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doctor: you do have a little bit of periphe- peripheral neuropathy . um , there is a medication we can use if they get really bad , but you're already on so many medications . patient: my girl that i talk to and stuff , she uses on her feet ; she really likes it . it's , like , a foot scrub or some type of cream . i pu...
D2N178
51
[ "Discussion", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
you do have a little bit of periphe- peripheral neuropathy . um , there is a medication we can use if they get really bad , but you're already on so many medications .
4,500
doctor: that sounds good . so for now , your sugars , we're gon na check your ... we're going to recheck your blood work today , but the sugars last time we checked , the a1c , your blood sugar average was above nine . i really want you to increase the glimepiride . so the ones you have at home , the two milligram , ta...
D2N178
52
[ "Medication", "Lab Examination" ]
[ "Objective", "Plan" ]
that sounds good . so for now , your sugars , we're gon na check your ... we're going to recheck your blood work today , but the sugars last time we checked , the a1c , your blood sugar average was above nine . i really want you to increase the glimepiride . so the ones you have at home , the two milligram , take two o...
4,501
doctor: okay . watch for low sugars , weak , shaky , sweaty . if that happens , let us know , and i do n't expect it to . patient: okay .
D2N178
53
[ "Discussion" ]
[ "Plan" ]
okay . watch for low sugars , weak , shaky , sweaty . if that happens , let us know , and i do n't expect it to .
4,502
doctor: okay . the new prescription that i'm going to write is gon na be for the , uh , four milligram pill . so when you get the new one , just one pill twice a day . also , continue the metformin , okay ? blood pressure , when i rechecked it , i got 140 over 60 s- so the numbers at home are better , so we're gon na c...
D2N178
54
[ "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
okay . the new prescription that i'm going to write is gon na be for the , uh , four milligram pill . so when you get the new one , just one pill twice a day . also , continue the metformin , okay ? blood pressure , when i rechecked it , i got 140 over 60 s- so the numbers at home are better , so we're gon na continue ...
4,503
doctor: i want you to quit smoking , but we've had this battle before . patient: yeah .
D2N178
55
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
i want you to quit smoking , but we've had this battle before .
4,504
doctor: hmm . and then , we will leave everything else the same . we'll get the labs today and we'll see you back here in four months . sound good ? patient: okay .
D2N178
56
[ "Follow-up", "Diagnostic Testing" ]
[ "Plan" ]
hmm . and then , we will leave everything else the same . we'll get the labs today and we'll see you back here in four months . sound good ?
4,505
doctor: great . have a good day , ma'am . take care of yourself . patient: thank you . you too .
D2N178
57
[ "Chitchat" ]
[ "Null" ]
great . have a good day , ma'am . take care of yourself .
4,506
doctor: patient mrn : abc123 . date of birth : january 1st , 1960 . patient is a 60 year old , right-handed male , referred today for evaluation of numbness and tingling . hello , mr. cook . how are you doing this morning ? patient: hi , dr. martinez . this weekend was a bit rough . i've had this numbness and tingling ...
D2N179
0
[ "Acute Symptoms", "Personal History", "Greetings" ]
[ "Subjective" ]
patient mrn : abc123 . date of birth : january 1st , 1960 . patient is a 60 year old , right-handed male , referred today for evaluation of numbness and tingling . hello , mr. cook . how are you doing this morning ?
4,507
doctor: so it's in both of your hands ? patient: yes , ever since my car wreck last december when i broke them ... well , once they healed , i mean , i noticed it more , the tingling and the numbness .
D2N179
1
[ "Acute Symptoms" ]
[ "Subjective" ]
so it's in both of your hands ?
4,508
doctor: and you still wear the splint only on the right wrist ? patient: no , i also wear the left sometimes . the right is just worse , but the splint helps . both have really gotten worse over the last month . when i broke them , my right wrist was definitely in worse shape . i've also been having some s- mild stiffn...
