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DATEXIS
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aci_bench_intent_annotated

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doctor: i'm good . you're ready to get started ? patient: yes , i am .
D2N128
1
[ "Chitchat" ]
[ "Null" ]
i'm good . you're ready to get started ?
3,200
doctor: so carolyn is a 49-year-old female here for follow-up of her chronic problems . so , how are you doing , carolyn ? patient: i'm doing okay . um , my osteoarthritis has been flaring up a little bit lately , um , so i wan na get- talk about that primarily . so , it's mostly in um , my elbows and it's really been bothering me . i've been sitting at the computer , at the desk more , um , in the office so i do n't know if it's being stagnant in that position all day has um , increased flare-ups for that , but i wanted to talk to you about that .
D2N128
2
[ "Personal History" ]
[ "Subjective" ]
so carolyn is a 49-year-old female here for follow-up of her chronic problems . so , how are you doing , carolyn ?
3,201
doctor: okay , sure . and , are you right or left-handed ? patient: i'm right-handed .
D2N128
3
[ "Personal History" ]
[ "Subjective" ]
okay , sure . and , are you right or left-handed ?
3,202
doctor: okay , and does one elbow bother you more than the other ? patient: my right elbow does bother me more than the other , but primarily , i'm typing all day versus writing , so it- it flares up in both .
D2N128
4
[ "Personal History" ]
[ "Subjective" ]
okay , and does one elbow bother you more than the other ?
3,203
doctor: okay . all right , and um , any other joint pain ? patient: no , just- just really focused on my elbows .
D2N128
5
[ "Personal History" ]
[ "Subjective" ]
okay . all right , and um , any other joint pain ?
3,204
doctor: okay , and any numbing or tingling in your hands ? patient: uh , sometimes . when i'm typing for long periods of time , i feel a little bit of numbing , um , i try to shake out my arms a little bit . um , just to kind of relieve that um , sensation .
D2N128
6
[ "Vegetative History" ]
[ "Subjective" ]
okay , and any numbing or tingling in your hands ?
3,205
doctor: okay . all right , and i know that you've had this also , had this history of gout . and the last episode you had was about three months ago . you had some inflammation of your toe . have you had any other issues with that ? patient: no , i have n't . um , the medication you gave me really controlled it , and i have n't seen a flare-up since .
D2N128
7
[ "Personal History" ]
[ "Subjective" ]
okay . all right , and i know that you've had this also , had this history of gout . and the last episode you had was about three months ago . you had some inflammation of your toe . have you had any other issues with that ?
3,206
doctor: okay . all right , and how are you doing with your psoriasis ? patient: that's been under control too . that has n't been a- a major problem for me either .
D2N128
8
[ "Personal History" ]
[ "Subjective" ]
okay . all right , and how are you doing with your psoriasis ?
3,207
doctor: okay . i- i know that we had given you some clobetasol for your scalp . is that- so that's doing okay ? patient: yeah , that's doing a lot better .
D2N128
9
[ "Therapeutic History" ]
[ "Subjective" ]
okay . i- i know that we had given you some clobetasol for your scalp . is that- so that's doing okay ?
3,208
doctor: okay , great . um , all right , well , i'd like to go ahead and do a physical exam on you . patient: okay .
D2N128
10
[ "Physical Examination" ]
[ "Objective" ]
okay , great . um , all right , well , i'd like to go ahead and do a physical exam on you .
3,209
doctor: let's first look at your vital signs . hey , dragon , show me the vital signs . great , so everything looks good from that perspective . um , so looking at you , i do n't appreciate any cervical lymphadenopathy . your heart is a nice regular rate and rhythm , and your lungs sound really clear . on your right elbow , you do have some edema and inflammation of your right olecranon and there's some tenderness and an effusion right there . so um , does that hurt when i press it ? patient: yeah , that does hurt .
D2N128
11
[ "Physical Examination" ]
[ "Objective" ]
let's first look at your vital signs . hey , dragon , show me the vital signs . great , so everything looks good from that perspective . um , so looking at you , i do n't appreciate any cervical lymphadenopathy . your heart is a nice regular rate and rhythm , and your lungs sound really clear . on your right elbow , you do have some edema and inflammation of your right olecranon and there's some tenderness and an effusion right there . so um , does that hurt when i press it ?
3,210
doctor: okay , and when i turn your arm , do you have pain ? patient: yeah , that hurts a bit too .
D2N128
12
[ "Physical Examination" ]
[ "Objective" ]
okay , and when i turn your arm , do you have pain ?
3,211
doctor: okay , so she has pain- to palpation of the olecranon bursa and pain with pronation and supination . and when you flex- and when you bend it and straighten it , does that hurt ? patient: yeah , it does and it's a bit stiff too .
