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|---|---|---|---|---|---|---|
doctor: okay you're welcome i'll be in touch bye patient: okay alright bye-bye | D2N157 | 34 | [
"Chitchat"
] | [
"Null"
] | okay you're welcome i'll be in touch bye | 4,000 |
doctor: yeah so sorry so barbara is a 31 -year-old female and she has history of diabetes type two and asthma and she is here today with abdominal pain so barbara tell me a little more about your abdominal pain what's been going on patient: so i've been having this pain for the past one week and as you know i have a lo... | D2N158 | 0 | [
"Acute Symptoms",
"Personal History",
"Greetings"
] | [
"Subjective"
] | yeah so sorry so barbara is a 31 -year-old female and she has history of diabetes type two and asthma and she is here today with abdominal pain so barbara tell me a little more about your abdominal pain what's been going on | 4,001 |
doctor: okay alright and so is it increasing in severity would you say or staying about the same or what patient: it's gradually increasing for sure | D2N158 | 2 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay alright and so is it increasing in severity would you say or staying about the same or what | 4,002 |
doctor: okay alright and along with the pain have you had any nausea or vomiting or diarrhea patient: nausea and vomiting is on and off | D2N158 | 3 | [
"Vegetative History"
] | [
"Subjective"
] | okay alright and along with the pain have you had any nausea or vomiting or diarrhea | 4,003 |
doctor: okay okay and and so and you vomited how many times patient: a couple of times | D2N158 | 5 | [
"Vegetative History"
] | [
"Subjective"
] | okay okay and and so and you vomited how many times | 4,004 |
doctor: okay alright been drinking a lot of coffee you said too uh is that is that starbucks i love those nitrocolbrus and starbucks we ever had those those are incredible patient: yeah | D2N158 | 6 | [
"Vegetative History"
] | [
"Subjective"
] | okay alright been drinking a lot of coffee you said too uh is that is that starbucks i love those nitrocolbrus and starbucks we ever had those those are incredible | 4,005 |
doctor: that's patient: and the venti | D2N158 | 7 | [
"Vegetative History"
] | [
"Subjective"
] | that's | 4,006 |
doctor: yeah the for sure you got ta go venti on that you really have to coax them into it though they wo n't even give you it's it's like you need a license to get a venti on that that nitro it's so strong so that's my achilles heel i tell you but okay so you think that might have you think maybe coffee contributed to... | D2N158 | 8 | [
"Vegetative History"
] | [
"Subjective"
] | yeah the for sure you got ta go venti on that you really have to coax them into it though they wo n't even give you it's it's like you need a license to get a venti on that that nitro it's so strong so that's my achilles heel i tell you but okay so you think that might have you think maybe coffee contributed to your ab... | 4,007 |
doctor: okay yeah okay and so is the pain in your upper abdomen or where in your abdomen is it patient: it's on both the sides of my upper abdomen | D2N158 | 9 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay yeah okay and so is the pain in your upper abdomen or where in your abdomen is it | 4,008 |
doctor: hmmm okay patient: so i it also increases when i work out like if i wan na jog or like go for a run my abdominal pain just like spikes you know so i have to take it easy | D2N158 | 10 | [
"Acute Symptoms"
] | [
"Subjective"
] | hmmm okay | 4,009 |
doctor: okay alright understood you've not had any fever with that pain have you patient: no i have n't | D2N158 | 11 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | okay alright understood you've not had any fever with that pain have you | 4,010 |
doctor: okay alright and so how about your diabetes how's your diabetes been doing how your blood sugars been what low one hundreds two hundreds where where is it patient: i think it's been under control it's eight hundred so | D2N158 | 12 | [
"Personal History"
] | [
"Subjective"
] | okay alright and so how about your diabetes how's your diabetes been doing how your blood sugars been what low one hundreds two hundreds where where is it | 4,011 |
doctor: okay good and you're still taking the metformin five hundred milligrams once a day right no actually it looks like last visit we increased that to five hundred milligrams twice per day is that correct patient: yes that's probably helping me keeping it under control so | D2N158 | 13 | [
"Therapeutic History"
] | [
"Subjective"
] | okay good and you're still taking the metformin five hundred milligrams once a day right no actually it looks like last visit we increased that to five hundred milligrams twice per day is that correct | 4,012 |
doctor: okay good good and then for your asthma have you had any recent asthma attacks and are you still taking the flovent twice a day and albuterol as needed for wheezing patient: yes but sometimes i forget you know i have n't had any asthma attacks lately so i just figured i could decrease | D2N158 | 14 | [
"Personal History"
] | [
"Subjective"
] | okay good good and then for your asthma have you had any recent asthma attacks and are you still taking the flovent twice a day and albuterol as needed for wheezing | 4,013 |
doctor: yep okay patient: i think that's a good decision though | D2N158 | 15 | [
"Personal History"
