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DATEXIS
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aci_bench_intent_annotated

Dataset card Data Studio Files
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doctor: hey , dragon , finalize the note .
D2N131
16
[ "Chitchat" ]
[ "Null" ]
doctor: hey , dragon , finalize the note .
3,300
doctor: hello mrs. lee , i see you're here for back pain . patient: yes .
D2N132
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
hello mrs. lee , i see you're here for back pain .
3,301
doctor: hey dragon , i'm seeing mrs. lee today for , uh , back pain . she's a 40-year-old female . so can you tell me what happened to you ? patient: yes . i was at a birthday party and it was surprise party . so we were all like crunched behind and hiding . and when the person came in we all jumped out , and then i fell down the little stair and i rammed my back into the railing of the s- , uh , staircase .
D2N132
1
[ "Acute Symptoms" ]
[ "Subjective" ]
hey dragon , i'm seeing mrs. lee today for , uh , back pain . she's a 40-year-old female . so can you tell me what happened to you ?
3,302
doctor: so it was a surprise for you too ? patient: yes it was .
D2N132
2
[ "Acute Symptoms" ]
[ "Subjective" ]
so it was a surprise for you too ?
3,303
doctor: very good . okay . so , um , did it hurt because you hit it , or did you twist ? what happened when you ? patient: i think it was my motion-
D2N132
3
[ "Acute Symptoms" ]
[ "Subjective" ]
very good . okay . so , um , did it hurt because you hit it , or did you twist ? what happened when you ?
3,304
doctor: okay . any pain shooting down your legs at all ? patient: no .
D2N132
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . any pain shooting down your legs at all ?
3,305
doctor: is it on one side or the other of your back ? patient: um , it's more on the right .
D2N132
7
[ "Acute Symptoms" ]
[ "Subjective" ]
is it on one side or the other of your back ?
3,306
doctor: on the right . is there anything that makes it better or worse ? patient: uh , if i'm lying flat it hurts a little more , and any twisting motion for sure .
D2N132
8
[ "Acute Symptoms" ]
[ "Subjective" ]
on the right . is there anything that makes it better or worse ?
3,307
doctor: okay . all right . and do you have any history or any back problems before ? patient: i did . i had a fusion done .
D2N132
9
[ "Personal History" ]
[ "Subjective" ]
okay . all right . and do you have any history or any back problems before ?
3,308
doctor: okay , yeah that lumbar fusion . um , let's take an x-ray . hey . or let's look at an x-ray . hey dragon , show me the latest x-ray . okay , we can see where you had your fusion , t4 here on the x-ray . but i do n't see anything that looks , um , significantly abnormal . it does n't appear to have any compression fractures or anything like that . so , it's essentially , except for the fusion , a normal exam . let me do your exam for you here . can i have you stand up please ? does it hurt when i twist you that way ? patient: yes .
D2N132
10
[ "Physical Examination", "Radiology Examination" ]
[ "Objective" ]
okay , yeah that lumbar fusion . um , let's take an x-ray . hey . or let's look at an x-ray . hey dragon , show me the latest x-ray . okay , we can see where you had your fusion , t4 here on the x-ray . but i do n't see anything that looks , um , significantly abnormal . it does n't appear to have any compression fractures or anything like that . so , it's essentially , except for the fusion , a normal exam . let me do your exam for you here . can i have you stand up please ? does it hurt when i twist you that way ?
3,309
doctor: okay . you can sit back down . if i lift your leg here , does that bother you ? patient: no .
D2N132
11
[ "Physical Examination" ]
[ "Objective" ]
okay . you can sit back down . if i lift your leg here , does that bother you ?
3,310
doctor: how 'bout when i lift this leg ? patient: no .
D2N132
12
[ "Physical Examination" ]
[ "Objective" ]
how 'bout when i lift this leg ?
3,311
doctor: any pain shooting down your legs when i do that ? patient: no .
D2N132
13
[ "Physical Examination" ]
[ "Objective" ]
any pain shooting down your legs when i do that ?
3,312
doctor: okay . and can you feel me touching down here . patient: yes .
D2N132
14
[ "Physical Examination" ]
[ "Objective" ]
okay . and can you feel me touching down here .
3,313
doctor: okay , great . so , you had a injury to your back when you were twisting at the birthday party . you do n't really have any pain or numbness down your legs . you have some stiffness with rotation , um , but you do n't have any evidence of a , um , what we would call a pinched nerved or radiculopathy . so , i think you basically have a strain of your lower back . um , have you been taking any medications ? patient: just some ibuprofen .
D2N132
15
[ "Acute Symptoms", "Therapeutic History", "Acute Assessment" ]
[ "Subjective", "Assessment" ]
okay , great . so , you had a injury to your back when you were twisting at the birthday party . you do n't really have any pain or numbness down your legs . you have some stiffness with rotation , um , but you do n't have any evidence of a , um , what we would call a pinched nerved or radiculopathy . so , i think you basically have a strain of your lower back . um , have you been taking any medications ?
