Datasets:
DATEXIS
/
aci_bench_intent_annotated

Dataset card Data Studio Files
xet
Community
1
text
stringlengths
14
3.73k
encounter_id
stringclasses
207 values
text_id
int64
0
69
intents
listlengths
1
9
sections
listlengths
1
4
doc_only
stringlengths
6
3.62k
__index_level_0__
int64
0
5.29k
doctor: but in general , doxycycline is such a low risk . we're not gon na have you on this forever . but especially since we're adding the tacrolimus , i expect it will clear quickly . patient: sounds good .
D2N145
52
[ "Discussion", "Medication" ]
[ "Plan" ]
but in general , doxycycline is such a low risk . we're not gon na have you on this forever . but especially since we're adding the tacrolimus , i expect it will clear quickly .
3,700
doctor: all right . and i just wan na really help knock it out as fast as possible , since you've been dealing with it for so long now . i would take it twice a day until it's gone , and then once a day for a week before you stop . i'll write it out like that . so twice a day until rash is gone , and then once a day for another week before stopping . patient: okay .
D2N145
53
[ "Medication" ]
[ "Plan" ]
all right . and i just wan na really help knock it out as fast as possible , since you've been dealing with it for so long now . i would take it twice a day until it's gone , and then once a day for a week before you stop . i'll write it out like that . so twice a day until rash is gone , and then once a day for another week before stopping .
3,701
doctor: once the rash stops , you can stop the tacrolimus ointment . um , continue doxycycline another week and then stop . but you can keep using the wash and the metro cream . patient: okay , that sounds good . i can do that .
D2N145
54
[ "Medication" ]
[ "Plan" ]
once the rash stops , you can stop the tacrolimus ointment . um , continue doxycycline another week and then stop . but you can keep using the wash and the metro cream .
3,702
doctor: and then hold off until i see you again before you start back any of your old products . um , if it's starting to flair again , um , if it's just a little bit , you can try just doing the tacrolimus for a couple days , to see if that's enough . if it's not , then restart the dy- doxycycline as well . patient: all right .
D2N145
55
[ "Medication" ]
[ "Plan" ]
and then hold off until i see you again before you start back any of your old products . um , if it's starting to flair again , um , if it's just a little bit , you can try just doing the tacrolimus for a couple days , to see if that's enough . if it's not , then restart the dy- doxycycline as well .
3,703
doctor: i do n't expect that to happen , but , you know , if it does , you have the tools . um , then you'll be seeing me for a followup . we can figure out what to do next . i would say if it's getting worse rather than better , just give me a call or send me a mychart message , okay ? patient: yeah , sounds good .
D2N145
56
[ "Discussion", "Follow-up" ]
[ "Plan" ]
i do n't expect that to happen , but , you know , if it does , you have the tools . um , then you'll be seeing me for a followup . we can figure out what to do next . i would say if it's getting worse rather than better , just give me a call or send me a mychart message , okay ?
3,704
doctor: do you have enough refills ? patient: yeah , i think so .
D2N145
57
[ "Discussion", "Medication" ]
[ "Plan" ]
do you have enough refills ?
3,705
doctor: okay . so it looks like you have another refill of the doxycycline , so you're good there . metro cream , you probably still have enough of that one . patient: yes , i do .
D2N145
58
[ "Discussion", "Medication" ]
[ "Plan" ]
okay . so it looks like you have another refill of the doxycycline , so you're good there . metro cream , you probably still have enough of that one .
3,706
doctor: all right . and i'll cancel the elidel cream , just so we do n't complicate your list . uh , you have plenty of the face wash still . patient: yes .
D2N145
59
[ "Discussion", "Medication" ]
[ "Plan" ]
all right . and i'll cancel the elidel cream , just so we do n't complicate your list . uh , you have plenty of the face wash still .
3,707
doctor: okay . uh , and we'll get rid of the clindamycin from your list as well . patient: and what would you suggest for a moisturizer ?
D2N145
60
[ "Discussion", "Medication" ]
[ "Plan" ]
okay . uh , and we'll get rid of the clindamycin from your list as well .
3,708
doctor: yeah , so for that i would do something really basic like vanicream . or even , if it's just really dry , you could use a little bit of petroleum jelly . um , i'll give you a couple samples , okay ? let's make sure we have a followup in about four weeks . patient: okay , thank you .
D2N145
61
[ "Discussion", "Follow-up", "Medication" ]
[ "Plan" ]
yeah , so for that i would do something really basic like vanicream . or even , if it's just really dry , you could use a little bit of petroleum jelly . um , i'll give you a couple samples , okay ? let's make sure we have a followup in about four weeks .
3,709
doctor: okay . and i would stay away from any kind of anti-aging thing , any kind of plant thing . um , really let's just be sure we talk about any new products , or reach out to me if you're gon na try something else . um , let's go get those samples . patient: okay , that sounds good .
D2N145
62
[ "Discussion", "Medication" ]
[ "Plan" ]
okay . and i would stay away from any kind of anti-aging thing , any kind of plant thing . um , really let's just be sure we talk about any new products , or reach out to me if you're gon na try something else . um , let's go get those samples .