D2N128
13
[ "Physical Examination" ]
[ "Objective" ]
okay , so she has pain- to palpation of the olecranon bursa and pain with pronation and supination . and when you flex- and when you bend it and straighten it , does that hurt ?
3,212
doctor: okay , so pain with flexion and extension of the right arm . uh , your abdomen is nice and soft , and there's no lower extremity edema . uh , let's go ahead and take a look at some of your labs . you know , you have a lot of arthritis for someone so young , so we had sent off that autoimmune panel . hey , dragon . show me the autoimmune labs . hey , dragon . show me the autoimmune profile . hey , dragon . show me the esr . okay , so that's good . hey , dragon . show me the uric acid . okay . all right , well , good . that's great . so , you know , it does n't look like you have any systemic arthritis , or sys- systemic inflammatory in process going on . so , my impression of you at this time is that from a gout standpoint , everything is nice and stable . i think that we should continue you on the colchicine 0.6 milligrams twice a day as needed for flare-ups of your gout . um , and then for your osteoarthritis , i'd like to go ahead and order a right elbow x-ray . hey , dragon . order a right elbow x-ray , and then i'd like to prescribe some meloxicam 15 milligrams once a day for the pain and the swelling . patient: okay .
D2N128
14
[ "Physical Examination", "Medication", "Lab Examination", "Diagnostic Testing", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
okay , so pain with flexion and extension of the right arm . uh , your abdomen is nice and soft , and there's no lower extremity edema . uh , let's go ahead and take a look at some of your labs . you know , you have a lot of arthritis for someone so young , so we had sent off that autoimmune panel . hey , dragon . show me the autoimmune labs . hey , dragon . show me the autoimmune profile . hey , dragon . show me the esr . okay , so that's good . hey , dragon . show me the uric acid . okay . all right , well , good . that's great . so , you know , it does n't look like you have any systemic arthritis , or sys- systemic inflammatory in process going on . so , my impression of you at this time is that from a gout standpoint , everything is nice and stable . i think that we should continue you on the colchicine 0.6 milligrams twice a day as needed for flare-ups of your gout . um , and then for your osteoarthritis , i'd like to go ahead and order a right elbow x-ray . hey , dragon . order a right elbow x-ray , and then i'd like to prescribe some meloxicam 15 milligrams once a day for the pain and the swelling .
3,213
doctor: hey , dragon . order meloxicam 15 milligrams once a day . and then i'd like to um , just see those- how- the x-ray show- shows up and the results of that before we refer you for any type of physical therapy , okay ? patient: okay .
D2N128
15
[ "Discussion", "Medication", "Referral", "Diagnostic Testing" ]
[ "Plan" ]
hey , dragon . order meloxicam 15 milligrams once a day . and then i'd like to um , just see those- how- the x-ray show- shows up and the results of that before we refer you for any type of physical therapy , okay ?
3,214
doctor: and then from a psoriasis standpoint , i think everything is stable . we'll continue you on the steroid cream for your scalp , okay ? patient: that sounds good .
D2N128
16
[ "Discussion", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
and then from a psoriasis standpoint , i think everything is stable . we'll continue you on the steroid cream for your scalp , okay ?
3,215
doctor: all right , do you have any questions ? patient: no , that's it .
D2N128
17
[ "Discussion" ]
[ "Plan" ]
all right , do you have any questions ?
3,216
doctor: all right , take care . patient: thank you .
D2N128
18
[ "Chitchat" ]
[ "Null" ]
all right , take care .
3,217
doctor: hey , dragon . finalize the note .
D2N128
19
[ "Chitchat" ]
[ "Null" ]
doctor: hey , dragon . finalize the note .
3,218
doctor: good afternoon , beverly . good to see you . patient: nice to see you too .
D2N129
0
[ "Greetings" ]
[ "Subjective" ]
good afternoon , beverly . good to see you .
3,219
doctor: so , i know my nurse told you a little bit about dax . um , now , if you do n't mind , i'd like to tell dax a little bit about you . patient: go for it .
D2N129
1
[ "Chitchat" ]
[ "Null" ]
so , i know my nurse told you a little bit about dax . um , now , if you do n't mind , i'd like to tell dax a little bit about you .
3,220
doctor: great . um , beverly's a 24 year old female patient , and i know you have a history of type 2 diabetes and high blood pressure . correct ? patient: yep .
D2N129
2
[ "Personal History" ]
[ "Subjective" ]
great . um , beverly's a 24 year old female patient , and i know you have a history of type 2 diabetes and high blood pressure . correct ?
3,221
doctor: okay . so , you're here today for your yearly exam . have n't seen you in a year . how're you doing ? patient: i've been doing well . i began working in a bakery this summer which has been super fun. i have really been enjoying working there, but i find myself, since i am so close to so many delicious treats, snacking a lot during shifts and eating a lot more desserts than i normally would.