3,314
doctor: okay . and do you have any other , um , medical problems ? patient: um i take medication for anxiety .
D2N132
16
[ "Personal History" ]
[ "Subjective" ]
okay . and do you have any other , um , medical problems ?
3,315
doctor: okay . and that's all ? okay . um , so what we're gon na do is i'm gon na give you , um , just continue the motrin at 800mg , three times a day , with food . i want you to use some ice and heat , alternating on your back . but i do want you walking . patient: okay .
D2N132
17
[ "Medication", "Referral" ]
[ "Plan" ]
okay . and that's all ? okay . um , so what we're gon na do is i'm gon na give you , um , just continue the motrin at 800mg , three times a day , with food . i want you to use some ice and heat , alternating on your back . but i do want you walking .
3,316
doctor: um , and , uh , this should sort of take care of itself after a few days . if it's not , or it's getting worse , i want you to come back and see me over the next week . patient: okay .
D2N132
18
[ "Discussion", "Follow-up" ]
[ "Plan" ]
um , and , uh , this should sort of take care of itself after a few days . if it's not , or it's getting worse , i want you to come back and see me over the next week .
3,317
doctor: does that sound good ? patient: it does .
D2N132
19
[ "Discussion" ]
[ "Plan" ]
does that sound good ?
3,318
doctor: okay , dragon . hey dragon , go ahead and order the medications and procedures and close out the note . come on i'll bring you out to check out . patient: thank you .
D2N132
20
[ "Chitchat" ]
[ "Null" ]
okay , dragon . hey dragon , go ahead and order the medications and procedures and close out the note . come on i'll bring you out to check out .
3,319
doctor: good morning rebecca , nice to see you . patient: nice to see you too .
D2N133
0
[ "Greetings" ]
[ "Subjective" ]
good morning rebecca , nice to see you .
3,320
doctor: so , my nurse told you a little bit about dax , now i'm wondering if i can tell dax a little bit about you . patient: go for it .
D2N133
1
[ "Chitchat" ]
[ "Null" ]
so , my nurse told you a little bit about dax , now i'm wondering if i can tell dax a little bit about you .
3,321
doctor: okay , so rebecca is a 27-year-old female patient . um , you have a history of carpal tunnel , um , uh , release done couple of years ago , you have some chronic back pain , some depression . why am i seeing you today ? patient: so last week , um , and over the course of the month , i have taken up swimming more regularly .
D2N133
2
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
okay , so rebecca is a 27-year-old female patient . um , you have a history of carpal tunnel , um , uh , release done couple of years ago , you have some chronic back pain , some depression . why am i seeing you today ?
3,322
doctor: just in your right knee ? patient: yeah .
D2N133
5
[ "Acute Symptoms" ]
[ "Subjective" ]
just in your right knee ?
3,323
doctor: okay . just when swimming ? are you swimming freestyle with your legs kicking straight or more like breaststroke where your legs kick out ? patient: yeah , it's only while swimming. i use the breaststroke so i guess where the legs are kicking out like a frog ... it kinda starts hurting a little bit after i swim a couple laps , which a month ago when i started i was able to do ten .
D2N133
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . just when swimming ? are you swimming freestyle with your legs kicking straight or more like breaststroke where your legs kick out ?
3,324
doctor: and no injury ? like you did n't fall or twist it or anything like that that you remember ? patient: no , not that i can remember .
D2N133
8
[ "Acute Symptoms" ]
[ "Subjective" ]
and no injury ? like you did n't fall or twist it or anything like that that you remember ?
3,325
doctor: okay . so just swimming a lot and you feeling more and more discomfort ? patient: yeah .
D2N133
9
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . so just swimming a lot and you feeling more and more discomfort ?
3,326
doctor: okay , good . so , um ... i know my nurse did a review of systems before you came in . there were really no significant issues . you have a history of chronic back pain , that's been doing well ? patient: yeah , it comes and goes , but right now it's been doing really well .
D2N133
10
[ "Personal History" ]
[ "Subjective" ]
okay , good . so , um ... i know my nurse did a review of systems before you came in . there were really no significant issues . you have a history of chronic back pain , that's been doing well ?
3,327
doctor: okay , no pain going down your legs or anything like that ? patient: no .
D2N133
11
[ "Personal History" ]
[ "Subjective" ]
okay , no pain going down your legs or anything like that ?
3,328
doctor: okay . and i know you have some depression , you've been on medication . how's that been going ? patient: that's been going really well .
D2N133
12
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
okay . and i know you have some depression , you've been on medication . how's that been going ?
3,329
doctor: sleeping well ? patient: yeah .
D2N133
14
[ "Vegetative History" ]
[ "Subjective" ]
sleeping well ?