3,710
doctor: for assessment and plan , perioral dermatitis , rosacea , including ocular rosacea , and copy and paste her patient instructions . i recommend that she gently wash her eyelids once a day with gentle cleanser such as vanicream , also use bruder mask as needed .
D2N145
63
[ "Acute Assessment", "Medication" ]
[ "Assessment", "Plan" ]
doctor: for assessment and plan , perioral dermatitis , rosacea , including ocular rosacea , and copy and paste her patient instructions . i recommend that she gently wash her eyelids once a day with gentle cleanser such as vanicream , also use bruder mask as needed .
3,711
doctor: hey good morning bobby how are you patient: i'm doing okay i as you're aware doctor miller sent me over for this pain in my belly that i've had for several weeks they did he did an ultrasound and and said i had gallstones and they recommended i stay several way from some high fat food but i'm just still having a lot of pain and he referred me to you
D2N146
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
hey good morning bobby how are you
3,712
doctor: alright well i'm i'm sorry to hear that you're having pain but i i'm glad that he sent you over to see me i wan na talk a little bit more about that pain can you describe the kind of pain that you feel patient: well it's it's on the right hand side of my belly it's it's right underneath my ribs and it feels like a a squeezing severe pain it comes and goes but when it comes it's really severe and i get kind of nauseated and sick in my stomach
D2N146
1
[ "Acute Symptoms" ]
[ "Subjective" ]
alright well i'm i'm sorry to hear that you're having pain but i i'm glad that he sent you over to see me i wan na talk a little bit more about that pain can you describe the kind of pain that you feel
3,713
doctor: okay and then when you get that pain can you rate that pain for me on a scale like zero being none ten being the worst pain you've ever been in your life patient: when it's severe it's it's probably an eight
D2N146
2
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and then when you get that pain can you rate that pain for me on a scale like zero being none ten being the worst pain you've ever been in your life
3,714
doctor: okay alright and then time wise are we looking at can it just come and go anytime or is it specifically around mealtimes how how does that pain kinda wax and wane for you patient: most of the time it comes right after i eat
D2N146
3
[ "Acute Symptoms" ]
[ "Subjective" ]
okay alright and then time wise are we looking at can it just come and go anytime or is it specifically around mealtimes how how does that pain kinda wax and wane for you
3,715
doctor: do n't weigh all so speaking of eating let's talk a little bit about your diet i see here on your chart that you're a type two diabetic and it looked like that you were gon na handle that with diet and exercise let's talk about that a little bit patient: well you know i my my diet was worse when i before i was diagnosed with the the type two diabetes
D2N146
6
[ "Personal History" ]
[ "Subjective" ]
do n't weigh all so speaking of eating let's talk a little bit about your diet i see here on your chart that you're a type two diabetic and it looked like that you were gon na handle that with diet and exercise let's talk about that a little bit
3,716
doctor: okay so other than the weight loss how how is your diet is that has that been working out for you i mean do you does does that does that fit your lifestyle pretty well patient: yeah it does it does it it i was surprised it was n't as hard as i thought to go back and cut back and go more of a keto diet
D2N146
8
[ "Personal History", "Other Socials" ]
[ "Subjective" ]
okay so other than the weight loss how how is your diet is that has that been working out for you i mean do you does does that does that fit your lifestyle pretty well
3,717
doctor: yeah and that can happen and one of those things that causes that is that those intake of that fatty foods which is you know kind of the the keystone or the hallmark of the keto diet and have you noticed any improvement when you do cut out that fatty food and has that been difficult since you are watching your carb intake patient: the fatty food it is a little bit difficult you know i like those pork grinds and you know i i've had to kind of cut those out they were a nice staple for me when i was on the keto diet but i have cut out the those pork rinses because those were just so delicious and you know i would say it's a little bit better but i still get that pain
D2N146
11
[ "Personal History" ]
[ "Subjective" ]
yeah and that can happen and one of those things that causes that is that those intake of that fatty foods which is you know kind of the the keystone or the hallmark of the keto diet and have you noticed any improvement when you do cut out that fatty food and has that been difficult since you are watching your carb intake
3,718
doctor: okay and then do you have any family history of gallbladder disease patient: yeah but you know you know i knew that was coming both my dad and my mother both had gallbladder disease and had to have their gallbladders off
D2N146
12
[ "Family History" ]
[ "Subjective" ]
okay and then do you have any family history of gallbladder disease
3,719
doctor: okay so both both your parents your mom and your dad had your had their gallbladders taken out patient: yeah
D2N146
13
[ "Family History" ]
[ "Subjective" ]
okay so both both your parents your mom and your dad had your had their gallbladders taken out
3,720
doctor: okay and then i wan na talk a little bit about your activity level and your and and if you're exercising has this affected your ability to to get out and exercise patient: not really i mean i usually i got ta watch it around meals you know but i've never been a big exerciser right after eating anyhow but you know i'm i'm so glad springs here because it gives me that opportunity to get back out and you know i love photography i i love nature of photography and with the with the the woods going from you know that dark barron look to coming alive with that green and and butting i i love to get out and take foot photographs there
D2N146
14
[ "Other Socials" ]
[ "Subjective" ]