] | [
"Subjective"
] | yep okay | 4,014 |
doctor: yeah well better to stay on the flovent daily and then just use the albuterol if you need it but if you stay on the flovent daily it will decrease the frequency of those attacks so yeah alright well let's go ahead and examine you okay so on your physical exam it's pretty normal for the most part unremarkable bu... | D2N158 | 16 | [
"Physical Examination",
"Discussion",
"Follow-up",
"Medication",
"Other Treatments",
"Diagnostic Testing",
"Reassessment",
"Acute Assessment",
"Drug History"
] | [
"Objective",
"Assessment",
"Plan"
] | yeah well better to stay on the flovent daily and then just use the albuterol if you need it but if you stay on the flovent daily it will decrease the frequency of those attacks so yeah alright well let's go ahead and examine you okay so on your physical exam it's pretty normal for the most part unremarkable but i i'll... | 4,015 |
doctor: okay yeah i'd also recommend while this is hurting you definitely cut back on the spices the spicy food easier said than done sometimes i know but yep yep alright sounds good well listen i'll see you back in four weeks give me a holler if if you have any questions or anything else in the meantime patient: i wil... | D2N158 | 18 | [
"Discussion",
"Follow-up",
"Other Treatments"
] | [
"Plan"
] | okay yeah i'd also recommend while this is hurting you definitely cut back on the spices the spicy food easier said than done sometimes i know but yep yep alright sounds good well listen i'll see you back in four weeks give me a holler if if you have any questions or anything else in the meantime | 4,016 |
doctor: alright you take care sure you got | D2N158 | 19 | [
"Chitchat"
] | [
"Null"
] | doctor: alright you take care sure you got | 4,017 |
doctor: good afternoon alexis i understand you're having some issues with your hand patient: yes i sit at the keyboard all day long and recently i've been having some numbness and tingling in my right hand | D2N159 | 0 | [
"Acute Symptoms",
"Greetings"
] | [
"Subjective"
] | good afternoon alexis i understand you're having some issues with your hand | 4,018 |
doctor: okay how long has that been going on patient: i do n't know probably on and off for six months but over the last month or so it's been a little more persistent | D2N159 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay how long has that been going on | 4,019 |
doctor: okay okay and when does that numbness and tingling do you get a lot of pain with it first let me ask that question patient: some pain | D2N159 | 2 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | okay okay and when does that numbness and tingling do you get a lot of pain with it first let me ask that question | 4,020 |
doctor: some pain patient: mostly when i'm actually typing on the keyboard is when i experience the pain | D2N159 | 3 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | some pain | 4,021 |
doctor: okay and when you get this pain what makes it better is it stopping and just resting for a while or do you take medications or try other patient: i've been taking ibuprofen so ibuprofen and seem like not typing on the keyboard helps the most | D2N159 | 5 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay and when you get this pain what makes it better is it stopping and just resting for a while or do you take medications or try other | 4,022 |
doctor: your mouth okay patient: wow | D2N159 | 7 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | your mouth okay | 4,023 |
doctor: yeah when you're moving that around okay patient: yeah | D2N159 | 8 | [
"Acute Symptoms"
] | [
"Subjective"
] | yeah when you're moving that around okay | 4,024 |
doctor: does this pain ever wake you up in the middle of the night or the pain or the tingling patient: no | D2N159 | 9 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | does this pain ever wake you up in the middle of the night or the pain or the tingling | 4,025 |
doctor: no okay patient: not affecting my sleep hmmm | D2N159 | 10 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | no okay | 4,026 |
doctor: okay so and you're using motrin for for ibuprofen for for the pain well let me go ahead and take a take a look here at your is it both hands or just your right hand patient: mostly my right hand | D2N159 | 11 | [
"Physical Examination"
] | [
"Objective"
] | okay so and you're using motrin for for ibuprofen for for the pain well let me go ahead and take a take a look here at your is it both hands or just your right hand | 4,027 |
doctor: mostly your right hand okay so let's go ahead and take a look at that right hand when i bend your wrist does that cause any pain patient: yes | D2N159 | 12 | [
"Physical Examination"
] | [
"Objective"
] | mostly your right hand okay so let's go ahead and take a look at that right hand when i bend your wrist does that cause any pain | 4,028 |
doctor: it does okay and so you do have some pain on extension and if you pull your your hand wrist up towards you does that cause the pain also patient: yes | D2N159 | 13 | [
"Physical Examination"
] | [
"Objective"
] | it does okay and so you do have some pain on extension and if you pull your your hand wrist up towards you does that cause the pain also | 4,029 |
