever smoked or do you smoke marijuana on a regular basis | 3,021 |
doctor: okay and then you said you do n't vape so no vaping or e-cigarette use at all patient: hmmm hmmm | D2N119 | 18 | [
"Vegetative History"
] | [
"Subjective"
] | okay and then you said you do n't vape so no vaping or e-cigarette use at all | 3,022 |
doctor: okay and then are you routinely in an area where there is a lot of airborne particular like smoking in bars or around any type of of you know like race tracks or anything like that patient: sometimes i go to the bars with some friends and yeah the smoking does irritate me | D2N119 | 19 | [
"Other Socials",
"Drug History"
] | [
"Subjective"
] | okay and then are you routinely in an area where there is a lot of airborne particular like smoking in bars or around any type of of you know like race tracks or anything like that | 3,023 |
doctor: okay thank you for sharing that with me so if it's okay with you i'd like to go ahead and do a quick physical exam patient: okay | D2N119 | 21 | [
"Physical Examination"
] | [
"Objective"
] | okay thank you for sharing that with me so if it's okay with you i'd like to go ahead and do a quick physical exam | 3,024 |
doctor: now i reviewed your vitals for today and your your blood pressure is good it's one twenty eight over eighty two your respiratory rate is sixteen and your oxygen saturation is ninety nine percent on room air which is a good thing i'm gon na take a listen to your heart here your heart is regular rate and rhythm a... | D2N119 | 22 | [
"Physical Examination",
"Follow-up",
"Medication",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | now i reviewed your vitals for today and your your blood pressure is good it's one twenty eight over eighty two your respiratory rate is sixteen and your oxygen saturation is ninety nine percent on room air which is a good thing i'm gon na take a listen to your heart here your heart is regular rate and rhythm and i do ... | 3,025 |
doctor: you're welcome so let me tell you a little bit about my assessment and plan for your first problem of asthma your symptoms are consistent with moderate intermittent asthma i'm gon na start you on flovent one hundred ten micrograms one puff twice per day that's gon na be important for you to be consistent with y... | D2N119 | 23 | [
"Follow-up",
"Medication",
"Acute Assessment"
] | [
"Assessment",
"Plan"
] | you're welcome so let me tell you a little bit about my assessment and plan for your first problem of asthma your symptoms are consistent with moderate intermittent asthma i'm gon na start you on flovent one hundred ten micrograms one puff twice per day that's gon na be important for you to be consistent with your inha... | 3,026 |
doctor: you're welcome i'll see you in a month patient: alright thanks | D2N119 | 24 | [
"Chitchat"
] | [
"Null"
] | you're welcome i'll see you in a month | 3,027 |
doctor: hello larry how are you doing today patient: i've been better my primary care doctor wanted me to see you for this back pain that i've been having for a couple of years now | D2N120 | 0 | [
"Acute Symptoms",
"Greetings"
] | [
"Subjective"
] | hello larry how are you doing today | 3,028 |
doctor: i'm sorry to hear that now do you remember what caused the pain initially patient: you know i never fell or was in an accident but i do remember it all happened like i started having back pain after i was moving furniture one weekend | D2N120 | 2 | [
"Personal History"
] | [
"Subjective"
] | i'm sorry to hear that now do you remember what caused the pain initially | 3,029 |
doctor: okay and now can you describe the pain for me patient: yeah it feels like a sharp stabbing pain in my back and it does go down even down to my right leg sometimes all the way down to my toe it feels like my big toe | D2N120 | 3 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and now can you describe the pain for me | 3,030 |
doctor: okay now with that do you have any numbness or tingling associated with your back pain patient: yeah i do get some numbness and tingling especially to my right leg that goes down to my foot | D2N120 | 5 | [
"Vegetative History"
] | [
"Subjective"
] | okay now with that do you have any numbness or tingling associated with your back pain | 3,031 |
doctor: and how about a loss of sensation in the genital or the rectal area patient: no nothing like that | D2N120 | 7 | [
"Vegetative History"
] | [
"Subjective"
] | and how about a loss of sensation in the genital or the rectal area | 3,032 |
doctor: okay now do you have any weakness patient: i would n't say i have any weakness no | D2N120 | 8 | [
"Vegetative History"
] | [
"Subjective"
] | okay now do you have any weakness | 3,033 |
doctor: okay do you experience like any loss of control of your bladder or your bowels patient: no | D2N120 | 9 | [
