DATEXIS/aci_bench_intent_annotated · Datasets at Hugging Face

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doctor: all right , new patient , jordan roberts . date of birth : 3/2/1972 . he's a 49 year old , uh hm , with hypertension and palpitations . please copy forward his thyroid profile from march 1st , 2021 . hello mr. roberts , how are you doing today ? patient: i'm fine , thank you .	D2N139	0	[ "Acute Symptoms", "Personal History", "Greetings" ]	[ "Subjective" ]	all right , new patient , jordan roberts . date of birth : 3/2/1972 . he's a 49 year old , uh hm , with hypertension and palpitations . please copy forward his thyroid profile from march 1st , 2021 . hello mr. roberts , how are you doing today ?	3,500
doctor: good . good . so , i saw you were recently in the emergency room with high blood pressure and some palpitations . patient: yeah . that was back in march i think , but my girlfriend and i , we talked about it , and on that day i had a few cups of coffee , and no breakfast . so , i think it was probably more of a panic attack than anything else .	D2N139	1	[ "Personal History" ]	[ "Subjective" ]	good . good . so , i saw you were recently in the emergency room with high blood pressure and some palpitations .	3,501
doctor: yeah . have you , uh , have you felt it again since ? patient: uh , no .	D2N139	2	[ "Personal History" ]	[ "Subjective" ]	yeah . have you , uh , have you felt it again since ?	3,502
doctor: okay . uh , so tell me about the blood pressure then . patient: well , i've had issues with my blood pressure since i was young .	D2N139	3	[ "Personal History" ]	[ "Subjective" ]	okay . uh , so tell me about the blood pressure then .	3,503
doctor: do you have a family history of this ? patient: yeah . a lot of my family does have high blood pressure .	D2N139	4	[ "Family History" ]	[ "Subjective" ]	do you have a family history of this ?	3,504
doctor: uh , can you tell me which medications you're taking ? patient: my new med is , uh , a combo med , something 40-25 .	D2N139	6	[ "Therapeutic History" ]	[ "Subjective" ]	uh , can you tell me which medications you're taking ?	3,505
doctor: okay . um . yes , i see that in your chart . the benicar hct . it has hydrochlorothiazide in it . patient: yeah , that's it . my water pill i call it .	D2N139	7	[ "Therapeutic History" ]	[ "Subjective" ]	okay . um . yes , i see that in your chart . the benicar hct . it has hydrochlorothiazide in it .	3,506
doctor: okay . are you still taking the amlodipine , 10 milligrams daily ? patient: uh , yes i am .	D2N139	8	[ "Therapeutic History" ]	[ "Subjective" ]	okay . are you still taking the amlodipine , 10 milligrams daily ?	3,507
doctor: that's- that's a good start on a regimen . are you checking your blood pressure at home , and if yes , what numbers are you seeing ? patient: um , every day .	D2N139	9	[ "Personal History" ]	[ "Subjective" ]	that's- that's a good start on a regimen . are you checking your blood pressure at home , and if yes , what numbers are you seeing ?	3,508
doctor: awesome . patient: yeah . every morning , i take it when i get up , and it's been running at about , uh , 146 to 155 lately .	D2N139	10	[ "Personal History" ]	[ "Subjective" ]	awesome .	3,509
doctor: so you're not down in the 120s yet ? patient: no , not yet . well , we're trying to get there though .	D2N139	11	[ "Personal History" ]	[ "Subjective" ]	so you're not down in the 120s yet ?	3,510
doctor: okay . uh , how are you doing with your salt intake ? patient: i'm trying to back off of it . i think i'm doing good with it , not eating too much .	D2N139	12	[ "Vegetative History" ]	[ "Subjective" ]	okay . uh , how are you doing with your salt intake ?	3,511
doctor: good , uh , it plays a huge part in lowering your pressure and , uh , staying away from salt is important . um , i'll give you some information on the dash eating plan , which is the only eating plan that has been shown to lower blood pressure . patient: sounds good .	D2N139	13	[ "Vegetative History" ]	[ "Subjective" ]	good , uh , it plays a huge part in lowering your pressure and , uh , staying away from salt is important . um , i'll give you some information on the dash eating plan , which is the only eating plan that has been shown to lower blood pressure .	3,512
doctor: are you doing any exercise ? patient: i do try to walk on the treadmill when i can .	D2N139	14	[ "Other Socials" ]	[ "Subjective" ]	are you doing any exercise ?	3,513
doctor: okay , great . um , all right . so , let's take a look . patient: all right .	D2N139	15	[ "Physical Examination" ]	[ "Objective" ]	okay , great . um , all right . so , let's take a look .	3,514
doctor: uh , you're gon na hear me talk throughout your exam , just so i can make sure i get everything documented . patient: okay .	D2N139	16	[ "Chitchat" ]	[ "Null" ]	uh , you're gon na hear me talk throughout your exam , just so i can make sure i get everything documented .	3,515
doctor: so , use my general physical exam template . let me take a listen to you and make sure everything sounds good . patient: all right .	D2N139	17	[ "Chitchat" ]	[ "Null" ]	so , use my general physical exam template . let me take a listen to you and make sure everything sounds good .	3,516
doctor: your heart and lungs sound good , so that's great . patient: good to hear .	D2N139	18	[ "Physical Examination" ]	[ "Objective" ]	your heart and lungs sound good , so that's great .	3,517
doctor: all right . go ahead and lie down . uh , and let me know if anywhere i press hurts . patient: nope . nowhere .	D2N139	19	[ "Physical Examination" ]	[ "Objective" ]	all right . go ahead and lie down . uh , and let me know if anywhere i press hurts .	3,518
doctor: all right . so , i'm gon na take a look at your ankles and feet . i'm just gon na look for some swelling . patient: all right .	D2N139	20	[ "Physical Examination" ]	[ "Objective" ]	all right . so , i'm gon na take a look at your ankles and feet . i'm just gon na look for some swelling .	3,519
doctor: all right . it all looks good . go ahead and sit up . so , in terms of getting that pressure down , you're on three meds that are maxed out and your blood pressure is still not down . and , the question is what do we need to do to get your- to get it down . uh , your potassium one week ago was 4.0 . uh , has it been redone since in the last week ? patient: uh , no .	D2N139	21	[ "Physical Examination" ]	[ "Objective" ]	all right . it all looks good . go ahead and sit up . so , in terms of getting that pressure down , you're on three meds that are maxed out and your blood pressure is still not down . and , the question is what do we need to do to get your- to get it down . uh , your potassium one week ago was 4.0 . uh , has it been redone since in the last week ?	3,520
doctor: okay . uh , four is good for your potassium level , some people have what is called resistant hypertension that is driven by something else in their body , uh , often it is a form , uh , hormonal response . if i were to take 10 people under the age of 50 who have high blood pressure who developed it at a young age , eight out of 10 would respond to reduced salt in their diet with a lower blood pressure . but , for the two out of 10 , there is something else driving it , uh , parathyroid levels or something called your adrenal glands overproduce , um , aldosterone , which we call hyperaldosterone . patient: okay . so , is there something we can do about it ?	D2N139	22	[ "Discussion", "Reassessment" ]	[ "Assessment", "Plan" ]	okay . uh , four is good for your potassium level , some people have what is called resistant hypertension that is driven by something else in their body , uh , often it is a form , uh , hormonal response . if i were to take 10 people under the age of 50 who have high blood pressure who developed it at a young age , eight out of 10 would respond to reduced salt in their diet with a lower blood pressure . but , for the two out of 10 , there is something else driving it , uh , parathyroid levels or something called your adrenal glands overproduce , um , aldosterone , which we call hyperaldosterone .	3,521
doctor: um , in these cases , there's medicine called , uh , spironolactone , that is very effective at dropping the ald- aldosterone level , and your blood pressure , and i think we should give that a try . patient: all right . i mean , i'm willing to give it a try .	D2N139	23	[ "Discussion", "Medication" ]	[ "Plan" ]	um , in these cases , there's medicine called , uh , spironolactone , that is very effective at dropping the ald- aldosterone level , and your blood pressure , and i think we should give that a try .	3,522
doctor: okay . so , let's discuss the piss- the possible risk of , uh , being on hydrochlorothiazide , which is the fluid med that you're now on . and , the spironolactone . one issue is that they can affect your electrolyte balance . um , they can also cause dehydration . so , when ... so , you got ta make sure that you hydrate . if you do not hydrate , and you get dehydrated , you will know it because you will get dizzy standing up . um , second thing is the spironolactone can raise your potassium too far , it's rare , but it can . uh , you're starting with your potassium at four , so that gives us some room . patient: all right . i guess that makes me feel a little bit better .	D2N139	24	[ "Discussion", "Medication", "Other Treatments" ]	[ "Plan" ]	okay . so , let's discuss the piss- the possible risk of , uh , being on hydrochlorothiazide , which is the fluid med that you're now on . and , the spironolactone . one issue is that they can affect your electrolyte balance . um , they can also cause dehydration . so , when ... so , you got ta make sure that you hydrate . if you do not hydrate , and you get dehydrated , you will know it because you will get dizzy standing up . um , second thing is the spironolactone can raise your potassium too far , it's rare , but it can . uh , you're starting with your potassium at four , so that gives us some room .	3,523
doctor: yeah . and then the third thing is that spironolactone combined with hydrocholorozide- chlorothiazide can cause your sodium levels to go down . now , this does not mean- mean that you need to be eating more salt , okay ? but , it does mean that you will need to do blood tests in two weeks to make sure that it's okay . patient: all right . no , that i can do . um , are there any other side effects i need to worry about ?	D2N139	25	[ "Medication", "Diagnostic Testing" ]	[ "Plan" ]	yeah . and then the third thing is that spironolactone combined with hydrocholorozide- chlorothiazide can cause your sodium levels to go down . now , this does not mean- mean that you need to be eating more salt , okay ? but , it does mean that you will need to do blood tests in two weeks to make sure that it's okay .	3,524
doctor: uh , dizziness possibly , as well as , uh , one in 100 guys might develop tenderness in their chest , swollen breasts , or enlarged breasts . this is a rare side effect , um , called gynecomastia , and if it happens , you just cut the medication and you let me know , but it is very uncommon . patient: i'll definitely let you know if that happens .	D2N139	26	[ "Discussion", "Medication" ]	[ "Plan" ]	uh , dizziness possibly , as well as , uh , one in 100 guys might develop tenderness in their chest , swollen breasts , or enlarged breasts . this is a rare side effect , um , called gynecomastia , and if it happens , you just cut the medication and you let me know , but it is very uncommon .	3,525
doctor: okay . uh , we'll keep working at it until your blood pressure gets better . um , it can be tricky when your blood pressure starts to go up at a young age though , it is important to get it under control because it can lead to your heart getting bigger or enlarged . um , same thing that happens when you lift weights and your muscles get bigger , uh , and if your heart pumps against high blood pressure , it can eventually lead to heart failure . patient: i understand .	D2N139	27	[ "Discussion" ]	[ "Plan" ]	okay . uh , we'll keep working at it until your blood pressure gets better . um , it can be tricky when your blood pressure starts to go up at a young age though , it is important to get it under control because it can lead to your heart getting bigger or enlarged . um , same thing that happens when you lift weights and your muscles get bigger , uh , and if your heart pumps against high blood pressure , it can eventually lead to heart failure .	3,526
doctor: yeah , so getting that under control is really important to help prevent kidney failure , strokes , and- and things like that- that you're at high risk for with high blood pressure . patient: okay .	D2N139	28	[ "Discussion" ]	[ "Plan" ]	yeah , so getting that under control is really important to help prevent kidney failure , strokes , and- and things like that- that you're at high risk for with high blood pressure .	3,527
doctor: um , the american heart association has a website called heart.org , it has a lot of really good information about blood pressure to teach- to teach you about it and how to control your diet with exercise . um , if you do your treadmill routinely for 30 minutes or so most days , that could be seven to 10 points off your blood pressure . patient: really ? i did n't realize that .	D2N139	29	[ "Discussion", "Other Treatments" ]	[ "Plan" ]	um , the american heart association has a website called heart.org , it has a lot of really good information about blood pressure to teach- to teach you about it and how to control your diet with exercise . um , if you do your treadmill routinely for 30 minutes or so most days , that could be seven to 10 points off your blood pressure .	3,528