doctor: yeah okay so you do have pain on flexion and extension and when i touch the fingertips here now you said you had some numbness in your thumb and your index finger and a little bit in your your middle finger the other two fingers they feel okay or do you think that there is different than the other hand patient:... | D2N159 | 14 | [
"Physical Examination"
] | [
"Objective"
] | yeah okay so you do have pain on flexion and extension and when i touch the fingertips here now you said you had some numbness in your thumb and your index finger and a little bit in your your middle finger the other two fingers they feel okay or do you think that there is different than the other hand | 4,030 |
doctor: okay so i i want you to grip my hands here and just squeeze tight okay so you do have a a little bit of a less grip strength on the right and that's typical that we would see with this type of pain and and numbness that you have going on now i want you to turn your arm over for me and i'm gon na touch on or tap... | D2N159 | 16 | [
"Physical Examination",
"Acute Assessment"
] | [
"Objective",
"Assessment"
] | okay so i i want you to grip my hands here and just squeeze tight okay so you do have a a little bit of a less grip strength on the right and that's typical that we would see with this type of pain and and numbness that you have going on now i want you to turn your arm over for me and i'm gon na touch on or tap on the ... | 4,031 |
doctor: yeah you see this frequently but people who are doing data entry spend a lot of time on keyboards or you know some a lotta manufacturing people who do a repetitive procedure again and again will get that type of pain so here is my plan i'd like to put you in a splint and it's it's it's kind of a wrist splint i ... | D2N159 | 17 | [
"Medication",
"Other Treatments"
] | [
"Plan"
] | yeah you see this frequently but people who are doing data entry spend a lot of time on keyboards or you know some a lotta manufacturing people who do a repetitive procedure again and again will get that type of pain so here is my plan i'd like to put you in a splint and it's it's it's kind of a wrist splint i would li... | 4,032 |
doctor: we're gon na do that now i am going to order some a a outpatient test called an emg where we look at that nerve conduction study in that wrist and that's really what's happening here is you've got some thickening in the the in the wrist and the the the membranes of the wrist that are just pressing down and just... | D2N159 | 18 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | we're gon na do that now i am going to order some a a outpatient test called an emg where we look at that nerve conduction study in that wrist and that's really what's happening here is you've got some thickening in the the in the wrist and the the the membranes of the wrist that are just pressing down and just compres... | 4,033 |
doctor: yeah we'll start with the the wrist splint and once i get the nerve conduction studies that will give me another idea whether or not i need to send you some physical therapy in addition or if we need to go directly to surgery but that will all hinge on that nerve conduction test do you so do you have any furthe... | D2N159 | 19 | [
"Discussion",
"Other Treatments"
] | [
"Plan"
] | yeah we'll start with the the wrist splint and once i get the nerve conduction studies that will give me another idea whether or not i need to send you some physical therapy in addition or if we need to go directly to surgery but that will all hinge on that nerve conduction test do you so do you have any further questi... | 4,034 |
doctor: thank you very much | D2N159 | 20 | [
"Chitchat"
] | [
"Null"
] | doctor: thank you very much | 4,035 |
doctor: hey good to see you philip so i see here you're coming in you had some right elbow pain also you have a past medical history of hypertension diabetes we are gon na check up on those as well so can you tell me what happened to your elbow patient: sure i hurt it about a week ago playing lacrosse with my kids just... | D2N160 | 0 | [
"Acute Symptoms",
"Personal History",
"Greetings"
] | [
"Subjective"
] | hey good to see you philip so i see here you're coming in you had some right elbow pain also you have a past medical history of hypertension diabetes we are gon na check up on those as well so can you tell me what happened to your elbow | 4,036 |
doctor: okay okay so how old are your kids patient: my oldest is thirteen and the other one is ten i was playing with a thirteen -year-old | D2N160 | 1 | [
"Other Socials"
] | [
"Subjective"
] | okay okay so how old are your kids | 4,037 |
doctor: okay yeah i know i i play with my kids sometimes and i think i'm getting too old to do all that so i just i've hurt myself before as well alright so with your your elbow what part of your elbow would you say hurts patient: it's really like right at the point of the elbow right at right at like the tip of it | D2N160 | 2 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay yeah i know i i play with my kids sometimes and i think i'm getting too old to do all that so i just i've hurt myself before as well alright so with your your elbow what part of your elbow would you say hurts | 4,038 |
doctor: anytime i move it do you remember falling patient: no i do n't think so but my kid got pretty rough with me and was checking me several times with a sick | D2N160 | 4 | [
"Acute Symptoms"
] | [
"Subjective"
] | anytime i move it do you remember falling | 4,039 |