okay and then i wan na talk a little bit about your activity level and your and and if you're exercising has this affected your ability to to get out and exercise
3,721
doctor: that's awesome to hear yeah i my wife and i like to go over and take nature hikes through the new park behind the rex center that just opened up have you ever been over there to do any any picture taken we've got a bunch of beautiful nature pictures that we took about a week ago patient: no i have n't been there i might have to try that out yeah
D2N146
15
[ "Chitchat" ]
[ "Null" ]
that's awesome to hear yeah i my wife and i like to go over and take nature hikes through the new park behind the rex center that just opened up have you ever been over there to do any any picture taken we've got a bunch of beautiful nature pictures that we took about a week ago
3,722
doctor: yeah it's awesome patient: i like to get down near the river that's where i i like to catch especially around spring time
D2N146
16
[ "Chitchat" ]
[ "Null" ]
yeah it's awesome
3,723
doctor: that's great yeah next time you come in maybe you can bring in some of your pictures that'd be awesome to see patient: okay cool
D2N146
17
[ "Chitchat" ]
[ "Null" ]
that's great yeah next time you come in maybe you can bring in some of your pictures that'd be awesome to see
3,724
doctor: so i'm just curious talking about your symptoms here have you had any fevers you mentioned something about nausea but have you actually vomited from those symptoms patient: there's times when the pain is really bad for a couple of days i've had some what i i would describe as low grade fevers and yes you're right i have feel nauseated but i have n't thrown up
D2N146
18
[ "Vegetative History" ]
[ "Subjective" ]
so i'm just curious talking about your symptoms here have you had any fevers you mentioned something about nausea but have you actually vomited from those symptoms
3,725
doctor: okay so if it's okay with you i'm gon na go ahead and do a quick physical exam your vital signs look good today blood pressure was one twenty eight over eighty eight respiratory rate was sixteen your pulse rate was sixty eight you were afebrile today which is a good thing and your oxygen saturation on room air was ninety nine percent taking a listen to your heart here your heart is regular of rate and rhythm no i do n't hear any ectopic beats no clicks rubs or murmurs noted listening to your lungs here they are clear and equal bilaterally to auscultation now i'm gon na go ahead and do an an abdominal exam i do note positive bowel sounds soft nondistended abdomen however you are positive for some slight guarding there to the right upper quadrant but i do n't note any rebound tenderness now i'm gon na press slightly here beneath your ribs on the right hand side now take a breath in does that hurt when i press so i i see that you're guarded there so i'm gon na say that that it did hurt when i it did hurt when i patient: absolutely that hurts so much when you push right there
D2N146
19
[ "Physical Examination" ]
[ "Objective" ]
okay so if it's okay with you i'm gon na go ahead and do a quick physical exam your vital signs look good today blood pressure was one twenty eight over eighty eight respiratory rate was sixteen your pulse rate was sixty eight you were afebrile today which is a good thing and your oxygen saturation on room air was ninety nine percent taking a listen to your heart here your heart is regular of rate and rhythm no i do n't hear any ectopic beats no clicks rubs or murmurs noted listening to your lungs here they are clear and equal bilaterally to auscultation now i'm gon na go ahead and do an an abdominal exam i do note positive bowel sounds soft nondistended abdomen however you are positive for some slight guarding there to the right upper quadrant but i do n't note any rebound tenderness now i'm gon na press slightly here beneath your ribs on the right hand side now take a breath in does that hurt when i press so i i see that you're guarded there so i'm gon na say that that it did hurt when i it did hurt when i
3,726
doctor: okay that's that's no problem so you are positive for murphy's signs but i do n't appreciate any peritoneal signs so let's talk a little bit about your results that i reviewed before you came in today so your abdominal ultrasound shows multiple gallstones present in the gallbladder and i do appreciate some mild thickening now the common bile duct size is within normal limits at four . one millimeters now let's talk a little bit about my assessment and plan for you okay i do believe you have some mild cholecystitis with gallstones i do n't appreciate any frank obstruction but it looks like your gallbladder is inflamed and it looks like that's happened maybe over the last few weeks since you've been having those symptoms now since you have n't had any improvement with dietary modifications i am going to make the recommendation that we do remove your gallbladder and i would like to perform a laparoscopic cholecystectomy now what that means is i'll make a few small incisions and insert a scope with some of those instruments that's gon na remove that gallbladder through one of those little bitty incisions now the surgery is gon na take about an hour to an hour and a half and you'll probably spend the night in the hospital because we just wan na monitor you post procedure to make sure everything is okay you're still gon na wan na avoid those high fat foods after surgery and eat foods that are gon na be high in fiber now do you have any questions about what our assessment and plan is for for this patient: no no questions today
D2N146
21
[ "Physical Examination", "Discussion", "Other Treatments", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
