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doctor: um , and then i'm gon na prescribe some steroids to help , also some prednisone . so let me just order those . patient: okay .
|
D2N015
| 27
|
[
"Medication"
] |
[
"Plan"
] |
um , and then i'm gon na prescribe some steroids to help , also some prednisone . so let me just order those .
| 400
|
doctor: hey , dragon , order combivent , uh , two puffs twice a day . order albuterol , two puffs as needed . and order , uh , prednisone uh taper pack . okay , so and then it sounds like your depression's stable , so we're not gon na change anything . you're gon na keep taking the effexor . um , do yoga for depression and your back pain , so for your back pain , stay on the neurontin , and we just wo n't do anything different . any questions for me . patient: no , i think this is good . thank you .
|
D2N015
| 28
|
[
"Discussion",
"Medication"
] |
[
"Plan"
] |
hey , dragon , order combivent , uh , two puffs twice a day . order albuterol , two puffs as needed . and order , uh , prednisone uh taper pack . okay , so and then it sounds like your depression's stable , so we're not gon na change anything . you're gon na keep taking the effexor . um , do yoga for depression and your back pain , so for your back pain , stay on the neurontin , and we just wo n't do anything different . any questions for me .
| 401
|
doctor: perfect . hey , dragon , finalize the note . why do n't you ...
|
D2N015
| 29
|
[
"Chitchat"
] |
[
"Null"
] |
doctor: perfect . hey , dragon , finalize the note . why do n't you ...
| 402
|
doctor: hi , edward , how are you ? patient: i'm doing well , yourself ?
|
D2N016
| 0
|
[
"Greetings"
] |
[
"Subjective"
] |
hi , edward , how are you ?
| 403
|
doctor: i'm doing okay . patient: good .
|
D2N016
| 1
|
[
"Chitchat"
] |
[
"Null"
] |
i'm doing okay .
| 404
|
doctor: so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . patient: absolutely .
|
D2N016
| 2
|
[
"Chitchat"
] |
[
"Null"
] |
so , i know the nurse told you about dax . i'd like to tell dax a little bit about you .
| 405
|
doctor: edward is a 59 year old male with a past medical history significant for depression , hypertension and prior rotator cuff repair who presents for followup of his chronic problems . so , edward , it's been a little while since i saw you . patient: mm-hmm .
|
D2N016
| 3
|
[
"Personal History"
] |
[
"Subjective"
] |
edward is a 59 year old male with a past medical history significant for depression , hypertension and prior rotator cuff repair who presents for followup of his chronic problems . so , edward , it's been a little while since i saw you .
| 406
|
doctor: how are you doing ? patient: i'm doing pretty well , actually . it's been a good , uh , good six months .
|
D2N016
| 4
|
[
"Personal History"
] |
[
"Subjective"
] |
how are you doing ?
| 407
|
doctor: good . okay . so , you know , the last time we spoke , you know , you were trying to think of some new strategies to manage your depression . you did n't wan na go on medication because you're already on a bunch of meds . patient: absolutely .
|
D2N016
| 5
|
[
"Personal History",
"Therapeutic History"
] |
[
"Subjective"
] |
good . okay . so , you know , the last time we spoke , you know , you were trying to think of some new strategies to manage your depression . you did n't wan na go on medication because you're already on a bunch of meds .
| 408
|
doctor: so , how are you doing with that ? patient: i'm doing well . i see a counselor , uh , once a week . uh , and i've been out swimming at the pool a lot this , this , uh , summer , and , uh , fall . so , things have been well , going well with my depression .
|
D2N016
| 6
|
[
"Personal History"
] |
[
"Subjective"
] |
so , how are you doing with that ?
| 409
|
doctor: okay , so , you do n't wan na , you do n't feel the need to start any medications at this time ? patient: no , no , no . but , i know i can call you if i do .
|
D2N016
| 7
|
[
"Personal History"
] |
[
"Subjective"
] |
okay , so , you do n't wan na , you do n't feel the need to start any medications at this time ?
| 410
|
doctor: yeah , absolutely . patient: okay .