doctor: yeah , yeah . it's very important to be active , lower your salt , and increase your potassium . um , the goal is to keep your salt under 2000 milligrams a day , the actual recommendation is- is 1500 milligrams per day , but most people have a hard time with that . um , so just take a look at the website and the dash diet information . um , that will give you a lot of tips and information to help you start learning about this stuff . patient: okay . i'll definitely check that out .	D2N139	30	[ "Discussion", "Other Treatments" ]	[ "Plan" ]	yeah , yeah . it's very important to be active , lower your salt , and increase your potassium . um , the goal is to keep your salt under 2000 milligrams a day , the actual recommendation is- is 1500 milligrams per day , but most people have a hard time with that . um , so just take a look at the website and the dash diet information . um , that will give you a lot of tips and information to help you start learning about this stuff .	3,529
doctor: all right . so , we'll try the spironolactone and schedule a followup in two weeks to check your blood pressure and electrolytes . uh , if the new med does n't work , the next up is going to be the resistant hypertension clinic . patient: all right .	D2N139	31	[ "Discussion", "Follow-up", "Referral", "Medication" ]	[ "Plan" ]	all right . so , we'll try the spironolactone and schedule a followup in two weeks to check your blood pressure and electrolytes . uh , if the new med does n't work , the next up is going to be the resistant hypertension clinic .	3,530
doctor: all right . so , there they will look into secondary causes of your hypertension . they have access to newer procedure based technologies that can lower your blood pressure without medication , uh , for example , there is something called a renal , uh , denervation , uh , where they go inside the artery that feeds your kidney with almost like a little coil and heat that artery up . when they do that , they can block the nerve endings that get into your kidneys and lower your blood pressure . patient: that's interesting .	D2N139	32	[ "Discussion" ]	[ "Plan" ]	all right . so , there they will look into secondary causes of your hypertension . they have access to newer procedure based technologies that can lower your blood pressure without medication , uh , for example , there is something called a renal , uh , denervation , uh , where they go inside the artery that feeds your kidney with almost like a little coil and heat that artery up . when they do that , they can block the nerve endings that get into your kidneys and lower your blood pressure .	3,531
doctor: yeah . so , that procedure has been shown to lower blood pressure by 10 points . um , there are of course some risks , so not everyone is a candidate . uh , but we'll cross that road , uh , when we need to , and let's just- let's just see how you do with the addition of the medication . patient: sounds good to me .	D2N139	33	[ "Discussion" ]	[ "Plan" ]	yeah . so , that procedure has been shown to lower blood pressure by 10 points . um , there are of course some risks , so not everyone is a candidate . uh , but we'll cross that road , uh , when we need to , and let's just- let's just see how you do with the addition of the medication .	3,532
doctor: all right . so , we will see you in two weeks then . patient: sounds good . thanks doc .	D2N139	34	[ "Follow-up" ]	[ "Plan" ]	all right . so , we will see you in two weeks then .	3,533
doctor: yeah , you're welcome . let me know if you have any questions . patient: will do .	D2N139	35	[ "Discussion" ]	[ "Plan" ]	yeah , you're welcome . let me know if you have any questions .	3,534
doctor: all right . have a great day mr. roberts . patient: you too .	D2N139	36	[ "Chitchat" ]	[ "Null" ]	all right . have a great day mr. roberts .	3,535
doctor: mr. roberts presents with resistant hypertension . he's on three meds and maximum dose . i have added spironolactone to his regiment . we will need to monitor his potassium and sodium . he will have a metabolic panel and blood pressure check in two weeks . uh , next medication would be carvedilol , uh , which i try to avoid giving , it's potential for erectile dysfunction . i have talked to the patient about that , and the potential side effects of spironolactone , including the gynecomastia and electrolyte disturbances . if he is not controlled on spironolactone , the next step would be sending him to resistant hypertension clinic .	D2N139	37	[ "Acute Assessment", "Medication", "Diagnostic Testing", "Follow-up", "Discussion" ]	[ "Assessment", "Plan" ]	doctor: mr. roberts presents with resistant hypertension . he's on three meds and maximum dose . i have added spironolactone to his regiment . we will need to monitor his potassium and sodium . he will have a metabolic panel and blood pressure check in two weeks . uh , next medication would be carvedilol , uh , which i try to avoid giving , it's potential for erectile dysfunction . i have talked to the patient about that , and the potential side effects of spironolactone , including the gynecomastia and electrolyte disturbances . if he is not controlled on spironolactone , the next step would be sending him to resistant hypertension clinic .	3,536
doctor: brittany edwards , 07 , 1898 . she is a return visit for ibs with functional abdominal pain , nausea , vomiting . ms. edwards is a pleasant , 32-year-old female who was last seen in august of 2019 with flares of abdominal pain , who was diagnosed with irritable bowl that was treated with bentyl . she had a previous prescription for reglan that she received from the emergency room that she used as needed for nausea . she was instructed to start a low dose fiber supplement , such as citrucel , daily , probiotics to help with gas and bloating , bentyl up to four times daily for intestinal cramping , and stop reglan and use zofran as needed . neuromodulators such as elavil and buspar were discussed but not started . hello , how are you ? patient: i'm okay .	D2N140	0	[ "Personal History", "Greetings" ]	[ "Subjective" ]	brittany edwards , 07 , 1898 . she is a return visit for ibs with functional abdominal pain , nausea , vomiting . ms. edwards is a pleasant , 32-year-old female who was last seen in august of 2019 with flares of abdominal pain , who was diagnosed with irritable bowl that was treated with bentyl . she had a previous prescription for reglan that she received from the emergency room that she used as needed for nausea . she was instructed to start a low dose fiber supplement , such as citrucel , daily , probiotics to help with gas and bloating , bentyl up to four times daily for intestinal cramping , and stop reglan and use zofran as needed . neuromodulators such as elavil and buspar were discussed but not started . hello , how are you ?	3,537
doctor: good . how have you been feeling ? patient: not so good .	D2N140	1	[ "Acute Symptoms" ]	[ "Subjective" ]	good . how have you been feeling ?	3,538
doctor: yeah , so my nurse told me you have been going out to eat some on friday nights and saturday nights and that you have had some spicy foods or spicy shrimp . patient: yeah , i have .	D2N140	2	[ "Acute Symptoms" ]	[ "Subjective" ]	yeah , so my nurse told me you have been going out to eat some on friday nights and saturday nights and that you have had some spicy foods or spicy shrimp .	3,539
doctor: okay . well , your gut probably does not always appreciate that . patient: no , it does n't like it at all .	D2N140	3	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . well , your gut probably does not always appreciate that .	3,540
doctor: yeah , so ibs is one of those things where you are very sensitive to certain things such as spicy foods or fatty foods and alcohol . and this can cause lower belly stuff like cramps , or you can get upper belly stuff such as nausea . patient: i've been getting both .	D2N140	4	[ "Acute Symptoms", "Drug History" ]	[ "Subjective" ]	yeah , so ibs is one of those things where you are very sensitive to certain things such as spicy foods or fatty foods and alcohol . and this can cause lower belly stuff like cramps , or you can get upper belly stuff such as nausea .	3,541
doctor: okay . um , so how frequently have you been getting or having a bowel movement on normal days ? patient: i'm starting to notice it's between two and three times a day .	D2N140	5	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . um , so how frequently have you been getting or having a bowel movement on normal days ?	3,542
doctor: okay . and are they soft stools or formed stools ? patient: um , they're formed .	D2N140	6	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . and are they soft stools or formed stools ?	3,543
doctor: okay . and after you have gone out either drinking with your friends , do you tend to have more diarrhea ? patient: yeah , i do .	D2N140	7	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . and after you have gone out either drinking with your friends , do you tend to have more diarrhea ?	3,544
doctor: okay . do you feel it's the food or the alcohol or both ? patient: uh , well usually we go to friday's restaurant . i always eat pasta , the chicken alfredo .	D2N140	8	[ "Acute Symptoms", "Drug History" ]	[ "Subjective" ]	okay . do you feel it's the food or the alcohol or both ?	3,545
doctor: okay . i can s- i can bet it's the alfredo sauce . patient: but it normally does n't bother me .	D2N140	9	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . i can s- i can bet it's the alfredo sauce .	3,546
doctor: okay . well , pasta can make you bloated , uh , but it does n't usually cause diarrhea . grilled chi- uh , grilled chicken is usually all right . alfredo , though , is higher in fat , and it does contain dairy . but you're saying it usually does n't bother you ? patient: no .	D2N140	10	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . well , pasta can make you bloated , uh , but it does n't usually cause diarrhea . grilled chi- uh , grilled chicken is usually all right . alfredo , though , is higher in fat , and it does contain dairy . but you're saying it usually does n't bother you ?	3,547
doctor: okay . what type of alcohol drink do you drink when you are there ? is it a sweet drink ? patient: most of the time it's either tequila or dark liquor . i prefer patron , but if i get brown liquor , i only get two . um , every now and again , i'll drink a martini .sometimes it's the mixer they tend to put in the drinks , but it can be a variety of things .	D2N140	11	[ "Drug History" ]	[ "Subjective" ]	okay . what type of alcohol drink do you drink when you are there ? is it a sweet drink ?	3,548
doctor: um , so when you're not eating out or drinking , what we do on a daily basis does help keep us regular , so when it does flare up , it c- it might not be as bad . um , have you had any luck using the fiber like citrucel regularly ? patient: um , no . i guess i need to find a new drink .	D2N140	12	[ "Acute Symptoms" ]	[ "Subjective" ]	um , so when you're not eating out or drinking , what we do on a daily basis does help keep us regular , so when it does flare up , it c- it might not be as bad . um , have you had any luck using the fiber like citrucel regularly ?	3,549
doctor: okay . and how is it during the week ? patient: like what i eat ?	D2N140	13	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . and how is it during the week ?	3,550
doctor: yeah , and with the diarrhea and abdomal- um , abdominal pain . patient: right now , i'm still having the cramping and sharp pains , so i've been avoiding heavy foods . i did have some fried chicken today , though .	D2N140	14	[ "Acute Symptoms" ]	[ "Subjective" ]	yeah , and with the diarrhea and abdomal- um , abdominal pain .	3,551
doctor: and was everything all right after that ? patient: yeah , for the most part .	D2N140	15	[ "Acute Symptoms" ]	[ "Subjective" ]	and was everything all right after that ?	3,552
doctor: okay . remember , it's also the portion sizes . so i mean , if you eat a little and you feel fine , then that's okay . you have to just really watch the portions . patient: okay , good . i ca n't go out- go without some fried chicken at least once in a while .	D2N140	16	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . remember , it's also the portion sizes . so i mean , if you eat a little and you feel fine , then that's okay . you have to just really watch the portions .	3,553
doctor: sounds good . all right , well let's take a look at you today , and we'll do a brief physical exam . you will hear me call out some findings . i will answer any questions , and we will discuss once we have finished the exam . patient: sounds good .	D2N140	17	[ "Physical Examination" ]	[ "Objective" ]	sounds good . all right , well let's take a look at you today , and we'll do a brief physical exam . you will hear me call out some findings . i will answer any questions , and we will discuss once we have finished the exam .	3,554
doctor: all right . so the patient is alert and cooperative , appears stated age . all right . i'm going to listen to your heart and lungs . and lungs are clear to auscultation bilaterally . heart regular rate and rhythm . all right , so if you could just lay back for me , and i'll examine your abdomen . patient: okay .	D2N140	18	[ "Physical Examination" ]	[ "Objective" ]	all right . so the patient is alert and cooperative , appears stated age . all right . i'm going to listen to your heart and lungs . and lungs are clear to auscultation bilaterally . heart regular rate and rhythm . all right , so if you could just lay back for me , and i'll examine your abdomen .	3,555
doctor: all right . do you have any tenderness ? patient: no , not really .	D2N140	19	[ "Physical Examination" ]	[ "Objective" ]	all right . do you have any tenderness ?	3,556