"Vegetative History"
] | [
"Subjective"
] | okay do you experience like any loss of control of your bladder or your bowels | 3,034 |
doctor: okay now you mentioned earlier that you you have some tried tried some things in the past so tell me what were they patient: so i've tried some physical therapy before and so when it gets really bad they've even had to prescribe some strong pain medications for me but that was only temporary and they even menti... | D2N120 | 10 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | okay now you mentioned earlier that you you have some tried tried some things in the past so tell me what were they | 3,035 |
doctor: okay sure so tell me what is your day like patient: my day so i try to be as active as i can but of course it's been difficult with my back pain and so because of that i have gained some weight over the past years | D2N120 | 11 | [
"Other Socials"
] | [
"Subjective"
] | okay sure so tell me what is your day like | 3,036 |
doctor: okay alright well i'm sorry to hear that i know that you used to like playing golf patient: yeah i and you know golf is relatively new for me i've been trying to get into it but this has definitely set me back | D2N120 | 12 | [
"Other Socials"
] | [
"Subjective"
] | okay alright well i'm sorry to hear that i know that you used to like playing golf | 3,037 |
doctor: yeah i'm sorry yep probably now at the peak of you know just learning it and being able to do more with it this comes and this happens right patient: exactly | D2N120 | 13 | [
"Other Socials"
] | [
"Subjective"
] | yeah i'm sorry yep probably now at the peak of you know just learning it and being able to do more with it this comes and this happens right | 3,038 |
doctor: well let's see what we can do for you here so you can go out into the you know the golf course again now do you tell me do you have any family members with spine conditions patient: no i ca n't recall any family members | D2N120 | 14 | [
"Family History"
] | [
"Subjective"
] | well let's see what we can do for you here so you can go out into the you know the golf course again now do you tell me do you have any family members with spine conditions | 3,039 |
doctor: okay alright and do you smoke patient: not now i i quit about twenty years ago | D2N120 | 15 | [
"Vegetative History"
] | [
"Subjective"
] | okay alright and do you smoke | 3,040 |
doctor: okay alright well alright well i like to do a quick physical exam on you here patient: okay | D2N120 | 16 | [
"Physical Examination"
] | [
"Objective"
] | okay alright well alright well i like to do a quick physical exam on you here | 3,041 |
doctor: i'm gon na go ahead here i reviewed your vitals and they overall look pretty good so that's a good sign now on your musculoskeletal back exam there is no overlying erythema and that just means redness or ecchymosis and that just means bruising of the skin now there is midline tenderness at l4 l5 disk space with... | D2N120 | 17 | [
"Physical Examination"
] | [
"Objective"
] | i'm gon na go ahead here i reviewed your vitals and they overall look pretty good so that's a good sign now on your musculoskeletal back exam there is no overlying erythema and that just means redness or ecchymosis and that just means bruising of the skin now there is midline tenderness at l4 l5 disk space with right-s... | 3,042 |
doctor: sorry so definitely some pain with lumbar flexion and supine straight leg test is positive so on your neurological examination there is decreased sensation to light touch at the right lateral thigh at l4 dermatome okay and i'm just gon na take a look at your knees here real quick and then your your ankles so pa... | D2N120 | 18 | [
"Physical Examination",
"Discussion",
"Medication",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | sorry so definitely some pain with lumbar flexion and supine straight leg test is positive so on your neurological examination there is decreased sensation to light touch at the right lateral thigh at l4 dermatome okay and i'm just gon na take a look at your knees here real quick and then your your ankles so patellar a... | 3,043 |
doctor: well you know patients are different so what we do is we will monitor you and we see how you respond to the injection and the patient's intervals can be different as well but we usually do not do more than four times a year patient: okay okay | D2N120 | 19 | [
"Discussion"
] | [
"Plan"
] | well you know patients are different so what we do is we will monitor you and we see how you respond to the injection and the patient's intervals can be different as well but we usually do not do more than four times a year | 3,044 |
doctor: alright and it's not a long procedure it's it's relatively quick and common and you should be out of the office within an hour patient: okay | D2N120 | 20 | [
