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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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