3,330
doctor: eating well ? okay . do n't feel any concerns about hurting yourself or others or anything like that ? patient: no .
D2N133
15
[ "Vegetative History" ]
[ "Subjective" ]
eating well ? okay . do n't feel any concerns about hurting yourself or others or anything like that ?
3,331
doctor: okay , good . um , and the , you had ca- carpal tunnel done a few years ago . how's that doing ? patient: that's doing-
D2N133
16
[ "Personal History" ]
[ "Subjective" ]
okay , good . um , and the , you had ca- carpal tunnel done a few years ago . how's that doing ?
3,332
doctor: any flare up with that ? patient: . that's doing really well . i've been getting full range of motion and it's felt a lot better .
D2N133
17
[ "Personal History" ]
[ "Subjective" ]
any flare up with that ?
3,333
doctor: okay , great . do you mind if i do a quick exam ? patient: yeah , go for it .
D2N133
18
[ "Physical Examination" ]
[ "Objective" ]
okay , great . do you mind if i do a quick exam ?
3,334
doctor: squeeze my fingers for me . good . okay . is it painful if i move your patella like that ? patient: yeah , that hurts .
D2N133
19
[ "Physical Examination" ]
[ "Objective" ]
squeeze my fingers for me . good . okay . is it painful if i move your patella like that ?
3,335
doctor: okay . and i'm gon na hold your leg out , i'm gon na hold , i want you to stiffen your upper ... does that hurt when i do that ? patient: yeah , that hurts too .
D2N133
20
[ "Physical Examination" ]
[ "Objective" ]
okay . and i'm gon na hold your leg out , i'm gon na hold , i want you to stiffen your upper ... does that hurt when i do that ?
3,336
doctor: okay , good , all right . um , let's take a quick look at your x-ray , okay ? patient: okay .
D2N133
21
[ "Radiology Examination" ]
[ "Objective" ]
okay , good , all right . um , let's take a quick look at your x-ray , okay ?
3,337
doctor: hey dragon , show me the right knee x-ray . okay , so here's a picture of your right knee . actually normal x-ray , everything looks good , okay ? on my exam , um , you do n't really have any swelling in- in your joints , um , uh , of your knee . you have a little pain with , um , uh , range of motion of the knee . you have real pain when we do what we call patella in- ... patellar inhibition , okay ? so that's what caused most of that pain . so , um , your heart is regular , your lungs are clear , i do n't feel any adenopathy , your thyroid's , um , normal , your grips are equal , the rest of your exam is essentially normal , okay ? so my assessment is , you have what we call chondromalacia of the patella , okay ? it's just from the overuse and all- all the swimming you've been doing , okay ? so , um , to treat that we'll just use some anti-inflammatories , um , go ahead and take some ibuprofen , 600 milligrams four times a day with food . i do want you to do some straight leg raising exercises , that'll strengthen your quadriceps and that'll help with that pain , okay ? patient: okay .
D2N133
22
[ "Discussion", "Medication", "Radiology Examination", "Referral", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
hey dragon , show me the right knee x-ray . okay , so here's a picture of your right knee . actually normal x-ray , everything looks good , okay ? on my exam , um , you do n't really have any swelling in- in your joints , um , uh , of your knee . you have a little pain with , um , uh , range of motion of the knee . you have real pain when we do what we call patella in- ... patellar inhibition , okay ? so that's what caused most of that pain . so , um , your heart is regular , your lungs are clear , i do n't feel any adenopathy , your thyroid's , um , normal , your grips are equal , the rest of your exam is essentially normal , okay ? so my assessment is , you have what we call chondromalacia of the patella , okay ? it's just from the overuse and all- all the swimming you've been doing , okay ? so , um , to treat that we'll just use some anti-inflammatories , um , go ahead and take some ibuprofen , 600 milligrams four times a day with food . i do want you to do some straight leg raising exercises , that'll strengthen your quadriceps and that'll help with that pain , okay ?
3,338
doctor: um , basically you want to avoid anything that puts extra pressure on your knees for a little while and it should be fine . if it's not getting any better in a couple weeks i wan na see you again , okay ? so no lunges , avoid the breaststroke . if you're comfortable, you can also do other swimming strokes where your knees are straight instead . or you can take the opportunity to have a little break . patient: all right .
D2N133
23
[ "Discussion", "Follow-up" ]
[ "Plan" ]
um , basically you want to avoid anything that puts extra pressure on your knees for a little while and it should be fine . if it's not getting any better in a couple weeks i wan na see you again , okay ? so no lunges , avoid the breaststroke . if you're comfortable, you can also do other swimming strokes where your knees are straight instead . or you can take the opportunity to have a little break .
3,339
doctor: your second problem is your chronic back pain , that's been doing really well . um , keep swimming , that's okay after this gets better . patient: yeah .