doctor: okay . so the abdomen is soft , non-tender . no masses or organomegaly . and let me take a listen . normal active bowel sounds . all right . you can go ahead and sit up now . thank you . all right , so first i want you to try citrucel . it does come in a tablet . you should use it twice daily for regularity . then i would say , if you know you're going out and will possibly have diarrhea as a result , you can go ahead and use your bentyl 20 milligrams . you can do one tablet before you eat , and then repeat up to four times daily . and then on days when you feel good , you do n't have to use anything . um , and then on friday before you leave the house , you can take a bentyl and put one in your pocket for later , and then you can repeat the same thing on saturday if you want , and that will be totally fine . patient: okay , that sounds good .	D2N140	20	[ "Discussion", "Acute Assessment", "Medication" ]	[ "Assessment", "Plan" ]	okay . so the abdomen is soft , non-tender . no masses or organomegaly . and let me take a listen . normal active bowel sounds . all right . you can go ahead and sit up now . thank you . all right , so first i want you to try citrucel . it does come in a tablet . you should use it twice daily for regularity . then i would say , if you know you're going out and will possibly have diarrhea as a result , you can go ahead and use your bentyl 20 milligrams . you can do one tablet before you eat , and then repeat up to four times daily . and then on days when you feel good , you do n't have to use anything . um , and then on friday before you leave the house , you can take a bentyl and put one in your pocket for later , and then you can repeat the same thing on saturday if you want , and that will be totally fine .	3,557
doctor: okay . and so your bentyl , that's the anti-spasm medication , and i would take the higher dose . patient: can i get a refill of that ?	D2N140	21	[ "Discussion", "Medication" ]	[ "Plan" ]	okay . and so your bentyl , that's the anti-spasm medication , and i would take the higher dose .	3,558
doctor: yes , absolutely . uh , so take one tablet about 30 to 45 minutes before leaving the house and then the second tablet at the restaurant . then with the nausea , um , i think we should try and see if you can recognize a pattern with what you are eating and drinking , um , um , about , like , what makes it worse . patient: yeah , i noticed i've been doing better with drinking water instead of sodas .	D2N140	22	[ "Discussion", "Other Treatments", "Medication" ]	[ "Plan" ]	yes , absolutely . uh , so take one tablet about 30 to 45 minutes before leaving the house and then the second tablet at the restaurant . then with the nausea , um , i think we should try and see if you can recognize a pattern with what you are eating and drinking , um , um , about , like , what makes it worse .	3,559
doctor: okay , good . and then for your zofran , i would n't take that ahead of time . just plan on drinking plenty of water . patient: okay .	D2N140	23	[ "Discussion", "Other Treatments", "Medication" ]	[ "Plan" ]	okay , good . and then for your zofran , i would n't take that ahead of time . just plan on drinking plenty of water .	3,560
doctor: okay , and you can take it , but before you do , we want to try to reduce the triggers . uh , so watch out for greasy or fatty foods and sugary drinks . patient: okay , i can do that .	D2N140	24	[ "Discussion", "Other Treatments", "Medication" ]	[ "Plan" ]	okay , and you can take it , but before you do , we want to try to reduce the triggers . uh , so watch out for greasy or fatty foods and sugary drinks .	3,561
doctor: okay . and so , however , if it is not just these isolated inci- incidents and the symptoms are happening all the time , we could put you on a long term medication that would take ... that you would take every night . and so then you do n't have to use so much bentyl or the zofran . how do you feel about that ? patient: i was actually going to ask you about something like that to help avoid flares altogether .	D2N140	25	[ "Discussion", "Medication" ]	[ "Plan" ]	okay . and so , however , if it is not just these isolated inci- incidents and the symptoms are happening all the time , we could put you on a long term medication that would take ... that you would take every night . and so then you do n't have to use so much bentyl or the zofran . how do you feel about that ?	3,562
doctor: yeah , there is . and it actually works on the chemicals in your brain that are causing your gut to be overly sensitive . one is called elavil , but the only drawback is that it can make you a little sleepy . how does that sound ? patient: that sounds like a much better plan .	D2N140	26	[ "Discussion", "Medication" ]	[ "Plan" ]	yeah , there is . and it actually works on the chemicals in your brain that are causing your gut to be overly sensitive . one is called elavil , but the only drawback is that it can make you a little sleepy . how does that sound ?	3,563
doctor: okay , great . we can definitely do that . uh , just take it every night before bedtime . patient: okay , that sounds good . thank you so much .	D2N140	27	[ "Discussion" ]	[ "Plan" ]	okay , great . we can definitely do that . uh , just take it every night before bedtime .	3,564
doctor: you're welcome . and so i have gone ahead and sent your prescriptions to your pharmacy . just give us a call if you have any questions or need us for anything else . and then let's plan on touching base through mychart email in about a month to just check in to see how you're doing with symptoms . okay ? patient: okay , that sounds good . thank you .	D2N140	28	[ "Discussion", "Follow-up" ]	[ "Plan" ]	you're welcome . and so i have gone ahead and sent your prescriptions to your pharmacy . just give us a call if you have any questions or need us for anything else . and then let's plan on touching base through mychart email in about a month to just check in to see how you're doing with symptoms . okay ?	3,565
doctor: you're welcome , and have a good rest of your day . so review of symptoms is positive for diarrhea , nausea , and abdominal pain . assessment and plan . brittany edwards is a pleasant female with ibs and functional abdominal pain , aggravated by high stress , poor eating habits , and poor sleeping habits . i've encouraged dietary and lifestyle modifications , as well as starting a neuromodulator such as elavil 25 milligrams at bedtime for ibs . she can use bentyl 20 milligrams as needed 30 to 45 minutes prior to eating out at a restaurant . she can also use zofran if needed . however , i have encouraged her to reduce greasy and fatty foods and alcohol consumption . i have asked her to follow up in one month by emailing over mychart regarding any side effects and issues , or issues with elavil or if adjustments are needed .	D2N140	29	[ "Vegetative History", "Personal History", "Medication", "Other Treatments", "Reassessment", "Follow-up" ]	[ "Subjective", "Assessment", "Plan" ]	doctor: you're welcome , and have a good rest of your day . so review of symptoms is positive for diarrhea , nausea , and abdominal pain . assessment and plan . brittany edwards is a pleasant female with ibs and functional abdominal pain , aggravated by high stress , poor eating habits , and poor sleeping habits . i've encouraged dietary and lifestyle modifications , as well as starting a neuromodulator such as elavil 25 milligrams at bedtime for ibs . she can use bentyl 20 milligrams as needed 30 to 45 minutes prior to eating out at a restaurant . she can also use zofran if needed . however , i have encouraged her to reduce greasy and fatty foods and alcohol consumption . i have asked her to follow up in one month by emailing over mychart regarding any side effects and issues , or issues with elavil or if adjustments are needed .	3,566
doctor: okay , so our next patient is christopher watson . date of birth 04/12/1934 . mr . watson is- is an 86-year-old male who returns in follow-up for adult hydrocephalus . this is his first visit since undergoing sh- shunt surgery , excuse me , on august 1st , 2020 . i have followed mr . watson since may of 2020 when he first presented with eight to ten years of progressive gait impairment , cognitive impairment , and decreased bladder control . we established a diagnosis of adult hydrocephalus with a spino catheter protocol in june 2020 , and he underwent shunt surgery on august 1st , 2020 . a medtronic strata programmable shunt in the ventricular peritoneal configuration was programmed at a level 2.0 was placed . good morning , mr . watson , who is the nice lady you have with you today ? patient: hi , doc . this is my daughter , theresa . she is the one who helps me keep things straight .	D2N141	0	[ "Personal History", "Greetings" ]	[ "Subjective" ]	okay , so our next patient is christopher watson . date of birth 04/12/1934 . mr . watson is- is an 86-year-old male who returns in follow-up for adult hydrocephalus . this is his first visit since undergoing sh- shunt surgery , excuse me , on august 1st , 2020 . i have followed mr . watson since may of 2020 when he first presented with eight to ten years of progressive gait impairment , cognitive impairment , and decreased bladder control . we established a diagnosis of adult hydrocephalus with a spino catheter protocol in june 2020 , and he underwent shunt surgery on august 1st , 2020 . a medtronic strata programmable shunt in the ventricular peritoneal configuration was programmed at a level 2.0 was placed . good morning , mr . watson , who is the nice lady you have with you today ?	3,567
doctor: mr . watson , have you been sick or been hosp -- hospitalized since your shu- shunt surgery three months ago . patient: uh , not that i recall . patient_guest: no , he has n't . he has been doing much better .	D2N141	1	[ "Acute Symptoms" ]	[ "Subjective" ]	mr . watson , have you been sick or been hosp -- hospitalized since your shu- shunt surgery three months ago .	3,568
doctor: good , i'm glad to hear that . before surgery , you were having some progressive problems that affected your walking , thinking , and bladder control . are these symptoms better , worse , or unchanged ? patient_guest: his walking has improved . he's now able to walk to the dining room just fine . but he could not do that before surgery . he still has times where i have to help him .	D2N141	2	[ "Acute Symptoms" ]	[ "Subjective" ]	good , i'm glad to hear that . before surgery , you were having some progressive problems that affected your walking , thinking , and bladder control . are these symptoms better , worse , or unchanged ?	3,569
doctor: that's impressive , mr . watson . patient: yeah , i guess . patient_guest: now his bladder control did improve some after surgery , but now seems to have leveled out . so he is wearing diapers .	D2N141	3	[ "Acute Symptoms" ]	[ "Subjective" ]	that's impressive , mr . watson .	3,570
doctor: no issues with sores from wearing the diaper ? and any decreased or painful urination ? patient_guest: no , not at all .	D2N141	4	[ "Personal History", "Vegetative History" ]	[ "Subjective" ]	no issues with sores from wearing the diaper ? and any decreased or painful urination ?	3,571
doctor: and how about cognition ? patient: i think i'm better . i do n't feel lost when talking to someone anymore . patient_guest: dad and i both think my sister , hannah , summarized it best . she said " i feel like i can have a normal conversation with him again , "	D2N141	5	[ "Personal History" ]	[ "Subjective" ]	and how about cognition ?	3,572
doctor: that's so wonderful ! now have you had any headaches or pain where the shunt is ? patient: no . has n't bothered me one bit .	D2N141	6	[ "Personal History" ]	[ "Subjective" ]	that's so wonderful ! now have you had any headaches or pain where the shunt is ?	3,573
doctor: okay . and any pain in your belly at all ? patient: ca n't say that i have .	D2N141	7	[ "Personal History" ]	[ "Subjective" ]	okay . and any pain in your belly at all ?	3,574
doctor: okay , sounds like you have been improving . alrighty , mr . watson , i'm going to step out of the room while my resident comes in to do a few tests for me . is that all right ? patient: sounds good .	D2N141	8	[ "Personal History" ]	[ "Subjective" ]	okay , sounds like you have been improving . alrighty , mr . watson , i'm going to step out of the room while my resident comes in to do a few tests for me . is that all right ?	3,575
doctor: okay , i'm going to go out and review the ct scan you had last month , and then we'll chat about it when i come in . all righty , mr . watson , so you definitely have made some improvements since the shunt surgery . now on ct scan though i do believe i see a tiny bit of blood fluid collection in the right parietal region . now , i do n't believe that that's causing any symptoms , and i , it actually was n't documented by the radiologist when he read the ct scan . patient: so what does that mean ?	D2N141	9	[ "Radiology Examination" ]	[ "Objective" ]	okay , i'm going to go out and review the ct scan you had last month , and then we'll chat about it when i come in . all righty , mr . watson , so you definitely have made some improvements since the shunt surgery . now on ct scan though i do believe i see a tiny bit of blood fluid collection in the right parietal region . now , i do n't believe that that's causing any symptoms , and i , it actually was n't documented by the radiologist when he read the ct scan .	3,576
doctor: just that i would like to leave the shunt set for another two to three months before we go in changing it . like i said , if you're not having any headaches or pain and you have improved so that's all good for me . so really there's , there's nothing to worry about . patient: all right so i'll come back in three months ?	D2N141	10	[ "Discussion" ]	[ "Plan" ]	just that i would like to leave the shunt set for another two to three months before we go in changing it . like i said , if you're not having any headaches or pain and you have improved so that's all good for me . so really there's , there's nothing to worry about .	3,577