okay that's that's no problem so you are positive for murphy's signs but i do n't appreciate any peritoneal signs so let's talk a little bit about your results that i reviewed before you came in today so your abdominal ultrasound shows multiple gallstones present in the gallbladder and i do appreciate some mild thickening now the common bile duct size is within normal limits at four . one millimeters now let's talk a little bit about my assessment and plan for you okay i do believe you have some mild cholecystitis with gallstones i do n't appreciate any frank obstruction but it looks like your gallbladder is inflamed and it looks like that's happened maybe over the last few weeks since you've been having those symptoms now since you have n't had any improvement with dietary modifications i am going to make the recommendation that we do remove your gallbladder and i would like to perform a laparoscopic cholecystectomy now what that means is i'll make a few small incisions and insert a scope with some of those instruments that's gon na remove that gallbladder through one of those little bitty incisions now the surgery is gon na take about an hour to an hour and a half and you'll probably spend the night in the hospital because we just wan na monitor you post procedure to make sure everything is okay you're still gon na wan na avoid those high fat foods after surgery and eat foods that are gon na be high in fiber now do you have any questions about what our assessment and plan is for for this
3,727
doctor: okay now the other thing patient: how soon can i how soon will i be able to get up and get moving back outside after the surgery
D2N146
22
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
okay now the other thing
3,728
doctor: so the good news is since it's a laparoscopic procedure you're gon na be back on your feet pretty quick now for the first twenty four hours i'm gon na want you to take it pretty easy but after a couple of days if you feel like moving around on some solid ground you know we do n't want you hiking or anything like that but if you feel like moving around on some solid ground you can get up and walk around within a day or two and then in about a week or so i'll see you again and then we'll release you to go get back out there in nature patient: okay thank you very much
D2N146
23
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
so the good news is since it's a laparoscopic procedure you're gon na be back on your feet pretty quick now for the first twenty four hours i'm gon na want you to take it pretty easy but after a couple of days if you feel like moving around on some solid ground you know we do n't want you hiking or anything like that but if you feel like moving around on some solid ground you can get up and walk around within a day or two and then in about a week or so i'll see you again and then we'll release you to go get back out there in nature
3,729
doctor: you're very welcome the other thing i wan na talk briefly about is now your not your type two diabetes i want you to follow up with your physician just to make sure that you're handling your diabetes especially the fact that you're gon na have surgery and those type of things and we will just continue to monitor your diabetes as has been outlined by your your additional either your endocrinologist or your primary care provider i'm gon na have the nurse come in and get some paperwork signed and if you do n't have any questions for me i will see you next week and we will get this gallbladder out patient: well thank you very much i'm looking forward to i i do n't want anymore of that pain so
D2N146
24
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
you're very welcome the other thing i wan na talk briefly about is now your not your type two diabetes i want you to follow up with your physician just to make sure that you're handling your diabetes especially the fact that you're gon na have surgery and those type of things and we will just continue to monitor your diabetes as has been outlined by your your additional either your endocrinologist or your primary care provider i'm gon na have the nurse come in and get some paperwork signed and if you do n't have any questions for me i will see you next week and we will get this gallbladder out
3,730
doctor: alright that sounds good we'll see you next week then patient: okay take care
D2N146
25
[ "Chitchat" ]
[ "Null" ]
alright that sounds good we'll see you next week then
3,731
doctor: hi matthew how are you the medical assistant told me that you injured your shoulder patient: hey yeah i'm i'm hanging in there
D2N147
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
hi matthew how are you the medical assistant told me that you injured your shoulder
3,732
doctor: what happened patient: yeah so well when i was younger i used to be a little bit more active with my friends with the playing pick up football and so you know me being a little bit older now i thought i'll take back up with no problem well i did i tried and all the other guys were a little bit bigger than me so i got i got tackled a couple of times and it just i kinda landed on my shoulder a little bit weird one time and so like i got back into the game i was okay but yeah ever since then the past couple of days it's just been it's been really bothering me
D2N147
1
[ "Acute Symptoms" ]
[ "Subjective" ]
what happened
3,733
doctor: okay alright and so when exactly did this happen patient: yeah i'd say maybe it was probably about last weekends so i'd say about like four days ago
D2N147
2
[ "Acute Symptoms" ]
[ "Subjective" ]
okay alright and so when exactly did this happen
3,734
doctor: okay well i'm happy at age 67 you're out there playing tackle football so good good for you and was it your right shoulder or your left shoulder that you injured patient: it was my right
D2N147
3
[ "Acute Symptoms", "Chitchat" ]
[ "Subjective" ]
okay well i'm happy at age 67 you're out there playing tackle football so good good for you and was it your right shoulder or your left shoulder that you injured
3,735
doctor: okay and are you right or left handed patient: i'm right handed
D2N147
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and are you right or left handed
3,736
doctor: okay and have you had any numbing or tingling in your fingers at all patient: no fingers have been okay
D2N147
5
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and have you had any numbing or tingling in your fingers at all
3,737
doctor: okay and any problems with the strength of the arm at all are you able to grab a cup of coffee patient: yeah i hand's doing okay i can grab yeah i'm just trying to avoid lifting anything yeah anything anything anything a little bit too heavy like i had a chipment command so i had a box in the driveway the other day and reaching down and picking up the box was a little tough
