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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... | 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 ... | 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 o... | 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 ... | 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 lo... | 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 ... | 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... | 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 ... | 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 ... | 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 a... | 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... | 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... | 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 ... | 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 ... | 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 ... | 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 ... | 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 contro... | 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... | 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 f... | 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 i... | 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... | 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 t... | 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'r... | 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... | 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 hea... | 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... | 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 ... | 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 ho... | 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 las... | 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 tryin... | 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 concernin... | 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 you... | 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 pat... | 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 sten... | 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 ... | 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 o... | 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: ... | 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 pati... | 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 ... | 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 w... | 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 ... | 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 swe... | 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 ... | 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 advi... | 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 takin... | 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 m... | 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 aga... | 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 ... | 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... | 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 |
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