doctor: yep , that's right . patient: i do have a question for you though .	D2N141	11	[ "Discussion" ]	[ "Plan" ]	yep , that's right .	3,578
doctor: yeah , of course . patient: do you think i will be able to drive again ?	D2N141	12	[ "Discussion" ]	[ "Plan" ]	yeah , of course .	3,579
doctor: ah man , mr . watson , i knew you were gon na ask me that one . i think at this point it's unlikely that your movement speed will improve to the level that would be needed for you to pass the driver safety evaluation . now , i will say that i do occasionally have patients who surprise me by improving over a nine to 12 month range . and that , that definitely could be you . you could definitely pass it at that point . so if you improve and we can continue to talk about that then , ya know , i think it could be possible , um , and i'd be happy to recommend it . now , you could definitely also enroll in a driver safety program without my recommendation . so you could kind of do that preemptively , and then we could continue to watch for your improvement as we go . patient: okay . i kinda figured that anyway but i just thought i'd ask . i do n't like to burden anyone when i just need to run to the store but i also know that i need to be safe .	D2N141	13	[ "Discussion" ]	[ "Plan" ]	ah man , mr . watson , i knew you were gon na ask me that one . i think at this point it's unlikely that your movement speed will improve to the level that would be needed for you to pass the driver safety evaluation . now , i will say that i do occasionally have patients who surprise me by improving over a nine to 12 month range . and that , that definitely could be you . you could definitely pass it at that point . so if you improve and we can continue to talk about that then , ya know , i think it could be possible , um , and i'd be happy to recommend it . now , you could definitely also enroll in a driver safety program without my recommendation . so you could kind of do that preemptively , and then we could continue to watch for your improvement as we go .	3,580
doctor: yeah , your safety is our number one priority and , ya know , i'm sure your daughters do n't mind as much , right , they want to keep you here and have you safe . but , i overall am very pleased with how much you have improved . and so , i'm sure when we talk again in three months , we'll continue to be on that upward trajectory or improvement . patient: i sure hope so , doc . patient_guest: we really appreciate all that you've done . do we make the appointment out front ?	D2N141	14	[ "Discussion", "Follow-up" ]	[ "Plan" ]	yeah , your safety is our number one priority and , ya know , i'm sure your daughters do n't mind as much , right , they want to keep you here and have you safe . but , i overall am very pleased with how much you have improved . and so , i'm sure when we talk again in three months , we'll continue to be on that upward trajectory or improvement .	3,581
doctor: yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ? patient: thanks patient_guest: thank you .	D2N141	15	[ "Chitchat" ]	[ "Null" ]	yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ?	3,582
doctor: all righty , so ros is constitutional significant for impaired ability to carry out daily functions . negative for fever or unintentional weight loss . gu is significant for urinary incontinence and wearing a diaper . negative for genital sores , decreased or painful output . neurological significant for continued walking impairment and cognitive impairment . negative for headaches , recent falls , or hallucinations . psychiatric is negative for depression , excessive worrying , or mood swings . let's go ahead and use the short pe . vitals , let's see , blood pressure is 124/80 , heart rate 64 , respirations 18 , weight 174 pounds , and pain zero out of 10 . mr . watson is a pleasant and cooperative man who's able to converse easily through , um , though his daughter does add some details . the shunt sight was clean , dry , and intact with a confirmed setting of two . um he was tested um for recent and remote memory , attention span , and concentration in fund of knowledge . he scored a 26 out of 30 on the mmse when tested with spelling and 25 out of 30 when tested with calculations . of note , he was able to get two of the three memory words with cuing , and the third with multiple choice . this was a slight improvement over his initial score of 23 out of 30 with calculations and 24 out of 30 with spelling . and at the time he was unable um in the previous test , excuse me , he was unable to remember any memory words with cuing without and only one with multiple choice . gait testing using the tinetti assessment tool . he was tested without an assistive device and received a gait score of six to eight out of 12 and a balance score of 12 out of 16 for a total score of 18 to 20 out of 28 . this is slightly improved from his initial score of 15 to 17 out of 28 . cranial nerves , pupils are equal . eoms are intact . face symmetric . no disarchria . motor normal for bulk and strength . coordination slow from no- finger to nose . of note , the ct scan from the head of 10/15/2020 shows a frontal horn span at the level of foramen of monro of 4.6 centimeters with a third ventricular contour that is flat with a span of 10 millimeters . by my reading there is a tiny amount of blood in the right front region with a tiny subdermal collection . this was not noticed or noted by the radiologist who stated any extra axial fluid collections . there is also substantial small vessel ischemic change . diagnosis adult hydrocephalus , gait impairment , urinary incontinence and urgency , and cognitive impairment .	D2N141	16	[ "Personal History", "Vegetative History", "Physical Examination", "Radiology Examination", "Reassessment", "Lab Examination" ]	[ "Subjective", "Objective", "Assessment" ]	doctor: all righty , so ros is constitutional significant for impaired ability to carry out daily functions . negative for fever or unintentional weight loss . gu is significant for urinary incontinence and wearing a diaper . negative for genital sores , decreased or painful output . neurological significant for continued walking impairment and cognitive impairment . negative for headaches , recent falls , or hallucinations . psychiatric is negative for depression , excessive worrying , or mood swings . let's go ahead and use the short pe . vitals , let's see , blood pressure is 124/80 , heart rate 64 , respirations 18 , weight 174 pounds , and pain zero out of 10 . mr . watson is a pleasant and cooperative man who's able to converse easily through , um , though his daughter does add some details . the shunt sight was clean , dry , and intact with a confirmed setting of two . um he was tested um for recent and remote memory , attention span , and concentration in fund of knowledge . he scored a 26 out of 30 on the mmse when tested with spelling and 25 out of 30 when tested with calculations . of note , he was able to get two of the three memory words with cuing , and the third with multiple choice . this was a slight improvement over his initial score of 23 out of 30 with calculations and 24 out of 30 with spelling . and at the time he was unable um in the previous test , excuse me , he was unable to remember any memory words with cuing without and only one with multiple choice . gait testing using the tinetti assessment tool . he was tested without an assistive device and received a gait score of six to eight out of 12 and a balance score of 12 out of 16 for a total score of 18 to 20 out of 28 . this is slightly improved from his initial score of 15 to 17 out of 28 . cranial nerves , pupils are equal . eoms are intact . face symmetric . no disarchria . motor normal for bulk and strength . coordination slow from no- finger to nose . of note , the ct scan from the head of 10/15/2020 shows a frontal horn span at the level of foramen of monro of 4.6 centimeters with a third ventricular contour that is flat with a span of 10 millimeters . by my reading there is a tiny amount of blood in the right front region with a tiny subdermal collection . this was not noticed or noted by the radiologist who stated any extra axial fluid collections . there is also substantial small vessel ischemic change . diagnosis adult hydrocephalus , gait impairment , urinary incontinence and urgency , and cognitive impairment .	3,583
doctor: amanda taylor , birth date october 31st 1949 . patient is a 72 year old woman who comes for followup for hypertension . her history includes significant alcohol use disorder and mi- mild hypercholesterolemia . at last visit on april 16th her blood pressure was 130 over 90 . after presenting at 150 over 100 she was prescribed hydrochlorothiazide 12.5 milligrams by mouth once daily , and lisinopril 20 milligrams by mouth once daily . cmp and cbc were essentially unremarkable . hi miss taylor , how are you today ? patient: hi , i'm- i'm good , thank you .	D2N142	0	[ "Greetings", "Therapeutic History", "Drug History" ]	[ "Subjective" ]	amanda taylor , birth date october 31st 1949 . patient is a 72 year old woman who comes for followup for hypertension . her history includes significant alcohol use disorder and mi- mild hypercholesterolemia . at last visit on april 16th her blood pressure was 130 over 90 . after presenting at 150 over 100 she was prescribed hydrochlorothiazide 12.5 milligrams by mouth once daily , and lisinopril 20 milligrams by mouth once daily . cmp and cbc were essentially unremarkable . hi miss taylor , how are you today ?	3,584
doctor: thanks for coming in today . patient: yeah , no problem .	D2N142	1	[ "Chitchat" ]	[ "Null" ]	thanks for coming in today .	3,585
doctor: so how have things been going for you ? patient: uh , they've been all right . i'm struggling with not drinking . i wanted to discuss that , uh , shot that you had mentioned last time , but we did n't get to discuss it too much .	D2N142	2	[ "Acute Symptoms" ]	[ "Subjective" ]	so how have things been going for you ?	3,586
doctor: okay , well i'll be happy to provide you with more information . so tell me when did you last have a drink ? patient: on monday .	D2N142	3	[ "Vegetative History" ]	[ "Subjective" ]	okay , well i'll be happy to provide you with more information . so tell me when did you last have a drink ?	3,587
doctor: okay , so you've gone a couple days without it ? patient: yeah , yeah i have .	D2N142	4	[ "Vegetative History" ]	[ "Subjective" ]	okay , so you've gone a couple days without it ?	3,588
doctor: yeah , and had you been drinking for a while ? patient: yep .	D2N142	5	[ "Vegetative History" ]	[ "Subjective" ]	yeah , and had you been drinking for a while ?	3,589
doctor: how much had- how much had you been drinking ? patient: um , four or five times a week hard alcohol , so , you know .	D2N142	6	[ "Drug History" ]	[ "Subjective" ]	how much had- how much had you been drinking ?	3,590
doctor: okay . well it will certainly help your blood pressure if you're able to stop drinking . patient: yeah , yeah i- i- i agree with you .	D2N142	7	[ "Vegetative History" ]	[ "Subjective" ]	okay . well it will certainly help your blood pressure if you're able to stop drinking .	3,591
doctor: okay . are you taking your blood pressure medications ? patient: yeah , but i'm only taking half of the lisinopril .	D2N142	8	[ "Therapeutic History" ]	[ "Subjective" ]	okay . are you taking your blood pressure medications ?	3,592
doctor: and are you also taking the full dose of the hydrochlorothiazide ? do you have any , um , chest tightness or pressure or any shortness of breath ? patient: yeah i'm taking the full dose of that medicine too , and no none of those symptoms .	D2N142	10	[ "Therapeutic History", "Vegetative History" ]	[ "Subjective" ]	and are you also taking the full dose of the hydrochlorothiazide ? do you have any , um , chest tightness or pressure or any shortness of breath ?	3,593
doctor: okay . anything else i should be aware of or that we should be checking ? patient: mm , no .	D2N142	11	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . anything else i should be aware of or that we should be checking ?	3,594
doctor: okay , good . are you doing the blood pressure checks at home ? patient: yes . yes i am .	D2N142	12	[ "Personal History" ]	[ "Subjective" ]	okay , good . are you doing the blood pressure checks at home ?	3,595
doctor: okay good . what kind of numbers are you seeing ? patient: well , in the morning i'm seeing lower numbers than in the evening , um , where i run anywhere from like 130 to 145 or 150 over 95 to 100 on the bottom .	D2N142	13	[ "Personal History" ]	[ "Subjective" ]	okay good . what kind of numbers are you seeing ?	3,596
doctor: yeah , so it sounds like we are not too far out of where we wan na be . patient: right , mm-hmm .	D2N142	16	[ "Personal History" ]	[ "Subjective" ]	yeah , so it sounds like we are not too far out of where we wan na be .	3,597
doctor: okay . well let me get a listen to your heart , go ahead and hop up here . patient: okay .	D2N142	17	[ "Physical Examination" ]	[ "Objective" ]	okay . well let me get a listen to your heart , go ahead and hop up here .	3,598
doctor: use my general exam template . all right , go ahead and take some deep breaths . okay , good . any fever , cough , shortness of breath or sore throat ? patient: no .	D2N142	18	[ "Physical Examination", "Vegetative History" ]	[ "Subjective", "Objective" ]	use my general exam template . all right , go ahead and take some deep breaths . okay , good . any fever , cough , shortness of breath or sore throat ?	3,599