|
D2N016
| 8
|
[
"Chitchat"
] |
[
"Null"
] |
yeah , absolutely .
| 411
|
doctor: yeah . all right . and then , in terms of your high blood pressure , how are you doing with that ? i know we , we were kind of struggling with it la- six months ago . how are you doing ? patient: i still have my good days and my bad days . i do take my medicine daily . uh , but , you know that burger and wine , every once in a while , sneaks in there , and that salt be ... we know what that does .
|
D2N016
| 9
|
[
"Personal History"
] |
[
"Subjective"
] |
yeah . all right . and then , in terms of your high blood pressure , how are you doing with that ? i know we , we were kind of struggling with it la- six months ago . how are you doing ?
| 412
|
doctor: yeah . so , i love burgers and wine too . patient: okay .
|
D2N016
| 10
|
[
"Chitchat"
] |
[
"Null"
] |
yeah . so , i love burgers and wine too .
| 413
|
doctor: so , i get it . um , okay , so , and you're taking the norvasc ? patient: norvasc , yep .
|
D2N016
| 11
|
[
"Therapeutic History"
] |
[
"Subjective"
] |
so , i get it . um , okay , so , and you're taking the norvasc ?
| 414
|
doctor: okay . um , and , you're checking your blood pressures at home , it sounds like ? patient: i , i do . well , i go to cvs pharmacy . they , they have a , uh , machine that i can sit down at quickly and get my , uh , blood pressure taken . and , i go there about once a week .
|
D2N016
| 12
|
[
"Personal History"
] |
[
"Subjective"
] |
okay . um , and , you're checking your blood pressures at home , it sounds like ?
| 415
|
doctor: okay . all right . and then , i know that you had that rotator cuff repaired about eight months ago . how are you doing ? patient: um , it's doing well . i , i'm , i'm , been stretching with a yoga ball .
|
D2N016
| 13
|
[
"Personal History"
] |
[
"Subjective"
] |
okay . all right . and then , i know that you had that rotator cuff repaired about eight months ago . how are you doing ?
| 416
|
doctor: okay . are you still seeing the physical therapist in the center , or are you just doing exercises at home ? patient: i'm just , i progressed to exercises at home .
|
D2N016
| 15
|
[
"Personal History"
] |
[
"Subjective"
] |
okay . are you still seeing the physical therapist in the center , or are you just doing exercises at home ?
| 417
|
doctor: okay . all right . great . all right . well , i know you did a review of systems sheet when you checked in . patient: mm-hmm .
|
D2N016
| 16
|
[
"Vegetative History"
] |
[
"Subjective"
] |
okay . all right . great . all right . well , i know you did a review of systems sheet when you checked in .
| 418
|
doctor: and , you know , it seems like you're doing well . any symptoms at all ? any nasal congestion or chest pain , shortness of breath , anything ? patient: no . none of those . i do , do notice that i get a little bit of a de- , uh , swelling in my ankles .
|
D2N016
| 17
|
[
"Vegetative History"
] |
[
"Subjective"
] |
and , you know , it seems like you're doing well . any symptoms at all ? any nasal congestion or chest pain , shortness of breath , anything ?
| 419
|
doctor: okay . all right . all right . maybe that has to do with some of the salt intake you're , you're eating . patient: okay .
|
D2N016
| 20
|
[
"Vegetative History"
] |
[
"Subjective"
] |
okay . all right . all right . maybe that has to do with some of the salt intake you're , you're eating .
| 420
|
doctor: all right . well , i wan na go ahead and do a quick physical exam , okay ? patient: mm-hmm .
|
D2N016
| 21
|
[
"Physical Examination"
] |
[
"Objective"
] |
all right . well , i wan na go ahead and do a quick physical exam , okay ?
| 421
|
doctor: hey , dragon ? show me the blood pressure . yeah , so , your blood pressure's a little elevated today , 156 over 94 . patient: okay .
|
D2N016
| 22
|
[
"Physical Examination"
] |
[
"Objective"
] |
hey , dragon ? show me the blood pressure . yeah , so , your blood pressure's a little elevated today , 156 over 94 .
