DATEXIS/aci_bench_intent_annotated · Datasets at Hugging Face

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doctor: does the ibuprofen work patient: at night you know during the day i'm more active so it it really does n't impact it because i just work through it but at night it does help me to settle down and sleep better	D2N153	10	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	does the ibuprofen work	3,900
doctor: does your knee hurt when you're just resting and sitting there patient: no when it's up it's fine when it's down on the floor with my foot flat it's fine it does hurt when i rest it on my heel	D2N153	11	[ "Acute Symptoms" ]	[ "Subjective" ]	does your knee hurt when you're just resting and sitting there	3,901
doctor: okay and are you able to do things like bending or things like that patient: a full squat that's when i feel the most clicking like if i go all the way down to a full squat like a catcher that's when i feel the most clicking but otherwise no there is no pain it's just the clicking and i'm fearful that that's an injury of some type	D2N153	12	[ "Acute Symptoms" ]	[ "Subjective" ]	okay and are you able to do things like bending or things like that	3,902
doctor: okay alright now you said squats are you are you active are you doing like burpees going to patient: no i ride the bike	D2N153	13	[ "Other Socials" ]	[ "Subjective" ]	okay alright now you said squats are you are you active are you doing like burpees going to	3,903
doctor: okay alright well i have a peloton who is your favorite instructor patient: i i actually do n't have a favorite instructor i have more favorite rides	D2N153	15	[ "Chitchat" ]	[ "Null" ]	okay alright well i have a peloton who is your favorite instructor	3,904
doctor: okay what kind of rides do you like patient: i like rock music and regain music rides so whoever is doing those in a began or a medium content i'm cool with	D2N153	16	[ "Chitchat" ]	[ "Null" ]	okay what kind of rides do you like	3,905
doctor: i ca n't picture you as a regade person so that's interesting to know okay alright and any numbing or tingling in your foot at all patient: yes but not from the knee injury i broke my foot my second toe on my right foot and i have numbness depending upon the shoe i wear	D2N153	17	[ "Acute Symptoms" ]	[ "Subjective" ]	i ca n't picture you as a regade person so that's interesting to know okay alright and any numbing or tingling in your foot at all	3,906
doctor: okay when did you break your toe patient: i've broken it three times over the last ten years so it's just something that's a an annoyance but it was n't caused by this injury	D2N153	18	[ "Personal History" ]	[ "Subjective" ]	okay when did you break your toe	3,907
doctor: okay so you do have some numbing and tingling but it's not new patient: right correct	D2N153	19	[ "Personal History" ]	[ "Subjective" ]	okay so you do have some numbing and tingling but it's not new	3,908
doctor: alright alright well let's just go ahead and i'm 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 on your musculoskeletal exam on your right knee i do appreciate some slight edema you do have a slight effusion does it hurt when i press on the outside of your knee patient: no not physically	D2N153	20	[ "Physical Examination" ]	[ "Objective" ]	alright alright well let's just go ahead and i'm 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 on your musculoskeletal exam on your right knee i do appreciate some slight edema you do have a slight effusion does it hurt when i press on the outside of your knee	3,909
doctor: okay there is no pain to palpation of the right lateral knee i'm gon na be bending your knee in all sorts of positions does that hurt patient: only when you pull it to the outside	D2N153	21	[ "Physical Examination" ]	[ "Objective" ]	okay there is no pain to palpation of the right lateral knee i'm gon na be bending your knee in all sorts of positions does that hurt	3,910
doctor: okay the patient has a positive varus test there is full range of motion there is a negative lachman sign the patient does on cardiovascular exam the patient does have a palpable dorsalis pedis and posterior tibialis pulse okay well let's just i wan na talk a little bit about i had the nurse do an x-ray on you and i looked at the results of your knee x-ray and it does n't show any acute fracture or bony abnormality which is not surprising based on your injury so let's just talk a little bit about you know my assessment and my plan for you so i think you do have a a lateral a lateral collateral ligament strain based on your exam findings and this this type of injury essentially can be healed by itself you know i do n't think we're gon na need to refer you to surgery or anything like that i want you to go ahead and i'm gon na prescribe meloxicam fifteen milligrams once a day i do wan na go ahead and refer you to physical therapy because if we strengthen up those muscles and areas around that injury then that will make your knee stronger it help prevent future injuries are you able to ice it at all during the day now you said you working you work in sales so you said you're home patient: yeah i actually i'm at home so i can ice it and i have been icing it	D2N153	23	[ "Physical Examination", "Acute Assessment", "Other Socials", "Referral", "Radiology Examination", "Medication" ]	[ "Subjective", "Objective", "Assessment", "Plan" ]	okay the patient has a positive varus test there is full range of motion there is a negative lachman sign the patient does on cardiovascular exam the patient does have a palpable dorsalis pedis and posterior tibialis pulse okay well let's just i wan na talk a little bit about i had the nurse do an x-ray on you and i looked at the results of your knee x-ray and it does n't show any acute fracture or bony abnormality which is not surprising based on your injury so let's just talk a little bit about you know my assessment and my plan for you so i think you do have a a lateral a lateral collateral ligament strain based on your exam findings and this this type of injury essentially can be healed by itself you know i do n't think we're gon na need to refer you to surgery or anything like that i want you to go ahead and i'm gon na prescribe meloxicam fifteen milligrams once a day i do wan na go ahead and refer you to physical therapy because if we strengthen up those muscles and areas around that injury then that will make your knee stronger it help prevent future injuries are you able to ice it at all during the day now you said you working you work in sales so you said you're home	3,911
doctor: okay and so does that help at all patient: it's it it makes it feel better in the morning when i first go to my desk and at the end of the day before bed you know i take ibuprofen so i do n't have swelling overnight but honestly i have a pretty decent threshold for pain so it's not good it's not changing it by much	D2N153	25	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	okay and so does that help at all	3,912
doctor: okay do you feel like your symptoms are getting worse or better patient: i think i think pretty much for the last two weeks they've remained about the same the the only time i feel like they get worse is when i exert myself doing up and down like gardening in the yard or moving pots and stuff outside that's the only time i felt like it got any worse but nothing to the point where it stayed worse	D2N153	26	[ "Acute Symptoms" ]	[ "Subjective" ]	okay do you feel like your symptoms are getting worse or better	3,913
doctor: okay alright well let's go ahead and refer you to physical therapy if you're still having pain then we might have to consider an mri patient: okay	D2N153	27	[ "Discussion", "Diagnostic Testing", "Referral" ]	[ "Plan" ]	okay alright well let's go ahead and refer you to physical therapy if you're still having pain then we might have to consider an mri	3,914
doctor: any questions about that patient: no	D2N153	28	[ "Discussion" ]	[ "Plan" ]	any questions about that	3,915
doctor: okay alright well it was very nice seeing you today call me if you need anything patient: i will	D2N153	29	[ "Chitchat" ]	[ "Null" ]	okay alright well it was very nice seeing you today call me if you need anything	3,916
doctor: okay bye patient: bye	D2N153	30	[ "Chitchat" ]	[ "Null" ]	okay bye	3,917
doctor: hi dennis how are you today patient: good	D2N154	0	[ "Greetings" ]	[ "Subjective" ]	hi dennis how are you today	3,918
doctor: so what what brings you into the office i do n't believe i have ever seen you before here patient: the i'm training for a triathlon and the back of my heel hurts typically after a workout or when i first get up in the morning it will really hurt in the back of my heel all the way up into my calf	D2N154	1	[ "Acute Symptoms" ]	[ "Subjective" ]	so what what brings you into the office i do n't believe i have ever seen you before here	3,919
doctor: okay now tell me a little bit about this triathlon training what do you are you are you running far are you tell me kind of how you work out for that today patient: i i will run about ten klometers	D2N154	2	[ "Other Socials" ]	[ "Subjective" ]	okay now tell me a little bit about this triathlon training what do you are you are you running far are you tell me kind of how you work out for that today	3,920
doctor: wow that's that's a that's an aggressive campaign to get there so really hope you get that triathlon in so you're how many days a week does this occur that you're training patient: i i do that five days a week on the weekends i kinda alternate between you know a long run and a long bike do n't really do a long swim but	D2N154	5	[ "Other Socials" ]	[ "Subjective" ]	wow that's that's a that's an aggressive campaign to get there so really hope you get that triathlon in so you're how many days a week does this occur that you're training	3,921
doctor: okay on your running days or when you do the running tell me a little bit about your stretching routine do you are you aggressive stretchers you do not stretch at all i know people that do both patient: yeah i do n't i do n't stretch at all i do n't have time for that	D2N154	7	[ "Other Socials" ]	[ "Subjective" ]	okay on your running days or when you do the running tell me a little bit about your stretching routine do you are you aggressive stretchers you do not stretch at all i know people that do both	3,922
doctor: okay and i'm assuming that with the bicycle either you do n't really work the lower legs to get them stretched out you just jump on and go correct patient: yeah	D2N154	8	[ "Other Socials" ]	[ "Subjective" ]	okay and i'm assuming that with the bicycle either you do n't really work the lower legs to get them stretched out you just jump on and go correct	3,923
doctor: okay tell me a little bit about the pain is you said it it's after the activity but it you when you first wake up in the morning it it's it's there also patient: yeah when i first get out of bed it's just it just feels really tight and almost like it's tearing and i after i been walking around for about ten or fifteen minutes it eases up a little bit but if if i ever sit down for any extended period of time and then try to get back up it's really sore again	D2N154	10	[ "Acute Symptoms" ]	[ "Subjective" ]	okay tell me a little bit about the pain is you said it it's after the activity but it you when you first wake up in the morning it it's it's there also	3,924
doctor: no go ahead go ahead patient: or after a lot of activity it'll get sore too	D2N154	12	[ "Acute Symptoms" ]	[ "Subjective" ]	no go ahead go ahead	3,925
doctor: okay okay i'm sure this is impacting that ability to to really focus on your training uh as you're going with that with that type of a pain so lem me go ahead and let's let's take a look at your your and your lower extremities here and yeah okay so roll up your pants yeah okay good now does your left leg hurt at all do you get that severe pain or is it mainly on the right patient: no it's mainly just on the right	D2N154	13	[ "Physical Examination" ]	[ "Objective" ]	okay okay i'm sure this is impacting that ability to to really focus on your training uh as you're going with that with that type of a pain so lem me go ahead and let's let's take a look at your your and your lower extremities here and yeah okay so roll up your pants yeah okay good now does your left leg hurt at all do you get that severe pain or is it mainly on the right	3,926
doctor: okay okay so i'm gon na just hold your leg here and i want you to take your your foot and ankle and i want you to go ahead and just pull your your toes up towards you does that create some pain when you do that patient: yeah a little bit	D2N154	14	[ "Physical Examination" ]	[ "Objective" ]	okay okay so i'm gon na just hold your leg here and i want you to take your your foot and ankle and i want you to go ahead and just pull your your toes up towards you does that create some pain when you do that	3,927
doctor: a little bit okay now i'm just gon na hold your foot up and i want you to push against me and does that hurt patient: yeah that hurts a little bit too	D2N154	15	[ "Physical Examination" ]	[ "Objective" ]	a little bit okay now i'm just gon na hold your foot up and i want you to push against me and does that hurt	3,928
doctor: yeah okay okay roll over here on my my stretcher for me and i want you to dangle your your feet over the edge and what i wan na do is i just wan na i'm gon na squeeze your left calf first and when i do that does that hurt on your left side patient: no	D2N154	16	[ "Physical Examination" ]	[ "Objective" ]	yeah okay okay roll over here on my my stretcher for me and i want you to dangle your your feet over the edge and what i wan na do is i just wan na i'm gon na squeeze your left calf first and when i do that does that hurt on your left side	3,929
doctor: and i'm gon na squeeze on the right side anything there patient: no	D2N154	18	[ "Physical Examination" ]	[ "Objective" ]	and i'm gon na squeeze on the right side anything there	3,930
doctor: okay okay well that's good your your thompson test is negative that's a really good finding and i just wan na continue pressing here on your right from your heel when i squeeze your heel does that cause significant pain at all patient: yeah	D2N154	19	[ "Physical Examination" ]	[ "Objective" ]	okay okay well that's good your your thompson test is negative that's a really good finding and i just wan na continue pressing here on your right from your heel when i squeeze your heel does that cause significant pain at all	3,931
doctor: yeah okay and if i come up a little bit further as i i run up that achilles tendon does that hurt patient: that's real tender	D2N154	20	[ "Physical Examination" ]	[ "Objective" ]	yeah okay and if i come up a little bit further as i i run up that achilles tendon does that hurt	3,932