D2N147
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and any problems with the strength of the arm at all are you able to grab a cup of coffee
3,738
doctor: okay and where exactly on your shoulder does it hurt patient: yeah it's kinda on the on the back side right right around here
D2N147
7
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and where exactly on your shoulder does it hurt
3,739
doctor: mm-hmm okay alright and are you able to lift up your shoulder so that your shoulder touches your ear at all patient: yeah no that's that's that's hurting a little bit
D2N147
8
[ "Acute Symptoms" ]
[ "Subjective" ]
mm-hmm okay alright and are you able to lift up your shoulder so that your shoulder touches your ear at all
3,740
doctor: okay alright and what have you taken for the pain patient: just a little bit of tylenol trying to take it easy
D2N147
9
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay alright and what have you taken for the pain
3,741
doctor: did that help at all patient: it it kinda like kept it at the same spot that has been but it really did n't make it go down
D2N147
10
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
did that help at all
3,742
doctor: okay so are your symptoms any better since it happened or they about the same patient: no they are about the same
D2N147
11
[ "Acute Symptoms" ]
[ "Subjective" ]
okay so are your symptoms any better since it happened or they about the same
3,743
doctor: okay and any neck problems did you injure your neck when this happened patient: no neck has been okay
D2N147
12
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and any neck problems did you injure your neck when this happened
3,744
doctor: okay and any other joint problems like does your elbow hurt on that side or your wrist or is it just your shoulder patient: nope the the rest of it's doing okay it's just the just the shoulder
D2N147
13
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and any other joint problems like does your elbow hurt on that side or your wrist or is it just your shoulder
3,745
doctor: okay and any other orthopedic injuries in the past have you ever injured that shoulder before as far as you know patient: nope nope that one that one's been fine
D2N147
14
[ "Personal History" ]
[ "Subjective" ]
okay and any other orthopedic injuries in the past have you ever injured that shoulder before as far as you know
3,746
doctor: okay and any any other surgeries or any other medical problems patient: i mean i had a appendicitis so i had an appendectomy
D2N147
15
[ "Personal History" ]
[ "Subjective" ]
okay and any any other surgeries or any other medical problems
3,747
doctor: okay alright well i'm just gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so and last thing have you had any fever or chills since this happened at all patient: a slight headache but no no no fever
D2N147
17
[ "Physical Examination", "Vegetative History" ]
[ "Subjective", "Objective" ]
okay alright well i'm just gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so and last thing have you had any fever or chills since this happened at all
3,748
doctor: okay did you hit your head when you when this happened patient: a little bit
D2N147
18
[ "Personal History" ]
[ "Subjective" ]
okay did you hit your head when you when this happened
3,749
doctor: okay alright did you pass out patient: nope nope stayed conscious throughout
D2N147
19
[ "Personal History" ]
[ "Subjective" ]
okay alright did you pass out
3,750
doctor: okay alright well looking at your vital signs here in the office you do n't have any fever your blood pressure looks quite good it's about one twenty two over seventy six your heart rate is appropriate at eighty two beats per minute and your oxygenation is ninety five percent on room air on your cervical spine exam there is no tenderness to palpation of the cervical spine there is full range of motion on head exam there does not appear to be any trauma there is no ecchymosis or bruising on the right shoulder exam on your musculoskeletal exam there is pain to palpation of the posterior shoulder at the acromioclavicular joint there is decreased abduction and adduction to about ninety degrees only there is there is a he has pain with supination and pronation of the right arm and there is a palpable radial radial artery pulse okay so what does that mean that just means that you have some you know evidence of the injury there and we'll we're gon na talk about that so i had the nurse do a shoulder x-ray on you before i came in the room and the results of your right shoulder x-ray showed that you have an acute acromioclavicular joint fracture so you just have a a a small fracture of the acromion i do n't think that it it's gon na be anything that we need to do surgery for so let's just talk a little bit about my assessment and plan so for your right shoulder injury for your acute acromioclavicular joint fracture i wan na go ahead and just put you in a sling for now i wan na go ahead and prescribe meloxicam fifteen milligrams once a day i wan na go ahead and just order a cat scan of your right shoulder just to kinda get a better look of how the joint looks and we're gon na go ahead and refer you to physical therapy to strengthen your shoulder in hopes of avoiding surgery in the future how does that sound patient: yeah that that sounds great just being able to take a little bit of something for the pain would would would be really appreciated
D2N147
20
[ "Physical Examination", "Acute Assessment", "Other Treatments", "Referral", "Radiology Examination", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