| 422
|
doctor: you know , you could be a little happy to see me . i do n't know . um , but let's look at some of the readings . hey , dragon ? show me the blood pressure readings . yeah , so , they've been a , running a little high over the past couple months . patient: okay .
|
D2N016
| 23
|
[
"Physical Examination"
] |
[
"Objective"
] |
you know , you could be a little happy to see me . i do n't know . um , but let's look at some of the readings . hey , dragon ? show me the blood pressure readings . yeah , so , they've been a , running a little high over the past couple months .
| 423
|
doctor: so , we'll have to just kinda talk about that , okay ? patient: okay .
|
D2N016
| 24
|
[
"Chitchat"
] |
[
"Null"
] |
so , we'll have to just kinda talk about that , okay ?
| 424
|
doctor: i'm gon na go ahead and listen to your heart and lungs , and i'll let you know what i find , okay ? patient: okay .
|
D2N016
| 25
|
[
"Physical Examination"
] |
[
"Objective"
] |
i'm gon na go ahead and listen to your heart and lungs , and i'll let you know what i find , okay ?
| 425
|
doctor: okay . all right . so , on physical exam , you know , everything looks good . on your heart exam , i do appreciate a slight three out of six systolic ejection murmur , but we've heard that in the past . patient: okay .
|
D2N016
| 26
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . all right . so , on physical exam , you know , everything looks good . on your heart exam , i do appreciate a slight three out of six systolic ejection murmur , but we've heard that in the past .
| 426
|
doctor: so , that seems stable to me . um , on your lung exam , everything sounds nice and clear , and on your lower extremity exam , i do appreciate , you know , 1 to 2+ pitting edema in your legs , okay ? so , we'll have to just talk a little bit about your diet and decreasing the salt intake , okay ? patient: okay .
|
D2N016
| 27
|
[
"Physical Examination",
"Discussion"
] |
[
"Objective",
"Plan"
] |
so , that seems stable to me . um , on your lung exam , everything sounds nice and clear , and on your lower extremity exam , i do appreciate , you know , 1 to 2+ pitting edema in your legs , okay ? so , we'll have to just talk a little bit about your diet and decreasing the salt intake , okay ?
| 427
|
doctor: so , let me just look at some of your results , okay ? hey , dragon ? show me the labs . so , looking here at your lab results , everything looks really good . you know , your creatinine , that's your kidney function , that looks stable . everything looks good from that standpoint . hey , dragon ? show me the ekg . and , looking here at your ekg , everything , you know , looks fine . there's no evidence of any coronary artery disease . it's a nice , normal ekg , which is good . patient: okay .
|
D2N016
| 28
|
[
"Lab Examination",
"Radiology Examination"
] |
[
"Objective"
] |
so , let me just look at some of your results , okay ? hey , dragon ? show me the labs . so , looking here at your lab results , everything looks really good . you know , your creatinine , that's your kidney function , that looks stable . everything looks good from that standpoint . hey , dragon ? show me the ekg . and , looking here at your ekg , everything , you know , looks fine . there's no evidence of any coronary artery disease . it's a nice , normal ekg , which is good .
| 428
|
doctor: so , let me just talk a little bit about my assessment and my plan for you . okay ? so , from a depression standpoint , it's , you know , your first problem , i think that that sounds like you're doing really well managing it . you know , you have good strategies . it sounds like you have a good support system , um , and i agree . i do n't think you need to start on any medication at this time , but you said before , you know you can call me , okay ? patient: yes .
|
D2N016
| 30
|
[
"Discussion",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] |
so , let me just talk a little bit about my assessment and my plan for you . okay ? so , from a depression standpoint , it's , you know , your first problem , i think that that sounds like you're doing really well managing it . you know , you have good strategies . it sounds like you have a good support system , um , and i agree . i do n't think you need to start on any medication at this time , but you said before , you know you can call me , okay ?
| 429
|
doctor: for your second problem , your hypertension , i , i do n't believe it's well controlled at this time . so , i wan na go ahead and , you know , increase the norvasc up to 10 mg a day , and i wan na go ahead and order an echocardiogram and a lipid panel , okay ? patient: okay .