D2N133
24
[ "Discussion", "Reassessment" ]
[ "Assessment", "Plan" ]
your second problem is your chronic back pain , that's been doing really well . um , keep swimming , that's okay after this gets better .
3,340
doctor: um , but i think , um , i think that's been under control . but if it flares up go ahead and , uh , give me a call , okay ? patient: mm-hmm .
D2N133
25
[ "Discussion", "Follow-up" ]
[ "Plan" ]
um , but i think , um , i think that's been under control . but if it flares up go ahead and , uh , give me a call , okay ?
3,341
doctor: um , your third problem is your depression . that's been stable . we're gon na keep you on your current medication , not gon na change anything at this point , okay ? and as far as your carpal tunnel goes , that's relatively stable , so , um , uh , no changes there as well . okay ? so anything else i can do for you ? patient: no , that's it .
D2N133
26
[ "Discussion", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
um , your third problem is your depression . that's been stable . we're gon na keep you on your current medication , not gon na change anything at this point , okay ? and as far as your carpal tunnel goes , that's relatively stable , so , um , uh , no changes there as well . okay ? so anything else i can do for you ?
3,342
doctor: okay , well we'll get you checked out . patient: all right .
D2N133
27
[ "Chitchat" ]
[ "Null" ]
okay , well we'll get you checked out .
3,343
doctor: hey dragon , finalize the report .
D2N133
28
[ "Chitchat" ]
[ "Null" ]
doctor: hey dragon , finalize the report .
3,344
doctor: we're gon na go right to the front- . so when you touch that- hi , michelle , how are you ? patient: i'm good . how are you ?
D2N134
0
[ "Greetings" ]
[ "Subjective" ]
we're gon na go right to the front- . so when you touch that- hi , michelle , how are you ?
3,345
doctor: i'm good . so i know the nurse told you about dax . i'd like to dax a little bit about you , okay ? patient: okay .
D2N134
1
[ "Chitchat" ]
[ "Null" ]
i'm good . so i know the nurse told you about dax . i'd like to dax a little bit about you , okay ?
3,346
doctor: all right . so , michelle is a 31-year-old female with a past medical history of type 2 diabetes and hypertension who presents with abnormal lab finding . so , michelle , it came back to me that you had had a positive long ... lyme titer . patient: yeah .
D2N134
2
[ "Personal History", "Lab Examination" ]
[ "Subjective", "Objective" ]
all right . so , michelle is a 31-year-old female with a past medical history of type 2 diabetes and hypertension who presents with abnormal lab finding . so , michelle , it came back to me that you had had a positive long ... lyme titer .
3,347
doctor: and so , uh , can you , you , you know , can you tell me a little bit about it ? i know the last time i saw you , you had had an insect bite , and you know , it came back positive for lyme . so how are you feeling ? patient: i've been feeling ... i could feel better . um ... i've been feeling tired , um , really lacking a lot of energy , and i have swollen joints in my elbows , just really hurts .
D2N134
3
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
and so , uh , can you , you , you know , can you tell me a little bit about it ? i know the last time i saw you , you had had an insect bite , and you know , it came back positive for lyme . so how are you feeling ?
3,348
doctor: okay . all right . and have you had any , any body aches ? patient: yeah , i have .
D2N134
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . all right . and have you had any , any body aches ?
3,349
doctor: okay . all right . um , and i know that you were out hiking in the woods and , and that type of thing a couple of weeks ago , and we thought that that's where you got the bite . so , um , how's your , how's your appetite ? have you been okay ? a little nauseous ? patient: yeah , i've been a little nauseous . i have n't been able to eat much . i've been trying just to keep , you know , toast and crackers and that's all about i've been able to stomach , really .
D2N134
5
[ "Acute Symptoms", "Personal History", "Vegetative History" ]
[ "Subjective" ]
okay . all right . um , and i know that you were out hiking in the woods and , and that type of thing a couple of weeks ago , and we thought that that's where you got the bite . so , um , how's your , how's your appetite ? have you been okay ? a little nauseous ?
3,350
doctor: okay , and , and i know that you had had that , that , uh , bite there . have you noticed any other rash anywhere else ? patient: yeah , i have .
D2N134
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay , and , and i know that you had had that , that , uh , bite there . have you noticed any other rash anywhere else ?
3,351
doctor: okay . all right . sometimes they kind of describe it as looking as like a bull's-eye . patient: yes .
D2N134
7
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . all right . sometimes they kind of describe it as looking as like a bull's-eye .
3,352
doctor: is that what it looked like ? patient: mm-hmm .
D2N134
8
[ "Acute Symptoms" ]
[ "Subjective" ]
is that what it looked like ?
3,353
doctor: okay . all right . well , um , have you had any , any high fevers ? patient: uh , no , not that i've noticed .
