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DATEXIS
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aci_bench_intent_annotated

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doctor: i mean i'm sorry the tylenol patient: no it's okay but the tylenol it helps like a little bit but you know like it's it's got like a time limit right so by the time and i'm not supposed to take it like more than like every like four hours or something like that but by hour or two like it it hurts again
D2N167
12
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
i mean i'm sorry the tylenol
4,200
doctor: okay yeah that yeah you ca n't take too much of that tylenol because it'll it'll mess up your liver definitely patient: right
D2N167
13
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay yeah that yeah you ca n't take too much of that tylenol because it'll it'll mess up your liver definitely
4,201
doctor: alright so go ahead and do a quick exam on your knee here so when i press here does that hurt patient: yeah like when you press on the inside that hurts a lot
D2N167
14
[ "Physical Examination" ]
[ "Objective" ]
alright so go ahead and do a quick exam on your knee here so when i press here does that hurt
4,202
doctor: okay alright i'm gon na do a couple of other other maneuvers here for your knee so on your left knee exam i do appreciate some edema you also have some effusion some fluid in the knee you have moderate range of motion so you're able to move it a little bit but not all the way i also see you have some pain on flexion and extension of the knee even negative lachman's test and a negative valgus and varus test as well so all that to say is i do n't think anything is is torn in your knee based on the your physical exam so we did do a x-ray of your left knee and luckily it was normal so there is no fractures no bony abnormalities so everything is good there so let me talk to you little bit about my assessment and plan for your knee okay patient: yeah
D2N167
15
[ "Physical Examination", "Radiology Examination" ]
[ "Objective" ]
okay alright i'm gon na do a couple of other other maneuvers here for your knee so on your left knee exam i do appreciate some edema you also have some effusion some fluid in the knee you have moderate range of motion so you're able to move it a little bit but not all the way i also see you have some pain on flexion and extension of the knee even negative lachman's test and a negative valgus and varus test as well so all that to say is i do n't think anything is is torn in your knee based on the your physical exam so we did do a x-ray of your left knee and luckily it was normal so there is no fractures no bony abnormalities so everything is good there so let me talk to you little bit about my assessment and plan for your knee okay
4,203
doctor: alright so for your your left knee pain i believe you you have a mcl strain or a medial collateral ligament that's the inside of your knee i think when you were running with your knee she had somehow twisted it and so you strained that ligament there so for that what i want to do i'm going to give you some pain medication that's not an nsaid so i will put you on some tramadol you can take fifty milligrams you can do that twice a day and then you can take that tylenol as needed for breakthrough pain alright i'm gon na put you in a knee immobilizer leg knee immobilizer and you can wear that for the next week i just wan na keep the knee from moving so it can heal a little bit and reduce some of the inflammation that you're seeing here and i also want you to ice it and you can do that three or four times a day for twenty thirty minutes at a time and that should help some of that swelling as well and i i you know i know your niece is gon na be upset but i just do n't want you to be running probably for the next three weeks with her just to help us get time to let allow the knee to heal so how does that sound patient: that's alright how long do you think it'll be before i can like run or something like that
D2N167
16
[ "Discussion", "Medication", "Other Treatments", "Acute Assessment" ]
[ "Assessment", "Plan" ]
alright so for your your left knee pain i believe you you have a mcl strain or a medial collateral ligament that's the inside of your knee i think when you were running with your knee she had somehow twisted it and so you strained that ligament there so for that what i want to do i'm going to give you some pain medication that's not an nsaid so i will put you on some tramadol you can take fifty milligrams you can do that twice a day and then you can take that tylenol as needed for breakthrough pain alright i'm gon na put you in a knee immobilizer leg knee immobilizer and you can wear that for the next week i just wan na keep the knee from moving so it can heal a little bit and reduce some of the inflammation that you're seeing here and i also want you to ice it and you can do that three or four times a day for twenty thirty minutes at a time and that should help some of that swelling as well and i i you know i know your niece is gon na be upset but i just do n't want you to be running probably for the next three weeks with her just to help us get time to let allow the knee to heal so how does that sound
4,204
doctor: hmmm i think you'll be back to normal in about a month the strain does n't seem too bad but we just need to get you off of the knee so we can allow it to heal i mean once we do that you know along with you know the icing the mobilization and you taking the medication i think you'll be good to go in a month if you do feel like you're getting a little bit worse please feel free to call the office and we can get you in and possibly do more imaging such as an mri to you know to see if it's anything worse but i do n't think it is but just let us know how you feel in a couple of days patient: okay alright thanks
D2N167
17
[ "Discussion", "Follow-up", "Medication", "Diagnostic Testing" ]
[ "Plan" ]
hmmm i think you'll be back to normal in about a month the strain does n't seem too bad but we just need to get you off of the knee so we can allow it to heal i mean once we do that you know along with you know the icing the mobilization and you taking the medication i think you'll be good to go in a month if you do feel like you're getting a little bit worse please feel free to call the office and we can get you in and possibly do more imaging such as an mri to you know to see if it's anything worse but i do n't think it is but just let us know how you feel in a couple of days
4,205
doctor: alright any other questions patient: no that's it
D2N167
18
[ "Discussion" ]
[ "Plan" ]
alright any other questions
4,206
doctor: alright great thanks
D2N167
19
[ "Chitchat" ]
[ "Null" ]
doctor: alright great thanks
4,207
doctor: hi diane , how are you ? patient: i'm doing okay , how are you ?
D2N168
0
[ "Greetings" ]
[ "Subjective" ]
hi diane , how are you ?