|
D2N016
| 31
|
[
"Medication",
"Diagnostic Testing",
"Reassessment"
] |
[
"Assessment",
"Plan"
] |
for your second problem , your hypertension , i , i do n't believe it's well controlled at this time . so , i wan na go ahead and , you know , increase the norvasc up to 10 mg a day , and i wan na go ahead and order an echocardiogram and a lipid panel , okay ?
| 430
|
doctor: hey , dragon ? order an echocardiogram . and , for your third problem , your rotator cuff repair , i , i think you're doing really well with that . i would just continue with the exercises and , uh , i do n't think we need to intervene upon that anymore . it sounds like that's pretty much resolved , okay ? patient: good . good .
|
D2N016
| 32
|
[
"Referral",
"Diagnostic Testing",
"Reassessment"
] |
[
"Assessment",
"Plan"
] |
hey , dragon ? order an echocardiogram . and , for your third problem , your rotator cuff repair , i , i think you're doing really well with that . i would just continue with the exercises and , uh , i do n't think we need to intervene upon that anymore . it sounds like that's pretty much resolved , okay ?
| 431
|
doctor: do you have any questions about anything ? patient: no questions .
|
D2N016
| 33
|
[
"Chitchat"
] |
[
"Null"
] |
do you have any questions about anything ?
| 432
|
doctor: okay , great . hey , dragon ? finalize the note .
|
D2N016
| 34
|
[
"Chitchat"
] |
[
"Null"
] |
doctor: okay , great . hey , dragon ? finalize the note .
| 433
|
doctor: hello , mrs . peterson . patient: hi , doctor taylor . good to see you .
|
D2N017
| 0
|
[
"Greetings"
] |
[
"Subjective"
] |
hello , mrs . peterson .
| 434
|
doctor: you're here for your hip today , or your- your leg today ? patient: yes . i hurt my- the- my- top part of my right leg here .
|
D2N017
| 1
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
you're here for your hip today , or your- your leg today ?
| 435
|
doctor: hey , dragon . i'm seeing mrs . peterson , here , she's a 43-year-old patient . she's here for left leg pain . right leg pain , right leg pain ? patient: yes .
|
D2N017
| 2
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
hey , dragon . i'm seeing mrs . peterson , here , she's a 43-year-old patient . she's here for left leg pain . right leg pain , right leg pain ?
| 436
|
doctor: um so , what happened to you ? patient: i was bowling and as i was running up to the lane , i had my bowling ball all the way back , and when i slung it forward , i hit it right into my leg instead of the lane and so then i fell but- yeah-
|
D2N017
| 3
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
um so , what happened to you ?
| 437
|
doctor: did you get a strike ? patient: no . in fact , i actually dropped the ball and it jumped two lanes over and landed in the other people's gutter .
|
D2N017
| 4
|
[
"Chitchat"
] |
[
"Null"
] |
did you get a strike ?
| 438
|
doctor: terrific , terrific . so , did it swell up on you ? patient: it- not- did n't seem like it swelled that much .
|
D2N017
| 5
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
terrific , terrific . so , did it swell up on you ?
| 439
|
doctor: what about bruising ? patient: um , a little bit on the back- back end , that side .
|
D2N017
| 6
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
what about bruising ?
| 440
|
doctor: have- have you been able to walk on it ? patient: just a little bit . very carefully .
|
D2N017
| 7
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
have- have you been able to walk on it ?
| 441
|
doctor: sore to walk on ? patient: yes . it's very sore .
|
D2N017
| 8
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
sore to walk on ?
| 442
|
doctor: um , and going upstairs or downstairs , does that bother you at all ? patient: yeah , well , i do n't have stairs , but um , i would avoid that at all costs .
|
D2N017
| 9
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
um , and going upstairs or downstairs , does that bother you at all ?
| 443
|
doctor: okay . um , it looks like you had a history of atopic eczema in your past ? patient: yes . yes , i have eczema .
|
D2N017
| 10
|
[
"Personal History"
] |
[
"Subjective"
] |
okay . um , it looks like you had a history of atopic eczema in your past ?