"Discussion"
] | [
"Plan"
] | alright and it's not a long procedure it's it's relatively quick and common and you should be out of the office within an hour | 3,045 |
doctor: alright well let's go ahead and get you started on the first one today if that works for you if not we'll get you scheduled to start your first injection patient: alright thank you | D2N120 | 22 | [
"Chitchat"
] | [
"Null"
] | alright well let's go ahead and get you started on the first one today if that works for you if not we'll get you scheduled to start your first injection | 3,046 |
doctor: alright thank you patient: bye | D2N120 | 23 | [
"Chitchat"
] | [
"Null"
] | alright thank you | 3,047 |
doctor: hi kenneth how are you the medical assistant told me that you had some knee pain patient: yeah i was getting ready for the holiday weekend and i was out on my boat skiing and i i did a jump and kinda twisted when i landed and my knee has been hurting me ever since | D2N121 | 0 | [
"Greetings",
"Acute Symptoms"
] | [
"Subjective"
] | hi kenneth how are you the medical assistant told me that you had some knee pain | 3,048 |
doctor: okay so that was about five days ago then patient: yeah yeah that was last weekend | D2N121 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay so that was about five days ago then | 3,049 |
doctor: last weekend okay now which knee is it patient: it's my right knee | D2N121 | 2 | [
"Acute Symptoms"
] | [
"Subjective"
] | last weekend okay now which knee is it | 3,050 |
doctor: your right knee okay and i know that it sounds like you were on a motor boat as you were you know water skiing but did you hear anything pop or feel anything pop when it happened patient: no it just felt like something stretched and then it swelled up some afterwards | D2N121 | 3 | [
"Acute Symptoms"
] | [
"Subjective"
] | your right knee okay and i know that it sounds like you were on a motor boat as you were you know water skiing but did you hear anything pop or feel anything pop when it happened | 3,051 |
doctor: okay and were you i assume that you were were you able to get out of the water by yourself or did you need some assistance patient: i was able to get out but it was very sore to climb up and you know any kind of squatting or bending is really pretty sore | D2N121 | 4 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and were you i assume that you were were you able to get out of the water by yourself or did you need some assistance | 3,052 |
doctor: yeah okay and have you ever injured this knee before patient: no that was the first time | D2N121 | 5 | [
"Personal History"
] | [
"Subjective"
] | yeah okay and have you ever injured this knee before | 3,053 |
doctor: that was the first time okay where do you have a boat what lake do you have it on lake patient: lake martin | D2N121 | 6 | [
"Other Socials"
] | [
"Subjective"
] | that was the first time okay where do you have a boat what lake do you have it on lake | 3,054 |
doctor: okay nice and so you're a frequent water skier patient: yeah i try to go every weekend when we can | D2N121 | 7 | [
"Other Socials"
] | [
"Subjective"
] | okay nice and so you're a frequent water skier | 3,055 |
doctor: that's nice very very good are you looking forward to spring are you a baseball fan are you excited by opening day patient: no i'm not a baseball fan but i love spring and chicken time of year launds of outdoor activities nice nice i'm i'm not really a baseball fan either but my husband makes me watch the the m... | D2N121 | 8 | [
"Chitchat",
"Other Socials"
] | [
"Subjective"
] | that's nice very very good are you looking forward to spring are you a baseball fan are you excited by opening day | 3,056 |
doctor: yeah right so how about your high blood pressure how are you doing with that are you taking your blood pressure medication like i asked patient: i'm taking it everyday and i check my blood pressure at home and it's been about one twenty five over eighty most of the days | D2N121 | 9 | [
"Therapeutic History",
"Personal History"
] | [
"Subjective"
] | yeah right so how about your high blood pressure how are you doing with that are you taking your blood pressure medication like i asked | 3,057 |
doctor: nice okay so i believe we have you on lisinopril about twenty milligrams a day any side effects from that that you're noticing patient: not that i know of it's been a good medicine for me and i do n't have any trouble with it | D2N121 | 10 | [
"Therapeutic History",
"Personal History"
] | [
"Subjective"
] | nice okay so i believe we have you on lisinopril about twenty milligrams a day any side effects from that that you're noticing | 3,058 |