4,208
doctor: i'm doin' okay . so i know the nurse told you about dax and i'd like to tell dax a little bit about you okay ? patient: okay .
D2N168
1
[ "Chitchat" ]
[ "Null" ]
i'm doin' okay . so i know the nurse told you about dax and i'd like to tell dax a little bit about you okay ?
4,209
doctor: diane is a 28 year old female with a past medical history , significant for , depression and hypertension who presents for emergency room follow-up . so diane what's going on ? i heard that your- your blood pressure was really high in the emergency room . what happened ? patient: yeah , so i ended up going for a walk , um , yesterday 'cause it was sunny and it was really great . and i just felt really light-headed , um , and i started to fall a bit , and , um , luckily i was with my boyfriend and he caught me , um , and then we went right to the e , to the er .
D2N168
2
[ "Personal History" ]
[ "Subjective" ]
diane is a 28 year old female with a past medical history , significant for , depression and hypertension who presents for emergency room follow-up . so diane what's going on ? i heard that your- your blood pressure was really high in the emergency room . what happened ?
4,210
doctor: yeah , okay . yeah , i saw that the blood pressure was pretty high , like in , like , the , almost 200 . patient: yeah .
D2N168
3
[ "Personal History" ]
[ "Subjective" ]
yeah , okay . yeah , i saw that the blood pressure was pretty high , like in , like , the , almost 200 .
4,211
doctor: did you have a headache ? patient: yeah i did .
D2N168
4
[ "Vegetative History" ]
[ "Subjective" ]
did you have a headache ?
4,212
doctor: okay , all right . have your blood pressures been running high in the past ? patient: yeah , they have been . it's- it's , like , once a week , a month , it , kind of , just skyrockets .
D2N168
5
[ "Personal History" ]
[ "Subjective" ]
okay , all right . have your blood pressures been running high in the past ?
4,213
doctor: you're not taking your blood pressures , i take it- patient: yeah .
D2N168
7
[ "Personal History" ]
[ "Subjective" ]
you're not taking your blood pressures , i take it-
4,214
doctor: . when you're traveling ? patient: yeah , no , i do n't bring my cuff with me .
D2N168
8
[ "Personal History" ]
[ "Subjective" ]
. when you're traveling ?
4,215
doctor: okay , but you did buy the cuff like we talked about in the past ? patient: yes i did .
D2N168
9
[ "Personal History" ]
[ "Subjective" ]
okay , but you did buy the cuff like we talked about in the past ?
4,216
doctor: okay , all right . and are you taking your medication , are you taking the lisinopril ? patient: yes i am .
D2N168
10
[ "Therapeutic History" ]
[ "Subjective" ]
okay , all right . and are you taking your medication , are you taking the lisinopril ?
4,217
doctor: okay , all right . um , so i think we had started you at a , kind of , a moderate dose , so we'll have to talk about that a little bit , okay ? patient: okay .
D2N168
11
[ "Therapeutic History" ]
[ "Subjective" ]
okay , all right . um , so i think we had started you at a , kind of , a moderate dose , so we'll have to talk about that a little bit , okay ?
4,218
doctor: then in terms of your depression , how are you doing ? i know that we did n't start you on medication , since you're on a bunch of other medications . what- what are your strategies for dealing with that and how are you doing ? patient: so last year i started therapy and i've been going once a week and that's really helped .
D2N168
12
[ "Personal History" ]
[ "Subjective" ]
then in terms of your depression , how are you doing ? i know that we did n't start you on medication , since you're on a bunch of other medications . what- what are your strategies for dealing with that and how are you doing ?
4,219
doctor: okay , all right , great . and how is your support system ? patient: really great . my boyfriend , my mom , and my brother are- are s- , amazing and they're all super close to me , so it's been , it's been good .
D2N168
13
[ "Other Socials" ]
[ "Subjective" ]
okay , all right , great . and how is your support system ?
4,220
doctor: okay , well great . so i know you did a review of system sheet when you checked in and i know that you had the headache and the lightheadedness yesterday . do you have any other symptoms at this time , chest pain , shortness of breath , anything like that ? patient: uh , i have a little bit of nasal congestion , but that's just from my seasonal allergies .
D2N168
14
[ "Vegetative History" ]
[ "Subjective" ]
okay , well great . so i know you did a review of system sheet when you checked in and i know that you had the headache and the lightheadedness yesterday . do you have any other symptoms at this time , chest pain , shortness of breath , anything like that ?
4,221
doctor: okay , all right . well i want to go ahead and do a quick physical exam , okay ? patient: okay .
D2N168
15
[ "Physical Examination" ]
[ "Objective" ]
okay , all right . well i want to go ahead and do a quick physical exam , okay ?
4,222
doctor: hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it does look a little elevated still , so we'll have to talk about that . so i'm just gon na listen to your heart and your lungs and we'll go from there okay ? patient: okay .
D2N168
16
[ "Physical Examination" ]
[ "Objective" ]
hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it does look a little elevated still , so we'll have to talk about that . so i'm just gon na listen to your heart and your lungs and we'll go from there okay ?
4,223
doctor: so on physical examination , i- i do n't appreciate any carotid bruits in your neck . your heart on your heart exam , it does show that you have a slight two out of six systolic ejection murmur . your , there , your lung exam shows nice clear lungs bilaterally and you do have some trace pitting edema to your lower extremities bilaterally . so what that means is , you know , i- i think ultimately , uh , you know we just need to get your blood pressure under better control , okay ? patient: mm-hmm .