D2N134
9
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . all right . well , um , have you had any , any high fevers ?
3,354
doctor: all right . um , and how about from a diabetes standpoint ? how ... how's your blood sugar been running ? especially now that you kind of have this , like , acute thing going on ? have your blood sugars been okay ? patient: they've been okay . i've noticed that they sometimes get a little high and a little low . um , but nothing too far out of range .
D2N134
10
[ "Personal History" ]
[ "Subjective" ]
all right . um , and how about from a diabetes standpoint ? how ... how's your blood sugar been running ? especially now that you kind of have this , like , acute thing going on ? have your blood sugars been okay ?
3,355
doctor: okay . all right . um , and you're still taking the metformin ? patient: yes .
D2N134
11
[ "Therapeutic History" ]
[ "Subjective" ]
okay . all right . um , and you're still taking the metformin ?
3,356
doctor: okay . all right . good . and then in terms of your high blood pressure , are you monitoring the blood pressures at home ? patient: yeah , i , i have a ... i bought a cuff last year , and i've been , um , taking it myself at home . those have looked good . i've been staying away from the salty foods .
D2N134
12
[ "Therapeutic History", "Personal History" ]
[ "Subjective" ]
okay . all right . good . and then in terms of your high blood pressure , are you monitoring the blood pressures at home ?
3,357
doctor: mm-hmm . patient: um , so that's been good .
D2N134
13
[ "Personal History" ]
[ "Subjective" ]
mm-hmm .
3,358
doctor: okay . and , um , so you're still taking the lisinopril ? patient: yes .
D2N134
14
[ "Therapeutic History" ]
[ "Subjective" ]
okay . and , um , so you're still taking the lisinopril ?
3,359
doctor: okay , great . all right , well , you know , i know that you did the review of systems sheet when you checked in , and i know that you're endorsing some nausea and some joint pain and some body aches . any other symptoms ? abdominal pain ? diarrhea ? anything like that ? patient: no , nothing like that .
D2N134
15
[ "Acute Symptoms" ]
[ "Subjective" ]
okay , great . all right , well , you know , i know that you did the review of systems sheet when you checked in , and i know that you're endorsing some nausea and some joint pain and some body aches . any other symptoms ? abdominal pain ? diarrhea ? anything like that ?
3,360
doctor: okay . um , so let's go ahead , and we'll ... i'm gon na do a quick physical exam . patient: okay .
D2N134
16
[ "Physical Examination" ]
[ "Objective" ]
okay . um , so let's go ahead , and we'll ... i'm gon na do a quick physical exam .
3,361
doctor: hey , dragon , show me the vital signs . so i'm looking here at your vital signs . they look great . you do n't have a fever at that ... at this time , so that's really encouraging . i'm just gon na check you out , and , uh , i'm gon na listen to your heart and lungs and look for any rashes and let you know what i find , okay ? patient: okay .
D2N134
17
[ "Physical Examination", "Lab Examination" ]
[ "Objective" ]
hey , dragon , show me the vital signs . so i'm looking here at your vital signs . they look great . you do n't have a fever at that ... at this time , so that's really encouraging . i'm just gon na check you out , and , uh , i'm gon na listen to your heart and lungs and look for any rashes and let you know what i find , okay ?
3,362
doctor: okay , so on physical examination , you know , you do have some swelling of your , uh , elbow joints bilaterally . um , does it hurt when i touch them ? patient: yeah , it does .
D2N134
18
[ "Physical Examination" ]
[ "Objective" ]
okay , so on physical examination , you know , you do have some swelling of your , uh , elbow joints bilaterally . um , does it hurt when i touch them ?
3,363
doctor: okay , so she has pain to palpation to both elbow joints . um , and on your skin examination , you do have a bull's-eye rash on your , um , abdomen on the left-hand side . um , it's , it's warm to palpation . any pain with that ? patient: no , no pain for that .
D2N134
19
[ "Acute Symptoms", "Physical Examination" ]
[ "Subjective", "Objective" ]
okay , so she has pain to palpation to both elbow joints . um , and on your skin examination , you do have a bull's-eye rash on your , um , abdomen on the left-hand side . um , it's , it's warm to palpation . any pain with that ?
3,364
doctor: non-tender to palpation , no evidence of cellulitis . um , and the rest of , you know , the rest of your exam is pretty normal , okay ? so let me just go over some of the results with you , okay ? patient: okay .
D2N134
20
[ "Physical Examination", "Lab Examination" ]
[ "Objective" ]
non-tender to palpation , no evidence of cellulitis . um , and the rest of , you know , the rest of your exam is pretty normal , okay ? so let me just go over some of the results with you , okay ?
3,365
doctor: hey , dragon , show me the lyme titer . so you can see here , you know , in reviewing the results of your lyme titer , it is elevated . so we're gon na go ahead and do some further testing , but we're gon na , you know , we're gon na look into that , okay ? patient: okay .