doctor: okay great alright and since you had this knee pain any numbing or tingling in your foot at all patient: no just the swelling and the pain | D2N121 | 11 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay great alright and since you had this knee pain any numbing or tingling in your foot at all | 3,059 |
doctor: okay and what have you taken for the pain patient: i i took some aleve twice a day some over the counter aleve twice a day | D2N121 | 12 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay and what have you taken for the pain | 3,060 |
doctor: okay and patient: putting a cold pack on it | D2N121 | 13 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay and | 3,061 |
doctor: okay and has that helped at all patient: yeah that's helped a fair amount it's still pretty sore though | D2N121 | 14 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay and has that helped at all | 3,062 |
doctor: okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here patient: i had my tonsils out | D2N121 | 15 | [
"Personal History"
] | [
"Subjective"
] | okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here | 3,063 |
doctor: okay you had your tonsils out okay alright well let me go ahead i wan na do a just a quick physical exam i'm gon na go ahead and be calling out some of my clinical exam findings and i'll let you know what that means when i'm done okay so looking at your vital signs here in the office it does look like you're do... | D2N121 | 16 | [
"Physical Examination"
] | [
"Objective"
] | okay you had your tonsils out okay alright well let me go ahead i wan na do a just a quick physical exam i'm gon na go ahead and be calling out some of my clinical exam findings and i'll let you know what that means when i'm done okay so looking at your vital signs here in the office it does look like you're doing a re... | 3,064 |
doctor: okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt patient: yeah do n't do that anymore | D2N121 | 17 | [
"Physical Examination"
] | [
"Objective"
] | okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt | 3,065 |
doctor: alright the patient has decreased range of motion there is a negative varus and valgus test there is a negative lachman sign there is a palpable dorsalis pedis and posterior tibial pulse there is otherwise no lower extremity edema so what does that what does that mean kenneth so that so that means that you esse... | D2N121 | 18 | [
"Physical Examination",
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Referral",
"Medication"
] | [
"Objective",
"Assessment",
"Plan"
] | alright the patient has decreased range of motion there is a negative varus and valgus test there is a negative lachman sign there is a palpable dorsalis pedis and posterior tibial pulse there is otherwise no lower extremity edema so what does that what does that mean kenneth so that so that means that you essentially ... | 3,066 |
doctor: i would say i would like you to rest your knee i i think that my concern is that if you go skiing again and you fall that you might injure your knee even more so i think you'll recover from this injury right now but i do n't want you to injure it anymore so i would rest it for a little while at least until we h... | D2N121 | 19 | [
"Reassessment",
"Discussion",
"Diagnostic Testing",
"Medication"
] | [
"Assessment",
"Plan"
] | i would say i would like you to rest your knee i i think that my concern is that if you go skiing again and you fall that you might injure your knee even more so i think you'll recover from this injury right now but i do n't want you to injure it anymore so i would rest it for a little while at least until we have the ... | 3,067 |
doctor: okay sounds good alright so i'll see you later we'll get those ordered and i'll be in touch okay take care bye patient: thank you | D2N121 | 20 | [
"Chitchat"
] | [
"Null"
] | okay sounds good alright so i'll see you later we'll get those ordered and i'll be in touch okay take care bye | 3,068 |
doctor: hey kyle it's nice to see you today can you tell me a little bit about what brought you in patient: yeah i went to see my pcp for a cough which they diagnosed as bronchitis but then they did that chest x-ray to make sure i did n't have pneumonia and they found this lung nodule i went for a cat scan that confirm... | D2N122 | 0 | [
"Acute Symptoms",
"Greetings"
] | [
"Subjective"
] | hey kyle it's nice to see you today can you tell me a little bit about what brought you in | 3,069 |
doctor: okay well first of all i'm i'm sorry that you're nervous and what we're gon na do is we're gon na partner together okay and i'm gon na be right by your side the whole time to hopefully make you a little less nervous and and recognize the fact that we're you're gon na have a big support team around you okay pati... | D2N122 | 1 | [
"Chitchat"
] | [
"Null"