doctor: okay alright yeah that that that definitely makes sense so how would you describe the pain is it like a dull pain is it stabbing what what would you say patient: it it's a pretty sharp pain | D2N160 | 6 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay alright yeah that that that definitely makes sense so how would you describe the pain is it like a dull pain is it stabbing what what would you say | 4,040 |
doctor: okay and does it radiate down your arm or does it stay in that one spot patient: it radiates down the forearm | D2N160 | 8 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and does it radiate down your arm or does it stay in that one spot | 4,041 |
doctor: radiates down the forearm alright so have you taken any medications for it to make it better patient: i tried taking advil couple of days but i usually just forget about it | D2N160 | 9 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | radiates down the forearm alright so have you taken any medications for it to make it better | 4,042 |
doctor: okay when you took it did it did it help at all did it change your your pain score patient: yeah i i think it helped some | D2N160 | 10 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay when you took it did it did it help at all did it change your your pain score | 4,043 |
doctor: okay that's good alright so we'll we'll do a physical exam on that elbow we'll take a look at it in a second but i do wan na talk to you about your your hypertension you came in today i know you have past medical history of hypertension came in today your blood pressure's a little bit high it was a one fifty ov... | D2N160 | 11 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | okay that's good alright so we'll we'll do a physical exam on that elbow we'll take a look at it in a second but i do wan na talk to you about your your hypertension you came in today i know you have past medical history of hypertension came in today your blood pressure's a little bit high it was a one fifty over seven... | 4,044 |
doctor: okay so maybe you just have a little little white coat syndrome i know i have that myself and even though i'm a physician i i still do n't like to go to the doctor so i definitely understand how about your diet i know we talked a little bit about that before and you said kinda during the pandemic you fell off a... | D2N160 | 12 | [
"Personal History",
"Reassessment"
] | [
"Subjective",
"Assessment"
] | okay so maybe you just have a little little white coat syndrome i know i have that myself and even though i'm a physician i i still do n't like to go to the doctor so i definitely understand how about your diet i know we talked a little bit about that before and you said kinda during the pandemic you fell off a little ... | 4,045 |
doctor: okay yeah that's good that that's that's definitely good yeah i know a lot of people during the pandemic it was you know sitting at home and and eating more than we should but that's i'm very happy that you've been compliant and you have that low salt diet so let's talk about your diabetes i think you see here ... | D2N160 | 14 | [
"Therapeutic History"
] | [
"Subjective"
] | okay yeah that's good that that's that's definitely good yeah i know a lot of people during the pandemic it was you know sitting at home and and eating more than we should but that's i'm very happy that you've been compliant and you have that low salt diet so let's talk about your diabetes i think you see here on on fi... | 4,046 |
doctor: okay and your blood sugars how have they been patient: since i do n't take insulin i do n't check it everyday when i have checked it it's usually running somewhere between eighty to a hundred | D2N160 | 15 | [
"Personal History"
] | [
"Subjective"
] | okay and your blood sugars how have they been | 4,047 |
doctor: okay yeah that's that's really good yeah so i that's that's pretty good so what we're gon na do we're gon na get a a1c just to see you know that range and it's possibility we can we can you know lower that metformin dosage but we will do that after your visit then we will take a look at that so lem me go ahead ... | D2N160 | 16 | [
"Medication",
"Diagnostic Testing",
"Vegetative History"
] | [
"Subjective",
"Plan"
] | okay yeah that's that's really good yeah so i that's that's pretty good so what we're gon na do we're gon na get a a1c just to see you know that range and it's possibility we can we can you know lower that metformin dosage but we will do that after your visit then we will take a look at that so lem me go ahead and will... | 4,048 |
doctor: no belly pain patient: no | D2N160 | 17 | [
"Vegetative History"
] | [
"Subjective"
] | no belly pain | 4,049 |
doctor: alright so listen to your lungs so your lungs are clear bilaterally listen to your heart so your heart exam you do still have that grade two out of six systolic ejection murmur but we know it about that before so let me take a look at your elbow so when i press right here on the back of your elbow is that painf... | D2N160 | 18 | [
"Physical Examination"
] | [
"Objective"
] | alright so listen to your lungs so your lungs are clear bilaterally listen to your heart so your heart exam you do still have that grade two out of six systolic ejection murmur but we know it about that before so let me take a look at your elbow so when i press right here on the back of your elbow is that painful | 4,050 |
doctor: alright so when i have you you you flex and extend it it's painful does that does that hurt patient: yes it does | D2N160 | 19 | [