okay alright well looking at your vital signs here in the office you do n't have any fever your blood pressure looks quite good it's about one twenty two over seventy six your heart rate is appropriate at eighty two beats per minute and your oxygenation is ninety five percent on room air on your cervical spine exam there is no tenderness to palpation of the cervical spine there is full range of motion on head exam there does not appear to be any trauma there is no ecchymosis or bruising on the right shoulder exam on your musculoskeletal exam there is pain to palpation of the posterior shoulder at the acromioclavicular joint there is decreased abduction and adduction to about ninety degrees only there is there is a he has pain with supination and pronation of the right arm and there is a palpable radial radial artery pulse okay so what does that mean that just means that you have some you know evidence of the injury there and we'll we're gon na talk about that so i had the nurse do a shoulder x-ray on you before i came in the room and the results of your right shoulder x-ray showed that you have an acute acromioclavicular joint fracture so you just have a a a small fracture of the acromion i do n't think that it it's gon na be anything that we need to do surgery for so let's just talk a little bit about my assessment and plan so for your right shoulder injury for your acute acromioclavicular joint fracture i wan na go ahead and just put you in a sling for now i wan na go ahead and prescribe meloxicam fifteen milligrams once a day i wan na go ahead and just order a cat scan of your right shoulder just to kinda get a better look of how the joint looks and we're gon na go ahead and refer you to physical therapy to strengthen your shoulder in hopes of avoiding surgery in the future how does that sound
3,751
doctor: okay do you think you need something stronger than meloxicam patient: no i'll give that a shot
D2N147
21
[ "Discussion", "Medication" ]
[ "Plan" ]
okay do you think you need something stronger than meloxicam
3,752
doctor: okay any questions patient: when can i get back out on the field
D2N147
23
[ "Discussion" ]
[ "Plan" ]
okay any questions
3,753
doctor: well you ca n't play taggle football for a while you have to have this fracture healed patient: okay
D2N147
24
[ "Discussion" ]
[ "Plan" ]
well you ca n't play taggle football for a while you have to have this fracture healed
3,754
doctor: and i would avoid doing it you know as we get older you know our bones get a little bit weaker so i would avoid the tackle football maybe flag football in the future okay patient: yeah yeah that sounds good
D2N147
25
[ "Discussion" ]
[ "Plan" ]
and i would avoid doing it you know as we get older you know our bones get a little bit weaker so i would avoid the tackle football maybe flag football in the future okay
3,755
doctor: okay anything else patient: no i think that's that's been great thank you so much
D2N147
26
[ "Discussion" ]
[ "Plan" ]
okay anything else
3,756
doctor: okay you're welcome have a good day bye patient: thanks
D2N147
27
[ "Chitchat" ]
[ "Null" ]
okay you're welcome have a good day bye
3,757
doctor: hi jeremy how are you the medical assistant told me that you injured your back patient: yeah i was moving some boxes when my son was moving out of his college dorm and i really hurt my lower back
D2N148
0
[ "Acute Symptoms", "Chitchat" ]
[ "Subjective" ]
hi jeremy how are you the medical assistant told me that you injured your back
3,758
doctor: okay how long ago did that happen patient: this was about four months ago
D2N148
1
[ "Acute Symptoms" ]
[ "Subjective" ]
okay how long ago did that happen
3,759
doctor: about four months ago okay that's quite a long time and you're just seeing me now for it patient: yeah the appointments were backed up and i tried some pt at my gym but it it really did n't seem to help and i was really concerned
D2N148
2
[ "Acute Symptoms" ]
[ "Subjective" ]
about four months ago okay that's quite a long time and you're just seeing me now for it
3,760
doctor: okay and what exactly are your symptoms are you having pain when you're just sitting there or when you're moving around for a very short period of time patient: it felt like i was gon na tapple over i like i could n't support my my upper body weight and then my right toe or the the toes on my right foot tingled a little bit but that went away after about an hour
D2N148
3
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and what exactly are your symptoms are you having pain when you're just sitting there or when you're moving around for a very short period of time
3,761
doctor: okay are you still getting that numbing and tingling periodically in your feet or is that completely gone patient: that's completely gone it it just happened when i first felt the the tweak in my lower back i felt that sensation but i have n't since
D2N148
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay are you still getting that numbing and tingling periodically in your feet or is that completely gone
3,762
doctor: okay and how about any difficulty or weakness in your legs patient: only if i'm carrying something heavy otherwise it seems relatively normal but i i feel the sensation so i'm a little nervous about carrying something heavy
D2N148
5
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and how about any difficulty or weakness in your legs
3,763
doctor: okay and are and do you still have pain down there in your lower back patient: if i turn a certain way or if i roll over in my sleep i'll wake up from it from a like a sharp pain but then that that goes away if i if i position myself the right way
D2N148
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and are and do you still have pain down there in your lower back
3,764
doctor: okay and what have you been taking for the pain patient: i took some tylenol i took some ibuprofen i've tried heat i've tried ice and nothing really seems to help
D2N148
7
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay and what have you been taking for the pain
3,765
doctor: okay is the ibuprofen any better than the tylenol patient: a little bit but for sure a shorter period of time
D2N148
8
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay is the ibuprofen any better than the tylenol
3,766
doctor: okay and did you get any stomach upset from the ibuprofen patient: no i try not to take too much so i i do n't have an upset stomach from it
D2N148
9
[ "Therapeutic History", "Vegetative History" ]
[ "Subjective" ]
okay and did you get any stomach upset from the ibuprofen
3,767
doctor: okay and did you go to like an urgent care centing or an emergency room have you had any imaging on this at all patient: i went to an urgent care and they wanted me to do an mri but i was a little concerned because i think we maxed out our insurance so i i did n't do it because it started to feel better but because it's been going on so long i'm i'm a little bit concerned now i i do wan na actually move forward with that