] | okay well first of all i'm i'm sorry that you're nervous and what we're gon na do is we're gon na partner together okay and i'm gon na be right by your side the whole time to hopefully make you a little less nervous and and recognize the fact that we're you're gon na have a big support team around you okay | 3,070 |
doctor: so let's talk a little bit about how long you've had that cough before you went to see your doctor patient: i you know off and on i've had it for about three months i first noticed it when i was loading some pay i have horses and i i bought you know four hundred bills a day and when i spent a day loading it and... | D2N122 | 2 | [
"Personal History"
] | [
"Subjective"
] | so let's talk a little bit about how long you've had that cough before you went to see your doctor | 3,071 |
doctor: okay that's good to hear you mentioned exercise and biking i love to bike myself i've got a track seventy one hundred hybrid have you been on the the new trails they opened it was the old the old rail the old rail road right away they've opened that up it's like sixty miles of trails patient: i love that that r... | D2N122 | 3 | [
"Other Socials"
] | [
"Subjective"
] | okay that's good to hear you mentioned exercise and biking i love to bike myself i've got a track seventy one hundred hybrid have you been on the the new trails they opened it was the old the old rail the old rail road right away they've opened that up it's like sixty miles of trails | 3,072 |
doctor: yeah i love riding over there way we will we will get you all fixed up we will have to go for a bike ride patient: absolutely i'd love it | D2N122 | 5 | [
"Chitchat"
] | [
"Null"
] | yeah i love riding over there way we will we will get you all fixed up we will have to go for a bike ride | 3,073 |
doctor: that'd be great so i see here on your medical history that you also have a history of rheumatoid arthritis is that under control at this time and and and what do you do to to take care of your ra patient: yeah it's it's it's fair you know arthritis never really goes away but i take methotrexate | D2N122 | 6 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | that'd be great so i see here on your medical history that you also have a history of rheumatoid arthritis is that under control at this time and and and what do you do to to take care of your ra | 3,074 |
doctor: okay that's good i also see here that you marked down that you were a previous smoker and and when when did you when did you stop smoking patient: i stopped smoking probably about seven years ago | D2N122 | 8 | [
"Drug History"
] | [
"Subjective"
] | okay that's good i also see here that you marked down that you were a previous smoker and and when when did you when did you stop smoking | 3,075 |
doctor: okay that's good and i'm glad to hear that you were able to to to stop and and stay tobacco free that that's great to hear do you have any pain or any shortness of breath or anything like that patient: no not at all | D2N122 | 10 | [
"Drug History"
] | [
"Subjective"
] | okay that's good and i'm glad to hear that you were able to to to stop and and stay tobacco free that that's great to hear do you have any pain or any shortness of breath or anything like that | 3,076 |
doctor: okay and i would like to talk about your familial history here for just a second do you have any family history of lung cancer or any other type of malignancies patient: no lung cancer my mom did have breast cancer but she is doing well now | D2N122 | 11 | [
"Family History"
] | [
"Subjective"
] | okay and i would like to talk about your familial history here for just a second do you have any family history of lung cancer or any other type of malignancies | 3,077 |
doctor: okay alright and then things like lung infections or pneumonia do you have any previous history of that patient: no no not not anything that i'm aware of | D2N122 | 12 | [
"Personal History"
] | [
"Subjective"
] | okay alright and then things like lung infections or pneumonia do you have any previous history of that | 3,078 |
doctor: okay if it's okay with you i'm gon na do a quick physical exam your vital signs look good today blood pressure of one twenty four over seventy six heart rate of seventy respiration rate of sixteen o2 sat on room air of ninety eight percent and you are afebrile so you do n't have a fever today i'm gon na take a ... | D2N122 | 13 | [
"Physical Examination",
"Discussion",
"Follow-up",
"Radiology Examination",
"Acute Assessment",
"Drug History",
"Other Treatments"
] | [
"Objective",
"Assessment",
"Plan"
] | okay if it's okay with you i'm gon na do a quick physical exam your vital signs look good today blood pressure of one twenty four over seventy six heart rate of seventy respiration rate of sixteen o2 sat on room air of ninety eight percent and you are afebrile so you do n't have a fever today i'm gon na take a quick li... | 3,079 |