| 444
|
doctor: okay . and you take uh- uh , fluocinonide for that ? patient: yes , when it gets really itchy , i'll- i'll use that and it usually takes care of it .
|
D2N017
| 11
|
[
"Personal History",
"Therapeutic History"
] |
[
"Subjective"
] |
okay . and you take uh- uh , fluocinonide for that ?
| 445
|
doctor: okay . and , it looks like you have a pre- previous surgical history of a colectomy ? what happened there ? patient: yes , i had a- um , some diverticulosis and then um , i actually went into diverticulitis and they ended up going in and having to remove a little bit of my colon .
|
D2N017
| 12
|
[
"Personal History"
] |
[
"Subjective"
] |
okay . and , it looks like you have a pre- previous surgical history of a colectomy ? what happened there ?
| 446
|
doctor: okay , let me examine you . does it hurt when i push on your leg like that ? patient: yes , it does .
|
D2N017
| 13
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay , let me examine you . does it hurt when i push on your leg like that ?
| 447
|
doctor: okay . if i lift your leg up like this , does that hurt ? patient: no .
|
D2N017
| 14
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . if i lift your leg up like this , does that hurt ?
| 448
|
doctor: so , on my exam , you have some significant tenderness to the lateral aspect of your um right upper leg . you do n't seem to have any pain or tenderness with flexion or extension of your um your lower leg . um , are you taking anything for it right now ? patient: i've been going back and forth between taking ibuprofen and tylenol .
|
D2N017
| 15
|
[
"Physical Examination",
"Therapeutic History"
] |
[
"Subjective",
"Objective"
] |
so , on my exam , you have some significant tenderness to the lateral aspect of your um right upper leg . you do n't seem to have any pain or tenderness with flexion or extension of your um your lower leg . um , are you taking anything for it right now ?
| 449
|
doctor: okay . well , my impression is that you- you probably have a contusion , but let's take a look at your x-ray first . hey , dragon . show me the x-ray . yeah , so if you look at this , this is a normal femur . um , really do n't see any evidence of a fracture or any swelling , so it's essentially , a normal x-ray . so , what we're going to do is , i'm going to start you on um an anti-inflammatory . it's going to be mobic 15 milligrams uh , once a day . i want you to use some ice for the pain , um , and it should , honestly , just being a contusion , get better in the next week or so . if it's not getting better , of course , come on back and- and see me . patient: okay , sounds good .
|
D2N017
| 16
|
[
"Medication",
"Radiology Examination",
"Acute Assessment"
] |
[
"Objective",
"Assessment",
"Plan"
] |
okay . well , my impression is that you- you probably have a contusion , but let's take a look at your x-ray first . hey , dragon . show me the x-ray . yeah , so if you look at this , this is a normal femur . um , really do n't see any evidence of a fracture or any swelling , so it's essentially , a normal x-ray . so , what we're going to do is , i'm going to start you on um an anti-inflammatory . it's going to be mobic 15 milligrams uh , once a day . i want you to use some ice for the pain , um , and it should , honestly , just being a contusion , get better in the next week or so . if it's not getting better , of course , come on back and- and see me .
| 450
|
doctor: hey , dragon . go ahead and um , pres- do the orders and um , procedures uh , as described . come with me , and uh , i'll get you checked out . dragon , go ahead and finish off the note .
|
D2N017
| 17
|
[
"Chitchat"
] |
[
"Null"
] |
doctor: hey , dragon . go ahead and um , pres- do the orders and um , procedures uh , as described . come with me , and uh , i'll get you checked out . dragon , go ahead and finish off the note .
| 451
|
doctor: hi miss russell . patient: hi-
|
D2N018
| 0
|
[
"Greetings"
] |
[
"Subjective"
] |
hi miss russell .
| 452
|
doctor: nice to meet you- patient: doctor gutierrez . how are you ?
|
D2N018
| 1
|
[
"Greetings"
] |
[
"Subjective"
] |
nice to meet you-
| 453
|
doctor: i'm well . patient: good .