D2N129
3
[ "Personal History" ]
[ "Subjective" ]
okay . so , you're here today for your yearly exam . have n't seen you in a year . how're you doing ?
3,222
doctor: okay , so , that brings me to your diabetes . so , how have your blood sugars been ? patient: uh , not so good .
D2N129
4
[ "Personal History" ]
[ "Subjective" ]
okay , so , that brings me to your diabetes . so , how have your blood sugars been ?
3,223
doctor: pretty bad lately ? patient: yeah .
D2N129
6
[ "Personal History" ]
[ "Subjective" ]
pretty bad lately ?
3,224
doctor: okay . and , that's really the only thing that's different is your diet , pretty much ? patient: yeah .
D2N129
7
[ "Personal History" ]
[ "Subjective" ]
okay . and , that's really the only thing that's different is your diet , pretty much ?
3,225
doctor: and , that's because of the new job and all that ? patient: yeah. it has been really challenging to resist the temptation.
D2N129
8
[ "Other Socials" ]
[ "Subjective" ]
and , that's because of the new job and all that ?
3,226
doctor: it's hard to ignore those desserts , are n't they ? patient: yeah .
D2N129
9
[ "Chitchat" ]
[ "Null" ]
it's hard to ignore those desserts , are n't they ?
3,227
doctor: no willpower like me ? patient: no , no willpower .
D2N129
10
[ "Chitchat" ]
[ "Null" ]
no willpower like me ?
3,228
doctor: okay . all right . and , and then , um , i know you've had high blood pressure , hypertension . how is , how have your blood sugars been ? have you been checking them ? patient: so , my blood pressure's been good . um , despite my , um , my diabetes levels being up and down .
D2N129
11
[ "Personal History" ]
[ "Subjective" ]
okay . all right . and , and then , um , i know you've had high blood pressure , hypertension . how is , how have your blood sugars been ? have you been checking them ?
3,229
doctor: okay , so , your blood pressures have been normal . you've been sleeping well ? patient: yep , getting a full eight hours .
D2N129
13
[ "Vegetative History" ]
[ "Subjective" ]
okay , so , your blood pressures have been normal . you've been sleeping well ?
3,230
doctor: no concerns about hurting yourself or anything like that ? patient: no .
D2N129
14
[ "Vegetative History" ]
[ "Subjective" ]
no concerns about hurting yourself or anything like that ?
3,231
doctor: okay , good . okay , and i know my , um , nurse did a review of systems . other than what we've talked about so far , is there anything else that you needed to add ? patient: no .
D2N129
15
[ "Acute Symptoms" ]
[ "Subjective" ]
okay , good . okay , and i know my , um , nurse did a review of systems . other than what we've talked about so far , is there anything else that you needed to add ?
3,232
doctor: good . so , pretty much status quo except for those things that we've been working on , right ? patient: yep .
D2N129
16
[ "Acute Symptoms" ]
[ "Subjective" ]
good . so , pretty much status quo except for those things that we've been working on , right ?
3,233
doctor: okay , good . all right . well , let me do a quick physical exam , okay ? patient: okay .
D2N129
17
[ "Physical Examination" ]
[ "Objective" ]
okay , good . all right . well , let me do a quick physical exam , okay ?
3,234
doctor: okay , squeeze my finger here . good . can you feel me touch out here ? patient: yep .
D2N129
18
[ "Physical Examination" ]
[ "Objective" ]
okay , squeeze my finger here . good . can you feel me touch out here ?
3,235
doctor: okay . and , can you feel me touch you down here ? patient: yep .
D2N129
19
[ "Physical Examination" ]
[ "Objective" ]
okay . and , can you feel me touch you down here ?
3,236
doctor: okay . no swelling . push your leg out . good . pull it back . mm-hmm . go . good . okay . so , on my exam , um , essentially , your exam is normal . your , um , heart is regular . you do have that grade 2 , um , systolic ejection fraction back ejection murmur that you , um , that we've heard in the past . okay ? so , um , we definitely know that's there . that's unchanged , okay ? um , your lungs are clear . um , your grips are equal . neurovascular's intact . you do n't have any carotid bruits in your neck , no thyromegaly . no edema . um , pulses are good , so essentially , your exam is , is essentially normal . let's take a look at some of your lab work , okay ? patient: okay .
D2N129
20
[ "Physical Examination" ]
[ "Objective" ]
okay . no swelling . push your leg out . good . pull it back . mm-hmm . go . good . okay . so , on my exam , um , essentially , your exam is normal . your , um , heart is regular . you do have that grade 2 , um , systolic ejection fraction back ejection murmur that you , um , that we've heard in the past . okay ? so , um , we definitely know that's there . that's unchanged , okay ? um , your lungs are clear . um , your grips are equal . neurovascular's intact . you do n't have any carotid bruits in your neck , no thyromegaly . no edema . um , pulses are good , so essentially , your exam is , is essentially normal . let's take a look at some of your lab work , okay ?