doctor: yeah okay okay great not great so yeah go ahead and sit up for me so dennis my diagnosis is achilles tendinitis and it's really from overuse when we see this frequently when somebody starts to you know get in and train aggressively for an event i'm unfortunately i'm gon na have to ask you to stop training for a a week or two i know that's concerning but i really want this to heal before we move into that next phase i did n't ask you about medication but i'm assuming whatever you were doing was n't working significantly so what i'd like you to do is take some ibuprofen or advil that's the same medication and i want you to take three tablets every six hours and that's really an anti-inflammatory see if we can eliminate some of that tendinitis type pain that you're getting that inflammation around that achilles tendon i'm gon na also order a couple physical therapy visits and the reason for that is i'd like you to get some strength and stretching understanding i think it's important for you especially here at the beginning is to get some of that real stretching knowledge in and learn how to stretch those muscles before you start these activities and they are gon na help strengthen your your lower extremities also and i want you to come back to me within you know a week to ten days following your first couple physical therapy appointments so i can monitor how you're doing i see no reason for an x-ray at this point but if this continues we're gon na you know if you're still having pain ten days in significant pain without change modification of your activity then we may have to look at more aggressive treatment plans how does that sound for you patient: sounds good	D2N154	21	[ "Discussion", "Medication", "Referral", "Acute Assessment" ]	[ "Assessment", "Plan" ]	yeah okay okay great not great so yeah go ahead and sit up for me so dennis my diagnosis is achilles tendinitis and it's really from overuse when we see this frequently when somebody starts to you know get in and train aggressively for an event i'm unfortunately i'm gon na have to ask you to stop training for a a week or two i know that's concerning but i really want this to heal before we move into that next phase i did n't ask you about medication but i'm assuming whatever you were doing was n't working significantly so what i'd like you to do is take some ibuprofen or advil that's the same medication and i want you to take three tablets every six hours and that's really an anti-inflammatory see if we can eliminate some of that tendinitis type pain that you're getting that inflammation around that achilles tendon i'm gon na also order a couple physical therapy visits and the reason for that is i'd like you to get some strength and stretching understanding i think it's important for you especially here at the beginning is to get some of that real stretching knowledge in and learn how to stretch those muscles before you start these activities and they are gon na help strengthen your your lower extremities also and i want you to come back to me within you know a week to ten days following your first couple physical therapy appointments so i can monitor how you're doing i see no reason for an x-ray at this point but if this continues we're gon na you know if you're still having pain ten days in significant pain without change modification of your activity then we may have to look at more aggressive treatment plans how does that sound for you	3,933
doctor: okay hey did you happen to catch that pittsburgh pang one hockey game last night patient: no i i was watching the track meet	D2N154	22	[ "Chitchat" ]	[ "Null" ]	okay hey did you happen to catch that pittsburgh pang one hockey game last night	3,934
doctor: my gosh the the pang ones are on fire you know they beat up on new york seven to two i mean the hockey's just an amazing sport i i just do you guy do you do a lot of hockey down there in town here patient: used to when i lived in detroit	D2N154	23	[ "Chitchat" ]	[ "Null" ]	my gosh the the pang ones are on fire you know they beat up on new york seven to two i mean the hockey's just an amazing sport i i just do you guy do you do a lot of hockey down there in town here	3,935
doctor: no yeah detroit is a hockey town yeah the red wings okay well i'm gon na go ahead and i'll send my nurse in and go ahead and get you discharged and like i said i'd like to see you back here in seven to ten days after that first physical therapy appointment i've got a great phenomenal office staff you just call in once that gets scheduled they will get you in to that next available appointment so take care and i will talk to you later patient: thanks	D2N154	25	[ "Follow-up", "Referral" ]	[ "Plan" ]	no yeah detroit is a hockey town yeah the red wings okay well i'm gon na go ahead and i'll send my nurse in and go ahead and get you discharged and like i said i'd like to see you back here in seven to ten days after that first physical therapy appointment i've got a great phenomenal office staff you just call in once that gets scheduled they will get you in to that next available appointment so take care and i will talk to you later	3,936
doctor: so hey christina good to see you today i see you're here you have a nonhealing foot ulcer well also looks like in my notes that you got some you've got type two diabetes and that probably the reason for your ear but ulcer not healing so how you doing today what's going on patient: doing pretty good except i ca n't get this ulcer to heal	D2N155	0	[ "Personal History", "Greetings" ]	[ "Subjective" ]	so hey christina good to see you today i see you're here you have a nonhealing foot ulcer well also looks like in my notes that you got some you've got type two diabetes and that probably the reason for your ear but ulcer not healing so how you doing today what's going on	3,937
doctor: okay how long has that wound been present patient: maybe about a year	D2N155	1	[ "Acute Symptoms" ]	[ "Subjective" ]	okay how long has that wound been present	3,938
doctor: a year well that that's a that's a a long time so when it started i guess did you have any trauma to the foot or did was it just all of a sudden patient: no trauma it just it seemed like a little blister and then i picked at it and it did get a little bit red and infected so i talked to my primary about it	D2N155	2	[ "Acute Symptoms" ]	[ "Subjective" ]	a year well that that's a that's a a long time so when it started i guess did you have any trauma to the foot or did was it just all of a sudden	3,939
doctor: okay when was the last time you were on antibiotics patient: it's probably been five months	D2N155	4	[ "Therapeutic History" ]	[ "Subjective" ]	okay when was the last time you were on antibiotics	3,940
doctor: five months alright do you remember which antibiotics you were on patient: keflex	D2N155	5	[ "Therapeutic History" ]	[ "Subjective" ]	five months alright do you remember which antibiotics you were on	3,941
doctor: keflex alright so kinda does your foot hurt or is it just just the patient: no pain but i do n't have much feeling in my foot	D2N155	6	[ "Acute Symptoms" ]	[ "Subjective" ]	keflex alright so kinda does your foot hurt or is it just just the	3,942
doctor: alright so you've got neuropathy yeah that that that makes sense with the the diabetes so have you had any other symptoms like a fever chills any drainage coming from it patient: lately there has been a lot more drainage and i just feel a little more tired	D2N155	7	[ "Vegetative History" ]	[ "Subjective" ]	alright so you've got neuropathy yeah that that that makes sense with the the diabetes so have you had any other symptoms like a fever chills any drainage coming from it	3,943
doctor: okay alright well that that sounds good so today is thursday so what do you have for the weekend patient: not too much i'll probably be walking around at the zoo on this ulcer all weekend and eating out and not doing anything my doctor wants me to do	D2N155	8	[ "Other Socials" ]	[ "Subjective" ]	okay alright well that that sounds good so today is thursday so what do you have for the weekend	3,944
doctor: no yeah i yeah i know you do have that diabetes i know your pcp probably would n't be excited about you you eating out and all that but you know hopefully we can we i can at least get your your foot a little bit better so your diabetes i know we talked a little bit earlier how is that going for you is it controlled you know what's your your blood sugars running patient: yeah they are running better than they were but they are still in the two hundreds so my doctor does n't like that my last a1c was about ten	D2N155	9	[ "Personal History" ]	[ "Subjective" ]	no yeah i yeah i know you do have that diabetes i know your pcp probably would n't be excited about you you eating out and all that but you know hopefully we can we i can at least get your your foot a little bit better so your diabetes i know we talked a little bit earlier how is that going for you is it controlled you know what's your your blood sugars running	3,945
doctor: okay alright yeah i i you probably definitely need to get back with your pcp about that because the a1c is is pretty high and i know he probably had you on some medication and insulin and metformin and insulin just to try to to get that lower but patient: yes	D2N155	10	[ "Therapeutic History" ]	[ "Subjective" ]	okay alright yeah i i you probably definitely need to get back with your pcp about that because the a1c is is pretty high and i know he probably had you on some medication and insulin and metformin and insulin just to try to to get that lower but	3,946
doctor: you know we are here for your foot so let's let me take a look at that so we will do a quick exam of your foot so you do n't have any fever your vitals look good so on your your right foot exam i can see here you do have a one by two centimeter two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint i do see some yellow slough that's present with minimal granulation tissue you have no surrounding erythema or cellulitis and there is n't any evidence of fluid collection i do n't see necrosis so there is no dead tissue around it there's no odor and i i do n't appreciate any bony exposure and does it hurt when i touch it here patient: no	D2N155	11	[ "Physical Examination" ]	[ "Objective" ]	you know we are here for your foot so let's let me take a look at that so we will do a quick exam of your foot so you do n't have any fever your vitals look good so on your your right foot exam i can see here you do have a one by two centimeter two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint i do see some yellow slough that's present with minimal granulation tissue you have no surrounding erythema or cellulitis and there is n't any evidence of fluid collection i do n't see necrosis so there is no dead tissue around it there's no odor and i i do n't appreciate any bony exposure and does it hurt when i touch it here	3,947
doctor: okay so we did a x-ray of your right foot before you came in and it showed no evidence of osteomyelitis that means that there is no bone infection which is really good so let me just talk a little about my assessment and plan of your your foot so you do have that diabetic foot ulcer so what i'm gon na do is i'm going to order a abi or ankle brachial index and that's just to determine your blood supply just to see if we can actually heal that wound i know it's been there for about a year which is a pretty long time and so we just need to see if we can if you do have that blood flow just in case we need to to make other goals for that foot just to depend upon that i'm also gon na do a debridement here have you had that done before of the patient: yes i think so	D2N155	12	[ "Discussion", "Radiology Examination", "Diagnostic Testing", "Acute Assessment" ]	[ "Objective", "Assessment", "Plan" ]	okay so we did a x-ray of your right foot before you came in and it showed no evidence of osteomyelitis that means that there is no bone infection which is really good so let me just talk a little about my assessment and plan of your your foot so you do have that diabetic foot ulcer so what i'm gon na do is i'm going to order a abi or ankle brachial index and that's just to determine your blood supply just to see if we can actually heal that wound i know it's been there for about a year which is a pretty long time and so we just need to see if we can if you do have that blood flow just in case we need to to make other goals for that foot just to depend upon that i'm also gon na do a debridement here have you had that done before of the	3,948
doctor: okay so you know you know pretty much about that so i'm just gon na try to take off some of that dead tissue we'll do that here in the office afterwards and then i'm going to prescribe you some colaganase ointment and you could just add that to your wound once a day and cover it with a sterile dressing and we're gon na try to continue that until we see it start to shrink and hopefully you know that will work between the debridement and then the ointment did they give you at your pcp they give you a surgical shoe or have you been wearing your regular shoes patient: i've just been wearing my regular shoes	D2N155	13	[ "Discussion", "Medication", "Other Treatments" ]	[ "Plan" ]	okay so you know you know pretty much about that so i'm just gon na try to take off some of that dead tissue we'll do that here in the office afterwards and then i'm going to prescribe you some colaganase ointment and you could just add that to your wound once a day and cover it with a sterile dressing and we're gon na try to continue that until we see it start to shrink and hopefully you know that will work between the debridement and then the ointment did they give you at your pcp they give you a surgical shoe or have you been wearing your regular shoes	3,949
doctor: okay so we're gon na get you a surgical shoe and i want you to to wear that and that can help you take pressure off the area because i know you said you're gon na walk around with this zoo this this weekend so i definitely do n't want you to put much pressure on it from now on and hopefully that can help it heal and so after all that i'm just gon na see you back in two weeks and we could take another look and possible do another debridement of the ulcer so do you have any questions for me patient: i do n't think so	D2N155	14	[ "Discussion", "Follow-up", "Other Treatments" ]	[ "Plan" ]	okay so we're gon na get you a surgical shoe and i want you to to wear that and that can help you take pressure off the area because i know you said you're gon na walk around with this zoo this this weekend so i definitely do n't want you to put much pressure on it from now on and hopefully that can help it heal and so after all that i'm just gon na see you back in two weeks and we could take another look and possible do another debridement of the ulcer so do you have any questions for me	3,950
doctor: alright so i'll see you back in two weeks and i hope you have fun at the zoo this weekend patient: thank you	D2N155	15	[ "Follow-up" ]	[ "Plan" ]	alright so i'll see you back in two weeks and i hope you have fun at the zoo this weekend	3,951
doctor: alright thanks	D2N155	16	[ "Chitchat" ]	[ "Null" ]	doctor: alright thanks	3,952
doctor: alright julia so you've been coming to see me for a while now ever since you had an rca stent placed back in twenty eighteen but i see you're here for follow-up after an interior stemi where we had to put in another stent right so like how are you doing patient: well i mean it was a real shock for me i thought everything was fine after my last heart attack and then i just started having this horrible chest pain and it would n't go away so i went to the emergency room and yeah they told me i needed another stent	D2N156	0	[ "Personal History", "Greetings" ]	[ "Subjective" ]	alright julia so you've been coming to see me for a while now ever since you had an rca stent placed back in twenty eighteen but i see you're here for follow-up after an interior stemi where we had to put in another stent right so like how are you doing	3,953