D2N134
21
[ "Discussion", "Diagnostic Testing", "Lab Examination" ]
[ "Objective", "Plan" ]
hey , dragon , show me the lyme titer . so you can see here , you know , in reviewing the results of your lyme titer , it is elevated . so we're gon na go ahead and do some further testing , but we're gon na , you know , we're gon na look into that , okay ?
3,366
doctor: hey , dragon , show me the labs . and in reviewing the results of your labs , everything else looks good . so again , you know , you do n't have an elevated white blood cell count or anything like that . so i think we got this early enough , and we can go ahead and , and treat it , okay ? patient: okay .
D2N134
22
[ "Acute Assessment", "Lab Examination" ]
[ "Objective", "Assessment" ]
hey , dragon , show me the labs . and in reviewing the results of your labs , everything else looks good . so again , you know , you do n't have an elevated white blood cell count or anything like that . so i think we got this early enough , and we can go ahead and , and treat it , okay ?
3,367
doctor: so i wan na talk a little bit about , you know , my assessment and my plan for you . so for your first problem , this newly diagnosed lyme disease , i wan na go ahead and prescribe you doxycycline , 100 milligrams twice a day . you have to take it for three weeks , okay ? patient: okay .
D2N134
23
[ "Discussion", "Acute Assessment", "Medication" ]
[ "Assessment", "Plan" ]
so i wan na talk a little bit about , you know , my assessment and my plan for you . so for your first problem , this newly diagnosed lyme disease , i wan na go ahead and prescribe you doxycycline , 100 milligrams twice a day . you have to take it for three weeks , okay ?
3,368
doctor: i'm gon na just touch base with an infectious disease doctor to make sure that there's not anything else that we need to do , okay ? and i wan na see you again next week for a follow-up for this , okay ? patient: okay .
D2N134
24
[ "Discussion", "Follow-up", "Referral" ]
[ "Plan" ]
i'm gon na just touch base with an infectious disease doctor to make sure that there's not anything else that we need to do , okay ? and i wan na see you again next week for a follow-up for this , okay ?
3,369
doctor: so for your second problem , your type 2 diabetes , i wan na go ahead and order a hemoglobin a1c and just this ... make sure we do n't have to make any changes to the metformin , okay ? patient: okay .
D2N134
25
[ "Reassessment", "Discussion", "Diagnostic Testing" ]
[ "Assessment", "Plan" ]
so for your second problem , your type 2 diabetes , i wan na go ahead and order a hemoglobin a1c and just this ... make sure we do n't have to make any changes to the metformin , okay ?
3,370
doctor: hey , dragon , order a hemoglobin a1c . and for your last problem , your high blood pressure . it looks today like everything is fine . i think you're doing a really good job of managing your hypertension , and i'm going to continue you on the lisinopril , 10 milligrams a day , and i'm gon na go ahead and order a lipid panel , and , um , i want you to continue to record your blood , blood pressure regularly , okay ? patient: okay .
D2N134
26
[ "Reassessment", "Discussion", "Diagnostic Testing", "Medication" ]
[ "Assessment", "Plan" ]
hey , dragon , order a hemoglobin a1c . and for your last problem , your high blood pressure . it looks today like everything is fine . i think you're doing a really good job of managing your hypertension , and i'm going to continue you on the lisinopril , 10 milligrams a day , and i'm gon na go ahead and order a lipid panel , and , um , i want you to continue to record your blood , blood pressure regularly , okay ?
3,371
doctor: all right . do you need a refill of that ? patient: uh , yes , i do .
D2N134
27
[ "Medication" ]
[ "Plan" ]
all right . do you need a refill of that ?
3,372
doctor: okay . hey , dragon , order lisinopril , 10 milligrams daily . do you have any questions ? patient: no , i do n't .
D2N134
28
[ "Discussion", "Medication" ]
[ "Plan" ]
okay . hey , dragon , order lisinopril , 10 milligrams daily . do you have any questions ?
3,373
doctor: okay , so i'm gon na , you know , the nurse is gon na come in , and she's gon na check you out , and then we'll make a follow-up appointment for you , okay ? patient: okay .
D2N134
29
[ "Discussion", "Follow-up" ]
[ "Plan" ]
okay , so i'm gon na , you know , the nurse is gon na come in , and she's gon na check you out , and then we'll make a follow-up appointment for you , okay ?
3,374
doctor: hey , dragon , finalize the note .
D2N134
30
[ "Chitchat" ]
[ "Null" ]
doctor: hey , dragon , finalize the note .
3,375
doctor: hi , hannah . how are you ? patient: good , how are you ?
D2N135
0
[ "Greetings" ]
[ "Subjective" ]
hi , hannah . how are you ?
3,376
doctor: i'm good . you ready to get started ? patient: yes , i am .