D2N179
2
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
and you still wear the splint only on the right wrist ?
4,509
doctor: and where would you say the tingling and numbness is ? patient: on this side , it goes from here and here up to about here . on the other side , it's from here to here .
D2N179
3
[ "Acute Symptoms" ]
[ "Subjective" ]
and where would you say the tingling and numbness is ?
4,510
doctor: i see . so on the right side , you're pointing from the middle and ring finger , all the way up the forearm . and on the left , the symptoms extend from the pinky and ring finger . and is there any pain or just tingling and numbness ? patient: eh , it's mainly just sore . sometimes they throb , but overall , th...
D2N179
4
[ "Acute Symptoms" ]
[ "Subjective" ]
i see . so on the right side , you're pointing from the middle and ring finger , all the way up the forearm . and on the left , the symptoms extend from the pinky and ring finger . and is there any pain or just tingling and numbness ?
4,511
doctor: and when do you feel these symptoms ? patient: well , really , i guess , just more so at night , and they come and go throughout the day .
D2N179
5
[ "Acute Symptoms" ]
[ "Subjective" ]
and when do you feel these symptoms ?
4,512
doctor: okay . and do you experience any loss of sensation in your hands or fingers ? patient: like , feeling something ? no , not that i can really think of . though , in general , they may be less sensitive than they should be , but i can still feel . they also gave me some nerve pain medicine , but i have n't been t...
D2N179
6
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay . and do you experience any loss of sensation in your hands or fingers ?
4,513
doctor: and are you still on the coreg for hypertension and the lexapro for anxiety ? patient: yes , i'm still taking those . i had prediabetes too , but i got it under control by changing my diet .
D2N179
7
[ "Therapeutic History" ]
[ "Subjective" ]
and are you still on the coreg for hypertension and the lexapro for anxiety ?
4,514
doctor: and no history of thyroid issues , correct ? patient: nope .
D2N179
8
[ "Personal History" ]
[ "Subjective" ]
and no history of thyroid issues , correct ?
4,515
doctor: all right , thank you , mr. cook . okay , first , we'll go over your review of systems . correct me if i'm wrong in any of this . constitutional , you have fatigue and weight gain ; gi , you have excessive appetite and bloating ; eyes have floaters ; cardiovascular shows shortness of breath and leg swelling ; e...
D2N179
9
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
all right , thank you , mr. cook . okay , first , we'll go over your review of systems . correct me if i'm wrong in any of this . constitutional , you have fatigue and weight gain ; gi , you have excessive appetite and bloating ; eyes have floaters ; cardiovascular shows shortness of breath and leg swelling ; endocrine...
4,516
doctor: all right , we're going to go ahead and do the neurologic examination . let's look at the right hand first . can you feel this ? patient: yeah , but a little less on these two fingers .
D2N179
10
[ "Physical Examination" ]
[ "Objective" ]
all right , we're going to go ahead and do the neurologic examination . let's look at the right hand first . can you feel this ?
4,517
doctor: sensation is normal , except pin prick sensation diminished in third and fourth fingers on the right . and how about on the left ? patient: um , yeah , but these two a little less .
D2N179
11
[ "Acute Symptoms", "Physical Examination" ]
[ "Subjective", "Objective" ]
sensation is normal , except pin prick sensation diminished in third and fourth fingers on the right . and how about on the left ?
4,518
doctor: sensation is decreased in the fourth and fifth fingers on the left okay , let's test your reflexes now . reflexes are 1+ and symmetric ; 2+ knees ; toes are downgoing bilaterally . all right , i'm going to tap on your right wrist . do you feel anything ? patient: yeah , it feels like a zing up my wrist and some...
D2N179
12
[ "Acute Symptoms", "Physical Examination" ]
[ "Subjective", "Objective" ]
sensation is decreased in the fourth and fifth fingers on the left okay , let's test your reflexes now . reflexes are 1+ and symmetric ; 2+ knees ; toes are downgoing bilaterally . all right , i'm going to tap on your right wrist . do you feel anything ?