doctor: wow so you were experiencing similar symptoms similar to what you had the first time patient: yeah yeah it was yeah it was bad it was just like the last time	D2N156	1	[ "Personal History" ]	[ "Subjective" ]	wow so you were experiencing similar symptoms similar to what you had the first time	3,954
doctor: okay have you had any chest pain or shortness of breath patient: no i think i saw you about six months ago and and i was doing fine	D2N156	2	[ "Vegetative History" ]	[ "Subjective" ]	okay have you had any chest pain or shortness of breath	3,955
doctor: okay have you been able to like exercise at all since since you last saw me patient: yeah you know i walk my dog everyday and you know we go like a mile and a half or two miles	D2N156	3	[ "Other Socials" ]	[ "Subjective" ]	okay have you been able to like exercise at all since since you last saw me	3,956
doctor: awesome okay yeah you know because like fall is setting in like are you excited patient: yeah yeah i'm excited	D2N156	4	[ "Chitchat" ]	[ "Null" ]	awesome okay yeah you know because like fall is setting in like are you excited	3,957
doctor: do you have any like plans for the holiday patient: no mm-hmm no i'm just you know looking forward to seeing family and having some nice weather and yeah	D2N156	5	[ "Other Socials" ]	[ "Subjective" ]	do you have any like plans for the holiday	3,958
doctor: okay so i do wan na ask i know that you have a history of coronary artery disease hypertension and diabetes so i wan na get an idea of like where you stand with those have you been experiencing any kind of leg swelling patient: i have noticed that my legs are a little swollen since they sent me home from the hospital	D2N156	6	[ "Personal History" ]	[ "Subjective" ]	okay so i do wan na ask i know that you have a history of coronary artery disease hypertension and diabetes so i wan na get an idea of like where you stand with those have you been experiencing any kind of leg swelling	3,959
doctor: okay are you able to lie flat at night when you sleep patient: yeah i mean i always use a couple of pillows you know i maybe i've had to sit up a little bit more but i mean for the most part i think it's pretty normal	D2N156	7	[ "Personal History" ]	[ "Subjective" ]	okay are you able to lie flat at night when you sleep	3,960
doctor: okay and then have you been able to afford your medications and are you taking them like your like you were prescribed patient: yeah i'm able to afford afford them i have good insurance i am taking them they told me it's really important to take them so so yeah	D2N156	8	[ "Therapeutic History" ]	[ "Subjective" ]	okay and then have you been able to afford your medications and are you taking them like your like you were prescribed	3,961
doctor: yeah that's very accurate you know like there are huge consequences to not taking them so if you are noticing any problems please please please please let us know how about your diet are you watching your salt intake patient: i mean i'm not i i i have n't really adjusted i mean i tried to watch it after the last heart attack and now you know i i've kind of been less strict with my diet but i'll have to go back to watching the salt intake	D2N156	9	[ "Personal History" ]	[ "Subjective" ]	yeah that's very accurate you know like there are huge consequences to not taking them so if you are noticing any problems please please please please let us know how about your diet are you watching your salt intake	3,962
doctor: mm-hmm patient: i love pizza it's my favorite food	D2N156	10	[ "Vegetative History" ]	[ "Subjective" ]	mm-hmm	3,963
doctor: what are you for her toppings on pizza patient: pepperoni occasionally vegetables	D2N156	12	[ "Vegetative History" ]	[ "Subjective" ]	what are you for her toppings on pizza	3,964
doctor: mm-hmm alright but you know that pepperoni is pretty high in salt on top of a cheesy pizza right patient: i know i know i'm gon na work on it	D2N156	13	[ "Vegetative History" ]	[ "Subjective" ]	mm-hmm alright but you know that pepperoni is pretty high in salt on top of a cheesy pizza right	3,965
doctor: okay so we are we are gon na have to negotiate some of these diet things and then especially since you have diabetes like have you been managing that well patient: my i've been watching my sugars yep because i do n't wan na go on insulin so i'm taking that metformin that's why i've been walking my dog i'm trying to stay active	D2N156	14	[ "Personal History" ]	[ "Subjective" ]	okay so we are we are gon na have to negotiate some of these diet things and then especially since you have diabetes like have you been managing that well	3,966
doctor: okay okay so you know maybe this is just a situation of like where we are on the right path but probably need to step up a few things okay patient: okay	D2N156	15	[ "Personal History" ]	[ "Subjective" ]	okay okay so you know maybe this is just a situation of like where we are on the right path but probably need to step up a few things okay	3,967
doctor: alright so i do want to do a quick physical exam so you are aware i'm going to be calling out my findings as i run through it alright patient: okay	D2N156	16	[ "Physical Examination" ]	[ "Objective" ]	alright so i do want to do a quick physical exam so you are aware i'm going to be calling out my findings as i run through it alright	3,968
doctor: alright so your vital signs look good you know so i'm glad that it looks like you're tolerating your medication pretty well on your neck exam i do n't appreciate any jugular venous distention so and then on top of that i'm not i do n't appreciate any carotid bruits so i'm not feeling anything like too concerning on your heart exam though there is a three over six systolic ejection murmur heard at the that i'm hearing at the left base that's not like a huge deal especially considering like what you've been through already in terms of the hospital but it is something that i wan na know in your chart when i listen to you your lungs your lungs are clear over here with your extremities i do notice you know some lower lower edema swelling sorry some lower swelling edema lower limb edema and it it is pitting one plus on your right radial artery the cath site is clean dry and intact without hematoma and i also your right radial artery pulses are palpable so i did review the results of your ekg and they show a normal sinus rhythm and a good r wave progression and a a evolutionary changes that are anticipated after a stemi one of the reasons though that we had you come in is that we noticed on your echo there is a reduced ejection fraction of thirty five percent we are a little bit concerned about that so let's talk about my assessment and plan for you your primary and like first diagnosis is gon na be coronary artery disease right you already have a history of that but you know we're gon na do some things to make we're gon na continue to evaluate that over time i want you to continue your aspirin eighty one milligrams daily and your brilinta ninety milligrams twice daily i wan na continue you on a high dose statin called lipitor and you're gon na be taking that eighty milligrams a day and we're gon na continue you on your toprol and that's gon na be fifty milligrams daily i am gon na refer you to cardiac rehab so we can get you some education and give you some confidence to get back to exercising regularly i know it was kinda scary to have such an episode but i promise like most of the patients i have love cardiac rehab and i think you'll do pretty well for your second diagnosis we have newly you have newly reduced left ventricular dysfunction and moderate mitral regurgitation what i think is like what that means is that you're you're pumping like the way that your heart is pumping is a bit concerning but i think like given your history that it will improve over time they got you into the cath lab pretty quickly so i think that the muscle is just kinda like stunned like surprised and since you're compliant with your meds i think you will recover we are gon na continue you on your lisinopril twenty milligrams daily however considering that you are retaining fluid i think that your third diagnosis is like we are crossing into acute heart failure i'm gon na prescribe something called a diuretic it's called lasix and i do want to we need to take that forty milligrams once a day i wan na add aldactone twelve . five milligrams daily and i need you to get labs finally we will repeat another echo in about two months last but not least there is the hypertension your blood pressure seems fine i think with the aldactone that you'll tolerate that pretty well but we do want to maybe get you into some nutrition counseling to consider like what other diet options might be available to you maybe suggestions of things that you have n't thought about like cutting out meat especially any kind of preserved meat like pepperoni but maybe finding you some alternatives how does that sound patient: that sounds good yeah so i'm yeah as long as you tell me i'm gon na get better i believe you	D2N156	17	[ "Physical Examination", "Discussion", "Referral", "Medication", "Other Treatments", "Radiology Examination", "Diagnostic Testing", "Reassessment", "Acute Assessment" ]	[ "Objective", "Assessment", "Plan" ]	alright so your vital signs look good you know so i'm glad that it looks like you're tolerating your medication pretty well on your neck exam i do n't appreciate any jugular venous distention so and then on top of that i'm not i do n't appreciate any carotid bruits so i'm not feeling anything like too concerning on your heart exam though there is a three over six systolic ejection murmur heard at the that i'm hearing at the left base that's not like a huge deal especially considering like what you've been through already in terms of the hospital but it is something that i wan na know in your chart when i listen to you your lungs your lungs are clear over here with your extremities i do notice you know some lower lower edema swelling sorry some lower swelling edema lower limb edema and it it is pitting one plus on your right radial artery the cath site is clean dry and intact without hematoma and i also your right radial artery pulses are palpable so i did review the results of your ekg and they show a normal sinus rhythm and a good r wave progression and a a evolutionary changes that are anticipated after a stemi one of the reasons though that we had you come in is that we noticed on your echo there is a reduced ejection fraction of thirty five percent we are a little bit concerned about that so let's talk about my assessment and plan for you your primary and like first diagnosis is gon na be coronary artery disease right you already have a history of that but you know we're gon na do some things to make we're gon na continue to evaluate that over time i want you to continue your aspirin eighty one milligrams daily and your brilinta ninety milligrams twice daily i wan na continue you on a high dose statin called lipitor and you're gon na be taking that eighty milligrams a day and we're gon na continue you on your toprol and that's gon na be fifty milligrams daily i am gon na refer you to cardiac rehab so we can get you some education and give you some confidence to get back to exercising regularly i know it was kinda scary to have such an episode but i promise like most of the patients i have love cardiac rehab and i think you'll do pretty well for your second diagnosis we have newly you have newly reduced left ventricular dysfunction and moderate mitral regurgitation what i think is like what that means is that you're you're pumping like the way that your heart is pumping is a bit concerning but i think like given your history that it will improve over time they got you into the cath lab pretty quickly so i think that the muscle is just kinda like stunned like surprised and since you're compliant with your meds i think you will recover we are gon na continue you on your lisinopril twenty milligrams daily however considering that you are retaining fluid i think that your third diagnosis is like we are crossing into acute heart failure i'm gon na prescribe something called a diuretic it's called lasix and i do want to we need to take that forty milligrams once a day i wan na add aldactone twelve . five milligrams daily and i need you to get labs finally we will repeat another echo in about two months last but not least there is the hypertension your blood pressure seems fine i think with the aldactone that you'll tolerate that pretty well but we do want to maybe get you into some nutrition counseling to consider like what other diet options might be available to you maybe suggestions of things that you have n't thought about like cutting out meat especially any kind of preserved meat like pepperoni but maybe finding you some alternatives how does that sound	3,969
doctor: yes yeah i i strongly believe this is our best course of action and that you will get better given enough time i i see that you are making efforts i'm really glad that you are out there walking and that you're cognizant of your diet and willing to make changes we will just you know monitor it over time okay patient: okay	D2N156	18	[ "Chitchat" ]	[ "Null" ]	yes yeah i i strongly believe this is our best course of action and that you will get better given enough time i i see that you are making efforts i'm really glad that you are out there walking and that you're cognizant of your diet and willing to make changes we will just you know monitor it over time okay	3,970
doctor: alright thank you	D2N156	19	[ "Chitchat" ]	[ "Null" ]	doctor: alright thank you	3,971
doctor: hey jose how are you doing it's been about you know three or four months since i last saw you what's going on patient: i'm doing okay i i guess the medications are helping i'm concerned about all the medications i'm taking but i think i'm doing okay	D2N157	0	[ "Greetings" ]	[ "Subjective" ]	hey jose how are you doing it's been about you know three or four months since i last saw you what's going on	3,972
doctor: yeah yeah you are on a fair amount of medications you know we do have you on those medications because you did have a heart attack about six months ago they put that that stent into your left anterior descending artery and so that's a major artery on the left side of your heart and so we need to keep those stents open and and kinda help your heart heal so it is gon na be very important for you to continue on those medications so you're still taking your aspirin and are you still taking the brilinta patient: yes and and fish oil	D2N157	1	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	yeah yeah you are on a fair amount of medications you know we do have you on those medications because you did have a heart attack about six months ago they put that that stent into your left anterior descending artery and so that's a major artery on the left side of your heart and so we need to keep those stents open and and kinda help your heart heal so it is gon na be very important for you to continue on those medications so you're still taking your aspirin and are you still taking the brilinta	3,973