3,237
doctor: hey , dragon , show me the hemoglobin a1c . okay , so , blood sugars have been elevated . your hemoglobin a1c is elevated as well , so that tells me your blood sugars have been a little bit out of control . you're still taking the metformin , correct ? patient: yes , i am .
D2N129
21
[ "Therapeutic History", "Lab Examination" ]
[ "Subjective", "Objective" ]
hey , dragon , show me the hemoglobin a1c . okay , so , blood sugars have been elevated . your hemoglobin a1c is elevated as well , so that tells me your blood sugars have been a little bit out of control . you're still taking the metformin , correct ?
3,238
doctor: okay , and you take that twice a day ? patient: yep .
D2N129
22
[ "Therapeutic History" ]
[ "Subjective" ]
okay , and you take that twice a day ?
3,239
doctor: okay . um , uh , hey , dragon ? show me the vital signs . okay , good news here is your blood pressure's good . everything , um , there is fine . so , um , so , my assessment is , is , um , your first problem is diabetes . it's a little out of control . we'd like that hemoglobin a1c to be under seven , um , at least . you know , preferably , under six . patient: mm-hmm .
D2N129
23
[ "Physical Examination", "Discussion", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
okay . um , uh , hey , dragon ? show me the vital signs . okay , good news here is your blood pressure's good . everything , um , there is fine . so , um , so , my assessment is , is , um , your first problem is diabetes . it's a little out of control . we'd like that hemoglobin a1c to be under seven , um , at least . you know , preferably , under six .
3,240
doctor: so , um , uh , i'm not gon na change your medication . i think this is diet related , so i want you to try to cut down on the snacking and additional sweets , okay ? patient: yeah .
D2N129
24
[ "Discussion", "Medication", "Other Treatments" ]
[ "Plan" ]
so , um , uh , i'm not gon na change your medication . i think this is diet related , so i want you to try to cut down on the snacking and additional sweets , okay ?
3,241
doctor: and , i want you to check your blood sugars in the morning . i want you to call them in in about two weeks so we know what your first , um , fasting blood sugar was in the morning , and then , we'll come back and see you in about two months and see if everything has straightened out . if it has n't , then we'll talk about adding another medication , okay ? patient: okay .
D2N129
25
[ "Discussion", "Follow-up", "Medication", "Other Treatments" ]
[ "Plan" ]
and , i want you to check your blood sugars in the morning . i want you to call them in in about two weeks so we know what your first , um , fasting blood sugar was in the morning , and then , we'll come back and see you in about two months and see if everything has straightened out . if it has n't , then we'll talk about adding another medication , okay ?
3,242
doctor: your second problem is your hypertension . that seems to be relatively stable . i want you to stay on your current medication . you're on li- lisinopril 10 mg once a day . just stay right on that medication . no changes at this point . seems to be doing well , okay ? patient: okay .
D2N129
26
[ "Discussion", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
your second problem is your hypertension . that seems to be relatively stable . i want you to stay on your current medication . you're on li- lisinopril 10 mg once a day . just stay right on that medication . no changes at this point . seems to be doing well , okay ?
3,243
doctor: good . anything else i can do for you today ? patient: no . that's it .
D2N129
27
[ "Discussion" ]
[ "Plan" ]
good . anything else i can do for you today ?
3,244
doctor: good . come with me , we'll get you checked out . patient: thank you .
D2N129
28
[ "Chitchat" ]
[ "Null" ]
good . come with me , we'll get you checked out .
3,245
doctor: hey , dragon ? finalize the note .
D2N129
29
[ "Chitchat" ]
[ "Null" ]
doctor: hey , dragon ? finalize the note .
3,246
doctor: hi , anna , how are you ? patient: i'm doing okay . how are you ?
D2N130
0
[ "Greetings" ]
[ "Subjective" ]
hi , anna , how are you ?
3,247
doctor: i'm doing well . uh , so i know the nurse told you a little bit about dax . i'd like to tell dax a little bit about you . patient: okay .
D2N130
1
[ "Chitchat" ]
[ "Null" ]
i'm doing well . uh , so i know the nurse told you a little bit about dax . i'd like to tell dax a little bit about you .
3,248
doctor: all right . so , uh , anna is a 26-year-old female with a past medical history , significant for epilepsy , depression , and , uh , peptic ulcer disease , who presents with , uh , some joint pain . so , anna , what's going on with your , uh , what's going on with your joints ? patient: so , um , it's my left elbow that's really been bothering me . uh , i sit at my desk a lot for work , and type , and i stay in this motion specifically all day . and then after , um , work , it's really hard for me to , uh , open and , and close my , my elbow here , my left elbow , and it's been just really stiff and , and hurts .