D2N148
10
[ "Personal History" ]
[ "Subjective" ]
okay and did you go to like an urgent care centing or an emergency room have you had any imaging on this at all
3,768
doctor: okay alright and any other symptoms any problems with like your bladder or your bowels any incontinence or you know you feel like you ca n't go to the bathroom patient: no i have n't had any of those issues
D2N148
11
[ "Vegetative History" ]
[ "Subjective" ]
okay alright and any other symptoms any problems with like your bladder or your bowels any incontinence or you know you feel like you ca n't go to the bathroom
3,769
doctor: okay alright and any other any other past medical history do you that you have any patient: i had knee surgery about two years ago on my right knee
D2N148
12
[ "Personal History" ]
[ "Subjective" ]
okay alright and any other any other past medical history do you that you have any
3,770
doctor: okay and what did you have done to your right knee patient: it was a total knee replacement
D2N148
14
[ "Personal History" ]
[ "Subjective" ]
okay and what did you have done to your right knee
3,771
doctor: okay a total knee replacement in twenty eighteen is that what you said patient: no it was actually about two years ago so it's the spring of twenty twenty
D2N148
15
[ "Personal History" ]
[ "Subjective" ]
okay a total knee replacement in twenty eighteen is that what you said
3,772
doctor: okay alright alright well i wan na go ahead and just move on to a physical exam i'm gon na be calling out some of my exam findings patient: mm-hmm
D2N148
16
[ "Physical Examination" ]
[ "Objective" ]
okay alright alright well i wan na go ahead and just move on to a physical exam i'm gon na be calling out some of my exam findings
3,773
doctor: now you have you had any fever or chills with this patient: no
D2N148
17
[ "Vegetative History" ]
[ "Subjective" ]
now you have you had any fever or chills with this
3,774
doctor: okay alright alright so looking at your vital signs here in the office you know they look really good your you you do n't have any temperature your blood pressure is good it's about one seventeen over fifty six patient: mm-hmm
D2N148
18
[ "Physical Examination" ]
[ "Objective" ]
okay alright alright so looking at your vital signs here in the office you know they look really good your you you do n't have any temperature your blood pressure is good it's about one seventeen over fifty six
3,775
doctor: your heart rate is nice and slow at sixty eight and your oxygenation is fine at ninety five percent on room air so that means everything looks good patient: good
D2N148
19
[ "Physical Examination" ]
[ "Objective" ]
your heart rate is nice and slow at sixty eight and your oxygenation is fine at ninety five percent on room air so that means everything looks good
3,776
doctor: on your neck exam i i do appreciate some bony protuberance of the c5 c6 do you have any pain when i touch here patient: no
D2N148
20
[ "Physical Examination" ]
[ "Objective" ]
on your neck exam i i do appreciate some bony protuberance of the c5 c6 do you have any pain when i touch here
3,777
doctor: no okay on your lumbar spine exam i do appreciate do you have pain when i touch here patient: no
D2N148
21
[ "Physical Examination" ]
[ "Objective" ]
no okay on your lumbar spine exam i do appreciate do you have pain when i touch here
3,778
doctor: okay so there is no pain to palpation of the lumbar spine there is decreased flexion and extension of the lower back the patient does have a positive straight leg raise and there is some spasm of the paraspinal muscles of the lumbar spine on musculoskeletal exam the lower extremities strength is equal bilaterally so what does that mean jeremy that means that you have some you know maybe a some arthritis in your neck here and or maybe just a a little bit of some injury from from that from that back that back thing that you told me about patient: mm-hmm
D2N148
22
[ "Physical Examination", "Acute Assessment" ]
[ "Objective", "Assessment" ]
okay so there is no pain to palpation of the lumbar spine there is decreased flexion and extension of the lower back the patient does have a positive straight leg raise and there is some spasm of the paraspinal muscles of the lumbar spine on musculoskeletal exam the lower extremities strength is equal bilaterally so what does that mean jeremy that means that you have some you know maybe a some arthritis in your neck here and or maybe just a a little bit of some injury from from that from that back that back thing that you told me about
3,779
doctor: okay but i think overall things look really good so you know i had them do an lumbar spine x-ray on you before i saw you and i looked at the results of your lumbar spine x-ray which showed no acute bony abnormality you know there was no fracture of your back or anything which is not surprising based on your history so let's just talk a little bit about my assessment and plan so i do believe it sounds like you have an acute disk herniation now this did happen a few months ago but it sounds like that's what you had based on the fact that you're still having symptoms patient: mm-hmm
D2N148
23
[ "Acute Assessment", "Radiology Examination" ]
[ "Objective", "Assessment" ]
okay but i think overall things look really good so you know i had them do an lumbar spine x-ray on you before i saw you and i looked at the results of your lumbar spine x-ray which showed no acute bony abnormality you know there was no fracture of your back or anything which is not surprising based on your history so let's just talk a little bit about my assessment and plan so i do believe it sounds like you have an acute disk herniation now this did happen a few months ago but it sounds like that's what you had based on the fact that you're still having symptoms
3,780
doctor: i do wan na go ahead and order a a lumbar spine mri to get a a a better look at what's going on you know x-rays really just look at the bones they do n't show us any of the soft tissue so let's go ahead and order the lumbar spine mri i wan na continue with physical therapy so i'm going to refer you to a a physical therapist through our health system patient: mm-hmm