doctor: and fish oil okay good now how are you doing with the crestor i know that that's you know that's the statin that's the cholesterol medication you were concerned that it might cause you to have some muscle aches are you taking that patient: i i think i'm doing good but i i am i feel like i i when i i guess the only complaint that i have is ever since i i do n't know if this is the heart attack or if this this is the the medication but when i stand up real fast i get really dizzy	D2N157	2	[ "Therapeutic History" ]	[ "Subjective" ]	and fish oil okay good now how are you doing with the crestor i know that that's you know that's the statin that's the cholesterol medication you were concerned that it might cause you to have some muscle aches are you taking that	3,974
doctor: you get you get dizzy okay yeah you know we do have you on a what we call a beta-blocker metoprolol i think your dose is fifty milligrams once a day and you know sometimes it takes a little bit for your body to adjust to that but yes if you stand up too quickly it can cause you to be a little dizzy so patient: okay okay that makes sense okay that's good to know because i did n't know what what what the problem was so can i ask you a question regarding the stents	D2N157	3	[ "Medication", "Therapeutic History" ]	[ "Subjective", "Plan" ]	you get you get dizzy okay yeah you know we do have you on a what we call a beta-blocker metoprolol i think your dose is fifty milligrams once a day and you know sometimes it takes a little bit for your body to adjust to that but yes if you stand up too quickly it can cause you to be a little dizzy so	3,975
doctor: so the stents are permanent we do n't we do n't remove them so yep so that's why it's gon na be super important for you you know you're gon na be on aspirin for the rest of your life and then i'm gon na keep you on that brilinta for another six months that's gon na help prevent the that stent from clogging patient: okay okay do i need to ever replace the stents then	D2N157	5	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	so the stents are permanent we do n't we do n't remove them so yep so that's why it's gon na be super important for you you know you're gon na be on aspirin for the rest of your life and then i'm gon na keep you on that brilinta for another six months that's gon na help prevent the that stent from clogging	3,976
doctor: no i mean every so often the stents can become narrowed again but you know that's why you're seeing me your cardiologist so that i can follow you for that now if you start to have symptoms again of any chest pain like you had before or any shortness of breath when you start to exert yourself i want you to tell me and we might have to go ahead and send you for further testing to make sure that those stents are okay but typically if you continue to take the medication watch your diet that type of thing your stents will will stay open for a long time patient: okay alright that sounds good you know i have n't i had a i had i know you asked me to follow up with the dietitian because i had diabetes as well which probably contributed to my heart attack	D2N157	6	[ "Referral", "Medication", "Diagnostic Testing" ]	[ "Plan" ]	no i mean every so often the stents can become narrowed again but you know that's why you're seeing me your cardiologist so that i can follow you for that now if you start to have symptoms again of any chest pain like you had before or any shortness of breath when you start to exert yourself i want you to tell me and we might have to go ahead and send you for further testing to make sure that those stents are okay but typically if you continue to take the medication watch your diet that type of thing your stents will will stay open for a long time	3,977
doctor: okay that's okay yeah i certainly can help you with that now managing your diabetes is also going to play an important role in your coronary artery disease which it sounds like you already know that which is really good so i will put in another referral for diabetic education for you how are you doing watching your sweets i know that you know you do have an afinity for those chocolate chip cookies patient: it's okay my a1c was n't where i wanted but my glucose is coming in in about one thirty	D2N157	8	[ "Referral", "Vegetative History" ]	[ "Subjective", "Plan" ]	okay that's okay yeah i certainly can help you with that now managing your diabetes is also going to play an important role in your coronary artery disease which it sounds like you already know that which is really good so i will put in another referral for diabetic education for you how are you doing watching your sweets i know that you know you do have an afinity for those chocolate chip cookies	3,978
doctor: okay what was the what was the a1c the hemoglobin a1c if you do n't mind me asking patient: i thought it was close to sixty	D2N157	10	[ "Lab Examination" ]	[ "Objective" ]	okay what was the what was the a1c the hemoglobin a1c if you do n't mind me asking	3,979
doctor: okay yeah that's really high so we want it to be about six so you you do have some work to do with your diet patient: yeah yeah so okay so i know you asked me to do a blood test so i did that i was wondering if you got the results	D2N157	11	[ "Other Treatments", "Lab Examination" ]	[ "Objective", "Plan" ]	okay yeah that's really high so we want it to be about six so you you do have some work to do with your diet	3,980
doctor: i did you know i looked at the results of your kidney function that's what we call your creatinine just because you had some contrast dye and sometimes contrast dye can impact the kidneys and your kidney function is stable which is great when was the last time you saw your nephrologist patient: oh	D2N157	12	[ "Personal History", "Lab Examination" ]	[ "Subjective", "Objective" ]	i did you know i looked at the results of your kidney function that's what we call your creatinine just because you had some contrast dye and sometimes contrast dye can impact the kidneys and your kidney function is stable which is great when was the last time you saw your nephrologist	3,981
doctor: that's your kidney doctor patient: i'm a bad i'm a bad patient so probably a year ago	D2N157	13	[ "Personal History" ]	[ "Subjective" ]	that's your kidney doctor	3,982
doctor: okay you know you do have the stage three ckd so that's the the stage three kidney disease so it is gon na be important for you to follow up with your nephrologist just to make sure that everything is okay now i did check your kidney function and and it was fine but are you staying away from things like motrin and advil patient: right yeah that's i threw all of those out	D2N157	14	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	okay you know you do have the stage three ckd so that's the the stage three kidney disease so it is gon na be important for you to follow up with your nephrologist just to make sure that everything is okay now i did check your kidney function and and it was fine but are you staying away from things like motrin and advil	3,983
doctor: okay good okay perfect now i know that you're from the west coast are you super excited that la one the super bowl or are you more of a san francisco forty nine or span patient: i'm a more of a san francisco fan	D2N157	15	[ "Chitchat" ]	[ "Null" ]	okay good okay perfect now i know that you're from the west coast are you super excited that la one the super bowl or are you more of a san francisco forty nine or span	3,984
doctor: so do you like jimmy g do you think he can beat erin rogers again patient: okay we'll see we'll see what happens but i'm pretty flexible when he comes to you know that is but one thing that since i ca n't take motrin what pain killer can i take for headaches	D2N157	16	[ "Discussion" ]	[ "Plan" ]	so do you like jimmy g do you think he can beat erin rogers again	3,985
doctor: you can take tylenol patient: okay	D2N157	17	[ "Discussion", "Medication" ]	[ "Plan" ]	you can take tylenol	3,986
doctor: yeah i can do that but i do wan na just do a physical exam on you okay so and looking here at your vital signs here you know your your vital signs look quite good you know your blood pressure is what right where it should be it's about one twenty seven over eighty which is great so you're doing a good job taking your metoprolol now in terms of on your neck exam i do n't appreciate any jugular venous distention or carotid bruits on your heart exam i do appreciate a slight three out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do appreciate some one plus nonpitting edema now what does that mean what does that mean jose so all of that means is that i do hear a little heart murmur on your heart which i've heard before in the past and it does n't it does n't look like you're retaining any fluid which is good but you do have a little puffiness in your legs which sometimes some of the medications can cause patient: yeah i do have that	D2N157	21	[ "Physical Examination" ]	[ "Objective" ]	yeah i can do that but i do wan na just do a physical exam on you okay so and looking here at your vital signs here you know your your vital signs look quite good you know your blood pressure is what right where it should be it's about one twenty seven over eighty which is great so you're doing a good job taking your metoprolol now in terms of on your neck exam i do n't appreciate any jugular venous distention or carotid bruits on your heart exam i do appreciate a slight three out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do appreciate some one plus nonpitting edema now what does that mean what does that mean jose so all of that means is that i do hear a little heart murmur on your heart which i've heard before in the past and it does n't it does n't look like you're retaining any fluid which is good but you do have a little puffiness in your legs which sometimes some of the medications can cause	3,987
doctor: so let's just go over a little bit about my assessment and and plan for you going forward so for your first problem of your coronary artery disease i think you're doing really well i wan na go ahead and refer you for cardiac rehab just so that you can be more active and have some confidence in in exercising again okay and i am gon na go ahead and refill your metoprolol your crestor forty milligrams once a day as well as the aspirin okay i do n't think we need to proceed with a a stress test or anything at this time but you know to let me know if you have any symptoms okay patient: okay	D2N157	22	[ "Referral", "Medication", "Reassessment" ]	[ "Assessment", "Plan" ]	so let's just go over a little bit about my assessment and and plan for you going forward so for your first problem of your coronary artery disease i think you're doing really well i wan na go ahead and refer you for cardiac rehab just so that you can be more active and have some confidence in in exercising again okay and i am gon na go ahead and refill your metoprolol your crestor forty milligrams once a day as well as the aspirin okay i do n't think we need to proceed with a a stress test or anything at this time but you know to let me know if you have any symptoms okay	3,988
doctor: okay for your patient: sounds really good	D2N157	23	[ "Chitchat" ]	[ "Null" ]	okay for your	3,989
doctor: good for your second problem of your stage three chronic kidney disease i am gon na reach out to doctor miller and make an appointment for you to be seen just because again i think it's important for you to follow up with your nephrologist okay patient: okay	D2N157	24	[ "Referral", "Reassessment" ]	[ "Assessment", "Plan" ]	good for your second problem of your stage three chronic kidney disease i am gon na reach out to doctor miller and make an appointment for you to be seen just because again i think it's important for you to follow up with your nephrologist okay	3,990
doctor: and then for your third problem of your diabetes i am gon na go ahead and order another hemoglobin a1c and i'm gon na put that referral in for the dietitian to give you some dietary education and i'm gon na go ahead and talk with your primary care physician about your your insulin regimen okay patient: okay	D2N157	25	[ "Referral", "Medication", "Diagnostic Testing", "Reassessment" ]	[ "Assessment", "Plan" ]	and then for your third problem of your diabetes i am gon na go ahead and order another hemoglobin a1c and i'm gon na put that referral in for the dietitian to give you some dietary education and i'm gon na go ahead and talk with your primary care physician about your your insulin regimen okay	3,991
doctor: any questions patient: yeah you know i've been kinda down ever since i had my heart attack is there any medication that i could take to make me feel a little bit less sad	D2N157	26	[ "Discussion" ]	[ "Plan" ]	any questions	3,992
doctor: yeah i mean are you having any thoughts of of harming yourself or harming others patient: no no i just feel kinda down	D2N157	27	[ "Vegetative History" ]	[ "Subjective" ]	yeah i mean are you having any thoughts of of harming yourself or harming others	3,993
doctor: you feel kinda down what's your patient: life sucks	D2N157	28	[ "Personal History" ]	[ "Subjective" ]	you feel kinda down what's your	3,994
doctor: what well i do n't think so what what's your support system like patient: you know i i live with my dog and that's it so it's kind of you know lonely	D2N157	29	[ "Other Socials" ]	[ "Subjective" ]	what well i do n't think so what what's your support system like	3,995
doctor: okay alright well would you be interested in in like a referral to psychiatry or something like that so that you have someone to talk to about some of of issues because medication can help but i do i think it's important to have you know talk some of these things out patient: okay yeah you know i'll give that a try i mean i'm retiring i got plenty of time	D2N157	30	[ "Discussion", "Referral" ]	[ "Plan" ]	okay alright well would you be interested in in like a referral to psychiatry or something like that so that you have someone to talk to about some of of issues because medication can help but i do i think it's important to have you know talk some of these things out	3,996
doctor: okay so why do n't we go ahead and i'm gon na place a referral to psychiatry for you know you know difficulty adjusting after having a heart attack maybe some some mild depression okay does that sound okay okay patient: yeah that sounds really good thank you	D2N157	31	[ "Discussion", "Referral", "Reassessment" ]	[ "Assessment", "Plan" ]	okay so why do n't we go ahead and i'm gon na place a referral to psychiatry for you know you know difficulty adjusting after having a heart attack maybe some some mild depression okay does that sound okay okay	3,997
doctor: okay you're welcome anything else patient: so you will do the medication refill do i so that's automatic	D2N157	32	[ "Discussion" ]	[ "Plan" ]	okay you're welcome anything else	3,998
doctor: yep i'm gon na put them into the computer and and whatever pharmacy you want yep mm-hmm patient: okay alright sounds great thank you	D2N157	33	[ "Discussion", "Medication" ]	[ "Plan" ]	yep i'm gon na put them into the computer and and whatever pharmacy you want yep mm-hmm	3,999