doctor: all right , new patient , jordan roberts . date of birth : 3/2/1972 . he's a 49 year old , uh hm , with hypertension and palpitations . please copy forward his thyroid profile from march 1st , 2021 . hello mr. roberts , how are you doing today ? patient: i'm fine , thank you .

D2N139

0

[ "Acute Symptoms", "Personal History", "Greetings" ]

[ "Subjective" ]

all right , new patient , jordan roberts . date of birth : 3/2/1972 . he's a 49 year old , uh hm , with hypertension and palpitations . please copy forward his thyroid profile from march 1st , 2021 . hello mr. roberts , how are you doing today ?

3,500

doctor: good . good . so , i saw you were recently in the emergency room with high blood pressure and some palpitations . patient: yeah . that was back in march i think , but my girlfriend and i , we talked about it , and on that day i had a few cups of coffee , and no breakfast . so , i think it was probably more of a panic attack than anything else .

D2N139

1

[ "Personal History" ]

[ "Subjective" ]

good . good . so , i saw you were recently in the emergency room with high blood pressure and some palpitations .

3,501

doctor: yeah . have you , uh , have you felt it again since ? patient: uh , no .

D2N139

2

[ "Personal History" ]

[ "Subjective" ]

yeah . have you , uh , have you felt it again since ?

3,502

doctor: okay . uh , so tell me about the blood pressure then . patient: well , i've had issues with my blood pressure since i was young .

D2N139

3

[ "Personal History" ]

[ "Subjective" ]

okay . uh , so tell me about the blood pressure then .

3,503

doctor: do you have a family history of this ? patient: yeah . a lot of my family does have high blood pressure .

D2N139

4

[ "Family History" ]

[ "Subjective" ]

do you have a family history of this ?

3,504

doctor: uh , can you tell me which medications you're taking ? patient: my new med is , uh , a combo med , something 40-25 .

D2N139

6

[ "Therapeutic History" ]

[ "Subjective" ]

uh , can you tell me which medications you're taking ?

3,505

doctor: okay . um . yes , i see that in your chart . the benicar hct . it has hydrochlorothiazide in it . patient: yeah , that's it . my water pill i call it .

D2N139

7

[ "Therapeutic History" ]

[ "Subjective" ]

okay . um . yes , i see that in your chart . the benicar hct . it has hydrochlorothiazide in it .

3,506

doctor: okay . are you still taking the amlodipine , 10 milligrams daily ? patient: uh , yes i am .

D2N139

8

[ "Therapeutic History" ]

[ "Subjective" ]

okay . are you still taking the amlodipine , 10 milligrams daily ?

3,507

doctor: that's- that's a good start on a regimen . are you checking your blood pressure at home , and if yes , what numbers are you seeing ? patient: um , every day .

D2N139

9

[ "Personal History" ]

[ "Subjective" ]

that's- that's a good start on a regimen . are you checking your blood pressure at home , and if yes , what numbers are you seeing ?

3,508

doctor: awesome . patient: yeah . every morning , i take it when i get up , and it's been running at about , uh , 146 to 155 lately .

D2N139

10

[ "Personal History" ]

[ "Subjective" ]

awesome .

3,509

doctor: so you're not down in the 120s yet ? patient: no , not yet . well , we're trying to get there though .

D2N139

11

[ "Personal History" ]

[ "Subjective" ]

so you're not down in the 120s yet ?

3,510

doctor: okay . uh , how are you doing with your salt intake ? patient: i'm trying to back off of it . i think i'm doing good with it , not eating too much .

D2N139

12

[ "Vegetative History" ]

[ "Subjective" ]

okay . uh , how are you doing with your salt intake ?

3,511

doctor: good , uh , it plays a huge part in lowering your pressure and , uh , staying away from salt is important . um , i'll give you some information on the dash eating plan , which is the only eating plan that has been shown to lower blood pressure . patient: sounds good .

D2N139

13

[ "Vegetative History" ]

[ "Subjective" ]

good , uh , it plays a huge part in lowering your pressure and , uh , staying away from salt is important . um , i'll give you some information on the dash eating plan , which is the only eating plan that has been shown to lower blood pressure .

3,512

doctor: are you doing any exercise ? patient: i do try to walk on the treadmill when i can .

D2N139

14

[ "Other Socials" ]

[ "Subjective" ]

are you doing any exercise ?

3,513

doctor: okay , great . um , all right . so , let's take a look . patient: all right .

D2N139

15

[ "Physical Examination" ]

[ "Objective" ]

okay , great . um , all right . so , let's take a look .

3,514

doctor: uh , you're gon na hear me talk throughout your exam , just so i can make sure i get everything documented . patient: okay .

D2N139

16

[ "Chitchat" ]

[ "Null" ]

uh , you're gon na hear me talk throughout your exam , just so i can make sure i get everything documented .

3,515

doctor: so , use my general physical exam template . let me take a listen to you and make sure everything sounds good . patient: all right .

D2N139

17

[ "Chitchat" ]

[ "Null" ]

so , use my general physical exam template . let me take a listen to you and make sure everything sounds good .

3,516

doctor: your heart and lungs sound good , so that's great . patient: good to hear .

D2N139

18

[ "Physical Examination" ]

[ "Objective" ]

your heart and lungs sound good , so that's great .

3,517

doctor: all right . go ahead and lie down . uh , and let me know if anywhere i press hurts . patient: nope . nowhere .

D2N139

19

[ "Physical Examination" ]

[ "Objective" ]

all right . go ahead and lie down . uh , and let me know if anywhere i press hurts .

3,518

doctor: all right . so , i'm gon na take a look at your ankles and feet . i'm just gon na look for some swelling . patient: all right .

D2N139

20

[ "Physical Examination" ]

[ "Objective" ]

all right . so , i'm gon na take a look at your ankles and feet . i'm just gon na look for some swelling .

3,519

doctor: all right . it all looks good . go ahead and sit up . so , in terms of getting that pressure down , you're on three meds that are maxed out and your blood pressure is still not down . and , the question is what do we need to do to get your- to get it down . uh , your potassium one week ago was 4.0 . uh , has it been redone since in the last week ? patient: uh , no .

D2N139

21

[ "Physical Examination" ]

[ "Objective" ]

all right . it all looks good . go ahead and sit up . so , in terms of getting that pressure down , you're on three meds that are maxed out and your blood pressure is still not down . and , the question is what do we need to do to get your- to get it down . uh , your potassium one week ago was 4.0 . uh , has it been redone since in the last week ?

3,520

doctor: okay . uh , four is good for your potassium level , some people have what is called resistant hypertension that is driven by something else in their body , uh , often it is a form , uh , hormonal response . if i were to take 10 people under the age of 50 who have high blood pressure who developed it at a young age , eight out of 10 would respond to reduced salt in their diet with a lower blood pressure . but , for the two out of 10 , there is something else driving it , uh , parathyroid levels or something called your adrenal glands overproduce , um , aldosterone , which we call hyperaldosterone . patient: okay . so , is there something we can do about it ?

D2N139

22

[ "Discussion", "Reassessment" ]

[ "Assessment", "Plan" ]

okay . uh , four is good for your potassium level , some people have what is called resistant hypertension that is driven by something else in their body , uh , often it is a form , uh , hormonal response . if i were to take 10 people under the age of 50 who have high blood pressure who developed it at a young age , eight out of 10 would respond to reduced salt in their diet with a lower blood pressure . but , for the two out of 10 , there is something else driving it , uh , parathyroid levels or something called your adrenal glands overproduce , um , aldosterone , which we call hyperaldosterone .

3,521

doctor: um , in these cases , there's medicine called , uh , spironolactone , that is very effective at dropping the ald- aldosterone level , and your blood pressure , and i think we should give that a try . patient: all right . i mean , i'm willing to give it a try .

D2N139

23

[ "Discussion", "Medication" ]

[ "Plan" ]

um , in these cases , there's medicine called , uh , spironolactone , that is very effective at dropping the ald- aldosterone level , and your blood pressure , and i think we should give that a try .

3,522

doctor: okay . so , let's discuss the piss- the possible risk of , uh , being on hydrochlorothiazide , which is the fluid med that you're now on . and , the spironolactone . one issue is that they can affect your electrolyte balance . um , they can also cause dehydration . so , when ... so , you got ta make sure that you hydrate . if you do not hydrate , and you get dehydrated , you will know it because you will get dizzy standing up . um , second thing is the spironolactone can raise your potassium too far , it's rare , but it can . uh , you're starting with your potassium at four , so that gives us some room . patient: all right . i guess that makes me feel a little bit better .

D2N139

24

[ "Discussion", "Medication", "Other Treatments" ]

[ "Plan" ]

okay . so , let's discuss the piss- the possible risk of , uh , being on hydrochlorothiazide , which is the fluid med that you're now on . and , the spironolactone . one issue is that they can affect your electrolyte balance . um , they can also cause dehydration . so , when ... so , you got ta make sure that you hydrate . if you do not hydrate , and you get dehydrated , you will know it because you will get dizzy standing up . um , second thing is the spironolactone can raise your potassium too far , it's rare , but it can . uh , you're starting with your potassium at four , so that gives us some room .

3,523

doctor: yeah . and then the third thing is that spironolactone combined with hydrocholorozide- chlorothiazide can cause your sodium levels to go down . now , this does not mean- mean that you need to be eating more salt , okay ? but , it does mean that you will need to do blood tests in two weeks to make sure that it's okay . patient: all right . no , that i can do . um , are there any other side effects i need to worry about ?

D2N139

25

[ "Medication", "Diagnostic Testing" ]

[ "Plan" ]

yeah . and then the third thing is that spironolactone combined with hydrocholorozide- chlorothiazide can cause your sodium levels to go down . now , this does not mean- mean that you need to be eating more salt , okay ? but , it does mean that you will need to do blood tests in two weeks to make sure that it's okay .

3,524

doctor: uh , dizziness possibly , as well as , uh , one in 100 guys might develop tenderness in their chest , swollen breasts , or enlarged breasts . this is a rare side effect , um , called gynecomastia , and if it happens , you just cut the medication and you let me know , but it is very uncommon . patient: i'll definitely let you know if that happens .

D2N139

26

[ "Discussion", "Medication" ]

[ "Plan" ]

uh , dizziness possibly , as well as , uh , one in 100 guys might develop tenderness in their chest , swollen breasts , or enlarged breasts . this is a rare side effect , um , called gynecomastia , and if it happens , you just cut the medication and you let me know , but it is very uncommon .

3,525

doctor: okay . uh , we'll keep working at it until your blood pressure gets better . um , it can be tricky when your blood pressure starts to go up at a young age though , it is important to get it under control because it can lead to your heart getting bigger or enlarged . um , same thing that happens when you lift weights and your muscles get bigger , uh , and if your heart pumps against high blood pressure , it can eventually lead to heart failure . patient: i understand .

D2N139

27

[ "Discussion" ]

[ "Plan" ]

okay . uh , we'll keep working at it until your blood pressure gets better . um , it can be tricky when your blood pressure starts to go up at a young age though , it is important to get it under control because it can lead to your heart getting bigger or enlarged . um , same thing that happens when you lift weights and your muscles get bigger , uh , and if your heart pumps against high blood pressure , it can eventually lead to heart failure .

3,526

doctor: yeah , so getting that under control is really important to help prevent kidney failure , strokes , and- and things like that- that you're at high risk for with high blood pressure . patient: okay .

D2N139

28

[ "Discussion" ]

[ "Plan" ]

yeah , so getting that under control is really important to help prevent kidney failure , strokes , and- and things like that- that you're at high risk for with high blood pressure .

3,527

doctor: um , the american heart association has a website called heart.org , it has a lot of really good information about blood pressure to teach- to teach you about it and how to control your diet with exercise . um , if you do your treadmill routinely for 30 minutes or so most days , that could be seven to 10 points off your blood pressure . patient: really ? i did n't realize that .