D2N130
2
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
all right . so , uh , anna is a 26-year-old female with a past medical history , significant for epilepsy , depression , and , uh , peptic ulcer disease , who presents with , uh , some joint pain . so , anna , what's going on with your , uh , what's going on with your joints ?
3,249
doctor: okay . have you noticed any swelling there on the- patient: yeah , i have .
D2N130
3
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . have you noticed any swelling there on the-
3,250
doctor: okay , and is it right here on the , on the tip ? patient: yep , it is .
D2N130
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay , and is it right here on the , on the tip ?
3,251
doctor: okay , and are you right or left-handed ? patient: i am right-handed .
D2N130
5
[ "Other Socials" ]
[ "Subjective" ]
okay , and are you right or left-handed ?
3,252
doctor: okay , so it's your non-dominant hand ? patient: yeah , which is good .
D2N130
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay , so it's your non-dominant hand ?
3,253
doctor: okay , and any numbing or tingling in your hands at all ? patient: no , i have n't felt numbing or tingling .
D2N130
8
[ "Vegetative History" ]
[ "Subjective" ]
okay , and any numbing or tingling in your hands at all ?
3,254
doctor: and any weakness in your arm ? patient: a little bit of weakness , uh , but nothing too significant .
D2N130
9
[ "Vegetative History" ]
[ "Subjective" ]
and any weakness in your arm ?
3,255
doctor: okay , and ... and how about .. and how about , um , any fever or chills ? patient: no fever or chills .
D2N130
10
[ "Vegetative History" ]
[ "Subjective" ]
okay , and ... and how about .. and how about , um , any fever or chills ?
3,256
doctor: okay . all right , well , let's talk a little bit about your epilepsy , okay ? patient: okay .
D2N130
11
[ "Personal History" ]
[ "Subjective" ]
okay . all right , well , let's talk a little bit about your epilepsy , okay ?
3,257
doctor: um , have you had any recent seizures ? patient: uh , no , i have n't . i think my last seizure was a year ago .
D2N130
12
[ "Personal History" ]
[ "Subjective" ]
um , have you had any recent seizures ?
3,258
doctor: okay , good . patient: yeah .
D2N130
13
[ "Chitchat" ]
[ "Null" ]
okay , good .
3,259
doctor: and you're still taking the keppra ? patient: yes , i am .
D2N130
14
[ "Therapeutic History" ]
[ "Subjective" ]
and you're still taking the keppra ?
3,260
doctor: okay , great . and then , tell me a little about your depression . how're you doing with that ? i know that you went into therapy last year , and you tried to avoid medication since you're already on the keppra . how's that doing ? patient: uh , therapy , therapy's been good . it , it has definitely helped . uh , i still feel a little down , uh , and , and stressed .
D2N130
15
[ "Personal History" ]
[ "Subjective" ]
okay , great . and then , tell me a little about your depression . how're you doing with that ? i know that you went into therapy last year , and you tried to avoid medication since you're already on the keppra . how's that doing ?
3,261
doctor: okay . all right , but no , no feelings of wanting to hurt yourself or somebody else ? patient: no , nothing like that .
D2N130
16
[ "Vegetative History" ]
[ "Subjective" ]
okay . all right , but no , no feelings of wanting to hurt yourself or somebody else ?
3,262
doctor: okay . all right . and then , how are you doing with your , with your ulcer ? i know that you , you know , you had so much stress a year ago and , you know , you were having some issues there . we did the endoscopy- patient: mm-hmm .
D2N130
17
[ "Personal History" ]
[ "Subjective" ]
okay . all right . and then , how are you doing with your , with your ulcer ? i know that you , you know , you had so much stress a year ago and , you know , you were having some issues there . we did the endoscopy-
3,263
doctor: . and they showed that . so , how are you doing with that ? patient: i'm doing , i'm doing better . i have n't had any , um , issues with that , um , since we did the procedure , and everything's been good .
D2N130
18
[ "Personal History" ]
[ "Subjective" ]
. and they showed that . so , how are you doing with that ?
3,264
doctor: okay , well great . let's go ahead and ... i'm gon na go ahead with , um ... and , you know , i know that the nurse did a review of systems sheet on you when you came in , and i know that you were endorsing that left elbow pain . patient: mm-hmm .
D2N130
19
[ "Acute Symptoms" ]
[ "Subjective" ]
okay , well great . let's go ahead and ... i'm gon na go ahead with , um ... and , you know , i know that the nurse did a review of systems sheet on you when you came in , and i know that you were endorsing that left elbow pain .
3,265
doctor: any other symptoms , you know , chest pain , shortness of breath , abdominal pain , nausea or vomiting ? patient: no , nothing like that . i have a little bit of nasal , nasal congestion from allergies , uh , but that's it .