"Physical Examination"
] | [
"Objective"
] | alright so when i have you you you flex and extend it it's painful does that does that hurt | 4,051 |
doctor: alright so your right elbow exam shows you have pain to palpation of the olecranon area of the posterior elbow you do have mild pain with flexion and extension but you do have also normal range of motion at that elbow so we we did do an x-ray before you came in and luckily nothing's broken no fracture no bony a... | D2N160 | 20 | [
"Discussion",
"Medication",
"Other Treatments",
"Radiology Examination",
"Diagnostic Testing",
"Reassessment",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | alright so your right elbow exam shows you have pain to palpation of the olecranon area of the posterior elbow you do have mild pain with flexion and extension but you do have also normal range of motion at that elbow so we we did do an x-ray before you came in and luckily nothing's broken no fracture no bony abnormali... | 4,052 |
doctor: alright so we will see you next time and my nurse will be in with those prescriptions patient: alright thank you | D2N160 | 21 | [
"Chitchat"
] | [
"Null"
] | alright so we will see you next time and my nurse will be in with those prescriptions | 4,053 |
doctor: patient is an 82 -year-old male with past medical history significant for hypertension and stage three chronic kidney disease who presents for hospital follow-up after an acute on chronic chf exacerbation alright hey hey kevin how are you doing today patient: hi document well i mean i thought i was doing good b... | D2N161 | 0 | [
"Personal History",
"Greetings"
] | [
"Subjective"
] | patient is an 82 -year-old male with past medical history significant for hypertension and stage three chronic kidney disease who presents for hospital follow-up after an acute on chronic chf exacerbation alright hey hey kevin how are you doing today | 4,054 |
doctor: yeah okay so yeah so i saw that and i was notified that you were in the hospital for heart failure now i do see here that your blood pressure was two hundred over ninety are you have you been taking your medications patient: well i take them most times but i do n't know sometimes i miss a dose or two but i real... | D2N161 | 1 | [
"Therapeutic History"
] | [
"Subjective"
] | yeah okay so yeah so i saw that and i was notified that you were in the hospital for heart failure now i do see here that your blood pressure was two hundred over ninety are you have you been taking your medications | 4,055 |
doctor: okay well good i'm i'm glad you're trying there you do need to take them though okay consistently now you said you were watching your diet did you have some slips you said your ankles were swelling patient: well be honest with you you know i'm a big cheese man i love me some football and and we go to parties on... | D2N161 | 2 | [
"Personal History"
] | [
"Subjective"
] | okay well good i'm i'm glad you're trying there you do need to take them though okay consistently now you said you were watching your diet did you have some slips you said your ankles were swelling | 4,056 |
doctor: man i know i i totally understand i mean i do love pizza too and i love chicken minks but i do love them with dallas cowboys not so much the cheese but everybody's got your preference but but you do have to you know you have to watch those right you can you can you can have a little pizza maybe a little chicken... | D2N161 | 3 | [
"Vegetative History"
] | [
"Subjective"
] | man i know i i totally understand i mean i do love pizza too and i love chicken minks but i do love them with dallas cowboys not so much the cheese but everybody's got your preference but but you do have to you know you have to watch those right you can you can you can have a little pizza maybe a little chicken wings e... | 4,057 |
doctor: okay thank you so tell me how are you feeling now though patient: man doc i feel good i was in the hospital a couple of days and they gave me this medicine made me go to the bathroom like nobody's business and then they gave me this water pill through my iv and i think i'm on different medications for my blood ... | D2N161 | 4 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay thank you so tell me how are you feeling now though | 4,058 |
doctor: okay well that's good to hear so have you been watching your diet too and taking taking your pills since you've been home patient: yeah i've been doing just what they told me to do because i do n't wan na go back to the hospital | D2N161 | 5 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | okay well that's good to hear so have you been watching your diet too and taking taking your pills since you've been home | 4,059 |
doctor: okay alright and we do n't want you to go back to the hospital it's never a good experience so you know being in a hospital it's better to be well and be at home and watching your chiefs play now have you bought a blood pressure cuff at home i know we talked about that patient: yes ma'am i finally did what you ... | D2N161 | 6 | [
"Personal History"
] | [
"Subjective"
] | okay alright and we do n't want you to go back to the hospital it's never a good experience so you know being in a hospital it's better to be well and be at home and watching your chiefs play now have you bought a blood pressure cuff at home i know we talked about that | 4,060 |