D2N139

29

[ "Discussion", "Other Treatments" ]

[ "Plan" ]

um , the american heart association has a website called heart.org , it has a lot of really good information about blood pressure to teach- to teach you about it and how to control your diet with exercise . um , if you do your treadmill routinely for 30 minutes or so most days , that could be seven to 10 points off your blood pressure .

3,528

doctor: yeah , yeah . it's very important to be active , lower your salt , and increase your potassium . um , the goal is to keep your salt under 2000 milligrams a day , the actual recommendation is- is 1500 milligrams per day , but most people have a hard time with that . um , so just take a look at the website and the dash diet information . um , that will give you a lot of tips and information to help you start learning about this stuff . patient: okay . i'll definitely check that out .

D2N139

30

[ "Discussion", "Other Treatments" ]

[ "Plan" ]

yeah , yeah . it's very important to be active , lower your salt , and increase your potassium . um , the goal is to keep your salt under 2000 milligrams a day , the actual recommendation is- is 1500 milligrams per day , but most people have a hard time with that . um , so just take a look at the website and the dash diet information . um , that will give you a lot of tips and information to help you start learning about this stuff .

3,529

doctor: all right . so , we'll try the spironolactone and schedule a followup in two weeks to check your blood pressure and electrolytes . uh , if the new med does n't work , the next up is going to be the resistant hypertension clinic . patient: all right .

D2N139

31

[ "Discussion", "Follow-up", "Referral", "Medication" ]

[ "Plan" ]

all right . so , we'll try the spironolactone and schedule a followup in two weeks to check your blood pressure and electrolytes . uh , if the new med does n't work , the next up is going to be the resistant hypertension clinic .

3,530

doctor: all right . so , there they will look into secondary causes of your hypertension . they have access to newer procedure based technologies that can lower your blood pressure without medication , uh , for example , there is something called a renal , uh , denervation , uh , where they go inside the artery that feeds your kidney with almost like a little coil and heat that artery up . when they do that , they can block the nerve endings that get into your kidneys and lower your blood pressure . patient: that's interesting .

D2N139

32

[ "Discussion" ]

[ "Plan" ]

all right . so , there they will look into secondary causes of your hypertension . they have access to newer procedure based technologies that can lower your blood pressure without medication , uh , for example , there is something called a renal , uh , denervation , uh , where they go inside the artery that feeds your kidney with almost like a little coil and heat that artery up . when they do that , they can block the nerve endings that get into your kidneys and lower your blood pressure .

3,531

doctor: yeah . so , that procedure has been shown to lower blood pressure by 10 points . um , there are of course some risks , so not everyone is a candidate . uh , but we'll cross that road , uh , when we need to , and let's just- let's just see how you do with the addition of the medication . patient: sounds good to me .

D2N139

33

[ "Discussion" ]

[ "Plan" ]

yeah . so , that procedure has been shown to lower blood pressure by 10 points . um , there are of course some risks , so not everyone is a candidate . uh , but we'll cross that road , uh , when we need to , and let's just- let's just see how you do with the addition of the medication .

3,532

doctor: all right . so , we will see you in two weeks then . patient: sounds good . thanks doc .

D2N139

34

[ "Follow-up" ]

[ "Plan" ]

all right . so , we will see you in two weeks then .

3,533

doctor: yeah , you're welcome . let me know if you have any questions . patient: will do .

D2N139

35

[ "Discussion" ]

[ "Plan" ]

yeah , you're welcome . let me know if you have any questions .

3,534

doctor: all right . have a great day mr. roberts . patient: you too .

D2N139

36

[ "Chitchat" ]

[ "Null" ]

all right . have a great day mr. roberts .

3,535

doctor: mr. roberts presents with resistant hypertension . he's on three meds and maximum dose . i have added spironolactone to his regiment . we will need to monitor his potassium and sodium . he will have a metabolic panel and blood pressure check in two weeks . uh , next medication would be carvedilol , uh , which i try to avoid giving , it's potential for erectile dysfunction . i have talked to the patient about that , and the potential side effects of spironolactone , including the gynecomastia and electrolyte disturbances . if he is not controlled on spironolactone , the next step would be sending him to resistant hypertension clinic .

D2N139

37

[ "Acute Assessment", "Medication", "Diagnostic Testing", "Follow-up", "Discussion" ]

[ "Assessment", "Plan" ]

doctor: mr. roberts presents with resistant hypertension . he's on three meds and maximum dose . i have added spironolactone to his regiment . we will need to monitor his potassium and sodium . he will have a metabolic panel and blood pressure check in two weeks . uh , next medication would be carvedilol , uh , which i try to avoid giving , it's potential for erectile dysfunction . i have talked to the patient about that , and the potential side effects of spironolactone , including the gynecomastia and electrolyte disturbances . if he is not controlled on spironolactone , the next step would be sending him to resistant hypertension clinic .

3,536

doctor: brittany edwards , 07 , 1898 . she is a return visit for ibs with functional abdominal pain , nausea , vomiting . ms. edwards is a pleasant , 32-year-old female who was last seen in august of 2019 with flares of abdominal pain , who was diagnosed with irritable bowl that was treated with bentyl . she had a previous prescription for reglan that she received from the emergency room that she used as needed for nausea . she was instructed to start a low dose fiber supplement , such as citrucel , daily , probiotics to help with gas and bloating , bentyl up to four times daily for intestinal cramping , and stop reglan and use zofran as needed . neuromodulators such as elavil and buspar were discussed but not started . hello , how are you ? patient: i'm okay .

D2N140

0

[ "Personal History", "Greetings" ]

[ "Subjective" ]

brittany edwards , 07 , 1898 . she is a return visit for ibs with functional abdominal pain , nausea , vomiting . ms. edwards is a pleasant , 32-year-old female who was last seen in august of 2019 with flares of abdominal pain , who was diagnosed with irritable bowl that was treated with bentyl . she had a previous prescription for reglan that she received from the emergency room that she used as needed for nausea . she was instructed to start a low dose fiber supplement , such as citrucel , daily , probiotics to help with gas and bloating , bentyl up to four times daily for intestinal cramping , and stop reglan and use zofran as needed . neuromodulators such as elavil and buspar were discussed but not started . hello , how are you ?

3,537

doctor: good . how have you been feeling ? patient: not so good .

D2N140

1

[ "Acute Symptoms" ]

[ "Subjective" ]

good . how have you been feeling ?

3,538

doctor: yeah , so my nurse told me you have been going out to eat some on friday nights and saturday nights and that you have had some spicy foods or spicy shrimp . patient: yeah , i have .

D2N140

2

[ "Acute Symptoms" ]

[ "Subjective" ]

yeah , so my nurse told me you have been going out to eat some on friday nights and saturday nights and that you have had some spicy foods or spicy shrimp .

3,539

doctor: okay . well , your gut probably does not always appreciate that . patient: no , it does n't like it at all .

D2N140

3

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . well , your gut probably does not always appreciate that .

3,540

doctor: yeah , so ibs is one of those things where you are very sensitive to certain things such as spicy foods or fatty foods and alcohol . and this can cause lower belly stuff like cramps , or you can get upper belly stuff such as nausea . patient: i've been getting both .

D2N140

4

[ "Acute Symptoms", "Drug History" ]

[ "Subjective" ]

yeah , so ibs is one of those things where you are very sensitive to certain things such as spicy foods or fatty foods and alcohol . and this can cause lower belly stuff like cramps , or you can get upper belly stuff such as nausea .

3,541

doctor: okay . um , so how frequently have you been getting or having a bowel movement on normal days ? patient: i'm starting to notice it's between two and three times a day .

D2N140

5

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . um , so how frequently have you been getting or having a bowel movement on normal days ?

3,542

doctor: okay . and are they soft stools or formed stools ? patient: um , they're formed .

D2N140

6

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . and are they soft stools or formed stools ?

3,543

doctor: okay . and after you have gone out either drinking with your friends , do you tend to have more diarrhea ? patient: yeah , i do .

D2N140

7

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . and after you have gone out either drinking with your friends , do you tend to have more diarrhea ?

3,544

doctor: okay . do you feel it's the food or the alcohol or both ? patient: uh , well usually we go to friday's restaurant . i always eat pasta , the chicken alfredo .

D2N140

8

[ "Acute Symptoms", "Drug History" ]

[ "Subjective" ]

okay . do you feel it's the food or the alcohol or both ?

3,545

doctor: okay . i can s- i can bet it's the alfredo sauce . patient: but it normally does n't bother me .

D2N140

9

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . i can s- i can bet it's the alfredo sauce .

3,546

doctor: okay . well , pasta can make you bloated , uh , but it does n't usually cause diarrhea . grilled chi- uh , grilled chicken is usually all right . alfredo , though , is higher in fat , and it does contain dairy . but you're saying it usually does n't bother you ? patient: no .

D2N140

10

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . well , pasta can make you bloated , uh , but it does n't usually cause diarrhea . grilled chi- uh , grilled chicken is usually all right . alfredo , though , is higher in fat , and it does contain dairy . but you're saying it usually does n't bother you ?

3,547

doctor: okay . what type of alcohol drink do you drink when you are there ? is it a sweet drink ? patient: most of the time it's either tequila or dark liquor . i prefer patron , but if i get brown liquor , i only get two . um , every now and again , i'll drink a martini .sometimes it's the mixer they tend to put in the drinks , but it can be a variety of things .

D2N140

11

[ "Drug History" ]

[ "Subjective" ]

okay . what type of alcohol drink do you drink when you are there ? is it a sweet drink ?

3,548

doctor: um , so when you're not eating out or drinking , what we do on a daily basis does help keep us regular , so when it does flare up , it c- it might not be as bad . um , have you had any luck using the fiber like citrucel regularly ? patient: um , no . i guess i need to find a new drink .

D2N140

12

[ "Acute Symptoms" ]

[ "Subjective" ]

um , so when you're not eating out or drinking , what we do on a daily basis does help keep us regular , so when it does flare up , it c- it might not be as bad . um , have you had any luck using the fiber like citrucel regularly ?

3,549

doctor: okay . and how is it during the week ? patient: like what i eat ?

D2N140

13

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . and how is it during the week ?

3,550

doctor: yeah , and with the diarrhea and abdomal- um , abdominal pain . patient: right now , i'm still having the cramping and sharp pains , so i've been avoiding heavy foods . i did have some fried chicken today , though .

D2N140

14

[ "Acute Symptoms" ]

[ "Subjective" ]

yeah , and with the diarrhea and abdomal- um , abdominal pain .

3,551

doctor: and was everything all right after that ? patient: yeah , for the most part .

D2N140

15

[ "Acute Symptoms" ]

[ "Subjective" ]

and was everything all right after that ?

3,552

doctor: okay . remember , it's also the portion sizes . so i mean , if you eat a little and you feel fine , then that's okay . you have to just really watch the portions . patient: okay , good . i ca n't go out- go without some fried chicken at least once in a while .

D2N140

16

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . remember , it's also the portion sizes . so i mean , if you eat a little and you feel fine , then that's okay . you have to just really watch the portions .

3,553

doctor: sounds good . all right , well let's take a look at you today , and we'll do a brief physical exam . you will hear me call out some findings . i will answer any questions , and we will discuss once we have finished the exam . patient: sounds good .

D2N140

17

[ "Physical Examination" ]

[ "Objective" ]

sounds good . all right , well let's take a look at you today , and we'll do a brief physical exam . you will hear me call out some findings . i will answer any questions , and we will discuss once we have finished the exam .

3,554

doctor: all right . so the patient is alert and cooperative , appears stated age . all right . i'm going to listen to your heart and lungs . and lungs are clear to auscultation bilaterally . heart regular rate and rhythm . all right , so if you could just lay back for me , and i'll examine your abdomen . patient: okay .

D2N140

18

[ "Physical Examination" ]

[ "Objective" ]

all right . so the patient is alert and cooperative , appears stated age . all right . i'm going to listen to your heart and lungs . and lungs are clear to auscultation bilaterally . heart regular rate and rhythm . all right , so if you could just lay back for me , and i'll examine your abdomen .

3,555

doctor: all right . do you have any tenderness ? patient: no , not really .