doctor: i i know you're scared but we'll be right here with you the whole way patient: okay | D2N122 | 14 | [
"Chitchat"
] | [
"Null"
] | i i know you're scared but we'll be right here with you the whole way | 3,080 |
doctor: alright we'll get some paperwork and i'll see you again in a few minutes patient: okay thank you | D2N122 | 15 | [
"Chitchat"
] | [
"Null"
] | alright we'll get some paperwork and i'll see you again in a few minutes | 3,081 |
doctor: so tyler is a 56 -year-old male who presents today complaining of difficulty swallowing and has a past medical history of diabetes and high blood pressure so tyler tell me what's going on with your swallowing problem patient: well it's just been something that i have noticed over the last you know four to five ... | D2N123 | 0 | [
"Acute Symptoms",
"Personal History",
"Greetings"
] | [
"Subjective"
] | so tyler is a 56 -year-old male who presents today complaining of difficulty swallowing and has a past medical history of diabetes and high blood pressure so tyler tell me what's going on with your swallowing problem | 3,082 |
doctor: okay and is it seem to be stuck in your throat or does it seem to go in your lungs area or are you coughing with this at all or just mostly when you're swallowing patient: no coughing just kinda when i swallow it's all okay with liquids but when i kinda swallow you know like a bite of a sandwich sometimes it ju... | D2N123 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and is it seem to be stuck in your throat or does it seem to go in your lungs area or are you coughing with this at all or just mostly when you're swallowing | 3,083 |
doctor: okay and is it more kind of a like heart like steaks or heart like larger solid like things that are that you have to chew more or is it even soft stuff like you know to eat yogurt and stuff like that patient: i'm not a hundred percent sure but i think it's probably more with solids | D2N123 | 2 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and is it more kind of a like heart like steaks or heart like larger solid like things that are that you have to chew more or is it even soft stuff like you know to eat yogurt and stuff like that | 3,084 |
doctor: okay how about have you noticed anything different with when you're swallowing cold or or or hot liquids is there is there a temperature change any modification to that patient: it's really just about solids | D2N123 | 3 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay how about have you noticed anything different with when you're swallowing cold or or or hot liquids is there is there a temperature change any modification to that | 3,085 |
doctor: okay alright so have you noticed any blood in any place or blood in your stools or are you vomiting anything up at all patient: no | D2N123 | 4 | [
"Vegetative History"
] | [
"Subjective"
] | okay alright so have you noticed any blood in any place or blood in your stools or are you vomiting anything up at all | 3,086 |
doctor: okay that so no vomiting blood no coughing up blood or anything like that any weight loss or changes in your weight at all patient: not that i want | D2N123 | 5 | [
"Vegetative History"
] | [
"Subjective"
] | okay that so no vomiting blood no coughing up blood or anything like that any weight loss or changes in your weight at all | 3,087 |
doctor: okay yeah i mean i think we all like to lose a little bit of weight but yeah it's a it says it's a struggle so no no chest pain or shortness of breath with this patient: no | D2N123 | 6 | [
"Vegetative History"
] | [
"Subjective"
] | okay yeah i mean i think we all like to lose a little bit of weight but yeah it's a it says it's a struggle so no no chest pain or shortness of breath with this | 3,088 |
doctor: okay so i i'm gon na you know we'll talk about that in a second i'll look at your throat as well and see what we need to do but it sounds like we may have to send you to a specialist to take a look at that and see if there is something causing this how about how are you doing with your diabetes by the way since... | D2N123 | 7 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | okay so i i'm gon na you know we'll talk about that in a second i'll look at your throat as well and see what we need to do but it sounds like we may have to send you to a specialist to take a look at that and see if there is something causing this how about how are you doing with your diabetes by the way since i have ... | 3,089 |
doctor: okay are you checking your blood sugars in the morning or are you checking those at all patient: yeah i do i mean once in a while i i'm in a hurry and i skip it but i have to say i probably do so about eighty percent of the time | D2N123 | 8 | [
