text stringlengths 14 3.73k | encounter_id stringclasses 207
values | text_id int64 0 69 | intents listlengths 1 9 | sections listlengths 1 4 | doc_only stringlengths 6 3.62k | __index_level_0__ int64 0 5.29k |
|---|---|---|---|---|---|---|
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 fe... | 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 compressi... | 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 fract... | 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 th... | 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 ... | 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 mor... | 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... | 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 kn... | 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... | 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... | 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 kn... | 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... | 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 , reall... | 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 ... | 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 ... | 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 wha... | 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... | 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... | 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... | 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 some... | 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... | 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 ab... | 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... | 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'... | 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 ahe... | 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 res... | 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 , o... | 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 |
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