D2N168
17
[ "Physical Examination", "Reassessment" ]
[ "Objective", "Assessment" ]
so on physical examination , i- i do n't appreciate any carotid bruits in your neck . your heart on your heart exam , it does show that you have a slight two out of six systolic ejection murmur . your , there , your lung exam shows nice clear lungs bilaterally and you do have some trace pitting edema to your lower extremities bilaterally . so what that means is , you know , i- i think ultimately , uh , you know we just need to get your blood pressure under better control , okay ?
4,224
doctor: um , uh , let me just go ahead , i want to take a look at some of your results , okay ? patient: okay .
D2N168
18
[ "Lab Examination" ]
[ "Objective" ]
um , uh , let me just go ahead , i want to take a look at some of your results , okay ?
4,225
doctor: hey , dragon , show me the ecg . yeah , so in reviewing the results of your ekg , it looks the same as last year . um , you do have just blood , those changes from your chronic high blood pressure that we'll address , okay ? hey , dragon , show me the echocardiogram . and this is just the echocardiogram from just a few months ago that just , you know , show that you have that slightly leaky heart valve , nothing to do for it , and that the heart murmur is stable , okay ? patient: okay .
D2N168
19
[ "Radiology Examination" ]
[ "Objective" ]
hey , dragon , show me the ecg . yeah , so in reviewing the results of your ekg , it looks the same as last year . um , you do have just blood , those changes from your chronic high blood pressure that we'll address , okay ? hey , dragon , show me the echocardiogram . and this is just the echocardiogram from just a few months ago that just , you know , show that you have that slightly leaky heart valve , nothing to do for it , and that the heart murmur is stable , okay ?
4,226
doctor: so let's just talk a little bit about , you know , my assessment and my plan for you . so , for your first problem , your high blood pressure , it's not controlled at this time , so i want to go ahead and increase the lisinopril to 40 milligrams once a day . i want you to continue to check your blood pressures and report them to me through the patient portal and we'll have to make adjustments if necessary and maybe have to add a second agent , okay ? patient: okay .
D2N168
20
[ "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
so let's just talk a little bit about , you know , my assessment and my plan for you . so , for your first problem , your high blood pressure , it's not controlled at this time , so i want to go ahead and increase the lisinopril to 40 milligrams once a day . i want you to continue to check your blood pressures and report them to me through the patient portal and we'll have to make adjustments if necessary and maybe have to add a second agent , okay ?
4,227
doctor: and then for your second problem , uh , i want , you know , for your depression , i do n't think that we need to start you on any medication , it sounds like you're doing really well from that standpoint , but you know that you can contact me if you , if you need anything , okay ? patient: okay .
D2N168
21
[ "Discussion", "Follow-up", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
and then for your second problem , uh , i want , you know , for your depression , i do n't think that we need to start you on any medication , it sounds like you're doing really well from that standpoint , but you know that you can contact me if you , if you need anything , okay ?
4,228
doctor: do you have any questions ? patient: no , not at this time .
D2N168
22
[ "Discussion" ]
[ "Plan" ]
do you have any questions ?
4,229
doctor: okay , all right , well it's good to see you . patient: good seeing you too .
D2N168
23
[ "Chitchat" ]
[ "Null" ]
okay , all right , well it's good to see you .
4,230
doctor: hey , dragon , finalize the note .
D2N168
24
[ "Chitchat" ]
[ "Null" ]
doctor: hey , dragon , finalize the note .
4,231
doctor: hi alan , how are you ? patient: hi , good to see you .
D2N169
0
[ "Greetings" ]
[ "Subjective" ]
hi alan , how are you ?
4,232
doctor: good to see you as well . are you ready to get started ? patient: yes i am .
D2N169
1
[ "Chitchat" ]
[ "Null" ]
good to see you as well . are you ready to get started ?
4,233
doctor: so , alan is a 61-year-old male , here with complaints of shortness of breath . so alan , what's going on ? patient: so over the weekend , uh , i took a very long bike ride , about three hours or so and i got back , i was very light headed , i was short of breath and it really surprised me because i pretty much bike ride every morning and it was never an issue before so i'm a little concerned about that .
D2N169
2
[ "Acute Symptoms" ]
[ "Subjective" ]
so , alan is a 61-year-old male , here with complaints of shortness of breath . so alan , what's going on ?
4,234
doctor: okay , and have you had any other symptoms ? have you had any fever- patient: no-
D2N169
3
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
okay , and have you had any other symptoms ? have you had any fever-
4,235
doctor: . chest pain ? patient: no , but i felt very light headed and , uh , i- it was hard to catch my breath afterwards , so maybe i did have a little chest pain but , uh , it , it eventually went away after about an hour .
D2N169
4
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
. chest pain ?
4,236
doctor: okay , um , and anyone else sick in your , in your family ? patient: no .
D2N169
5
[ "Family History" ]
[ "Subjective" ]
okay , um , and anyone else sick in your , in your family ?
4,237
doctor: okay , and any cough ? patient: um , i had a little bit of a cough with my first cold in the last year and a half , but that went away after about a week or so .
D2N169
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay , and any cough ?
4,238
doctor: okay , all right . um , and any other symptoms ? i know you went through the review of symptoms- patient: mm-hmm .
D2N169
7
[ "Vegetative History" ]
[ "Subjective" ]
okay , all right . um , and any other symptoms ? i know you went through the review of symptoms-
4,239
doctor: . with the nurse but any nausea or vomiting or abdominal pain ? patient: n- no .