4,519
doctor: and how about the left side ? patient: yeah , same on that side too .
D2N179
13
[ "Physical Examination" ]
[ "Objective" ]
and how about the left side ?
4,520
doctor: tinel sign positive at both wrists and both elbows . rest of exam is normal . all right , so what i am seeing today is bilateral carpal tunnel syndrome or , potentially , this could also be bilateral cubital tunnel syndrome . however , your symptom presentation suggests car- bilateral carpal syndrome , as the n...
D2N179
14
[ "Physical Examination", "Acute Assessment" ]
[ "Objective", "Assessment" ]
tinel sign positive at both wrists and both elbows . rest of exam is normal . all right , so what i am seeing today is bilateral carpal tunnel syndrome or , potentially , this could also be bilateral cubital tunnel syndrome . however , your symptom presentation suggests car- bilateral carpal syndrome , as the nerve in ...
4,521
doctor: first , i want to determine exactly where the nerve irritation is coming from . we'll need to schedule you for a nerve test , which is called an emg test . they will measure the responsiveness of your nerves to truly pinpoint where you are having your issues . patient: that sounds fine to me .
D2N179
15
[ "Diagnostic Testing" ]
[ "Plan" ]
first , i want to determine exactly where the nerve irritation is coming from . we'll need to schedule you for a nerve test , which is called an emg test . they will measure the responsiveness of your nerves to truly pinpoint where you are having your issues .
4,522
doctor: great . after the tests are complete , you can return here for a follow-up visit . if you're still having symptoms , we can consider a referral to our hand clinic , possibly for injections or carpal tunnel release se- surgery . you could also refer ... we could also refer you to an orthopedist for the same trea...
D2N179
16
[ "Discussion" ]
[ "Plan" ]
great . after the tests are complete , you can return here for a follow-up visit . if you're still having symptoms , we can consider a referral to our hand clinic , possibly for injections or carpal tunnel release se- surgery . you could also refer ... we could also refer you to an orthopedist for the same treatment .
4,523
doctor: all right , keep wearing your splints , and i will see you after those studies . patient: thank you .
D2N179
17
[ "Discussion" ]
[ "Plan" ]
all right , keep wearing your splints , and i will see you after those studies .
4,524
doctor: patient shirley taylor . date of birth 5/4/1961 . mrn 0000123 . patient is a 60 year old right-handed female new patient referred by dr. jacob ward for evaluation of bilateral hand numbness and tingling . please note that i personally reviewed the ct brain with and without contrasting did 2/5/21 . uh , no metas...
D2N180
0
[ "Acute Symptoms", "Personal History", "Greetings" ]
[ "Subjective" ]
patient shirley taylor . date of birth 5/4/1961 . mrn 0000123 . patient is a 60 year old right-handed female new patient referred by dr. jacob ward for evaluation of bilateral hand numbness and tingling . please note that i personally reviewed the ct brain with and without contrasting did 2/5/21 . uh , no metastatic di...
4,525
doctor: so , in both of your hands ? patient: yeah . ever since my car wreck last december when i broke them . well , once they heal , i mean , i noticed it more , the , the tingling and numbness .
D2N180
1
[ "Personal History" ]
[ "Subjective" ]
so , in both of your hands ?
4,526
doctor: are you still wearing the splint only on your right wrist ? patient: no . i wear the left one also sometimes . the right one's just worse . the splint seems to help . both have gotten worse over the last month . when i broke them though , my wrist was definitely in worse shape than it is today . i've been havin...
D2N180
2
[ "Personal History" ]
[ "Subjective" ]
are you still wearing the splint only on your right wrist ?
4,527
doctor: okay . and where exactly on the right side would you say the tingling and numbness is ? patient: on the right , i can really notice it from my middle and ring finger all the way up to my forearm , and on my left , a bit more the pinky and the ring and not the middle .