D2N140

19

[ "Physical Examination" ]

[ "Objective" ]

all right . do you have any tenderness ?

3,556

doctor: okay . so the abdomen is soft , non-tender . no masses or organomegaly . and let me take a listen . normal active bowel sounds . all right . you can go ahead and sit up now . thank you . all right , so first i want you to try citrucel . it does come in a tablet . you should use it twice daily for regularity . then i would say , if you know you're going out and will possibly have diarrhea as a result , you can go ahead and use your bentyl 20 milligrams . you can do one tablet before you eat , and then repeat up to four times daily . and then on days when you feel good , you do n't have to use anything . um , and then on friday before you leave the house , you can take a bentyl and put one in your pocket for later , and then you can repeat the same thing on saturday if you want , and that will be totally fine . patient: okay , that sounds good .

D2N140

20

[ "Discussion", "Acute Assessment", "Medication" ]

[ "Assessment", "Plan" ]

okay . so the abdomen is soft , non-tender . no masses or organomegaly . and let me take a listen . normal active bowel sounds . all right . you can go ahead and sit up now . thank you . all right , so first i want you to try citrucel . it does come in a tablet . you should use it twice daily for regularity . then i would say , if you know you're going out and will possibly have diarrhea as a result , you can go ahead and use your bentyl 20 milligrams . you can do one tablet before you eat , and then repeat up to four times daily . and then on days when you feel good , you do n't have to use anything . um , and then on friday before you leave the house , you can take a bentyl and put one in your pocket for later , and then you can repeat the same thing on saturday if you want , and that will be totally fine .

3,557

doctor: okay . and so your bentyl , that's the anti-spasm medication , and i would take the higher dose . patient: can i get a refill of that ?

D2N140

21

[ "Discussion", "Medication" ]

[ "Plan" ]

okay . and so your bentyl , that's the anti-spasm medication , and i would take the higher dose .

3,558

doctor: yes , absolutely . uh , so take one tablet about 30 to 45 minutes before leaving the house and then the second tablet at the restaurant . then with the nausea , um , i think we should try and see if you can recognize a pattern with what you are eating and drinking , um , um , about , like , what makes it worse . patient: yeah , i noticed i've been doing better with drinking water instead of sodas .

D2N140

22

[ "Discussion", "Other Treatments", "Medication" ]

[ "Plan" ]

yes , absolutely . uh , so take one tablet about 30 to 45 minutes before leaving the house and then the second tablet at the restaurant . then with the nausea , um , i think we should try and see if you can recognize a pattern with what you are eating and drinking , um , um , about , like , what makes it worse .

3,559

doctor: okay , good . and then for your zofran , i would n't take that ahead of time . just plan on drinking plenty of water . patient: okay .

D2N140

23

[ "Discussion", "Other Treatments", "Medication" ]

[ "Plan" ]

okay , good . and then for your zofran , i would n't take that ahead of time . just plan on drinking plenty of water .

3,560

doctor: okay , and you can take it , but before you do , we want to try to reduce the triggers . uh , so watch out for greasy or fatty foods and sugary drinks . patient: okay , i can do that .

D2N140

24

[ "Discussion", "Other Treatments", "Medication" ]

[ "Plan" ]

okay , and you can take it , but before you do , we want to try to reduce the triggers . uh , so watch out for greasy or fatty foods and sugary drinks .

3,561

doctor: okay . and so , however , if it is not just these isolated inci- incidents and the symptoms are happening all the time , we could put you on a long term medication that would take ... that you would take every night . and so then you do n't have to use so much bentyl or the zofran . how do you feel about that ? patient: i was actually going to ask you about something like that to help avoid flares altogether .

D2N140

25

[ "Discussion", "Medication" ]

[ "Plan" ]

okay . and so , however , if it is not just these isolated inci- incidents and the symptoms are happening all the time , we could put you on a long term medication that would take ... that you would take every night . and so then you do n't have to use so much bentyl or the zofran . how do you feel about that ?

3,562

doctor: yeah , there is . and it actually works on the chemicals in your brain that are causing your gut to be overly sensitive . one is called elavil , but the only drawback is that it can make you a little sleepy . how does that sound ? patient: that sounds like a much better plan .

D2N140

26

[ "Discussion", "Medication" ]

[ "Plan" ]

yeah , there is . and it actually works on the chemicals in your brain that are causing your gut to be overly sensitive . one is called elavil , but the only drawback is that it can make you a little sleepy . how does that sound ?

3,563

doctor: okay , great . we can definitely do that . uh , just take it every night before bedtime . patient: okay , that sounds good . thank you so much .

D2N140

27

[ "Discussion" ]

[ "Plan" ]

okay , great . we can definitely do that . uh , just take it every night before bedtime .

3,564

doctor: you're welcome . and so i have gone ahead and sent your prescriptions to your pharmacy . just give us a call if you have any questions or need us for anything else . and then let's plan on touching base through mychart email in about a month to just check in to see how you're doing with symptoms . okay ? patient: okay , that sounds good . thank you .

D2N140

28

[ "Discussion", "Follow-up" ]

[ "Plan" ]

you're welcome . and so i have gone ahead and sent your prescriptions to your pharmacy . just give us a call if you have any questions or need us for anything else . and then let's plan on touching base through mychart email in about a month to just check in to see how you're doing with symptoms . okay ?

3,565

doctor: you're welcome , and have a good rest of your day . so review of symptoms is positive for diarrhea , nausea , and abdominal pain . assessment and plan . brittany edwards is a pleasant female with ibs and functional abdominal pain , aggravated by high stress , poor eating habits , and poor sleeping habits . i've encouraged dietary and lifestyle modifications , as well as starting a neuromodulator such as elavil 25 milligrams at bedtime for ibs . she can use bentyl 20 milligrams as needed 30 to 45 minutes prior to eating out at a restaurant . she can also use zofran if needed . however , i have encouraged her to reduce greasy and fatty foods and alcohol consumption . i have asked her to follow up in one month by emailing over mychart regarding any side effects and issues , or issues with elavil or if adjustments are needed .

D2N140

29

[ "Vegetative History", "Personal History", "Medication", "Other Treatments", "Reassessment", "Follow-up" ]

[ "Subjective", "Assessment", "Plan" ]

doctor: you're welcome , and have a good rest of your day . so review of symptoms is positive for diarrhea , nausea , and abdominal pain . assessment and plan . brittany edwards is a pleasant female with ibs and functional abdominal pain , aggravated by high stress , poor eating habits , and poor sleeping habits . i've encouraged dietary and lifestyle modifications , as well as starting a neuromodulator such as elavil 25 milligrams at bedtime for ibs . she can use bentyl 20 milligrams as needed 30 to 45 minutes prior to eating out at a restaurant . she can also use zofran if needed . however , i have encouraged her to reduce greasy and fatty foods and alcohol consumption . i have asked her to follow up in one month by emailing over mychart regarding any side effects and issues , or issues with elavil or if adjustments are needed .

3,566

doctor: okay , so our next patient is christopher watson . date of birth 04/12/1934 . mr . watson is- is an 86-year-old male who returns in follow-up for adult hydrocephalus . this is his first visit since undergoing sh- shunt surgery , excuse me , on august 1st , 2020 . i have followed mr . watson since may of 2020 when he first presented with eight to ten years of progressive gait impairment , cognitive impairment , and decreased bladder control . we established a diagnosis of adult hydrocephalus with a spino catheter protocol in june 2020 , and he underwent shunt surgery on august 1st , 2020 . a medtronic strata programmable shunt in the ventricular peritoneal configuration was programmed at a level 2.0 was placed . good morning , mr . watson , who is the nice lady you have with you today ? patient: hi , doc . this is my daughter , theresa . she is the one who helps me keep things straight .

D2N141

0

[ "Personal History", "Greetings" ]

[ "Subjective" ]

okay , so our next patient is christopher watson . date of birth 04/12/1934 . mr . watson is- is an 86-year-old male who returns in follow-up for adult hydrocephalus . this is his first visit since undergoing sh- shunt surgery , excuse me , on august 1st , 2020 . i have followed mr . watson since may of 2020 when he first presented with eight to ten years of progressive gait impairment , cognitive impairment , and decreased bladder control . we established a diagnosis of adult hydrocephalus with a spino catheter protocol in june 2020 , and he underwent shunt surgery on august 1st , 2020 . a medtronic strata programmable shunt in the ventricular peritoneal configuration was programmed at a level 2.0 was placed . good morning , mr . watson , who is the nice lady you have with you today ?

3,567

doctor: mr . watson , have you been sick or been hosp -- hospitalized since your shu- shunt surgery three months ago . patient: uh , not that i recall . patient_guest: no , he has n't . he has been doing much better .

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1

[ "Acute Symptoms" ]

[ "Subjective" ]

mr . watson , have you been sick or been hosp -- hospitalized since your shu- shunt surgery three months ago .

3,568

doctor: good , i'm glad to hear that . before surgery , you were having some progressive problems that affected your walking , thinking , and bladder control . are these symptoms better , worse , or unchanged ? patient_guest: his walking has improved . he's now able to walk to the dining room just fine . but he could not do that before surgery . he still has times where i have to help him .

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2

[ "Acute Symptoms" ]

[ "Subjective" ]

good , i'm glad to hear that . before surgery , you were having some progressive problems that affected your walking , thinking , and bladder control . are these symptoms better , worse , or unchanged ?

3,569

doctor: that's impressive , mr . watson . patient: yeah , i guess . patient_guest: now his bladder control did improve some after surgery , but now seems to have leveled out . so he is wearing diapers .

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3

[ "Acute Symptoms" ]

[ "Subjective" ]

that's impressive , mr . watson .

3,570

doctor: no issues with sores from wearing the diaper ? and any decreased or painful urination ? patient_guest: no , not at all .

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[ "Personal History", "Vegetative History" ]

[ "Subjective" ]

no issues with sores from wearing the diaper ? and any decreased or painful urination ?

3,571

doctor: and how about cognition ? patient: i think i'm better . i do n't feel lost when talking to someone anymore . patient_guest: dad and i both think my sister , hannah , summarized it best . she said " i feel like i can have a normal conversation with him again , "

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5

[ "Personal History" ]

[ "Subjective" ]

and how about cognition ?

3,572

doctor: that's so wonderful ! now have you had any headaches or pain where the shunt is ? patient: no . has n't bothered me one bit .

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6

[ "Personal History" ]

[ "Subjective" ]

that's so wonderful ! now have you had any headaches or pain where the shunt is ?

3,573

doctor: okay . and any pain in your belly at all ? patient: ca n't say that i have .

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7

[ "Personal History" ]

[ "Subjective" ]

okay . and any pain in your belly at all ?

3,574

doctor: okay , sounds like you have been improving . alrighty , mr . watson , i'm going to step out of the room while my resident comes in to do a few tests for me . is that all right ? patient: sounds good .

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8

[ "Personal History" ]

[ "Subjective" ]

okay , sounds like you have been improving . alrighty , mr . watson , i'm going to step out of the room while my resident comes in to do a few tests for me . is that all right ?

3,575

doctor: okay , i'm going to go out and review the ct scan you had last month , and then we'll chat about it when i come in . all righty , mr . watson , so you definitely have made some improvements since the shunt surgery . now on ct scan though i do believe i see a tiny bit of blood fluid collection in the right parietal region . now , i do n't believe that that's causing any symptoms , and i , it actually was n't documented by the radiologist when he read the ct scan . patient: so what does that mean ?

D2N141

9

[ "Radiology Examination" ]

[ "Objective" ]

okay , i'm going to go out and review the ct scan you had last month , and then we'll chat about it when i come in . all righty , mr . watson , so you definitely have made some improvements since the shunt surgery . now on ct scan though i do believe i see a tiny bit of blood fluid collection in the right parietal region . now , i do n't believe that that's causing any symptoms , and i , it actually was n't documented by the radiologist when he read the ct scan .

3,576

doctor: just that i would like to leave the shunt set for another two to three months before we go in changing it . like i said , if you're not having any headaches or pain and you have improved so that's all good for me . so really there's , there's nothing to worry about . patient: all right so i'll come back in three months ?