D2N130
20
[ "Vegetative History" ]
[ "Subjective" ]
any other symptoms , you know , chest pain , shortness of breath , abdominal pain , nausea or vomiting ?
3,266
doctor: okay , so you're endorsing some nasal congestion ? patient: yeah .
D2N130
21
[ "Vegetative History" ]
[ "Subjective" ]
okay , so you're endorsing some nasal congestion ?
3,267
doctor: okay . all right , well , let's go ahead to a physical exam , okay ? patient: okay .
D2N130
22
[ "Physical Examination" ]
[ "Objective" ]
okay . all right , well , let's go ahead to a physical exam , okay ?
3,268
doctor: hey , dragon , show me the vital signs . good , here in the office , everything looks great with your vital signs . i think that's great , so i'm just gon na take a listen to your heart and your lungs , and take a look at your elbow and , and we'll go from there , okay ? patient: okay .
D2N130
23
[ "Physical Examination" ]
[ "Objective" ]
hey , dragon , show me the vital signs . good , here in the office , everything looks great with your vital signs . i think that's great , so i'm just gon na take a listen to your heart and your lungs , and take a look at your elbow and , and we'll go from there , okay ?
3,269
doctor: all right , so , so on physical examination of your left elbow , you do have some erythema and edema of your left elbow . does it hurt when i touch ? patient: yeah , it does .
D2N130
24
[ "Physical Examination" ]
[ "Objective" ]
all right , so , so on physical examination of your left elbow , you do have some erythema and edema of your left elbow . does it hurt when i touch ?
3,270
doctor: okay , he ... she has some pain to palpation of the olecranon . of the left olecra- olecranon , and it is warm to palpation . um , can you straighten your elbow for me ? patient: yeah , it , it hurts , and it's , uh , it's a bit stiff .
D2N130
25
[ "Physical Examination" ]
[ "Objective" ]
okay , he ... she has some pain to palpation of the olecranon . of the left olecra- olecranon , and it is warm to palpation . um , can you straighten your elbow for me ?
3,271
doctor: okay , so she has pain with flexion and extension of the left elbow . there's a palpable right ... or s- ... palpable left radial pulse . okay , um , so let's go over ... i just wan na take a look at some of your results , okay ? patient: okay .
D2N130
26
[ "Physical Examination" ]
[ "Objective" ]
okay , so she has pain with flexion and extension of the left elbow . there's a palpable right ... or s- ... palpable left radial pulse . okay , um , so let's go over ... i just wan na take a look at some of your results , okay ?
3,272
doctor: hey , dragon , show me the left elbow x-ray . hey , dragon , show me the elbow x-ray . hey , dragon , show me the left arm x-ray . okay , so , in reviewing the results of your left arm x-ray , there's no evidence of any elbow fracture , which is not surprising , okay ? hey , dragon , show me the endoscopy results . hey , dragon , show me the endoscopy . okay , well , your recent endoscopy showed that you ... hey , dragon , show me the endoscope . all right , so here it looks like , you know ... your endoscopy results look like you had an episode of gastritis . that's for your , your peptic ulcer disease , and so everything , you know ... you took your , your protonix , and i think everything resolved at that point , okay . patient: okay .
D2N130
27
[ "Radiology Examination" ]
[ "Objective" ]
hey , dragon , show me the left elbow x-ray . hey , dragon , show me the elbow x-ray . hey , dragon , show me the left arm x-ray . okay , so , in reviewing the results of your left arm x-ray , there's no evidence of any elbow fracture , which is not surprising , okay ? hey , dragon , show me the endoscopy results . hey , dragon , show me the endoscopy . okay , well , your recent endoscopy showed that you ... hey , dragon , show me the endoscope . all right , so here it looks like , you know ... your endoscopy results look like you had an episode of gastritis . that's for your , your peptic ulcer disease , and so everything , you know ... you took your , your protonix , and i think everything resolved at that point , okay .
3,273
doctor: so , let's talk a little bit about my assessment and my plan for you . so for your first problem , this left elbow pain , you know , i think you have olecranon bursitis , and we're just gon na , you know , have you , you know , get a little pillow for your elbow there . it's just caused by repetitive trauma . patient: mm-hmm .
D2N130
28
[ "Discussion", "Other Treatments", "Acute Assessment" ]
[ "Assessment", "Plan" ]
so , let's talk a little bit about my assessment and my plan for you . so for your first problem , this left elbow pain , you know , i think you have olecranon bursitis , and we're just gon na , you know , have you , you know , get a little pillow for your elbow there . it's just caused by repetitive trauma .
3,274
doctor: so , maybe you're slamming your elbow down a little bit on the desk , so just get a little rest there- patient: yeah .