"Personal History"
] | [
"Subjective"
] | okay are you checking your blood sugars in the morning or are you checking those at all | 3,090 |
doctor: and how are the numbers looking patient: they're looking you know okay they are all within you know the range that we are targeting | D2N123 | 9 | [
"Personal History"
] | [
"Subjective"
] | and how are the numbers looking | 3,091 |
doctor: okay alright and any any no nausea vomiting or diarrhea or any other side effects from the metformin or anything like that patient: no | D2N123 | 10 | [
"Vegetative History"
] | [
"Subjective"
] | okay alright and any any no nausea vomiting or diarrhea or any other side effects from the metformin or anything like that | 3,092 |
doctor: okay good so i think we should probably repeat your hemoglobin a1c it sounds like you've you know you've improved your diet and it sounds like you've you're following the regimen so maybe the numbers will be better this time and we do n't have to change your medication so that will be awesome how are you doing ... | D2N123 | 11 | [
"Discussion",
"Personal History",
"Therapeutic History",
"Reassessment"
] | [
"Subjective",
"Assessment",
"Plan"
] | okay good so i think we should probably repeat your hemoglobin a1c it sounds like you've you know you've improved your diet and it sounds like you've you're following the regimen so maybe the numbers will be better this time and we do n't have to change your medication so that will be awesome how are you doing with you... | 3,093 |
doctor: okay alright good so let me examine you now so tyler i'm examining you now i'm gon na just verbalize some of my findings your neck is fine i do n't see any swelling in your neck your thyroid feels normal i do n't feel any masses in your neck there's no lymph nodes i'm looking at your throat and that looks okay ... | D2N123 | 12 | [
"Physical Examination",
"Discussion",
"Referral",
"Medication",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | okay alright good so let me examine you now so tyler i'm examining you now i'm gon na just verbalize some of my findings your neck is fine i do n't see any swelling in your neck your thyroid feels normal i do n't feel any masses in your neck there's no lymph nodes i'm looking at your throat and that looks okay there is... | 3,094 |
doctor: okay and for the diabetes i'm gon na order another hemoglobin a1c i'm gon na order some more blood work today we'll check a kidney function and i notice that you have not had an eye referral so i'm gon na also give you an eye referral to ophthalmology to check your eyes for your diabetic for your for any retino... | D2N123 | 13 | [
"Discussion",
"Follow-up",
"Referral",
"Diagnostic Testing",
"Reassessment"
] | [
"Assessment",
"Plan"
] | okay and for the diabetes i'm gon na order another hemoglobin a1c i'm gon na order some more blood work today we'll check a kidney function and i notice that you have not had an eye referral so i'm gon na also give you an eye referral to ophthalmology to check your eyes for your diabetic for your for any retinopathy co... | 3,095 |
doctor: okay and the high blood pressure i think you're doing great continue with the norvasc if you have any issues certainly call me but otherwise there is really nothing else to add for that did we forget anything or do you need refills for anything patient: you know i think i'm low on the norvasc so if you could se... | D2N123 | 14 | [
"Discussion",
"Medication",
"Reassessment"
] | [
"Assessment",
"Plan"
] | okay and the high blood pressure i think you're doing great continue with the norvasc if you have any issues certainly call me but otherwise there is really nothing else to add for that did we forget anything or do you need refills for anything | 3,096 |
doctor: okay sure i'll get you a refill for norvasc we'll get that sent over to the pharmacy okay patient: thank you | D2N123 | 15 | [
"Discussion",
"Medication"
] | [
"Plan"
] | okay sure i'll get you a refill for norvasc we'll get that sent over to the pharmacy okay | 3,097 |
doctor: alright thanks good seeing you thanks for coming in to them | D2N123 | 16 | [
"Chitchat"
] | [
"Null"
] | doctor: alright thanks good seeing you thanks for coming in to them | 3,098 |
doctor: so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened patient: hey doctor michael yeah so my son sean i think you met in the past he he started playing basketball and there we do multiple seasons and so we're kinda getting ready for the next season that starts in in april an... | D2N124 | 0 | [
"Acute Symptoms",
"Greetings"
] | [
"Subjective"
] | so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened | 3,099 |
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