D2N141

10

[ "Discussion" ]

[ "Plan" ]

just that i would like to leave the shunt set for another two to three months before we go in changing it . like i said , if you're not having any headaches or pain and you have improved so that's all good for me . so really there's , there's nothing to worry about .

3,577

doctor: yep , that's right . patient: i do have a question for you though .

D2N141

11

[ "Discussion" ]

[ "Plan" ]

yep , that's right .

3,578

doctor: yeah , of course . patient: do you think i will be able to drive again ?

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12

[ "Discussion" ]

[ "Plan" ]

yeah , of course .

3,579

doctor: ah man , mr . watson , i knew you were gon na ask me that one . i think at this point it's unlikely that your movement speed will improve to the level that would be needed for you to pass the driver safety evaluation . now , i will say that i do occasionally have patients who surprise me by improving over a nine to 12 month range . and that , that definitely could be you . you could definitely pass it at that point . so if you improve and we can continue to talk about that then , ya know , i think it could be possible , um , and i'd be happy to recommend it . now , you could definitely also enroll in a driver safety program without my recommendation . so you could kind of do that preemptively , and then we could continue to watch for your improvement as we go . patient: okay . i kinda figured that anyway but i just thought i'd ask . i do n't like to burden anyone when i just need to run to the store but i also know that i need to be safe .

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[ "Discussion" ]

[ "Plan" ]

ah man , mr . watson , i knew you were gon na ask me that one . i think at this point it's unlikely that your movement speed will improve to the level that would be needed for you to pass the driver safety evaluation . now , i will say that i do occasionally have patients who surprise me by improving over a nine to 12 month range . and that , that definitely could be you . you could definitely pass it at that point . so if you improve and we can continue to talk about that then , ya know , i think it could be possible , um , and i'd be happy to recommend it . now , you could definitely also enroll in a driver safety program without my recommendation . so you could kind of do that preemptively , and then we could continue to watch for your improvement as we go .

3,580

doctor: yeah , your safety is our number one priority and , ya know , i'm sure your daughters do n't mind as much , right , they want to keep you here and have you safe . but , i overall am very pleased with how much you have improved . and so , i'm sure when we talk again in three months , we'll continue to be on that upward trajectory or improvement . patient: i sure hope so , doc . patient_guest: we really appreciate all that you've done . do we make the appointment out front ?

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[ "Discussion", "Follow-up" ]

[ "Plan" ]

yeah , your safety is our number one priority and , ya know , i'm sure your daughters do n't mind as much , right , they want to keep you here and have you safe . but , i overall am very pleased with how much you have improved . and so , i'm sure when we talk again in three months , we'll continue to be on that upward trajectory or improvement .

3,581

doctor: yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ? patient: thanks patient_guest: thank you .

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15

[ "Chitchat" ]

[ "Null" ]

yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ?

3,582

doctor: all righty , so ros is constitutional significant for impaired ability to carry out daily functions . negative for fever or unintentional weight loss . gu is significant for urinary incontinence and wearing a diaper . negative for genital sores , decreased or painful output . neurological significant for continued walking impairment and cognitive impairment . negative for headaches , recent falls , or hallucinations . psychiatric is negative for depression , excessive worrying , or mood swings . let's go ahead and use the short pe . vitals , let's see , blood pressure is 124/80 , heart rate 64 , respirations 18 , weight 174 pounds , and pain zero out of 10 . mr . watson is a pleasant and cooperative man who's able to converse easily through , um , though his daughter does add some details . the shunt sight was clean , dry , and intact with a confirmed setting of two . um he was tested um for recent and remote memory , attention span , and concentration in fund of knowledge . he scored a 26 out of 30 on the mmse when tested with spelling and 25 out of 30 when tested with calculations . of note , he was able to get two of the three memory words with cuing , and the third with multiple choice . this was a slight improvement over his initial score of 23 out of 30 with calculations and 24 out of 30 with spelling . and at the time he was unable um in the previous test , excuse me , he was unable to remember any memory words with cuing without and only one with multiple choice . gait testing using the tinetti assessment tool . he was tested without an assistive device and received a gait score of six to eight out of 12 and a balance score of 12 out of 16 for a total score of 18 to 20 out of 28 . this is slightly improved from his initial score of 15 to 17 out of 28 . cranial nerves , pupils are equal . eoms are intact . face symmetric . no disarchria . motor normal for bulk and strength . coordination slow from no- finger to nose . of note , the ct scan from the head of 10/15/2020 shows a frontal horn span at the level of foramen of monro of 4.6 centimeters with a third ventricular contour that is flat with a span of 10 millimeters . by my reading there is a tiny amount of blood in the right front region with a tiny subdermal collection . this was not noticed or noted by the radiologist who stated any extra axial fluid collections . there is also substantial small vessel ischemic change . diagnosis adult hydrocephalus , gait impairment , urinary incontinence and urgency , and cognitive impairment .

D2N141

16

[ "Personal History", "Vegetative History", "Physical Examination", "Radiology Examination", "Reassessment", "Lab Examination" ]

[ "Subjective", "Objective", "Assessment" ]

doctor: all righty , so ros is constitutional significant for impaired ability to carry out daily functions . negative for fever or unintentional weight loss . gu is significant for urinary incontinence and wearing a diaper . negative for genital sores , decreased or painful output . neurological significant for continued walking impairment and cognitive impairment . negative for headaches , recent falls , or hallucinations . psychiatric is negative for depression , excessive worrying , or mood swings . let's go ahead and use the short pe . vitals , let's see , blood pressure is 124/80 , heart rate 64 , respirations 18 , weight 174 pounds , and pain zero out of 10 . mr . watson is a pleasant and cooperative man who's able to converse easily through , um , though his daughter does add some details . the shunt sight was clean , dry , and intact with a confirmed setting of two . um he was tested um for recent and remote memory , attention span , and concentration in fund of knowledge . he scored a 26 out of 30 on the mmse when tested with spelling and 25 out of 30 when tested with calculations . of note , he was able to get two of the three memory words with cuing , and the third with multiple choice . this was a slight improvement over his initial score of 23 out of 30 with calculations and 24 out of 30 with spelling . and at the time he was unable um in the previous test , excuse me , he was unable to remember any memory words with cuing without and only one with multiple choice . gait testing using the tinetti assessment tool . he was tested without an assistive device and received a gait score of six to eight out of 12 and a balance score of 12 out of 16 for a total score of 18 to 20 out of 28 . this is slightly improved from his initial score of 15 to 17 out of 28 . cranial nerves , pupils are equal . eoms are intact . face symmetric . no disarchria . motor normal for bulk and strength . coordination slow from no- finger to nose . of note , the ct scan from the head of 10/15/2020 shows a frontal horn span at the level of foramen of monro of 4.6 centimeters with a third ventricular contour that is flat with a span of 10 millimeters . by my reading there is a tiny amount of blood in the right front region with a tiny subdermal collection . this was not noticed or noted by the radiologist who stated any extra axial fluid collections . there is also substantial small vessel ischemic change . diagnosis adult hydrocephalus , gait impairment , urinary incontinence and urgency , and cognitive impairment .

3,583

doctor: amanda taylor , birth date october 31st 1949 . patient is a 72 year old woman who comes for followup for hypertension . her history includes significant alcohol use disorder and mi- mild hypercholesterolemia . at last visit on april 16th her blood pressure was 130 over 90 . after presenting at 150 over 100 she was prescribed hydrochlorothiazide 12.5 milligrams by mouth once daily , and lisinopril 20 milligrams by mouth once daily . cmp and cbc were essentially unremarkable . hi miss taylor , how are you today ? patient: hi , i'm- i'm good , thank you .

D2N142

0

[ "Greetings", "Therapeutic History", "Drug History" ]

[ "Subjective" ]

amanda taylor , birth date october 31st 1949 . patient is a 72 year old woman who comes for followup for hypertension . her history includes significant alcohol use disorder and mi- mild hypercholesterolemia . at last visit on april 16th her blood pressure was 130 over 90 . after presenting at 150 over 100 she was prescribed hydrochlorothiazide 12.5 milligrams by mouth once daily , and lisinopril 20 milligrams by mouth once daily . cmp and cbc were essentially unremarkable . hi miss taylor , how are you today ?

3,584

doctor: thanks for coming in today . patient: yeah , no problem .

D2N142

1

[ "Chitchat" ]

[ "Null" ]

thanks for coming in today .

3,585

doctor: so how have things been going for you ? patient: uh , they've been all right . i'm struggling with not drinking . i wanted to discuss that , uh , shot that you had mentioned last time , but we did n't get to discuss it too much .

D2N142

2

[ "Acute Symptoms" ]

[ "Subjective" ]

so how have things been going for you ?

3,586

doctor: okay , well i'll be happy to provide you with more information . so tell me when did you last have a drink ? patient: on monday .

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3

[ "Vegetative History" ]

[ "Subjective" ]

okay , well i'll be happy to provide you with more information . so tell me when did you last have a drink ?

3,587

doctor: okay , so you've gone a couple days without it ? patient: yeah , yeah i have .

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4

[ "Vegetative History" ]

[ "Subjective" ]

okay , so you've gone a couple days without it ?

3,588

doctor: yeah , and had you been drinking for a while ? patient: yep .

D2N142

5

[ "Vegetative History" ]

[ "Subjective" ]

yeah , and had you been drinking for a while ?

3,589

doctor: how much had- how much had you been drinking ? patient: um , four or five times a week hard alcohol , so , you know .

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[ "Drug History" ]

[ "Subjective" ]

how much had- how much had you been drinking ?

3,590

doctor: okay . well it will certainly help your blood pressure if you're able to stop drinking . patient: yeah , yeah i- i- i agree with you .

D2N142

7

[ "Vegetative History" ]

[ "Subjective" ]

okay . well it will certainly help your blood pressure if you're able to stop drinking .

3,591

doctor: okay . are you taking your blood pressure medications ? patient: yeah , but i'm only taking half of the lisinopril .

D2N142

8

[ "Therapeutic History" ]

[ "Subjective" ]

okay . are you taking your blood pressure medications ?

3,592

doctor: and are you also taking the full dose of the hydrochlorothiazide ? do you have any , um , chest tightness or pressure or any shortness of breath ? patient: yeah i'm taking the full dose of that medicine too , and no none of those symptoms .

D2N142

10

[ "Therapeutic History", "Vegetative History" ]

[ "Subjective" ]

and are you also taking the full dose of the hydrochlorothiazide ? do you have any , um , chest tightness or pressure or any shortness of breath ?

3,593

doctor: okay . anything else i should be aware of or that we should be checking ? patient: mm , no .

D2N142

11

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . anything else i should be aware of or that we should be checking ?

3,594

doctor: okay , good . are you doing the blood pressure checks at home ? patient: yes . yes i am .

D2N142

12

[ "Personal History" ]

[ "Subjective" ]

okay , good . are you doing the blood pressure checks at home ?

3,595

doctor: okay good . what kind of numbers are you seeing ? patient: well , in the morning i'm seeing lower numbers than in the evening , um , where i run anywhere from like 130 to 145 or 150 over 95 to 100 on the bottom .

D2N142

13

[ "Personal History" ]

[ "Subjective" ]

okay good . what kind of numbers are you seeing ?

3,596

doctor: yeah , so it sounds like we are not too far out of where we wan na be . patient: right , mm-hmm .

D2N142

16

[ "Personal History" ]

[ "Subjective" ]

yeah , so it sounds like we are not too far out of where we wan na be .

3,597

doctor: okay . well let me get a listen to your heart , go ahead and hop up here . patient: okay .

D2N142

17

[ "Physical Examination" ]

[ "Objective" ]

okay . well let me get a listen to your heart , go ahead and hop up here .

3,598

doctor: use my general exam template . all right , go ahead and take some deep breaths . okay , good . any fever , cough , shortness of breath or sore throat ? patient: no .

D2N142

18

[ "Physical Examination", "Vegetative History" ]

[ "Subjective", "Objective" ]

use my general exam template . all right , go ahead and take some deep breaths . okay , good . any fever , cough , shortness of breath or sore throat ?

3,599