D2N169
8
[ "Vegetative History" ]
[ "Subjective" ]
. with the nurse but any nausea or vomiting or abdominal pain ?
4,240
doctor: okay . all right . well , i know that i've treated you for migraines in the past . how are you doing with those ? patient: that's been under control . i've , uh , taken medication , i've , uh , avoided bright lights and it's so far so good .
D2N169
9
[ "Personal History" ]
[ "Subjective" ]
okay . all right . well , i know that i've treated you for migraines in the past . how are you doing with those ?
4,241
doctor: okay . all right . and i think we had you on imitrex for that . have you- patient: yes , i'm still taking that .
D2N169
10
[ "Therapeutic History", "Personal History" ]
[ "Subjective" ]
okay . all right . and i think we had you on imitrex for that . have you-
4,242
doctor: all right . and then your reflux , how are you doing with that ? patient: managing that as well .
D2N169
11
[ "Personal History" ]
[ "Subjective" ]
all right . and then your reflux , how are you doing with that ?
4,243
doctor: okay and everything's working out well with the protonix ? patient: yes .
D2N169
12
[ "Therapeutic History" ]
[ "Subjective" ]
okay and everything's working out well with the protonix ?
4,244
doctor: okay . and then i know you had the cataract surgery about three months ago , your vision is okay ? patient: that was about four and a half months ago and it's been actually great ever since .
D2N169
13
[ "Personal History" ]
[ "Subjective" ]
okay . and then i know you had the cataract surgery about three months ago , your vision is okay ?
4,245
doctor: okay , great . all right , well , we're gon na go ahead and do a quick physical exam . i wan na see your vital signs first . patient: sure .
D2N169
14
[ "Physical Examination" ]
[ "Objective" ]
okay , great . all right , well , we're gon na go ahead and do a quick physical exam . i wan na see your vital signs first .
4,246
doctor: hey dragon , show me the vital signs . okay , so looking here , everything looks quite good . your oxygenation is perfect , which is wonderful . let me just take a listen . deep breath . another one . good . so , on your physical exam , your neck is nice and supple . i do n't appreciate any jugular venous distension . your heart is in a regular rhythm , i do n't hear any murmur . your lungs do have a slight wheeze , expiratory wheeze , bilaterally . i can hear it every time you breathe and i see trace lower extremity edema in your lower extremities . patient: so what does all that mean ?
D2N169
15
[ "Physical Examination" ]
[ "Objective" ]
hey dragon , show me the vital signs . okay , so looking here , everything looks quite good . your oxygenation is perfect , which is wonderful . let me just take a listen . deep breath . another one . good . so , on your physical exam , your neck is nice and supple . i do n't appreciate any jugular venous distension . your heart is in a regular rhythm , i do n't hear any murmur . your lungs do have a slight wheeze , expiratory wheeze , bilaterally . i can hear it every time you breathe and i see trace lower extremity edema in your lower extremities .
4,247
doctor: you know , you , uh , i'm not quite sure yet but we're gon na review some of your results . hey dragon , show me the chest x-ray . so looking here , this is a very normal chest x-ray . um , i do n't see any pulmonary edema , there's no pneumonia , so we're viewing your chest x-ray as , it's a norm- it's normal . patient: good .
D2N169
16
[ "Radiology Examination" ]
[ "Objective" ]
you know , you , uh , i'm not quite sure yet but we're gon na review some of your results . hey dragon , show me the chest x-ray . so looking here , this is a very normal chest x-ray . um , i do n't see any pulmonary edema , there's no pneumonia , so we're viewing your chest x-ray as , it's a norm- it's normal .
4,248
doctor: so , let's look at your pulmonary function test . hey dragon , show me your , the pfts . and looking here again , these look quite good , i'm , i'm quite encouraged by that . that's , that's normal pulmonary function tests . hey dragon , show me the labs . and all of your labs here look quite good here as well so , i- i- i'm very pleased . so , right now my impression of you is that you may have had an asthma exacerbation from exercising and with the allergies , so at this point in time i'd like to go ahead and prescribe you some albuterol inhaler . patient: mm-hmm .
D2N169
17
[ "Acute Assessment", "Lab Examination", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
so , let's look at your pulmonary function test . hey dragon , show me your , the pfts . and looking here again , these look quite good , i'm , i'm quite encouraged by that . that's , that's normal pulmonary function tests . hey dragon , show me the labs . and all of your labs here look quite good here as well so , i- i- i'm very pleased . so , right now my impression of you is that you may have had an asthma exacerbation from exercising and with the allergies , so at this point in time i'd like to go ahead and prescribe you some albuterol inhaler .
4,249
doctor: two puffs every four hours as needed for wheezing or for shortness of breath . and , i'd like to go ahead and order a pulmonary referral for you , okay . do you have any questions about that ? patient: no questions , thanks .
D2N169
18
[ "Discussion", "Diagnostic Testing", "Medication" ]
[ "Plan" ]
two puffs every four hours as needed for wheezing or for shortness of breath . and , i'd like to go ahead and order a pulmonary referral for you , okay . do you have any questions about that ?
4,250
doctor: hey dragon , order a pulmonary referral . hey dragon , order albuterol inhaler , two puffs every four hours , as needed for shortness of breath . and then i think from your reflux standpoint , everything seems stable and your migraines , i think that we should just continue on with the imitrex , as needed . does that sound good to you ? patient: that sounds fine .