doctor: does the ibuprofen work patient: at night you know during the day i'm more active so it it really does n't impact it because i just work through it but at night it does help me to settle down and sleep better

D2N153

10

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

does the ibuprofen work

3,900

doctor: does your knee hurt when you're just resting and sitting there patient: no when it's up it's fine when it's down on the floor with my foot flat it's fine it does hurt when i rest it on my heel

D2N153

11

[ "Acute Symptoms" ]

[ "Subjective" ]

does your knee hurt when you're just resting and sitting there

3,901

doctor: okay and are you able to do things like bending or things like that patient: a full squat that's when i feel the most clicking like if i go all the way down to a full squat like a catcher that's when i feel the most clicking but otherwise no there is no pain it's just the clicking and i'm fearful that that's an injury of some type

D2N153

12

[ "Acute Symptoms" ]

[ "Subjective" ]

okay and are you able to do things like bending or things like that

3,902

doctor: okay alright now you said squats are you are you active are you doing like burpees going to patient: no i ride the bike

D2N153

13

[ "Other Socials" ]

[ "Subjective" ]

okay alright now you said squats are you are you active are you doing like burpees going to

3,903

doctor: okay alright well i have a peloton who is your favorite instructor patient: i i actually do n't have a favorite instructor i have more favorite rides

D2N153

15

[ "Chitchat" ]

[ "Null" ]

okay alright well i have a peloton who is your favorite instructor

3,904

doctor: okay what kind of rides do you like patient: i like rock music and regain music rides so whoever is doing those in a began or a medium content i'm cool with

D2N153

16

[ "Chitchat" ]

[ "Null" ]

okay what kind of rides do you like

3,905

doctor: i ca n't picture you as a regade person so that's interesting to know okay alright and any numbing or tingling in your foot at all patient: yes but not from the knee injury i broke my foot my second toe on my right foot and i have numbness depending upon the shoe i wear

D2N153

17

[ "Acute Symptoms" ]

[ "Subjective" ]

i ca n't picture you as a regade person so that's interesting to know okay alright and any numbing or tingling in your foot at all

3,906

doctor: okay when did you break your toe patient: i've broken it three times over the last ten years so it's just something that's a an annoyance but it was n't caused by this injury

D2N153

18

[ "Personal History" ]

[ "Subjective" ]

okay when did you break your toe

3,907

doctor: okay so you do have some numbing and tingling but it's not new patient: right correct

D2N153

19

[ "Personal History" ]

[ "Subjective" ]

okay so you do have some numbing and tingling but it's not new

3,908

doctor: alright alright well let's just go ahead and i'm 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 on your musculoskeletal exam on your right knee i do appreciate some slight edema you do have a slight effusion does it hurt when i press on the outside of your knee patient: no not physically

D2N153

20

[ "Physical Examination" ]

[ "Objective" ]

alright alright well let's just go ahead and i'm 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 on your musculoskeletal exam on your right knee i do appreciate some slight edema you do have a slight effusion does it hurt when i press on the outside of your knee

3,909

doctor: okay there is no pain to palpation of the right lateral knee i'm gon na be bending your knee in all sorts of positions does that hurt patient: only when you pull it to the outside

D2N153

21

[ "Physical Examination" ]

[ "Objective" ]

okay there is no pain to palpation of the right lateral knee i'm gon na be bending your knee in all sorts of positions does that hurt

3,910

doctor: okay the patient has a positive varus test there is full range of motion there is a negative lachman sign the patient does on cardiovascular exam the patient does have a palpable dorsalis pedis and posterior tibialis pulse okay well let's just i wan na talk a little bit about i had the nurse do an x-ray on you and i looked at the results of your knee x-ray and it does n't show any acute fracture or bony abnormality which is not surprising based on your injury so let's just talk a little bit about you know my assessment and my plan for you so i think you do have a a lateral a lateral collateral ligament strain based on your exam findings and this this type of injury essentially can be healed by itself you know i do n't think we're gon na need to refer you to surgery or anything like that i want you to go ahead and i'm gon na prescribe meloxicam fifteen milligrams once a day i do wan na go ahead and refer you to physical therapy because if we strengthen up those muscles and areas around that injury then that will make your knee stronger it help prevent future injuries are you able to ice it at all during the day now you said you working you work in sales so you said you're home patient: yeah i actually i'm at home so i can ice it and i have been icing it

D2N153

23

[ "Physical Examination", "Acute Assessment", "Other Socials", "Referral", "Radiology Examination", "Medication" ]

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

okay the patient has a positive varus test there is full range of motion there is a negative lachman sign the patient does on cardiovascular exam the patient does have a palpable dorsalis pedis and posterior tibialis pulse okay well let's just i wan na talk a little bit about i had the nurse do an x-ray on you and i looked at the results of your knee x-ray and it does n't show any acute fracture or bony abnormality which is not surprising based on your injury so let's just talk a little bit about you know my assessment and my plan for you so i think you do have a a lateral a lateral collateral ligament strain based on your exam findings and this this type of injury essentially can be healed by itself you know i do n't think we're gon na need to refer you to surgery or anything like that i want you to go ahead and i'm gon na prescribe meloxicam fifteen milligrams once a day i do wan na go ahead and refer you to physical therapy because if we strengthen up those muscles and areas around that injury then that will make your knee stronger it help prevent future injuries are you able to ice it at all during the day now you said you working you work in sales so you said you're home

3,911

doctor: okay and so does that help at all patient: it's it it makes it feel better in the morning when i first go to my desk and at the end of the day before bed you know i take ibuprofen so i do n't have swelling overnight but honestly i have a pretty decent threshold for pain so it's not good it's not changing it by much

D2N153

25

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

okay and so does that help at all

3,912

doctor: okay do you feel like your symptoms are getting worse or better patient: i think i think pretty much for the last two weeks they've remained about the same the the only time i feel like they get worse is when i exert myself doing up and down like gardening in the yard or moving pots and stuff outside that's the only time i felt like it got any worse but nothing to the point where it stayed worse

D2N153

26

[ "Acute Symptoms" ]

[ "Subjective" ]

okay do you feel like your symptoms are getting worse or better

3,913

doctor: okay alright well let's go ahead and refer you to physical therapy if you're still having pain then we might have to consider an mri patient: okay

D2N153

27

[ "Discussion", "Diagnostic Testing", "Referral" ]

[ "Plan" ]

okay alright well let's go ahead and refer you to physical therapy if you're still having pain then we might have to consider an mri

3,914

doctor: any questions about that patient: no

D2N153

28

[ "Discussion" ]

[ "Plan" ]

any questions about that

3,915

doctor: okay alright well it was very nice seeing you today call me if you need anything patient: i will

D2N153

29

[ "Chitchat" ]

[ "Null" ]

okay alright well it was very nice seeing you today call me if you need anything

3,916

doctor: okay bye patient: bye

D2N153

30

[ "Chitchat" ]

[ "Null" ]

okay bye

3,917

doctor: hi dennis how are you today patient: good

D2N154

0

[ "Greetings" ]

[ "Subjective" ]

hi dennis how are you today

3,918

doctor: so what what brings you into the office i do n't believe i have ever seen you before here patient: the i'm training for a triathlon and the back of my heel hurts typically after a workout or when i first get up in the morning it will really hurt in the back of my heel all the way up into my calf

D2N154

1

[ "Acute Symptoms" ]

[ "Subjective" ]

so what what brings you into the office i do n't believe i have ever seen you before here

3,919

doctor: okay now tell me a little bit about this triathlon training what do you are you are you running far are you tell me kind of how you work out for that today patient: i i will run about ten klometers

D2N154

2

[ "Other Socials" ]

[ "Subjective" ]

okay now tell me a little bit about this triathlon training what do you are you are you running far are you tell me kind of how you work out for that today

3,920

doctor: wow that's that's a that's an aggressive campaign to get there so really hope you get that triathlon in so you're how many days a week does this occur that you're training patient: i i do that five days a week on the weekends i kinda alternate between you know a long run and a long bike do n't really do a long swim but

D2N154

5

[ "Other Socials" ]

[ "Subjective" ]

wow that's that's a that's an aggressive campaign to get there so really hope you get that triathlon in so you're how many days a week does this occur that you're training

3,921

doctor: okay on your running days or when you do the running tell me a little bit about your stretching routine do you are you aggressive stretchers you do not stretch at all i know people that do both patient: yeah i do n't i do n't stretch at all i do n't have time for that

D2N154

7

[ "Other Socials" ]

[ "Subjective" ]

okay on your running days or when you do the running tell me a little bit about your stretching routine do you are you aggressive stretchers you do not stretch at all i know people that do both

3,922

doctor: okay and i'm assuming that with the bicycle either you do n't really work the lower legs to get them stretched out you just jump on and go correct patient: yeah

D2N154

8

[ "Other Socials" ]

[ "Subjective" ]

okay and i'm assuming that with the bicycle either you do n't really work the lower legs to get them stretched out you just jump on and go correct

3,923

doctor: okay tell me a little bit about the pain is you said it it's after the activity but it you when you first wake up in the morning it it's it's there also patient: yeah when i first get out of bed it's just it just feels really tight and almost like it's tearing and i after i been walking around for about ten or fifteen minutes it eases up a little bit but if if i ever sit down for any extended period of time and then try to get back up it's really sore again

D2N154

10

[ "Acute Symptoms" ]

[ "Subjective" ]

okay tell me a little bit about the pain is you said it it's after the activity but it you when you first wake up in the morning it it's it's there also

3,924

doctor: no go ahead go ahead patient: or after a lot of activity it'll get sore too

D2N154

12

[ "Acute Symptoms" ]

[ "Subjective" ]

no go ahead go ahead

3,925

doctor: okay okay i'm sure this is impacting that ability to to really focus on your training uh as you're going with that with that type of a pain so lem me go ahead and let's let's take a look at your your and your lower extremities here and yeah okay so roll up your pants yeah okay good now does your left leg hurt at all do you get that severe pain or is it mainly on the right patient: no it's mainly just on the right

D2N154

13

[ "Physical Examination" ]

[ "Objective" ]

okay okay i'm sure this is impacting that ability to to really focus on your training uh as you're going with that with that type of a pain so lem me go ahead and let's let's take a look at your your and your lower extremities here and yeah okay so roll up your pants yeah okay good now does your left leg hurt at all do you get that severe pain or is it mainly on the right

3,926

doctor: okay okay so i'm gon na just hold your leg here and i want you to take your your foot and ankle and i want you to go ahead and just pull your your toes up towards you does that create some pain when you do that patient: yeah a little bit

D2N154

14

[ "Physical Examination" ]

[ "Objective" ]

okay okay so i'm gon na just hold your leg here and i want you to take your your foot and ankle and i want you to go ahead and just pull your your toes up towards you does that create some pain when you do that

3,927

doctor: a little bit okay now i'm just gon na hold your foot up and i want you to push against me and does that hurt patient: yeah that hurts a little bit too

D2N154

15

[ "Physical Examination" ]

[ "Objective" ]

a little bit okay now i'm just gon na hold your foot up and i want you to push against me and does that hurt

3,928

doctor: yeah okay okay roll over here on my my stretcher for me and i want you to dangle your your feet over the edge and what i wan na do is i just wan na i'm gon na squeeze your left calf first and when i do that does that hurt on your left side patient: no

D2N154

16

[ "Physical Examination" ]

[ "Objective" ]

yeah okay okay roll over here on my my stretcher for me and i want you to dangle your your feet over the edge and what i wan na do is i just wan na i'm gon na squeeze your left calf first and when i do that does that hurt on your left side

3,929

doctor: and i'm gon na squeeze on the right side anything there patient: no

D2N154

18

[ "Physical Examination" ]

[ "Objective" ]

and i'm gon na squeeze on the right side anything there

3,930

doctor: okay okay well that's good your your thompson test is negative that's a really good finding and i just wan na continue pressing here on your right from your heel when i squeeze your heel does that cause significant pain at all patient: yeah

D2N154

19

[ "Physical Examination" ]

[ "Objective" ]

okay okay well that's good your your thompson test is negative that's a really good finding and i just wan na continue pressing here on your right from your heel when i squeeze your heel does that cause significant pain at all

3,931

doctor: yeah okay and if i come up a little bit further as i i run up that achilles tendon does that hurt patient: that's real tender

D2N154

20

[ "Physical Examination" ]