doctor: good very good how about have you been having any shortness of breath or problems sleeping since you've been home patient: nope no shortness of breath i can get up and move around i do n't have any trouble and no problem sleeping i do have a good afternoon nap | D2N161 | 7 | [
"Vegetative History"
] | [
"Subjective"
] | good very good how about have you been having any shortness of breath or problems sleeping since you've been home | 4,061 |
doctor: good that's good you need to rest every now and then as well and now tell me have you had any chest pain patient: no chest pain at all since i've been home | D2N161 | 8 | [
"Vegetative History"
] | [
"Subjective"
] | good that's good you need to rest every now and then as well and now tell me have you had any chest pain | 4,062 |
doctor: okay alright very good alright well i'm gon na go ahead and do a quick physical exam on you here kevin and so i'm looking at your vital signs here and your blood pressure today is actually pretty good at one twenty eight over seventy two your vital signs also look good in general your heart rate's been nice at ... | D2N161 | 9 | [
"Physical Examination"
] | [
"Objective"
] | okay alright very good alright well i'm gon na go ahead and do a quick physical exam on you here kevin and so i'm looking at your vital signs here and your blood pressure today is actually pretty good at one twenty eight over seventy two your vital signs also look good in general your heart rate's been nice at like sev... | 4,063 |
doctor: now i did review the results of your echocardiogram which shows a preserved ef of fifty five percent abnormal diastolic filling and also mild to moderate mitral regurgitation so what all that means let me go ahead and tell you about my assessment and plan so for your first problem of your you know congestive he... | D2N161 | 10 | [
"Medication",
"Other Treatments",
"Radiology Examination",
"Reassessment"
] | [
"Objective",
"Assessment",
"Plan"
] | now i did review the results of your echocardiogram which shows a preserved ef of fifty five percent abnormal diastolic filling and also mild to moderate mitral regurgitation so what all that means let me go ahead and tell you about my assessment and plan so for your first problem of your you know congestive heart fail... | 4,064 |
doctor: alright now i want you to weigh yourself though everyday and then call me if you gain like three pounds in two days okay patient: okay | D2N161 | 11 | [
"Discussion",
"Follow-up"
] | [
"Plan"
] | alright now i want you to weigh yourself though everyday and then call me if you gain like three pounds in two days okay | 4,065 |
doctor: okay now i do want you to see a nutritionist too and give you some education about what foods you can eat patient: alright sounds good | D2N161 | 12 | [
"Referral"
] | [
"Plan"
] | okay now i do want you to see a nutritionist too and give you some education about what foods you can eat | 4,066 |
doctor: alright now for your second problem of hypertension i do want you to continue on that cozaar a hundred milligrams daily and then also continue on that norvasc five milligrams once daily and i'm gon na go ahead and order a renal artery ultrasound just to be sure that we are n't missing anything we wan na make su... | D2N161 | 13 | [
"Medication",
"Diagnostic Testing",
"Reassessment"
] | [
"Assessment",
"Plan"
] | alright now for your second problem of hypertension i do want you to continue on that cozaar a hundred milligrams daily and then also continue on that norvasc five milligrams once daily and i'm gon na go ahead and order a renal artery ultrasound just to be sure that we are n't missing anything we wan na make sure there... | 4,067 |
doctor: alright now for your third problem your kidney disease i do want to get some more labs some more blood work to make sure that you tolerate this regimen patient: alright that sounds good | D2N161 | 14 | [
"Diagnostic Testing",
"Reassessment"
] | [
"Assessment",
"Plan"
] | alright now for your third problem your kidney disease i do want to get some more labs some more blood work to make sure that you tolerate this regimen | 4,068 |
doctor: okay and if do you have any other questions for me patient: i do n't think right now | D2N161 | 15 | [
"Discussion"
] | [
"Plan"
] | okay and if do you have any other questions for me | 4,069 |
doctor: okay well then i'll see you again in three months then kevin okay take care of yourself patient: alright thanks document | D2N161 | 16 | [
"Follow-up"
] | [
"Plan"
] | okay well then i'll see you again in three months then kevin okay take care of yourself | 4,070 |
doctor: alrighty bye | D2N161 | 17 | [
"Chitchat"
] | [
"Null"
] | doctor: alrighty bye | 4,071 |
doctor: hi gregory hi how are you doing today patient: good how are you | D2N162 | 0 | [
"Greetings"
] | [
"Subjective"
] | hi gregory hi how are you doing today | 4,072 |
doctor: i'm alright so i understand that you were having some you know right ankle pain and some swelling after you fell can you can you tell me a little bit about what happened patient: yeah so i was going out to take off the trash and i you know i was icy and i i was being very careful and then i noticed that there m... | D2N162 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | i'm alright so i understand that you were having some you know right ankle pain and some swelling after you fell can you can you tell me a little bit about what happened | 4,073 |