D2N135
1
[ "Chitchat" ]
[ "Null" ]
i'm good . you ready to get started ?
3,377
doctor: so , hannah is a , uh , 52-year-old female here for evaluation of a high blood sugar . so , hannah , what ha- what happened ? i heard you were in the emergency room with a high blood sugar . patient: yes . so , i've been eating a ton of sweets recently . with the holidays it just feels like there is always something sweet available. whether i am at work and there are holiday gift baskets or clients bringing in treats or when i visit my family for the holidays and there is every baked good imaginable, there is always something sweet i can be eating. in the beginning i felt fine, but i have started to feel it after a couple of weeks, and this past week i just felt really light-headed and i could ... was seeing spots , really dizzy . so i went into the emergency room and they said i had a high blood sugar . um , so i wanted to come in and follow up with you to get that , um , get checked out .
D2N135
2
[ "Personal History" ]
[ "Subjective" ]
so , hannah is a , uh , 52-year-old female here for evaluation of a high blood sugar . so , hannah , what ha- what happened ? i heard you were in the emergency room with a high blood sugar .
3,378
doctor: okay . all right . and how , how are you feeling now ? did they , did , did they treat you in the emergency room ? did they gi- they give you some iv fluids and things like that ? patient: yeah . they gave me some fluids and they told me just to try to really cut out eating any extra sweets and get back into my normal routine and diet, but i am still staying with my family, and my mom and grandmother are big bakers so i think it will be really hard to get into a routine there so i just want to make sure i am nipping this high blood sugar thing in the bud.
D2N135
3
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay . all right . and how , how are you feeling now ? did they , did , did they treat you in the emergency room ? did they gi- they give you some iv fluids and things like that ?
3,379
doctor: okay . and i saw you went through a review of systems sheet with a nurse . i just want to ask you a few more questions from that standpoint . so you have had any fever or chills ? patient: no .
D2N135
4
[ "Vegetative History" ]
[ "Subjective" ]
okay . and i saw you went through a review of systems sheet with a nurse . i just want to ask you a few more questions from that standpoint . so you have had any fever or chills ?
3,380
doctor: any chest pain or shortness of breath ? patient: n- uh , no .
D2N135
5
[ "Vegetative History" ]
[ "Subjective" ]
any chest pain or shortness of breath ?
3,381
doctor: abdominal pain ? patient: no .
D2N135
6
[ "Vegetative History" ]
[ "Subjective" ]
abdominal pain ?
3,382
doctor: any burning when you urinate ? patient: no .
D2N135
7
[ "Vegetative History" ]
[ "Subjective" ]
any burning when you urinate ?
3,383
doctor: any joint pain or muscle aches ? patient: no .
D2N135
8
[ "Vegetative History" ]
[ "Subjective" ]
any joint pain or muscle aches ?
3,384
doctor: perfect . um , and then , i know that you have this history of a-fib , atrial fibrillation . have you felt your heart racing at all , recently ? patient: only when i'm really anxious . i , i feel it , um , pumping a little bit . but other than that i have n't .
D2N135
11
[ "Personal History" ]
[ "Subjective" ]
perfect . um , and then , i know that you have this history of a-fib , atrial fibrillation . have you felt your heart racing at all , recently ?
3,385
doctor: okay . all right . and how are you doing with your reflux ? patient: i've been doing well . i've been taking the medication that you prescribed to me and that's been helping a lot .
D2N135
12
[ "Personal History" ]
[ "Subjective" ]
okay . all right . and how are you doing with your reflux ?
3,386
doctor: okay , yeah . i see here you're on the protonix , 40 milligrams , once a day . patient: yes .
D2N135
13
[ "Therapeutic History" ]
[ "Subjective" ]
okay , yeah . i see here you're on the protonix , 40 milligrams , once a day .
3,387
doctor: so that's , you're doing well with that ? patient: yep .
D2N135
14
[ "Therapeutic History" ]
[ "Subjective" ]
so that's , you're doing well with that ?
3,388
doctor: okay . all right . so let's go ahead and do a quick physical exam . so , listening to you , um , look , or looking at you , you appear in no distress . your thyroid is a little enlarged , but non-tender . there's no carotid bruits , your heart is in irregular rate and rhythm , and your lungs are clear . your abdomen is nice and soft , and you have no edema in your lower extremities . let's go ahead and look at some of your test results . patient: okay .
D2N135
15
[ "Physical Examination" ]
[ "Objective" ]
okay . all right . so let's go ahead and do a quick physical exam . so , listening to you , um , look , or looking at you , you appear in no distress . your thyroid is a little enlarged , but non-tender . there's no carotid bruits , your heart is in irregular rate and rhythm , and your lungs are clear . your abdomen is nice and soft , and you have no edema in your lower extremities . let's go ahead and look at some of your test results .