[ "Objective" ]

yeah okay and if i come up a little bit further as i i run up that achilles tendon does that hurt

3,932

doctor: yeah okay okay great not great so yeah go ahead and sit up for me so dennis my diagnosis is achilles tendinitis and it's really from overuse when we see this frequently when somebody starts to you know get in and train aggressively for an event i'm unfortunately i'm gon na have to ask you to stop training for a a week or two i know that's concerning but i really want this to heal before we move into that next phase i did n't ask you about medication but i'm assuming whatever you were doing was n't working significantly so what i'd like you to do is take some ibuprofen or advil that's the same medication and i want you to take three tablets every six hours and that's really an anti-inflammatory see if we can eliminate some of that tendinitis type pain that you're getting that inflammation around that achilles tendon i'm gon na also order a couple physical therapy visits and the reason for that is i'd like you to get some strength and stretching understanding i think it's important for you especially here at the beginning is to get some of that real stretching knowledge in and learn how to stretch those muscles before you start these activities and they are gon na help strengthen your your lower extremities also and i want you to come back to me within you know a week to ten days following your first couple physical therapy appointments so i can monitor how you're doing i see no reason for an x-ray at this point but if this continues we're gon na you know if you're still having pain ten days in significant pain without change modification of your activity then we may have to look at more aggressive treatment plans how does that sound for you patient: sounds good

D2N154

21

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

[ "Assessment", "Plan" ]

yeah okay okay great not great so yeah go ahead and sit up for me so dennis my diagnosis is achilles tendinitis and it's really from overuse when we see this frequently when somebody starts to you know get in and train aggressively for an event i'm unfortunately i'm gon na have to ask you to stop training for a a week or two i know that's concerning but i really want this to heal before we move into that next phase i did n't ask you about medication but i'm assuming whatever you were doing was n't working significantly so what i'd like you to do is take some ibuprofen or advil that's the same medication and i want you to take three tablets every six hours and that's really an anti-inflammatory see if we can eliminate some of that tendinitis type pain that you're getting that inflammation around that achilles tendon i'm gon na also order a couple physical therapy visits and the reason for that is i'd like you to get some strength and stretching understanding i think it's important for you especially here at the beginning is to get some of that real stretching knowledge in and learn how to stretch those muscles before you start these activities and they are gon na help strengthen your your lower extremities also and i want you to come back to me within you know a week to ten days following your first couple physical therapy appointments so i can monitor how you're doing i see no reason for an x-ray at this point but if this continues we're gon na you know if you're still having pain ten days in significant pain without change modification of your activity then we may have to look at more aggressive treatment plans how does that sound for you

3,933

doctor: okay hey did you happen to catch that pittsburgh pang one hockey game last night patient: no i i was watching the track meet

D2N154

22

[ "Chitchat" ]

[ "Null" ]

okay hey did you happen to catch that pittsburgh pang one hockey game last night

3,934

doctor: my gosh the the pang ones are on fire you know they beat up on new york seven to two i mean the hockey's just an amazing sport i i just do you guy do you do a lot of hockey down there in town here patient: used to when i lived in detroit

D2N154

23

[ "Chitchat" ]

[ "Null" ]

my gosh the the pang ones are on fire you know they beat up on new york seven to two i mean the hockey's just an amazing sport i i just do you guy do you do a lot of hockey down there in town here

3,935

doctor: no yeah detroit is a hockey town yeah the red wings okay well i'm gon na go ahead and i'll send my nurse in and go ahead and get you discharged and like i said i'd like to see you back here in seven to ten days after that first physical therapy appointment i've got a great phenomenal office staff you just call in once that gets scheduled they will get you in to that next available appointment so take care and i will talk to you later patient: thanks

D2N154

25

[ "Follow-up", "Referral" ]

[ "Plan" ]

no yeah detroit is a hockey town yeah the red wings okay well i'm gon na go ahead and i'll send my nurse in and go ahead and get you discharged and like i said i'd like to see you back here in seven to ten days after that first physical therapy appointment i've got a great phenomenal office staff you just call in once that gets scheduled they will get you in to that next available appointment so take care and i will talk to you later

3,936

doctor: so hey christina good to see you today i see you're here you have a nonhealing foot ulcer well also looks like in my notes that you got some you've got type two diabetes and that probably the reason for your ear but ulcer not healing so how you doing today what's going on patient: doing pretty good except i ca n't get this ulcer to heal

D2N155

0

[ "Personal History", "Greetings" ]

[ "Subjective" ]

so hey christina good to see you today i see you're here you have a nonhealing foot ulcer well also looks like in my notes that you got some you've got type two diabetes and that probably the reason for your ear but ulcer not healing so how you doing today what's going on

3,937

doctor: okay how long has that wound been present patient: maybe about a year

D2N155

1

[ "Acute Symptoms" ]

[ "Subjective" ]

okay how long has that wound been present

3,938

doctor: a year well that that's a that's a a long time so when it started i guess did you have any trauma to the foot or did was it just all of a sudden patient: no trauma it just it seemed like a little blister and then i picked at it and it did get a little bit red and infected so i talked to my primary about it

D2N155

2

[ "Acute Symptoms" ]

[ "Subjective" ]

a year well that that's a that's a a long time so when it started i guess did you have any trauma to the foot or did was it just all of a sudden

3,939

doctor: okay when was the last time you were on antibiotics patient: it's probably been five months

D2N155

4

[ "Therapeutic History" ]

[ "Subjective" ]

okay when was the last time you were on antibiotics

3,940

doctor: five months alright do you remember which antibiotics you were on patient: keflex

D2N155

5

[ "Therapeutic History" ]

[ "Subjective" ]

five months alright do you remember which antibiotics you were on

3,941

doctor: keflex alright so kinda does your foot hurt or is it just just the patient: no pain but i do n't have much feeling in my foot

D2N155

6

[ "Acute Symptoms" ]

[ "Subjective" ]

keflex alright so kinda does your foot hurt or is it just just the

3,942

doctor: alright so you've got neuropathy yeah that that that makes sense with the the diabetes so have you had any other symptoms like a fever chills any drainage coming from it patient: lately there has been a lot more drainage and i just feel a little more tired

D2N155

7

[ "Vegetative History" ]

[ "Subjective" ]

alright so you've got neuropathy yeah that that that makes sense with the the diabetes so have you had any other symptoms like a fever chills any drainage coming from it

3,943

doctor: okay alright well that that sounds good so today is thursday so what do you have for the weekend patient: not too much i'll probably be walking around at the zoo on this ulcer all weekend and eating out and not doing anything my doctor wants me to do

D2N155

8

[ "Other Socials" ]

[ "Subjective" ]

okay alright well that that sounds good so today is thursday so what do you have for the weekend

3,944

doctor: no yeah i yeah i know you do have that diabetes i know your pcp probably would n't be excited about you you eating out and all that but you know hopefully we can we i can at least get your your foot a little bit better so your diabetes i know we talked a little bit earlier how is that going for you is it controlled you know what's your your blood sugars running patient: yeah they are running better than they were but they are still in the two hundreds so my doctor does n't like that my last a1c was about ten

D2N155

9

[ "Personal History" ]

[ "Subjective" ]

no yeah i yeah i know you do have that diabetes i know your pcp probably would n't be excited about you you eating out and all that but you know hopefully we can we i can at least get your your foot a little bit better so your diabetes i know we talked a little bit earlier how is that going for you is it controlled you know what's your your blood sugars running

3,945

doctor: okay alright yeah i i you probably definitely need to get back with your pcp about that because the a1c is is pretty high and i know he probably had you on some medication and insulin and metformin and insulin just to try to to get that lower but patient: yes

D2N155

10

[ "Therapeutic History" ]

[ "Subjective" ]

okay alright yeah i i you probably definitely need to get back with your pcp about that because the a1c is is pretty high and i know he probably had you on some medication and insulin and metformin and insulin just to try to to get that lower but

3,946

doctor: you know we are here for your foot so let's let me take a look at that so we will do a quick exam of your foot so you do n't have any fever your vitals look good so on your your right foot exam i can see here you do have a one by two centimeter two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint i do see some yellow slough that's present with minimal granulation tissue you have no surrounding erythema or cellulitis and there is n't any evidence of fluid collection i do n't see necrosis so there is no dead tissue around it there's no odor and i i do n't appreciate any bony exposure and does it hurt when i touch it here patient: no

D2N155

11

[ "Physical Examination" ]

[ "Objective" ]

you know we are here for your foot so let's let me take a look at that so we will do a quick exam of your foot so you do n't have any fever your vitals look good so on your your right foot exam i can see here you do have a one by two centimeter two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint i do see some yellow slough that's present with minimal granulation tissue you have no surrounding erythema or cellulitis and there is n't any evidence of fluid collection i do n't see necrosis so there is no dead tissue around it there's no odor and i i do n't appreciate any bony exposure and does it hurt when i touch it here

3,947

doctor: okay so we did a x-ray of your right foot before you came in and it showed no evidence of osteomyelitis that means that there is no bone infection which is really good so let me just talk a little about my assessment and plan of your your foot so you do have that diabetic foot ulcer so what i'm gon na do is i'm going to order a abi or ankle brachial index and that's just to determine your blood supply just to see if we can actually heal that wound i know it's been there for about a year which is a pretty long time and so we just need to see if we can if you do have that blood flow just in case we need to to make other goals for that foot just to depend upon that i'm also gon na do a debridement here have you had that done before of the patient: yes i think so

D2N155

12

[ "Discussion", "Radiology Examination", "Diagnostic Testing", "Acute Assessment" ]

[ "Objective", "Assessment", "Plan" ]

okay so we did a x-ray of your right foot before you came in and it showed no evidence of osteomyelitis that means that there is no bone infection which is really good so let me just talk a little about my assessment and plan of your your foot so you do have that diabetic foot ulcer so what i'm gon na do is i'm going to order a abi or ankle brachial index and that's just to determine your blood supply just to see if we can actually heal that wound i know it's been there for about a year which is a pretty long time and so we just need to see if we can if you do have that blood flow just in case we need to to make other goals for that foot just to depend upon that i'm also gon na do a debridement here have you had that done before of the

3,948

doctor: okay so you know you know pretty much about that so i'm just gon na try to take off some of that dead tissue we'll do that here in the office afterwards and then i'm going to prescribe you some colaganase ointment and you could just add that to your wound once a day and cover it with a sterile dressing and we're gon na try to continue that until we see it start to shrink and hopefully you know that will work between the debridement and then the ointment did they give you at your pcp they give you a surgical shoe or have you been wearing your regular shoes patient: i've just been wearing my regular shoes

D2N155

13

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

[ "Plan" ]

okay so you know you know pretty much about that so i'm just gon na try to take off some of that dead tissue we'll do that here in the office afterwards and then i'm going to prescribe you some colaganase ointment and you could just add that to your wound once a day and cover it with a sterile dressing and we're gon na try to continue that until we see it start to shrink and hopefully you know that will work between the debridement and then the ointment did they give you at your pcp they give you a surgical shoe or have you been wearing your regular shoes

3,949

doctor: okay so we're gon na get you a surgical shoe and i want you to to wear that and that can help you take pressure off the area because i know you said you're gon na walk around with this zoo this this weekend so i definitely do n't want you to put much pressure on it from now on and hopefully that can help it heal and so after all that i'm just gon na see you back in two weeks and we could take another look and possible do another debridement of the ulcer so do you have any questions for me patient: i do n't think so

D2N155

14

[ "Discussion", "Follow-up", "Other Treatments" ]

[ "Plan" ]

okay so we're gon na get you a surgical shoe and i want you to to wear that and that can help you take pressure off the area because i know you said you're gon na walk around with this zoo this this weekend so i definitely do n't want you to put much pressure on it from now on and hopefully that can help it heal and so after all that i'm just gon na see you back in two weeks and we could take another look and possible do another debridement of the ulcer so do you have any questions for me

3,950

doctor: alright so i'll see you back in two weeks and i hope you have fun at the zoo this weekend patient: thank you

D2N155

15

[ "Follow-up" ]

[ "Plan" ]

alright so i'll see you back in two weeks and i hope you have fun at the zoo this weekend

3,951

doctor: alright thanks

D2N155

16

[ "Chitchat" ]

[ "Null" ]

doctor: alright thanks

3,952

doctor: alright julia so you've been coming to see me for a while now ever since you had an rca stent placed back in twenty eighteen but i see you're here for follow-up after an interior stemi where we had to put in another stent right so like how are you doing patient: well i mean it was a real shock for me i thought everything was fine after my last heart attack and then i just started having this horrible chest pain and it would n't go away so i went to the emergency room and yeah they told me i needed another stent