|
D2N018
| 2
|
[
"Greetings"
] |
[
"Subjective"
] |
i'm well .
| 454
|
doctor: hey dragon . i'm seeing miss russell . she's a 39-year-old female here for , what are you here for ? patient: it's my right upper arm . it hurts really , really bad .
|
D2N018
| 3
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
hey dragon . i'm seeing miss russell . she's a 39-year-old female here for , what are you here for ?
| 455
|
doctor: so severe right upper arm pain . patient: yeah , uh yes .
|
D2N018
| 4
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
so severe right upper arm pain .
| 456
|
doctor: and how did this happen ? patient: i was playing volleyball yesterday , uh last night . um and i went to spike the ball , and the team we were playing , they're dirty . so um , somebody right across from me kinda kicked my legs from under me as i was going up , and i fell and landed on my arm .
|
D2N018
| 5
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
and how did this happen ?
| 457
|
doctor: mm-hmm , like right on your shoulder . patient: yeah .
|
D2N018
| 6
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
mm-hmm , like right on your shoulder .
| 458
|
doctor: that sounds like it hurt . patient: it was nasty .
|
D2N018
| 8
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
that sounds like it hurt .
| 459
|
doctor: um , so this happened , what ? like 12 hours ago now ? patient: uh , seven o'clock last night , so a little more than that .
|
D2N018
| 9
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
um , so this happened , what ? like 12 hours ago now ?
| 460
|
doctor: so less than a day . patient: yeah .
|
D2N018
| 11
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
so less than a day .
| 461
|
doctor: in severe pain . patient: yes .
|
D2N018
| 12
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
in severe pain .
| 462
|
doctor: have you taken anything for the pain ? patient: i've been taking ibuprofen every six hours i think , but it's really not helping at all .
|
D2N018
| 13
|
[
"Therapeutic History"
] |
[
"Subjective"
] |
have you taken anything for the pain ?
| 463
|
doctor: okay , what would you rate your pain ? patient: it's like a nine .
|
D2N018
| 14
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay , what would you rate your pain ?
| 464
|
doctor: nine out of 10 ? patient: yeah .
|
D2N018
| 15
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
nine out of 10 ?
| 465
|
doctor: so like really severe ? patient: yes .
|
D2N018
| 16
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
so like really severe ?
| 466
|
doctor: have you used any ice ? patient: no , i have n't .
|
D2N018
| 17
|
[
"Therapeutic History"
] |
[
"Subjective"
] |
have you used any ice ?
| 467
|
doctor: okay . and do you have any medical problems ? patient: i have gallstones .
|
D2N018
| 18
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . and do you have any medical problems ?
| 468
|
doctor: okay . do you take any medicine for it ? patient: pepcid .
|
D2N018
| 19
|
[
"Therapeutic History"
] |
[
"Subjective"
] |
okay . do you take any medicine for it ?
| 469
|
doctor: okay . and any surgeries in the past ? patient: yes , i had a lumbar fusion about six years ago .
|
D2N018
| 20
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . and any surgeries in the past ?
| 470
|
doctor: all right . let's uh , let's look at your x-ray . hey dragon . show me the last radiograph . so this is looking at your right arm , and what i see is a proximal humerus fracture . so you kinda think of your humerus as a snow cone , and you knocked the top of the snow cone ? the top off the snow cone . um , so i'll be gentle but i want to examine your arm . patient: all right .
|
D2N018
| 22
|
[
"Physical Examination",
"Acute Assessment",
"Radiology Examination"
] |
[
"Objective",
"Assessment"
] |
all right . let's uh , let's look at your x-ray . hey dragon . show me the last radiograph . so this is looking at your right arm , and what i see is a proximal humerus fracture . so you kinda think of your humerus as a snow cone , and you knocked the top of the snow cone ? the top off the snow cone . um , so i'll be gentle but i want to examine your arm .
| 471
|
doctor: all right . are you able to straighten your arm ? patient: yeah , i can just straighten the elbow as long as i do n't move up here .
|
D2N018
| 24
|
[
"Physical Examination"
] |
[
"Objective"
] |
all right . are you able to straighten your arm ?