doctor: okay yeah i know especially this this winter has been rough so you got ta watch for those little ice patches sometimes well okay so this occurred yesterday after falling on the ice so have you been able to walk on it at all patient: when it first happened i could n't and i actually had a friend who was with me ... | D2N162 | 2 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay yeah i know especially this this winter has been rough so you got ta watch for those little ice patches sometimes well okay so this occurred yesterday after falling on the ice so have you been able to walk on it at all | 4,074 |
doctor: okay alright and tell me what have you been doing for that foot pain since then patient: you know other than the icing i have taken some ibuprofen and i do feel like it's it it is helping | D2N162 | 3 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay alright and tell me what have you been doing for that foot pain since then | 4,075 |
doctor: okay okay very good alright and tell me have you ever injured this ankle before patient: you know considering i do a lot of sports my favorite right now is soccer or my favorite always is soccer and i've had a lot of injury but i ca n't remember if i actually injured this ankle i do n't think i ever have | D2N162 | 4 | [
"Personal History"
] | [
"Subjective"
] | okay okay very good alright and tell me have you ever injured this ankle before | 4,076 |
doctor: okay alright well good i mean considering how long you've been playing soccer i know you're actually playing for the community league now so that is really great representing the community patient: yes it's so much fun | D2N162 | 5 | [
"Other Socials"
] | [
"Subjective"
] | okay alright well good i mean considering how long you've been playing soccer i know you're actually playing for the community league now so that is really great representing the community | 4,077 |
doctor: yeah and and do your kids come and watch you play patient: yeah they come and watch and then now the oldest one is old enough to play himself so they have a leak for four and five -year-olds so he should be starting that soon too so i know he's really gon na enjoy that | D2N162 | 6 | [
"Chitchat"
] | [
"Null"
] | yeah and and do your kids come and watch you play | 4,078 |
doctor: that's gon na be exciting for him patient: so much fun | D2N162 | 7 | [
"Chitchat"
] | [
"Null"
] | that's gon na be exciting for him | 4,079 |
doctor: that's a great you had a great soccer league of your own here in your family patient: yeah my husband's really into soccer too | D2N162 | 8 | [
"Chitchat"
] | [
"Null"
] | that's a great you had a great soccer league of your own here in your family | 4,080 |
doctor: well you i guess you'll be watching it for a while instead of playing it though patient: i well i hope not not for too long | D2N162 | 11 | [
"Chitchat"
] | [
"Null"
] | well you i guess you'll be watching it for a while instead of playing it though | 4,081 |
doctor: yeah we'll we'll see what we can do just to get you back out there again okay so tell me have you experienced any kind of numbness in your foot at all patient: no not that no i have n't had any numbness | D2N162 | 12 | [
"Acute Symptoms"
] | [
"Subjective"
] | yeah we'll we'll see what we can do just to get you back out there again okay so tell me have you experienced any kind of numbness in your foot at all | 4,082 |
doctor: okay alright very good well let me go ahead and do a physical exam on you real quick here let me take a look at your vital signs good good everything here looks good lem me go ahead and take a look at your right ankle real quick i'm just gon na pull your pant leg up here and then look look at it now on the skin... | D2N162 | 13 | [
"Physical Examination"
] | [
"Objective"
] | okay alright very good well let me go ahead and do a physical exam on you real quick here let me take a look at your vital signs good good everything here looks good lem me go ahead and take a look at your right ankle real quick i'm just gon na pull your pant leg up here and then look look at it now on the skin here th... | 4,083 |
doctor: i'm sorry so you definitely there is some tenderness to palpation and anterolaterally in the soft tissue there is no laxity on anterior drawer and inversion stress and there is no bony tenderness on palpation of the foot now i'm just gon na take a look at your right foot here just to make sure it's still intact... | D2N162 | 14 | [
"Physical Examination",
"Acute Assessment",
"Other Treatments",
"Radiology Examination"
] | [
"Objective",
"Assessment",
"Plan"
] | i'm sorry so you definitely there is some tenderness to palpation and anterolaterally in the soft tissue there is no laxity on anterior drawer and inversion stress and there is no bony tenderness on palpation of the foot now i'm just gon na take a look at your right foot here just to make sure it's still intact here so... | 4,084 |
doctor: alright and then you're going to also be given an aircast which is really gon na help stabilize the ankle and then you also be given some crutches for the next one to two days and then you may start walking on it as tolerated patient: okay | D2N162 | 15 | [
"Other Treatments"
] | [
"Plan"
] | alright and then you're going to also be given an aircast which is really gon na help stabilize the ankle and then you also be given some crutches for the next one to two days and then you may start walking on it as tolerated | 4,085 |