D2N156

0

[ "Personal History", "Greetings" ]

[ "Subjective" ]

alright julia so you've been coming to see me for a while now ever since you had an rca stent placed back in twenty eighteen but i see you're here for follow-up after an interior stemi where we had to put in another stent right so like how are you doing

3,953

doctor: wow so you were experiencing similar symptoms similar to what you had the first time patient: yeah yeah it was yeah it was bad it was just like the last time

D2N156

1

[ "Personal History" ]

[ "Subjective" ]

wow so you were experiencing similar symptoms similar to what you had the first time

3,954

doctor: okay have you had any chest pain or shortness of breath patient: no i think i saw you about six months ago and and i was doing fine

D2N156

2

[ "Vegetative History" ]

[ "Subjective" ]

okay have you had any chest pain or shortness of breath

3,955

doctor: okay have you been able to like exercise at all since since you last saw me patient: yeah you know i walk my dog everyday and you know we go like a mile and a half or two miles

D2N156

3

[ "Other Socials" ]

[ "Subjective" ]

okay have you been able to like exercise at all since since you last saw me

3,956

doctor: awesome okay yeah you know because like fall is setting in like are you excited patient: yeah yeah i'm excited

D2N156

4

[ "Chitchat" ]

[ "Null" ]

awesome okay yeah you know because like fall is setting in like are you excited

3,957

doctor: do you have any like plans for the holiday patient: no mm-hmm no i'm just you know looking forward to seeing family and having some nice weather and yeah

D2N156

5

[ "Other Socials" ]

[ "Subjective" ]

do you have any like plans for the holiday

3,958

doctor: okay so i do wan na ask i know that you have a history of coronary artery disease hypertension and diabetes so i wan na get an idea of like where you stand with those have you been experiencing any kind of leg swelling patient: i have noticed that my legs are a little swollen since they sent me home from the hospital

D2N156

6

[ "Personal History" ]

[ "Subjective" ]

okay so i do wan na ask i know that you have a history of coronary artery disease hypertension and diabetes so i wan na get an idea of like where you stand with those have you been experiencing any kind of leg swelling

3,959

doctor: okay are you able to lie flat at night when you sleep patient: yeah i mean i always use a couple of pillows you know i maybe i've had to sit up a little bit more but i mean for the most part i think it's pretty normal

D2N156

7

[ "Personal History" ]

[ "Subjective" ]

okay are you able to lie flat at night when you sleep

3,960

doctor: okay and then have you been able to afford your medications and are you taking them like your like you were prescribed patient: yeah i'm able to afford afford them i have good insurance i am taking them they told me it's really important to take them so so yeah

D2N156

8

[ "Therapeutic History" ]

[ "Subjective" ]

okay and then have you been able to afford your medications and are you taking them like your like you were prescribed

3,961

doctor: yeah that's very accurate you know like there are huge consequences to not taking them so if you are noticing any problems please please please please let us know how about your diet are you watching your salt intake patient: i mean i'm not i i i have n't really adjusted i mean i tried to watch it after the last heart attack and now you know i i've kind of been less strict with my diet but i'll have to go back to watching the salt intake

D2N156

9

[ "Personal History" ]

[ "Subjective" ]

yeah that's very accurate you know like there are huge consequences to not taking them so if you are noticing any problems please please please please let us know how about your diet are you watching your salt intake

3,962

doctor: mm-hmm patient: i love pizza it's my favorite food

D2N156

10

[ "Vegetative History" ]

[ "Subjective" ]

mm-hmm

3,963

doctor: what are you for her toppings on pizza patient: pepperoni occasionally vegetables

D2N156

12

[ "Vegetative History" ]

[ "Subjective" ]

what are you for her toppings on pizza

3,964

doctor: mm-hmm alright but you know that pepperoni is pretty high in salt on top of a cheesy pizza right patient: i know i know i'm gon na work on it

D2N156

13

[ "Vegetative History" ]

[ "Subjective" ]

mm-hmm alright but you know that pepperoni is pretty high in salt on top of a cheesy pizza right

3,965

doctor: okay so we are we are gon na have to negotiate some of these diet things and then especially since you have diabetes like have you been managing that well patient: my i've been watching my sugars yep because i do n't wan na go on insulin so i'm taking that metformin that's why i've been walking my dog i'm trying to stay active

D2N156

14

[ "Personal History" ]

[ "Subjective" ]

okay so we are we are gon na have to negotiate some of these diet things and then especially since you have diabetes like have you been managing that well

3,966

doctor: okay okay so you know maybe this is just a situation of like where we are on the right path but probably need to step up a few things okay patient: okay

D2N156

15

[ "Personal History" ]

[ "Subjective" ]

okay okay so you know maybe this is just a situation of like where we are on the right path but probably need to step up a few things okay

3,967

doctor: alright so i do want to do a quick physical exam so you are aware i'm going to be calling out my findings as i run through it alright patient: okay

D2N156

16

[ "Physical Examination" ]

[ "Objective" ]

alright so i do want to do a quick physical exam so you are aware i'm going to be calling out my findings as i run through it alright

3,968

doctor: alright so your vital signs look good you know so i'm glad that it looks like you're tolerating your medication pretty well on your neck exam i do n't appreciate any jugular venous distention so and then on top of that i'm not i do n't appreciate any carotid bruits so i'm not feeling anything like too concerning on your heart exam though there is a three over six systolic ejection murmur heard at the that i'm hearing at the left base that's not like a huge deal especially considering like what you've been through already in terms of the hospital but it is something that i wan na know in your chart when i listen to you your lungs your lungs are clear over here with your extremities i do notice you know some lower lower edema swelling sorry some lower swelling edema lower limb edema and it it is pitting one plus on your right radial artery the cath site is clean dry and intact without hematoma and i also your right radial artery pulses are palpable so i did review the results of your ekg and they show a normal sinus rhythm and a good r wave progression and a a evolutionary changes that are anticipated after a stemi one of the reasons though that we had you come in is that we noticed on your echo there is a reduced ejection fraction of thirty five percent we are a little bit concerned about that so let's talk about my assessment and plan for you your primary and like first diagnosis is gon na be coronary artery disease right you already have a history of that but you know we're gon na do some things to make we're gon na continue to evaluate that over time i want you to continue your aspirin eighty one milligrams daily and your brilinta ninety milligrams twice daily i wan na continue you on a high dose statin called lipitor and you're gon na be taking that eighty milligrams a day and we're gon na continue you on your toprol and that's gon na be fifty milligrams daily i am gon na refer you to cardiac rehab so we can get you some education and give you some confidence to get back to exercising regularly i know it was kinda scary to have such an episode but i promise like most of the patients i have love cardiac rehab and i think you'll do pretty well for your second diagnosis we have newly you have newly reduced left ventricular dysfunction and moderate mitral regurgitation what i think is like what that means is that you're you're pumping like the way that your heart is pumping is a bit concerning but i think like given your history that it will improve over time they got you into the cath lab pretty quickly so i think that the muscle is just kinda like stunned like surprised and since you're compliant with your meds i think you will recover we are gon na continue you on your lisinopril twenty milligrams daily however considering that you are retaining fluid i think that your third diagnosis is like we are crossing into acute heart failure i'm gon na prescribe something called a diuretic it's called lasix and i do want to we need to take that forty milligrams once a day i wan na add aldactone twelve . five milligrams daily and i need you to get labs finally we will repeat another echo in about two months last but not least there is the hypertension your blood pressure seems fine i think with the aldactone that you'll tolerate that pretty well but we do want to maybe get you into some nutrition counseling to consider like what other diet options might be available to you maybe suggestions of things that you have n't thought about like cutting out meat especially any kind of preserved meat like pepperoni but maybe finding you some alternatives how does that sound patient: that sounds good yeah so i'm yeah as long as you tell me i'm gon na get better i believe you

D2N156

17

[ "Physical Examination", "Discussion", "Referral", "Medication", "Other Treatments", "Radiology Examination", "Diagnostic Testing", "Reassessment", "Acute Assessment" ]

[ "Objective", "Assessment", "Plan" ]

alright so your vital signs look good you know so i'm glad that it looks like you're tolerating your medication pretty well on your neck exam i do n't appreciate any jugular venous distention so and then on top of that i'm not i do n't appreciate any carotid bruits so i'm not feeling anything like too concerning on your heart exam though there is a three over six systolic ejection murmur heard at the that i'm hearing at the left base that's not like a huge deal especially considering like what you've been through already in terms of the hospital but it is something that i wan na know in your chart when i listen to you your lungs your lungs are clear over here with your extremities i do notice you know some lower lower edema swelling sorry some lower swelling edema lower limb edema and it it is pitting one plus on your right radial artery the cath site is clean dry and intact without hematoma and i also your right radial artery pulses are palpable so i did review the results of your ekg and they show a normal sinus rhythm and a good r wave progression and a a evolutionary changes that are anticipated after a stemi one of the reasons though that we had you come in is that we noticed on your echo there is a reduced ejection fraction of thirty five percent we are a little bit concerned about that so let's talk about my assessment and plan for you your primary and like first diagnosis is gon na be coronary artery disease right you already have a history of that but you know we're gon na do some things to make we're gon na continue to evaluate that over time i want you to continue your aspirin eighty one milligrams daily and your brilinta ninety milligrams twice daily i wan na continue you on a high dose statin called lipitor and you're gon na be taking that eighty milligrams a day and we're gon na continue you on your toprol and that's gon na be fifty milligrams daily i am gon na refer you to cardiac rehab so we can get you some education and give you some confidence to get back to exercising regularly i know it was kinda scary to have such an episode but i promise like most of the patients i have love cardiac rehab and i think you'll do pretty well for your second diagnosis we have newly you have newly reduced left ventricular dysfunction and moderate mitral regurgitation what i think is like what that means is that you're you're pumping like the way that your heart is pumping is a bit concerning but i think like given your history that it will improve over time they got you into the cath lab pretty quickly so i think that the muscle is just kinda like stunned like surprised and since you're compliant with your meds i think you will recover we are gon na continue you on your lisinopril twenty milligrams daily however considering that you are retaining fluid i think that your third diagnosis is like we are crossing into acute heart failure i'm gon na prescribe something called a diuretic it's called lasix and i do want to we need to take that forty milligrams once a day i wan na add aldactone twelve . five milligrams daily and i need you to get labs finally we will repeat another echo in about two months last but not least there is the hypertension your blood pressure seems fine i think with the aldactone that you'll tolerate that pretty well but we do want to maybe get you into some nutrition counseling to consider like what other diet options might be available to you maybe suggestions of things that you have n't thought about like cutting out meat especially any kind of preserved meat like pepperoni but maybe finding you some alternatives how does that sound

3,969

doctor: yes yeah i i strongly believe this is our best course of action and that you will get better given enough time i i see that you are making efforts i'm really glad that you are out there walking and that you're cognizant of your diet and willing to make changes we will just you know monitor it over time okay patient: okay

D2N156

18

[ "Chitchat" ]

[ "Null" ]

yes yeah i i strongly believe this is our best course of action and that you will get better given enough time i i see that you are making efforts i'm really glad that you are out there walking and that you're cognizant of your diet and willing to make changes we will just you know monitor it over time okay

3,970

doctor: alright thank you

D2N156

19

[ "Chitchat" ]

[ "Null" ]

doctor: alright thank you

3,971

doctor: hey jose how are you doing it's been about you know three or four months since i last saw you what's going on patient: i'm doing okay i i guess the medications are helping i'm concerned about all the medications i'm taking but i think i'm doing okay

D2N157

0

[ "Greetings" ]

[ "Subjective" ]

hey jose how are you doing it's been about you know three or four months since i last saw you what's going on

3,972

doctor: yeah yeah you are on a fair amount of medications you know we do have you on those medications because you did have a heart attack about six months ago they put that that stent into your left anterior descending artery and so that's a major artery on the left side of your heart and so we need to keep those stents open and and kinda help your heart heal so it is gon na be very important for you to continue on those medications so you're still taking your aspirin and are you still taking the brilinta patient: yes and and fish oil

D2N157

1

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

yeah yeah you are on a fair amount of medications you know we do have you on those medications because you did have a heart attack about six months ago they put that that stent into your left anterior descending artery and so that's a major artery on the left side of your heart and so we need to keep those stents open and and kinda help your heart heal so it is gon na be very important for you to continue on those medications so you're still taking your aspirin and are you still taking the brilinta