D2N169
19
[ "Reassessment", "Referral", "Medication" ]
[ "Assessment", "Plan" ]
hey dragon , order a pulmonary referral . hey dragon , order albuterol inhaler , two puffs every four hours , as needed for shortness of breath . and then i think from your reflux standpoint , everything seems stable and your migraines , i think that we should just continue on with the imitrex , as needed . does that sound good to you ?
4,251
doctor: i wan na see you in a couple weeks and if you have this shortness of breath again , i want you to call me right away , okay ? patient: you got it .
D2N169
20
[ "Follow-up" ]
[ "Plan" ]
i wan na see you in a couple weeks and if you have this shortness of breath again , i want you to call me right away , okay ?
4,252
doctor: all right . good to see you . patient: same here .
D2N169
21
[ "Chitchat" ]
[ "Null" ]
all right . good to see you .
4,253
doctor: hey dragon , finalize the note .
D2N169
22
[ "Chitchat" ]
[ "Null" ]
doctor: hey dragon , finalize the note .
4,254
doctor: hi joyce , how are you ? patient: i'm good . how are you ?
D2N170
0
[ "Greetings" ]
[ "Subjective" ]
hi joyce , how are you ?
4,255
doctor: i'm doing well . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you when we get started , okay ? patient: okay .
D2N170
1
[ "Chitchat" ]
[ "Null" ]
i'm doing well . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you when we get started , okay ?
4,256
doctor: all right . so , joyce is a 50 year old female with a past medical history significant for copd , congestive heart failure who presents for follow-up to an abnormal lab finding . so , joyce , i , i got the results of your lab , uh , your labs . your hemoglobin was low . uh , so , i asked them to schedule a follow-up appointment with me . so , how are you feeling ? patient: i've been feeling really tired lately . over the past couple of months , i've noticed that my energy has really gone down . i used to be really active , um , just trying to be as healthy as i can be , running, climbing . um , i at least try to do an hour or two a day . and over the past month , it's gone slowly downhill . i've just been so tired and exhausted and i have n't been able to really keep up with the way i , i was g- was going with my exercise .
D2N170
2
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
all right . so , joyce is a 50 year old female with a past medical history significant for copd , congestive heart failure who presents for follow-up to an abnormal lab finding . so , joyce , i , i got the results of your lab , uh , your labs . your hemoglobin was low . uh , so , i asked them to schedule a follow-up appointment with me . so , how are you feeling ?
4,257
doctor: okay . all right . um , now , have you had ... have you noticed any blood in your stools at all ? patient: uh , no , not really . not , not at this time .
D2N170
3
[ "Vegetative History" ]
[ "Subjective" ]
okay . all right . um , now , have you had ... have you noticed any blood in your stools at all ?
4,258
doctor: okay . and are your stools , like , dark or charry or black looking ? patient: no . not that i've noticed .
D2N170
4
[ "Vegetative History" ]
[ "Subjective" ]
okay . and are your stools , like , dark or charry or black looking ?
4,259
doctor: okay . and are you spotting a lot with your periods ? patient: no , i'm not .
D2N170
5
[ "Vegetative History" ]
[ "Subjective" ]
okay . and are you spotting a lot with your periods ?
4,260
doctor: okay . all right . um , and do you have any other ... i know that you are endorsing this fatigue and you feel kind of dizzy and that type of thing . do you have any other symptoms like chest pain , shortness of breath , fever , chills , body aches , anything ? patient: no , nothing like that .
D2N170
6
[ "Vegetative History" ]
[ "Subjective" ]
okay . all right . um , and do you have any other ... i know that you are endorsing this fatigue and you feel kind of dizzy and that type of thing . do you have any other symptoms like chest pain , shortness of breath , fever , chills , body aches , anything ?
4,261
doctor: okay . any weight loss ? patient: um , i've noticed a little bit , but that's because i think i've been doing really well with my exercise . um , but nothing too significant .
D2N170
7
[ "Vegetative History" ]
[ "Subjective" ]
okay . any weight loss ?
4,262
doctor: okay . all right . well , let me ask you a little bit about how's the , the copd doing . i , i know that , you know , you've stopped smoking several years ago , but , you know , you still have that em- those emphysema changes on your chest x-ray . so , how are you doing with that ? how's your breathing ? patient: it's been okay . um , i have n't been smoking . i ... after i quit , i quit cold turkey and i have n't gone back since . so , that's been doing well . i think , uh , during the changes of season , it gets a little bit harder for me to breathe , but i think that's just because of my allergies .
D2N170
8
[ "Drug History" ]
[ "Subjective" ]
okay . all right . well , let me ask you a little bit about how's the , the copd doing . i , i know that , you know , you've stopped smoking several years ago , but , you know , you still have that em- those emphysema changes on your chest x-ray . so , how are you doing with that ? how's your breathing ?
4,263
doctor: okay . all right . and then from a congestive heart failure standpoint , are you watching your diet , you're watching your salt intake ? patient: yeah . i've been doing really well with that . i've been staying away from the french fries , and all the other salty foods that i love to eat , uh , and everything looks great .
D2N170
9
[ "Personal History" ]
[ "Subjective" ]
okay . all right . and then from a congestive heart failure standpoint , are you watching your diet , you're watching your salt intake ?
4,264
doctor: um , so , french fries are one of my favorite foods , that and fried chicken , so- i give you a lot of credit for staying away from french fries . patient: thank you .
D2N170
10
[ "Chitchat" ]
[ "Null" ]
um , so , french fries are one of my favorite foods , that and fried chicken , so- i give you a lot of credit for staying away from french fries .
4,265
doctor: um , okay . so , you ... so , no swelling in your legs or any- anything like that . patient: no , not that i've noticed .