doctor: do you have any questions any other questions for me patient: so when will i will i be able to play | D2N162 | 17 | [
"Discussion"
] | [
"Plan"
] | do you have any questions any other questions for me | 4,086 |
doctor: well let's see now your symptoms should significantly improve in the next two weeks and what i'll do is i'm gon na follow up with you then and then see how you're doing okay and then just please continue to take the nsaids as needed to help with any of that pain that you may have okay patient: okay | D2N162 | 18 | [
"Follow-up",
"Medication"
] | [
"Plan"
] | well let's see now your symptoms should significantly improve in the next two weeks and what i'll do is i'm gon na follow up with you then and then see how you're doing okay and then just please continue to take the nsaids as needed to help with any of that pain that you may have okay | 4,087 |
doctor: and then we will see in in a few weeks how how if you're ready to go play soccer again okay alright patient: alrighty | D2N162 | 19 | [
"Chitchat"
] | [
"Null"
] | and then we will see in in a few weeks how how if you're ready to go play soccer again okay alright | 4,088 |
doctor: well do you have any other questions for me or is there anything else i can do for you patient: no i think that's it thank you | D2N162 | 20 | [
"Discussion"
] | [
"Plan"
] | well do you have any other questions for me or is there anything else i can do for you | 4,089 |
doctor: okay well i will have the nurse check you out and then if you experience any kind of symptoms in the next you know before your next visit with me go ahead and feel free to call the clinic okay patient: okay | D2N162 | 21 | [
"Chitchat"
] | [
"Null"
] | okay well i will have the nurse check you out and then if you experience any kind of symptoms in the next you know before your next visit with me go ahead and feel free to call the clinic okay | 4,090 |
doctor: alright alright take care gregory patient: alright thank you | D2N162 | 22 | [
"Chitchat"
] | [
"Null"
] | alright alright take care gregory | 4,091 |
doctor: julie cruz is a 17 -year-old non- binary immensipated minor with no significant past medical history presents for evaluation of newly diagnosed hypercholesterolemia patient is here at the clinic hi julie how're you doing patient: i'm okay | D2N163 | 0 | [
"Acute Symptoms",
"Greetings"
] | [
"Subjective"
] | julie cruz is a 17 -year-old non- binary immensipated minor with no significant past medical history presents for evaluation of newly diagnosed hypercholesterolemia patient is here at the clinic hi julie how're you doing | 4,092 |
doctor: so i now i know you're worried about you know what's been happening with your with your you know with your blood cholesterol so can you tell me a little bit more about what's going on patient: yeah i mean i'm worried about this finding i went for my annual checkup and they checked my cholesterol one of those fi... | D2N163 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | so i now i know you're worried about you know what's been happening with your with your you know with your blood cholesterol so can you tell me a little bit more about what's going on | 4,093 |
doctor: okay alright well i think it's a good thing that you know we're aware of this elevated cholesterol at a young age and that we can do something about it so lem me ask you julie a couple of questions here okay so what kind of activities do you like to do patient: well i really like to go outside i ride my bicycle... | D2N163 | 2 | [
"Other Socials"
] | [
"Subjective"
] | okay alright well i think it's a good thing that you know we're aware of this elevated cholesterol at a young age and that we can do something about it so lem me ask you julie a couple of questions here okay so what kind of activities do you like to do | 4,094 |
doctor: that's fun very nice so you stay pretty active it sounds like patient: well i keep pretty active during the week yeah | D2N163 | 4 | [
"Other Socials"
] | [
"Subjective"
] | that's fun very nice so you stay pretty active it sounds like | 4,095 |
doctor: okay very good good for you now tell me what what kind of foods do you like to eat patient: well i mean i really like chocolate chip cookies | D2N163 | 5 | [
"Vegetative History"
] | [
"Subjective"
] | okay very good good for you now tell me what what kind of foods do you like to eat | 4,096 |
doctor: yeah okay well we will we will try to look check and see what's going on there okay so so what kind of so have you you've done any fun activities that now that you know it's getting warm out patient: yeah i went for a bike ride over the weekend and some friends have morning we we went for a bike ride and then w... | D2N163 | 8 | [
"Other Socials"
] | [
"Subjective"
] | yeah okay well we will we will try to look check and see what's going on there okay so so what kind of so have you you've done any fun activities that now that you know it's getting warm out | 4,097 |
doctor: that's fun patient: it was pretty nice it was a little chilly but it's nice now that it's springtime | D2N163 | 9 | [
"Other Socials"
] | [
"Subjective"
] | that's fun | 4,098 |
doctor: yeah but yeah that sounds like fun patient: it was fun | D2N163 | 10 | [
"Chitchat"
] | [
"Null"
] | yeah but yeah that sounds like fun | 4,099 |
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