D2N148
24
[ "Diagnostic Testing", "Referral" ]
[ "Plan" ]
i do wan na go ahead and order a a lumbar spine mri to get a a a better look at what's going on you know x-rays really just look at the bones they do n't show us any of the soft tissue so let's go ahead and order the lumbar spine mri i wan na continue with physical therapy so i'm going to refer you to a a physical therapist through our health system
3,781
doctor: and then i also wan na go ahead and prescribe meloxicam fifteen milligrams once a day patient: mm-hmm
D2N148
25
[ "Medication" ]
[ "Plan" ]
and then i also wan na go ahead and prescribe meloxicam fifteen milligrams once a day
3,782
doctor: to help with that do you have any questions about that patient: no questions
D2N148
26
[ "Discussion" ]
[ "Plan" ]
to help with that do you have any questions about that
3,783
doctor: now if you do have a herniated disk we can go ahead and talk about some other treatment options maybe like an epidural steroid injection to help take down some of that inflammation patient: mm-hmm
D2N148
27
[ "Discussion", "Medication" ]
[ "Plan" ]
now if you do have a herniated disk we can go ahead and talk about some other treatment options maybe like an epidural steroid injection to help take down some of that inflammation
3,784
doctor: it might make you feel better but we'll we'll deal with that when we get get there okay patient: sure
D2N148
28
[ "Discussion", "Medication" ]
[ "Plan" ]
it might make you feel better but we'll we'll deal with that when we get get there okay
3,785
doctor: any questions patient: not at this point
D2N148
29
[ "Discussion" ]
[ "Plan" ]
any questions
3,786
doctor: okay great thank you patient: thank you
D2N148
30
[ "Chitchat" ]
[ "Null" ]
okay great thank you
3,787
doctor: so dennis is a 57 -year-old male today complaining of shortness of breath he has also got a history of diabetes high blood pressure and history of asthma so dennis tell me what's going on how're you doing patient: not too good
D2N149
0
[ "Acute Symptoms", "Personal History", "Greetings" ]
[ "Subjective" ]
so dennis is a 57 -year-old male today complaining of shortness of breath he has also got a history of diabetes high blood pressure and history of asthma so dennis tell me what's going on how're you doing
3,788
doctor: okay how long have you been feeling not too well patient: about a couple of weeks
D2N149
1
[ "Acute Symptoms" ]
[ "Subjective" ]
okay how long have you been feeling not too well
3,789
doctor: couple of weeks tell me what's going on patient: i wake up with shortness of breath
D2N149
2
[ "Acute Symptoms" ]
[ "Subjective" ]
couple of weeks tell me what's going on
3,790
doctor: have you noticed any are you coughing up anything any swelling in your legs or what's going on patient: yeah i've been i've been coughing up i've been coughing up blood
D2N149
4
[ "Vegetative History" ]
[ "Subjective" ]
have you noticed any are you coughing up anything any swelling in your legs or what's going on
3,791
doctor: okay how long has that been going on for patient: probably three weeks or so
D2N149
5
[ "Vegetative History" ]
[ "Subjective" ]
okay how long has that been going on for
3,792
doctor: okay and are you coughing a lot of blood or just a little bit of blood patient: i shave three to four cups a day
D2N149
6
[ "Vegetative History" ]
[ "Subjective" ]
okay and are you coughing a lot of blood or just a little bit of blood
3,793
doctor: wow that's a lot of blood okay are you throwing up any blood are you having bleeding in any place else or just when you cough patient: only when i cough
D2N149
7
[ "Vegetative History" ]
[ "Subjective" ]
wow that's a lot of blood okay are you throwing up any blood are you having bleeding in any place else or just when you cough
3,794
doctor: okay have you noticed any bruising or bleeding from your teeth or anything like that or from your gums or anything like that patient: no
D2N149
8
[ "Vegetative History" ]
[ "Subjective" ]
okay have you noticed any bruising or bleeding from your teeth or anything like that or from your gums or anything like that
3,795
doctor: okay any leg swelling or calf swelling or any any anything like that any recent travel history you've been on a plane or trip recently patient: i had some knee problem but there is no swelling but it hurts that's been going on for quite some time
D2N149
9
[ "Other Socials" ]
[ "Subjective" ]
okay any leg swelling or calf swelling or any any anything like that any recent travel history you've been on a plane or trip recently
3,796
doctor: okay so that's not near the knee problem okay and have you had any have you been to the hospital or been to the emergency room or anything like that for your coughing and coughing up blood patient: no i tried to get an appointment in the office but they were kinda booked up
D2N149
10
[ "Personal History" ]
[ "Subjective" ]
okay so that's not near the knee problem okay and have you had any have you been to the hospital or been to the emergency room or anything like that for your coughing and coughing up blood
3,797
doctor: alright and alright no but no fevers with this so since you're here your oxygen level looks pretty good in the clinic it's about ninety four percent on pulse your pulse oxygenation so that's good are you short of breath so when you walk or you or you exert yourself you're short of breath you said right okay and have you and how how is your blood sugar been doing since this has been going on i know you're on metformin how's your diabetes been doing patient: not so good you know it kinda going up and down i wear this dexcom
D2N149
12
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
alright and alright no but no fevers with this so since you're here your oxygen level looks pretty good in the clinic it's about ninety four percent on pulse your pulse oxygenation so that's good are you short of breath so when you walk or you or you exert yourself you're short of breath you said right okay and have you and how how is your blood sugar been doing since this has been going on i know you're on metformin how's your diabetes been doing
3,798
doctor: okay and patient: and morning when i get up they are around one fifty
D2N149
14
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
okay and
3,799