| 472
|
doctor: as long as you do n't move your shoulder . patient: yeah .
|
D2N018
| 25
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
as long as you do n't move your shoulder .
| 473
|
doctor: go ahead and bend . okay . so your exam is generally normal , meaning that the rest of your body is normal patient: okay.
|
D2N018
| 26
|
[
"Physical Examination",
"Acute Assessment"
] |
[
"Objective",
"Assessment"
] |
go ahead and bend . okay . so your exam is generally normal , meaning that the rest of your body is normal
| 474
|
doctor: but you've got some swelling and erythema- patient: yeah .
|
D2N018
| 27
|
[
"Acute Assessment"
] |
[
"Assessment"
] |
but you've got some swelling and erythema-
| 475
|
doctor: . on that right shoulder . you've got uh , tenderness over your right shoulder . you've got normal pulses , and everything else is normal . any numbness or tingling in that right arm ? patient: no .
|
D2N018
| 28
|
[
"Acute Symptoms",
"Acute Assessment"
] |
[
"Subjective",
"Assessment"
] |
. on that right shoulder . you've got uh , tenderness over your right shoulder . you've got normal pulses , and everything else is normal . any numbness or tingling in that right arm ?
| 476
|
doctor: okay . um , so what we're going to have to do- the good thing about um , these kinds of fractures is generally , they will heal up without surgery . um , but we have to put you in a sling that weighs your arm down and pulls it down . so we're going to put you in a long arm cast and a sling , and then we're gon na check you in two weeks to see if those bones have realigned and if they have n't , then we're gon na have to talk about doing surgery at that time . patient: okay .
|
D2N018
| 29
|
[
"Discussion",
"Follow-up",
"Other Treatments"
] |
[
"Plan"
] |
okay . um , so what we're going to have to do- the good thing about um , these kinds of fractures is generally , they will heal up without surgery . um , but we have to put you in a sling that weighs your arm down and pulls it down . so we're going to put you in a long arm cast and a sling , and then we're gon na check you in two weeks to see if those bones have realigned and if they have n't , then we're gon na have to talk about doing surgery at that time .
| 477
|
doctor: i'm going to prescribe you some pain medicine . we'll do lortab 500- lortab 5 milligram . um , you can take one to two tablets every uh , six hours as needed for pain . i'll give you 20 of those . patient: all right .
|
D2N018
| 30
|
[
"Discussion",
"Medication"
] |
[
"Plan"
] |
i'm going to prescribe you some pain medicine . we'll do lortab 500- lortab 5 milligram . um , you can take one to two tablets every uh , six hours as needed for pain . i'll give you 20 of those .
| 478
|
doctor: and um , do you have any allergies to medicines ? i did n't ask . patient: no , i do n't have no allergies .
|
D2N018
| 31
|
[
"Personal History"
] |
[
"Subjective"
] |
and um , do you have any allergies to medicines ? i did n't ask .
| 479
|
doctor: okay . um , hey dragon , go ahead and order any medications or procedures discussed . um , do you have any questions for me ? patient: no , i do n't .
|
D2N018
| 32
|
[
"Discussion"
] |
[
"Plan"
] |
okay . um , hey dragon , go ahead and order any medications or procedures discussed . um , do you have any questions for me ?
| 480
|
doctor: okay , great . why do n't you come with me , we'll get the tech to put the cast on . patient: okay .
|
D2N018
| 33
|
[
"Chitchat"
] |
[
"Null"
] |
okay , great . why do n't you come with me , we'll get the tech to put the cast on .
| 481
|
doctor: and we'll get you checked out . patient: thank you .
|
D2N018
| 34
|
[
"Chitchat"
] |
[
"Null"
] |
and we'll get you checked out .
| 482
|
doctor: hey dragon , finalize the report .
|
D2N018
| 35
|
[
"Chitchat"
] |
[
"Null"
] |
doctor: hey dragon , finalize the report .
| 483
|
doctor: hi ms. hernandez , dr. fisher , how are you ? patient: hi dr. fisher . i'm doing okay except for my elbow here .