D2N180
3
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . and where exactly on the right side would you say the tingling and numbness is ?
4,528
doctor: all right . and , um , is there is pain or , or just tingling and numbness ? patient: uh , mainly just sore . sometimes they throb , but overall , they feel weaker too , especially when i'm using them . the tingling happens some more , but when they hurt , you know , it goes away and then the tingling's just du...
D2N180
4
[ "Acute Symptoms" ]
[ "Subjective" ]
all right . and , um , is there is pain or , or just tingling and numbness ?
4,529
doctor: what kind of activities ? patient: well , really , i guess , just more so at night , and then it just kind of comes and goes throughout the day .
D2N180
5
[ "Acute Symptoms" ]
[ "Subjective" ]
what kind of activities ?
4,530
doctor: okay . and do you experience any loss of sensation in your hands or fingers ? patient: uh , like , like feeling something ? no , not that i can think of really . in general , they might be less sensitive than they should be , but i can still feel . they gave me some nerve pain medicine , but i have n't been tak...
D2N180
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . and do you experience any loss of sensation in your hands or fingers ?
4,531
doctor: okay . looks like your medical history is notable for chronic kidney disease , gout , hypertension , anxiety , gerd , and diabetes . patient: well , i had pre-diabetes , but i got in under control changing my diet .
D2N180
7
[ "Personal History" ]
[ "Subjective" ]
okay . looks like your medical history is notable for chronic kidney disease , gout , hypertension , anxiety , gerd , and diabetes .
4,532
doctor: okay . good . and are you still on the carvedilol 25 milligrams two times a day for hypertension and lexapro 10 milligrams a day for anxiety ? looks like your allergic to sulfa drugs as well . is that correct ? patient: yeah , i'm still taking those and sulfa just causes me to break out in a rash .
D2N180
8
[ "Therapeutic History", "Drug History" ]
[ "Subjective" ]
okay . good . and are you still on the carvedilol 25 milligrams two times a day for hypertension and lexapro 10 milligrams a day for anxiety ? looks like your allergic to sulfa drugs as well . is that correct ?
4,533
doctor: and no history of thyroid issues , right ? patient: nope .
D2N180
9
[ "Personal History" ]
[ "Subjective" ]
and no history of thyroid issues , right ?
4,534
doctor: all right . thank you ms. taylor . i'll be right back for your exam . i want to look up that medication you mentioned for your nerve pain . patient: all right . thanks .
D2N180
10
[ "Chitchat" ]
[ "Null" ]
all right . thank you ms. taylor . i'll be right back for your exam . i want to look up that medication you mentioned for your nerve pain .
4,535
doctor: review of systems , please make the following changes . uh , constitutional , patient reports fatigue and weight gain . gi , um , excessive appetite and bloating . eyes , floaters . uh , cardiovascular , shortness of breath and leg swelling . endocrine , positive diabetes , always hungry . skin , nail bed trenc...
D2N180
11
[ "Physical Examination", "Discussion", "Diagnostic Testing", "Acute Assessment", "Personal History", "Other Treatments", "Referral", "Vegetative History" ]
[ "Subjective", "Objective", "Assessment", "Plan" ]
doctor: review of systems , please make the following changes . uh , constitutional , patient reports fatigue and weight gain . gi , um , excessive appetite and bloating . eyes , floaters . uh , cardiovascular , shortness of breath and leg swelling . endocrine , positive diabetes , always hungry . skin , nail bed trenc...
4,536
doctor: michelle king , date of birth 01/05/1986 , mrnq27631 . new patient visit for acid reflux . past medical history of anxiety and seasonal allergies . hello , are you mrs. king ? patient: i am .
D2N181
0
[ "Acute Symptoms", "Personal History", "Greetings" ]
[ "Subjective" ]
michelle king , date of birth 01/05/1986 , mrnq27631 . new patient visit for acid reflux . past medical history of anxiety and seasonal allergies . hello , are you mrs. king ?