3,389
doctor: hey , dragon ? show me the blood sugar . hey , dragon ? show me the blood glucose . hey , dragon ? show me the hemoglobin a1c . okay , so i see here that both your blood sugar and your hemoglobin a1c are elevated . so your blood sugars have probably been running high for probably a few months . okay ? um , let's go ahead and look at some of your other results . hey , dragon ? show me the diabetes labs . yeah . okay . yeah , so , um , my impression of you at this time , um , for your high blood sugars , that you do have this diagnosis of diabetes . now , we're not sure if it's type i or type ii . even patients in , you know , in their mid-twenties can develop type i diabetes , so we're gon na go off and , we're gon na go ahead and , and send some labs to work that up . hey , dragon ? order a complete metabolic panel . and i'd like to start you on metformin , 500 milligrams , twice a day . that will help keep your blood sugars down . patient: okay .
D2N135
16
[ "Reassessment", "Diagnostic Testing", "Medication" ]
[ "Assessment", "Plan" ]
hey , dragon ? show me the blood sugar . hey , dragon ? show me the blood glucose . hey , dragon ? show me the hemoglobin a1c . okay , so i see here that both your blood sugar and your hemoglobin a1c are elevated . so your blood sugars have probably been running high for probably a few months . okay ? um , let's go ahead and look at some of your other results . hey , dragon ? show me the diabetes labs . yeah . okay . yeah , so , um , my impression of you at this time , um , for your high blood sugars , that you do have this diagnosis of diabetes . now , we're not sure if it's type i or type ii . even patients in , you know , in their mid-twenties can develop type i diabetes , so we're gon na go off and , we're gon na go ahead and , and send some labs to work that up . hey , dragon ? order a complete metabolic panel . and i'd like to start you on metformin , 500 milligrams , twice a day . that will help keep your blood sugars down .
3,390
doctor: hey , dragon ? order metformin , 500 milligrams , twice a day . and then if some of the autoimmune labs that come back show that you have an autoimmune disorder , meaning that you would have type i diabetes , then we would have to go ahead and put you on insulin . but i'm gon na hold off until we have those results , okay ? patient: okay .
D2N135
17
[ "Discussion", "Diagnostic Testing", "Medication" ]
[ "Plan" ]
hey , dragon ? order metformin , 500 milligrams , twice a day . and then if some of the autoimmune labs that come back show that you have an autoimmune disorder , meaning that you would have type i diabetes , then we would have to go ahead and put you on insulin . but i'm gon na hold off until we have those results , okay ?
3,391
doctor: but in the meantime , i really want you to avoid , uh , foods high in sugar . um , and the , the nurse will come in and she'll give you a glucometer and teach you how to do blood sugar testing . okay ? patient: okay .
D2N135
18
[ "Other Treatments" ]
[ "Plan" ]
but in the meantime , i really want you to avoid , uh , foods high in sugar . um , and the , the nurse will come in and she'll give you a glucometer and teach you how to do blood sugar testing . okay ?
3,392
doctor: and then , from an atrial fibrillation standpoint , your heart , even though you're in atrial fibrillation right now , is in a good rate . and we'll just continue you on your metoprolol , 25 milligrams , twice a day . do you need a refill on that ? patient: yes , i do .
D2N135
19
[ "Reassessment", "Discussion", "Medication" ]
[ "Assessment", "Plan" ]
and then , from an atrial fibrillation standpoint , your heart , even though you're in atrial fibrillation right now , is in a good rate . and we'll just continue you on your metoprolol , 25 milligrams , twice a day . do you need a refill on that ?
3,393
doctor: hey , dragon ? order a refill on metoprolol , 25 milligrams , twice a day . and for your reflux , we'll just continue you on the protonix , okay ? patient: okay .
D2N135
20
[ "Medication" ]
[ "Plan" ]
hey , dragon ? order a refill on metoprolol , 25 milligrams , twice a day . and for your reflux , we'll just continue you on the protonix , okay ?
3,394
doctor: do you have any questions , hannah ? patient: no , not at this time .
D2N135
21
[ "Discussion" ]
[ "Plan" ]
do you have any questions , hannah ?
3,395
doctor: okay , so the nurse will come in and she'll go over all that stuff with you . patient: okay .
D2N135
22
[ "Chitchat" ]
[ "Null" ]
okay , so the nurse will come in and she'll go over all that stuff with you .
3,396
doctor: take care . patient: thank you .
D2N135
23
[ "Chitchat" ]
[ "Null" ]
take care .
3,397
doctor: hey , dragon ? finalize the note .
D2N135
24
[ "Chitchat" ]
[ "Null" ]
doctor: hey , dragon ? finalize the note .
3,398
doctor: hi janet , how are you ? patient: good , how are you ?
D2N136
0
[ "Greetings" ]
[ "Subjective" ]
hi janet , how are you ?
3,399