D2N170
11
[ "Vegetative History" ]
[ "Subjective" ]
um , okay . so , you ... so , no swelling in your legs or any- anything like that .
4,266
doctor: okay . and you feel like you have a good support system ? patient: yeah . my boyfriend is , is great and i have , um , my brother right down the road .
D2N170
12
[ "Other Socials" ]
[ "Subjective" ]
okay . and you feel like you have a good support system ?
4,267
doctor: okay . all right . good . i'm glad to hear that . uh , so , let's go ahead . i wan na just do a quick physical exam , okay ? patient: okay .
D2N170
13
[ "Physical Examination" ]
[ "Objective" ]
okay . all right . good . i'm glad to hear that . uh , so , let's go ahead . i wan na just do a quick physical exam , okay ?
4,268
doctor: hey , dragon , show me the vital signs . all right . well , your vital signs here in the office look good , so , i'm , i'm really happy to see that with the abnormal hemoglobin that we saw . um , i'm gon na just listen to your heart and lungs and press on your belly a little bit and i'll let you know if i find anything , okay ? patient: okay .
D2N170
14
[ "Physical Examination" ]
[ "Objective" ]
hey , dragon , show me the vital signs . all right . well , your vital signs here in the office look good , so , i'm , i'm really happy to see that with the abnormal hemoglobin that we saw . um , i'm gon na just listen to your heart and lungs and press on your belly a little bit and i'll let you know if i find anything , okay ?
4,269
doctor: all right . okay . all right . so , on physical exam , you know , i , i do n't appreciate anything cervical lymphadenopathy . your heart sounds really good , but i do hear a , a slight two out of six systolic heart , uh , murmur , um , systolic ejection murmur on your heart exam . your lungs sound clear . your abdomen ... you know , you did have a little tenderness to palpation in your right lower quadrant on your abdominal exam , uh , but i do n't appreciate any lower extremity edema . so , all that means it that we , you know , we hear that heart murmur , which we heard in the past , um , and your belly had some tenderness , so we'll have to talk about that a little bit , uh , going forward , okay ? patient: okay .
D2N170
15
[ "Physical Examination" ]
[ "Objective" ]
all right . okay . all right . so , on physical exam , you know , i , i do n't appreciate anything cervical lymphadenopathy . your heart sounds really good , but i do hear a , a slight two out of six systolic heart , uh , murmur , um , systolic ejection murmur on your heart exam . your lungs sound clear . your abdomen ... you know , you did have a little tenderness to palpation in your right lower quadrant on your abdominal exam , uh , but i do n't appreciate any lower extremity edema . so , all that means it that we , you know , we hear that heart murmur , which we heard in the past , um , and your belly had some tenderness , so we'll have to talk about that a little bit , uh , going forward , okay ?
4,270
doctor: let's look at some of your results , okay ? patient: mm-hmm .
D2N170
16
[ "Lab Examination" ]
[ "Objective" ]
let's look at some of your results , okay ?
4,271
doctor: hey , dragon , show me the hemoglobin . so , here , looking at this , you know , your hemoglobin level is 8.2. somebody like you should have a hemoglobin o- of about 13 , 14 , okay ? patient: okay .
D2N170
17
[ "Lab Examination" ]
[ "Objective" ]
hey , dragon , show me the hemoglobin . so , here , looking at this , you know , your hemoglobin level is 8.2. somebody like you should have a hemoglobin o- of about 13 , 14 , okay ?
4,272
doctor: so , we need to investigate why it's low . hey , dragon , show me the anemia labs . okay . so , looking here at your labs , uh , everything looks good from , from this standpoint . i think some of your anemia labs are still pending at this time that's part of the workup . patient: mm-hmm .
D2N170
18
[ "Lab Examination" ]
[ "Objective" ]
so , we need to investigate why it's low . hey , dragon , show me the anemia labs . okay . so , looking here at your labs , uh , everything looks good from , from this standpoint . i think some of your anemia labs are still pending at this time that's part of the workup .
4,273
doctor: so , let's go over a little bit about the assessment and plan for you . so , you know , your main problem , this abnormal lab , this low hemoglobin that we found , so , you're anemic and we nee- ... you know , i'm waiting for those anemia labs to come back to find out exactly , you know , what type of anemia you have . i'd like to go ahead and schedule you for an endoscopy a- and a colonoscopy just to make sure that you're not bleeding from your , inside your belly , okay ? um , and i'm ... i'll be in touch when those labs come back to see what further workup we need to do , okay ? patient: mm-hmm .
D2N170
19
[ "Diagnostic Testing", "Acute Assessment" ]
[ "Assessment", "Plan" ]
so , let's go over a little bit about the assessment and plan for you . so , you know , your main problem , this abnormal lab , this low hemoglobin that we found , so , you're anemic and we nee- ... you know , i'm waiting for those anemia labs to come back to find out exactly , you know , what type of anemia you have . i'd like to go ahead and schedule you for an endoscopy a- and a colonoscopy just to make sure that you're not bleeding from your , inside your belly , okay ? um , and i'm ... i'll be in touch when those labs come back to see what further workup we need to do , okay ?
4,274
doctor: for your next problem , the copd , i think you're doing great . you know , i , i do n't think that you , uh , need any further referrals at this time for that . i would just continue staying away from smoking . it does n't sound to be like you need any inhalers at this time . uh , for your third problem , your congestive heart failure , you know , i wan na continue you on the toprol , continue you on the lisinopril and we'll continue you on your current diuretic dosing of 20 , lasix 20 milligrams a day . i'm gon na go ahead and order that referral to g- to gastroenterology . they're the ones who will do the endoscopy and the colonoscopy , okay ? patient: okay .