|
D2N019
| 0
|
[
"Greetings"
] |
[
"Subjective"
] |
hi ms. hernandez , dr. fisher , how are you ?
| 484
|
doctor: all right . so it's your right elbow ? patient: it's my right elbow , yes .
|
D2N019
| 1
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
all right . so it's your right elbow ?
| 485
|
doctor: okay . hey dragon , ms. hernandez is a 48-year-old female here for a right elbow . so , tell me what happened . patient: well , i was , um , moving to a new home-
|
D2N019
| 2
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . hey dragon , ms. hernandez is a 48-year-old female here for a right elbow . so , tell me what happened .
| 486
|
doctor: okay . and when- when did this happen ? patient: this was just yesterday .
|
D2N019
| 5
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . and when- when did this happen ?
| 487
|
doctor: all right . and have you tried anything for it ? i mean ... patient: i put ice on it . and i've been taking ibuprofen , but it still hurts at lot .
|
D2N019
| 6
|
[
"Acute Symptoms",
"Therapeutic History"
] |
[
"Subjective"
] |
all right . and have you tried anything for it ? i mean ...
| 488
|
doctor: okay , what makes it better or worse ? patient: the ice , when i have it on , is better .
|
D2N019
| 7
|
[
"Acute Symptoms",
"Therapeutic History"
] |
[
"Subjective"
] |
okay , what makes it better or worse ?
| 489
|
doctor: all right . uh , let's review your past medical history . uh ... looks like you've got a history of anaphylaxis , is that correct ? patient: yes . yes , i do . yeah .
|
D2N019
| 9
|
[
"Personal History"
] |
[
"Subjective"
] |
all right . uh , let's review your past medical history . uh ... looks like you've got a history of anaphylaxis , is that correct ?
| 490
|
doctor: do you take any medications for it ? patient: um , ep- ... just an epipen .
|
D2N019
| 10
|
[
"Personal History",
"Therapeutic History"
] |
[
"Subjective"
] |
do you take any medications for it ?
| 491
|
doctor: just epipen for anaphylaxis when you need it . um , and what surgeries have you had before ? patient: yeah , so carotid . yeah-
|
D2N019
| 11
|
[
"Personal History"
] |
[
"Subjective"
] |
just epipen for anaphylaxis when you need it . um , and what surgeries have you had before ?
| 492
|
doctor: . yeah , no , uh , your , uh , neck surgery .all right . well let's , uh , examine you here for a second .so it's your , uh , this elbow right here ? patient: yeah .
|
D2N019
| 12
|
[
"Personal History",
"Physical Examination"
] |
[
"Subjective",
"Objective"
] |
. yeah , no , uh , your , uh , neck surgery .all right . well let's , uh , examine you here for a second .so it's your , uh , this elbow right here ?
| 493
|
doctor: and is it hurt- ... tender right around that area ? patient: yes , it is .
|
D2N019
| 13
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
and is it hurt- ... tender right around that area ?
| 494
|
doctor: okay . can you flex it or can you bend it ? patient: it hurts when i do that , yeah .
|
D2N019
| 14
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . can you flex it or can you bend it ?
| 495
|
doctor: all right . and go ahead and straighten out as much as you can . patient: that's about it .
|
D2N019
| 15
|
[
"Physical Examination"
] |
[
"Objective"
] |
all right . and go ahead and straighten out as much as you can .
| 496
|
doctor: all right . patient: yeah .
|
D2N019
| 16
|
[
"Chitchat"
] |
[
"Null"
] |
all right .
| 497
|
doctor: so there's some swelling there . and how about , uh , can you move your fingers okay ? does that hurt ? patient: no , that's fine .
|
D2N019
| 17
|
[
"Physical Examination"
] |
[
"Objective"
] |
so there's some swelling there . and how about , uh , can you move your fingers okay ? does that hurt ?
| 498
|
doctor: how about right over here ? patient: uh , no that's fine . yeah .
|
D2N019
| 18
|
[
"Physical Examination"
] |
[
"Objective"
] |
how about right over here ?
| 499
|
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