D2N130
29
[ "Discussion" ]
[ "Plan" ]
so , maybe you're slamming your elbow down a little bit on the desk , so just get a little rest there-
3,275
doctor: . and we'll give you some melo- meloxicam , 15 mg , once a day . you can ice the area , okay ? um , for your next problem , the epilepsy , sounds like you're doing really well . i would go ahead and continue with the keppra , 500 mg , twice a day . do you need a refill of that ? patient: yes , i do .
D2N130
30
[ "Discussion", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
. and we'll give you some melo- meloxicam , 15 mg , once a day . you can ice the area , okay ? um , for your next problem , the epilepsy , sounds like you're doing really well . i would go ahead and continue with the keppra , 500 mg , twice a day . do you need a refill of that ?
3,276
doctor: hey , dragon , order a refill of keppra , 500 mg , twice daily . for your third problem , the depression , it sounds like you're doing well with the therapy and , if you want , we can talk about medical treatment options . patient: yeah , i think that would be great .
D2N130
31
[ "Discussion", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
hey , dragon , order a refill of keppra , 500 mg , twice daily . for your third problem , the depression , it sounds like you're doing well with the therapy and , if you want , we can talk about medical treatment options .
3,277
doctor: okay , well , let's go ahead and we'll start you on some lexapro , 10 mg , once a day , and we'll see how you do on that , okay ? patient: okay .
D2N130
32
[ "Medication" ]
[ "Plan" ]
okay , well , let's go ahead and we'll start you on some lexapro , 10 mg , once a day , and we'll see how you do on that , okay ?
3,278
doctor: all right , and then , for your last problem , the peptic ulcer disease , um , i want you to continue on the protonix , 40 mg , once a day before meals , okay ? patient: okay .
D2N130
33
[ "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
all right , and then , for your last problem , the peptic ulcer disease , um , i want you to continue on the protonix , 40 mg , once a day before meals , okay ?
3,279
doctor: do you have any questions ? patient: no , i do n't .
D2N130
34
[ "Discussion" ]
[ "Plan" ]
do you have any questions ?
3,280
doctor: okay . all right . well , the nurse will come in soon and see you , okay , and i'll , i'll see you in a couple of weeks . patient: okay .
D2N130
35
[ "Follow-up" ]
[ "Plan" ]
okay . all right . well , the nurse will come in soon and see you , okay , and i'll , i'll see you in a couple of weeks .
3,281
doctor: all right , take care . bye . patient: bye .
D2N130
36
[ "Chitchat" ]
[ "Null" ]
all right , take care . bye .
3,282
doctor: hey , dragon , finalize the note .
D2N130
37
[ "Chitchat" ]
[ "Null" ]
doctor: hey , dragon , finalize the note .
3,283
doctor: hi , susan , how are you ? patient: good . how are you ?
D2N131
0
[ "Greetings" ]
[ "Subjective" ]
hi , susan , how are you ?
3,284
doctor: good . are you ready to get started ? patient: yes , i am .
D2N131
1
[ "Greetings" ]
[ "Subjective" ]
good . are you ready to get started ?
3,285
doctor: so , susan is a 26-year-old female here for a high blood pressure check . susan , what's going on with your blood pressure ? patient: so , i've always struggled with , um , high blood pressure , but it's seeming to get really out of control lately . so , i wanted to come in and see if there's any type of new medication i can be on to help it get steady or if there is diet restrictions i should take , um , things like that .
D2N131
2
[ "Personal History" ]
[ "Subjective" ]
so , susan is a 26-year-old female here for a high blood pressure check . susan , what's going on with your blood pressure ?
3,286
doctor: okay . so , i know that we've had you on the norvasc and we had to increase your dose , so you're on 10 milligrams a day now . and what are your blood pressures running at home ? you c- ... like , have they been like over 150 ? patient: yeah , they have been .
D2N131
3
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay . so , i know that we've had you on the norvasc and we had to increase your dose , so you're on 10 milligrams a day now . and what are your blood pressures running at home ? you c- ... like , have they been like over 150 ?
3,287
doctor: okay . all right . and , have you had any headaches ? patient: i have had some headaches . i do n't know if that's just because of more stress at work or , um , because of the high blood pressure .
D2N131
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . all right . and , have you had any headaches ?
3,288
doctor: okay . all right . so , you've had some headaches . have you had any chest pain , shortness of breath , anything like that ? patient: no , nothing like that .
D2N131
5
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . all right . so , you've had some headaches . have you had any chest pain , shortness of breath , anything like that ?
3,289
doctor: okay . um , and , you know , i know that you've had a kidney transplant a few years ago . patient: yes .
D2N131
6
[ "Personal History" ]
[ "Subjective" ]
okay . um , and , you know , i know that you've had a kidney transplant a few years ago .
3,290
doctor: everything is okay with that ? patient: everything's been good and solid there .