D2N170
20
[ "Referral", "Medication", "Reassessment", "Drug History" ]
[ "Assessment", "Plan" ]
for your next problem , the copd , i think you're doing great . you know , i , i do n't think that you , uh , need any further referrals at this time for that . i would just continue staying away from smoking . it does n't sound to be like you need any inhalers at this time . uh , for your third problem , your congestive heart failure , you know , i wan na continue you on the toprol , continue you on the lisinopril and we'll continue you on your current diuretic dosing of 20 , lasix 20 milligrams a day . i'm gon na go ahead and order that referral to g- to gastroenterology . they're the ones who will do the endoscopy and the colonoscopy , okay ?
4,275
doctor: hey , dragon , order the referral to gastroenterology . so , i'll be in touch . i'm gon na stay in close contact with you over the next week or so and , uh , we'll get this all sorted out , okay ? patient: okay .
D2N170
21
[ "Discussion", "Follow-up", "Referral" ]
[ "Plan" ]
hey , dragon , order the referral to gastroenterology . so , i'll be in touch . i'm gon na stay in close contact with you over the next week or so and , uh , we'll get this all sorted out , okay ?
4,276
doctor: all right . take care , joyce . patient: thank you .
D2N170
22
[ "Chitchat" ]
[ "Null" ]
all right . take care , joyce .
4,277
doctor: hey , dragon , finalize the note .
D2N170
23
[ "Chitchat" ]
[ "Null" ]
doctor: hey , dragon , finalize the note .
4,278
doctor: hi evelyn , how are you ? patient: i'm good , how are you ?
D2N171
0
[ "Greetings" ]
[ "Subjective" ]
hi evelyn , how are you ?
4,279
doctor: i'm good . it's good to see you . patient: good to see you too .
D2N171
1
[ "Chitchat" ]
[ "Null" ]
i'm good . it's good to see you .
4,280
doctor: so i know the nurse told you a little bit about dax . i'm gon na tell dax about you , okay ? patient: okay .
D2N171
2
[ "Chitchat" ]
[ "Null" ]
so i know the nurse told you a little bit about dax . i'm gon na tell dax about you , okay ?
4,281
doctor: so evelyn is a 56-year-old female with a past medical history significant for coronary artery disease , prior carpal tunnel release , and a herniated disc who presents for her annual exam . so evelyn it's been a little while since i've seen you , how have you been doing over the last year ? patient: i've been doing okay , um , everything , um , with my herniated disc in my back has been doing really well . i have n't had any , um , back pain , or any , um , limitations in movement , so that's been doing well .
D2N171
3
[ "Personal History" ]
[ "Subjective" ]
so evelyn is a 56-year-old female with a past medical history significant for coronary artery disease , prior carpal tunnel release , and a herniated disc who presents for her annual exam . so evelyn it's been a little while since i've seen you , how have you been doing over the last year ?
4,282
doctor: okay , yeah , i know that we have done a steroid injection for that , uh , a couple of month- , uh , several months ago , so that's- that's doing well ? patient: yeah , it is .
D2N171
4
[ "Therapeutic History" ]
[ "Subjective" ]
okay , yeah , i know that we have done a steroid injection for that , uh , a couple of month- , uh , several months ago , so that's- that's doing well ?
4,283
doctor: okay , i'm glad to hear that . and then , how about your carpal tunnel issues , you had that fixed a couple of years ago , so are you having any recurrent issues , or you good , you back to work ? patient: i am back to work . i have n't had any issues , and i've had full range of motion , and it's- it feels really good .
D2N171
5
[ "Personal History" ]
[ "Subjective" ]
okay , i'm glad to hear that . and then , how about your carpal tunnel issues , you had that fixed a couple of years ago , so are you having any recurrent issues , or you good , you back to work ?
4,284
doctor: all right , so no numbing and tingling in your hands ? patient: no .
D2N171
6
[ "Acute Symptoms" ]
[ "Subjective" ]
all right , so no numbing and tingling in your hands ?
4,285
doctor: okay , that's good . and then , you know , i know that you've had , uh , prior stenting in the past for your- for your heart , and your heart vessels . patient: mm-hmm .
D2N171
7
[ "Personal History" ]
[ "Subjective" ]
okay , that's good . and then , you know , i know that you've had , uh , prior stenting in the past for your- for your heart , and your heart vessels .
4,286
doctor: how are you doing from that standpoint ? have you had any chest pain , shortness of breath , nausea or vomiting ? patient: over the last month i've been having a bit of chest pain , but i have n't had any of the other symptoms you mentioned .
D2N171
8
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
how are you doing from that standpoint ? have you had any chest pain , shortness of breath , nausea or vomiting ?
4,287
doctor: okay , does the chest pain happen when you walk ? patient: yeah , it does .
D2N171
9
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
okay , does the chest pain happen when you walk ?
4,288
doctor: okay , and does it- does it go away if you- if you rest ? patient: yeah , it does actually .
D2N171
10
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
okay , and does it- does it go away if you- if you rest ?
4,289
doctor: okay , all right . do you ever get it just sitting there at rest ? patient: no i do n't .
D2N171
11
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
okay , all right . do you ever get it just sitting there at rest ?
4,290
doctor: okay , all right . okay , and- and can you describe it ? patient: it's like a burn .
D2N171
12
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
okay , all right . okay , and- and can you describe it ?