3,973

doctor: and fish oil okay good now how are you doing with the crestor i know that that's you know that's the statin that's the cholesterol medication you were concerned that it might cause you to have some muscle aches are you taking that patient: i i think i'm doing good but i i am i feel like i i when i i guess the only complaint that i have is ever since i i do n't know if this is the heart attack or if this this is the the medication but when i stand up real fast i get really dizzy

D2N157

2

[ "Therapeutic History" ]

[ "Subjective" ]

and fish oil okay good now how are you doing with the crestor i know that that's you know that's the statin that's the cholesterol medication you were concerned that it might cause you to have some muscle aches are you taking that

3,974

doctor: you get you get dizzy okay yeah you know we do have you on a what we call a beta-blocker metoprolol i think your dose is fifty milligrams once a day and you know sometimes it takes a little bit for your body to adjust to that but yes if you stand up too quickly it can cause you to be a little dizzy so patient: okay okay that makes sense okay that's good to know because i did n't know what what what the problem was so can i ask you a question regarding the stents

D2N157

3

[ "Medication", "Therapeutic History" ]

[ "Subjective", "Plan" ]

you get you get dizzy okay yeah you know we do have you on a what we call a beta-blocker metoprolol i think your dose is fifty milligrams once a day and you know sometimes it takes a little bit for your body to adjust to that but yes if you stand up too quickly it can cause you to be a little dizzy so

3,975

doctor: so the stents are permanent we do n't we do n't remove them so yep so that's why it's gon na be super important for you you know you're gon na be on aspirin for the rest of your life and then i'm gon na keep you on that brilinta for another six months that's gon na help prevent the that stent from clogging patient: okay okay do i need to ever replace the stents then

D2N157

5

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

so the stents are permanent we do n't we do n't remove them so yep so that's why it's gon na be super important for you you know you're gon na be on aspirin for the rest of your life and then i'm gon na keep you on that brilinta for another six months that's gon na help prevent the that stent from clogging

3,976

doctor: no i mean every so often the stents can become narrowed again but you know that's why you're seeing me your cardiologist so that i can follow you for that now if you start to have symptoms again of any chest pain like you had before or any shortness of breath when you start to exert yourself i want you to tell me and we might have to go ahead and send you for further testing to make sure that those stents are okay but typically if you continue to take the medication watch your diet that type of thing your stents will will stay open for a long time patient: okay alright that sounds good you know i have n't i had a i had i know you asked me to follow up with the dietitian because i had diabetes as well which probably contributed to my heart attack

D2N157

6

[ "Referral", "Medication", "Diagnostic Testing" ]

[ "Plan" ]

no i mean every so often the stents can become narrowed again but you know that's why you're seeing me your cardiologist so that i can follow you for that now if you start to have symptoms again of any chest pain like you had before or any shortness of breath when you start to exert yourself i want you to tell me and we might have to go ahead and send you for further testing to make sure that those stents are okay but typically if you continue to take the medication watch your diet that type of thing your stents will will stay open for a long time

3,977

doctor: okay that's okay yeah i certainly can help you with that now managing your diabetes is also going to play an important role in your coronary artery disease which it sounds like you already know that which is really good so i will put in another referral for diabetic education for you how are you doing watching your sweets i know that you know you do have an afinity for those chocolate chip cookies patient: it's okay my a1c was n't where i wanted but my glucose is coming in in about one thirty

D2N157

8

[ "Referral", "Vegetative History" ]

[ "Subjective", "Plan" ]

okay that's okay yeah i certainly can help you with that now managing your diabetes is also going to play an important role in your coronary artery disease which it sounds like you already know that which is really good so i will put in another referral for diabetic education for you how are you doing watching your sweets i know that you know you do have an afinity for those chocolate chip cookies

3,978

doctor: okay what was the what was the a1c the hemoglobin a1c if you do n't mind me asking patient: i thought it was close to sixty

D2N157

10

[ "Lab Examination" ]

[ "Objective" ]

okay what was the what was the a1c the hemoglobin a1c if you do n't mind me asking

3,979

doctor: okay yeah that's really high so we want it to be about six so you you do have some work to do with your diet patient: yeah yeah so okay so i know you asked me to do a blood test so i did that i was wondering if you got the results

D2N157

11

[ "Other Treatments", "Lab Examination" ]

[ "Objective", "Plan" ]

okay yeah that's really high so we want it to be about six so you you do have some work to do with your diet

3,980

doctor: i did you know i looked at the results of your kidney function that's what we call your creatinine just because you had some contrast dye and sometimes contrast dye can impact the kidneys and your kidney function is stable which is great when was the last time you saw your nephrologist patient: oh

D2N157

12

[ "Personal History", "Lab Examination" ]

[ "Subjective", "Objective" ]

i did you know i looked at the results of your kidney function that's what we call your creatinine just because you had some contrast dye and sometimes contrast dye can impact the kidneys and your kidney function is stable which is great when was the last time you saw your nephrologist

3,981

doctor: that's your kidney doctor patient: i'm a bad i'm a bad patient so probably a year ago

D2N157

13

[ "Personal History" ]

[ "Subjective" ]

that's your kidney doctor

3,982

doctor: okay you know you do have the stage three ckd so that's the the stage three kidney disease so it is gon na be important for you to follow up with your nephrologist just to make sure that everything is okay now i did check your kidney function and and it was fine but are you staying away from things like motrin and advil patient: right yeah that's i threw all of those out

D2N157

14

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

okay you know you do have the stage three ckd so that's the the stage three kidney disease so it is gon na be important for you to follow up with your nephrologist just to make sure that everything is okay now i did check your kidney function and and it was fine but are you staying away from things like motrin and advil

3,983

doctor: okay good okay perfect now i know that you're from the west coast are you super excited that la one the super bowl or are you more of a san francisco forty nine or span patient: i'm a more of a san francisco fan

D2N157

15

[ "Chitchat" ]

[ "Null" ]

okay good okay perfect now i know that you're from the west coast are you super excited that la one the super bowl or are you more of a san francisco forty nine or span

3,984

doctor: so do you like jimmy g do you think he can beat erin rogers again patient: okay we'll see we'll see what happens but i'm pretty flexible when he comes to you know that is but one thing that since i ca n't take motrin what pain killer can i take for headaches

D2N157

16

[ "Discussion" ]

[ "Plan" ]

so do you like jimmy g do you think he can beat erin rogers again

3,985

doctor: you can take tylenol patient: okay

D2N157

17

[ "Discussion", "Medication" ]

[ "Plan" ]

you can take tylenol

3,986

doctor: yeah i can do that but i do wan na just do a physical exam on you okay so and looking here at your vital signs here you know your your vital signs look quite good you know your blood pressure is what right where it should be it's about one twenty seven over eighty which is great so you're doing a good job taking your metoprolol now in terms of on your neck exam i do n't appreciate any jugular venous distention or carotid bruits on your heart exam i do appreciate a slight three out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do appreciate some one plus nonpitting edema now what does that mean what does that mean jose so all of that means is that i do hear a little heart murmur on your heart which i've heard before in the past and it does n't it does n't look like you're retaining any fluid which is good but you do have a little puffiness in your legs which sometimes some of the medications can cause patient: yeah i do have that

D2N157

21

[ "Physical Examination" ]

[ "Objective" ]

yeah i can do that but i do wan na just do a physical exam on you okay so and looking here at your vital signs here you know your your vital signs look quite good you know your blood pressure is what right where it should be it's about one twenty seven over eighty which is great so you're doing a good job taking your metoprolol now in terms of on your neck exam i do n't appreciate any jugular venous distention or carotid bruits on your heart exam i do appreciate a slight three out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do appreciate some one plus nonpitting edema now what does that mean what does that mean jose so all of that means is that i do hear a little heart murmur on your heart which i've heard before in the past and it does n't it does n't look like you're retaining any fluid which is good but you do have a little puffiness in your legs which sometimes some of the medications can cause

3,987

doctor: so let's just go over a little bit about my assessment and and plan for you going forward so for your first problem of your coronary artery disease i think you're doing really well i wan na go ahead and refer you for cardiac rehab just so that you can be more active and have some confidence in in exercising again okay and i am gon na go ahead and refill your metoprolol your crestor forty milligrams once a day as well as the aspirin okay i do n't think we need to proceed with a a stress test or anything at this time but you know to let me know if you have any symptoms okay patient: okay

D2N157

22

[ "Referral", "Medication", "Reassessment" ]

[ "Assessment", "Plan" ]

so let's just go over a little bit about my assessment and and plan for you going forward so for your first problem of your coronary artery disease i think you're doing really well i wan na go ahead and refer you for cardiac rehab just so that you can be more active and have some confidence in in exercising again okay and i am gon na go ahead and refill your metoprolol your crestor forty milligrams once a day as well as the aspirin okay i do n't think we need to proceed with a a stress test or anything at this time but you know to let me know if you have any symptoms okay

3,988

doctor: okay for your patient: sounds really good

D2N157

23

[ "Chitchat" ]

[ "Null" ]

okay for your

3,989

doctor: good for your second problem of your stage three chronic kidney disease i am gon na reach out to doctor miller and make an appointment for you to be seen just because again i think it's important for you to follow up with your nephrologist okay patient: okay

D2N157

24

[ "Referral", "Reassessment" ]

[ "Assessment", "Plan" ]

good for your second problem of your stage three chronic kidney disease i am gon na reach out to doctor miller and make an appointment for you to be seen just because again i think it's important for you to follow up with your nephrologist okay

3,990

doctor: and then for your third problem of your diabetes i am gon na go ahead and order another hemoglobin a1c and i'm gon na put that referral in for the dietitian to give you some dietary education and i'm gon na go ahead and talk with your primary care physician about your your insulin regimen okay patient: okay

D2N157

25

[ "Referral", "Medication", "Diagnostic Testing", "Reassessment" ]

[ "Assessment", "Plan" ]

and then for your third problem of your diabetes i am gon na go ahead and order another hemoglobin a1c and i'm gon na put that referral in for the dietitian to give you some dietary education and i'm gon na go ahead and talk with your primary care physician about your your insulin regimen okay

3,991

doctor: any questions patient: yeah you know i've been kinda down ever since i had my heart attack is there any medication that i could take to make me feel a little bit less sad

D2N157

26

[ "Discussion" ]

[ "Plan" ]

any questions

3,992

doctor: yeah i mean are you having any thoughts of of harming yourself or harming others patient: no no i just feel kinda down

D2N157

27

[ "Vegetative History" ]

[ "Subjective" ]

yeah i mean are you having any thoughts of of harming yourself or harming others

3,993

doctor: you feel kinda down what's your patient: life sucks

D2N157

28

[ "Personal History" ]

[ "Subjective" ]

you feel kinda down what's your

3,994

doctor: what well i do n't think so what what's your support system like patient: you know i i live with my dog and that's it so it's kind of you know lonely

D2N157

29

[ "Other Socials" ]

[ "Subjective" ]

what well i do n't think so what what's your support system like

3,995

doctor: okay alright well would you be interested in in like a referral to psychiatry or something like that so that you have someone to talk to about some of of issues because medication can help but i do i think it's important to have you know talk some of these things out patient: okay yeah you know i'll give that a try i mean i'm retiring i got plenty of time

D2N157

30

[ "Discussion", "Referral" ]

[ "Plan" ]

okay alright well would you be interested in in like a referral to psychiatry or something like that so that you have someone to talk to about some of of issues because medication can help but i do i think it's important to have you know talk some of these things out

3,996

doctor: okay so why do n't we go ahead and i'm gon na place a referral to psychiatry for you know you know difficulty adjusting after having a heart attack maybe some some mild depression okay does that sound okay okay patient: yeah that sounds really good thank you

D2N157

31

[ "Discussion", "Referral", "Reassessment" ]

[ "Assessment", "Plan" ]

okay so why do n't we go ahead and i'm gon na place a referral to psychiatry for you know you know difficulty adjusting after having a heart attack maybe some some mild depression okay does that sound okay okay

3,997

doctor: okay you're welcome anything else patient: so you will do the medication refill do i so that's automatic

D2N157

32

[ "Discussion" ]

[ "Plan" ]

okay you're welcome anything else

3,998

doctor: yep i'm gon na put them into the computer and and whatever pharmacy you want yep mm-hmm patient: okay alright sounds great thank you

D2N157

33

[ "Discussion", "Medication" ]

[ "Plan" ]

yep i'm gon na put them into the computer and and whatever pharmacy you want yep mm-hmm

3,999