D2N131
7
[ "Personal History" ]
[ "Subjective" ]
everything is okay with that ?
3,291
doctor: and you're taking all of your auto , um , i- um , your immunosuppression medications ? patient: yes , i am .
D2N131
8
[ "Therapeutic History" ]
[ "Subjective" ]
and you're taking all of your auto , um , i- um , your immunosuppression medications ?
3,292
doctor: all right . so , let's go ahead and we'll do a quick physical exam . so , looking at you , you do n't appear any distress . your neck is nice and supple . your heart is irregular rate and rhythm . i do hear a slight , uh , two out of six systolic ejection murmur . your lungs are clear . i do see the scar on the left , uh , left plank for your kidney transplant which is healed . and you have no lower extremity edema . so , let's go ahead and look at some of your results , okay ? patient: okay .
D2N131
9
[ "Physical Examination", "Personal History", "Lab Examination" ]
[ "Subjective", "Objective" ]
all right . so , let's go ahead and we'll do a quick physical exam . so , looking at you , you do n't appear any distress . your neck is nice and supple . your heart is irregular rate and rhythm . i do hear a slight , uh , two out of six systolic ejection murmur . your lungs are clear . i do see the scar on the left , uh , left plank for your kidney transplant which is healed . and you have no lower extremity edema . so , let's go ahead and look at some of your results , okay ?
3,293
doctor: hey , dragon , show me the creatinine . so , your kidney function looks really good . so , that's really promising after your transplant . hey , dragon , show me the ekg . and your ekg looks great , uh , perfectly normal , so that's good . um , so , my impression of you at this time ... , let me see your blood pressure . patient: okay .
D2N131
10
[ "Reassessment", "Radiology Examination", "Lab Examination" ]
[ "Objective", "Assessment" ]
hey , dragon , show me the creatinine . so , your kidney function looks really good . so , that's really promising after your transplant . hey , dragon , show me the ekg . and your ekg looks great , uh , perfectly normal , so that's good . um , so , my impression of you at this time ... , let me see your blood pressure .
3,294
doctor: hey , dragon , show me the blood pressure . yeah , and you're right , it- patient: hm .
D2N131
11
[ "Lab Examination" ]
[ "Objective" ]
hey , dragon , show me the blood pressure . yeah , and you're right , it-
3,295
doctor: . it is high . so , there is something that we can do for that . so , let's go ahead and we'll put you on ... so , my impression of you is that your , your blood pressure is high and the norvasc is n't controlling it . and , you know , we can definitely get it under better control . so , what i would like to do is prescribe you coreg 25 milligrams , twice a day . and that will help bring your blood pressure down , okay ? patient: okay .
D2N131
12
[ "Discussion", "Acute Assessment", "Medication" ]
[ "Subjective", "Assessment", "Plan" ]
. it is high . so , there is something that we can do for that . so , let's go ahead and we'll put you on ... so , my impression of you is that your , your blood pressure is high and the norvasc is n't controlling it . and , you know , we can definitely get it under better control . so , what i would like to do is prescribe you coreg 25 milligrams , twice a day . and that will help bring your blood pressure down , okay ?
3,296
doctor: hey , dragon , order carvedilol 25 milligrams , twice a day . uh , i'd also like to go ahead and , uh , get a lipid panel and some routine labs on you just to make sure that everything is okay . patient: yeah .
D2N131
13
[ "Diagnostic Testing", "Medication" ]
[ "Plan" ]
hey , dragon , order carvedilol 25 milligrams , twice a day . uh , i'd also like to go ahead and , uh , get a lipid panel and some routine labs on you just to make sure that everything is okay .
3,297
doctor: hey , dragon , order a lipid panel . hey , dragon , order a complete metabolic panel . all right . and then , um , from a transplant standpoint , everything looks fine . your kidney function looks great , so we're just gon na continue you on all of those medications .so , the nurse will come in soon and she'll help you schedule all of the al- schedule a follow-up appointment with me , and we'll see what your blood pressure looks like in a couple weeks after taking that medication . okay ? patient: okay .
D2N131
14
[ "Diagnostic Testing", "Medication", "Reassessment", "Follow-up" ]
[ "Objective", "Assessment", "Plan" ]
hey , dragon , order a lipid panel . hey , dragon , order a complete metabolic panel . all right . and then , um , from a transplant standpoint , everything looks fine . your kidney function looks great , so we're just gon na continue you on all of those medications .so , the nurse will come in soon and she'll help you schedule all of the al- schedule a follow-up appointment with me , and we'll see what your blood pressure looks like in a couple weeks after taking that medication . okay ?
3,298
doctor: all right . thanks , susan . patient: thank you .
D2N131
15
[ "Chitchat" ]
[ "Null" ]
all right . thanks , susan .
3,299