4,291
doctor: okay , and where exactly is it located in your chest ? patient: just , um , right in the middle ...
D2N171
14
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
okay , and where exactly is it located in your chest ?
4,292
doctor: okay . and how often are you getting it ? patient: um , probably about three- three times a week .
D2N171
16
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
okay . and how often are you getting it ?
4,293
doctor: okay , all right . well i'm glad that you talked about that with me today , um , i know the nurse did a review of systems sheet with you , and , you know , you're obviously endorsing this- this chest pressure . um , have you had any other symptoms , i know the- the other ones that you have n't had , but any lower extremity edema , or muscle aches , or fever chills ? patient: no , nothing like that , but i have had a little bit of congestion , um , just from allergies , because of the pollen .
D2N171
17
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
okay , all right . well i'm glad that you talked about that with me today , um , i know the nurse did a review of systems sheet with you , and , you know , you're obviously endorsing this- this chest pressure . um , have you had any other symptoms , i know the- the other ones that you have n't had , but any lower extremity edema , or muscle aches , or fever chills ?
4,294
doctor: okay , so you're endorsing some nasal congestion ? patient: yeah .
D2N171
18
[ "Vegetative History" ]
[ "Subjective" ]
okay , so you're endorsing some nasal congestion ?
4,295
doctor: all right , well let's go ahead and we'll do a physical exam , okay ? patient: okay .
D2N171
19
[ "Physical Examination" ]
[ "Objective" ]
all right , well let's go ahead and we'll do a physical exam , okay ?
4,296
doctor: hey dragon ? show me the vital signs . so here your vital signs look really good , i'm- i'm happy to see that your blood pressure is under- under good control , and your oxygenation is fine , so i'm just gon na take a listen to your heart and lungs , and i'll let you know if i find anything , okay ? patient: okay .
D2N171
20
[ "Physical Examination" ]
[ "Objective" ]
hey dragon ? show me the vital signs . so here your vital signs look really good , i'm- i'm happy to see that your blood pressure is under- under good control , and your oxygenation is fine , so i'm just gon na take a listen to your heart and lungs , and i'll let you know if i find anything , okay ?
4,297
doctor: okay , so in physical exam your heart has a slight three out of six systolic ejection murmur , which we've heard before . your lungs are nice and clear , uh , i do n't appreciate any carotid bruits , and- and you have no lower extremity edema , you have healed , uh , surgical scars on your- on your , uh , right wrist . um , so let's go ahead , i wan na look at some of your results , okay ? patient: okay .
D2N171
21
[ "Physical Examination" ]
[ "Objective" ]
okay , so in physical exam your heart has a slight three out of six systolic ejection murmur , which we've heard before . your lungs are nice and clear , uh , i do n't appreciate any carotid bruits , and- and you have no lower extremity edema , you have healed , uh , surgical scars on your- on your , uh , right wrist . um , so let's go ahead , i wan na look at some of your results , okay ?
4,298
doctor: hey dragon , show me the echocardiogram ? so this is the echocardiogram from last year , you know , you did have a slightly low pumping function of your heart at 45 % , but , uh , i- , you know , i suspected that will improve over time , and you did have some slight , what we call , mitral regurgitation , that's just a leaky heart valve , and that's that murmur that i heard . hey dragon , show me the ecg ? and here , you know , in reviewing your results of your e- ecg , you know , it looks stable , it just kinda reflects your prior coronary artery disease . there's no new changes , which is good , so let's talk a little bit about my assessment and plan for you . so , from your first problem , you know , your carpal tunnel release , i do n't think that we need to anything further about that , 'cause you seem to be doing really well , you're back at work , if you have any recurring symptoms , just let me know , and we can take it from there . for your next problem , your herniated disc , that also sounds like your doing really well , i do n't think that we need to refer you for any further steroid injection , or physical therapy at this time . so , if you have recurrent symptoms , i want you to let me know . and finally , your last problem , the most concerning problem to me is your known coronary artery disease , and this recurrent chest pain you have . so , i wan na go ahead and continue you on your asprin , and your toprol , okay ? i wan na go ahead and order a stress test for you to see if you have more blockages that could be causing this chest discomfort , okay ? patient: okay .
D2N171
22
[ "Reassessment", "Diagnostic Testing", "Radiology Examination", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
hey dragon , show me the echocardiogram ? so this is the echocardiogram from last year , you know , you did have a slightly low pumping function of your heart at 45 % , but , uh , i- , you know , i suspected that will improve over time , and you did have some slight , what we call , mitral regurgitation , that's just a leaky heart valve , and that's that murmur that i heard . hey dragon , show me the ecg ? and here , you know , in reviewing your results of your e- ecg , you know , it looks stable , it just kinda reflects your prior coronary artery disease . there's no new changes , which is good , so let's talk a little bit about my assessment and plan for you . so , from your first problem , you know , your carpal tunnel release , i do n't think that we need to anything further about that , 'cause you seem to be doing really well , you're back at work , if you have any recurring symptoms , just let me know , and we can take it from there . for your next problem , your herniated disc , that also sounds like your doing really well , i do n't think that we need to refer you for any further steroid injection , or physical therapy at this time . so , if you have recurrent symptoms , i want you to let me know . and finally , your last problem , the most concerning problem to me is your known coronary artery disease , and this recurrent chest pain you have . so , i wan na go ahead and continue you on your asprin , and your toprol , okay ? i wan na go ahead and order a stress test for you to see if you have more blockages that could be causing this chest discomfort , okay ?
4,299