4,537
doctor: i'm dr. phillips . very nice to meet you . patient: you as well .
D2N181
1
[ "Chitchat" ]
[ "Null" ]
i'm dr. phillips . very nice to meet you .
4,538
doctor: how can i help you today ? patient: well , my primary doctor , dr. scott , he referred me here .
D2N181
2
[ "Acute Symptoms" ]
[ "Subjective" ]
how can i help you today ?
4,539
doctor: okay . can you tell me more about it ? patient: yeah . though i mean i ... right now , i take 40 milligrams of omeprazole twice a day . some days , it is fine , but others are just really bad .
D2N181
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . can you tell me more about it ?
4,540
doctor: what do you feel ? patient: it feels like burning .
D2N181
5
[ "Acute Symptoms" ]
[ "Subjective" ]
what do you feel ?
4,541
doctor: in your chest ? patient: yes , in my chest and also in my throat .
D2N181
6
[ "Acute Symptoms" ]
[ "Subjective" ]
in your chest ?
4,542
doctor: in your throat and chest . all right . any difficulty with swallowing ? feels like food or liquids kinda get stuck ? patient: no .
D2N181
7
[ "Vegetative History" ]
[ "Subjective" ]
in your throat and chest . all right . any difficulty with swallowing ? feels like food or liquids kinda get stuck ?
4,543
doctor: okay . that's good . any abdominal pain ? patient: no , not really .
D2N181
8
[ "Vegetative History" ]
[ "Subjective" ]
okay . that's good . any abdominal pain ?
4,544
doctor: nausea or vomiting , changes in bowel movements ? patient: no .
D2N181
9
[ "Vegetative History" ]
[ "Subjective" ]
nausea or vomiting , changes in bowel movements ?
4,545
doctor: constipation , diarrhea , rectal bleeding ? patient: nope .
D2N181
10
[ "Vegetative History" ]
[ "Subjective" ]
constipation , diarrhea , rectal bleeding ?
4,546
doctor: okay . very good . and how long have you had this problem ? patient: i've had acid reflux since i was around 12 , but it has gotten worse over the past few years .
D2N181
11
[ "Personal History" ]
[ "Subjective" ]
okay . very good . and how long have you had this problem ?
4,547
doctor: okay . and how long have you been on the omeprazole ? patient: on the way , it is now i think about a year .
D2N181
12
[ "Therapeutic History" ]
[ "Subjective" ]
okay . and how long have you been on the omeprazole ?
4,548
doctor: okay . do you find that it's done anything for you in the past ? patient: i mean , i can tell it's helped because some days , i'll be fine , and then some days , i eat something and it feels terrible .
D2N181
13
[ "Therapeutic History" ]
[ "Subjective" ]
okay . do you find that it's done anything for you in the past ?
4,549
doctor: are there any things that make your symptoms worse that you can pinpoint , like food choices or stress ? patient: sure . probably stress and food choices sometimes .
D2N181
14
[ "Vegetative History" ]
[ "Subjective" ]
are there any things that make your symptoms worse that you can pinpoint , like food choices or stress ?
4,550
doctor: okay . what things bother you ? patient: spicy foods , um , so i try not to eat them too often , but sometimes even drinking a soda can cause it .
D2N181
15
[ "Vegetative History" ]
[ "Subjective" ]
okay . what things bother you ?
4,551
doctor: we do know that caffeine and caffeinated beverages will do that , even sodas . um , even just the carbonation can cause that . how about tomato-based products or citrus products ? patient: yeah , sometimes , but i still eat them .
D2N181
16
[ "Vegetative History" ]
[ "Subjective" ]
we do know that caffeine and caffeinated beverages will do that , even sodas . um , even just the carbonation can cause that . how about tomato-based products or citrus products ?
4,552
doctor: okay . it's reassuring that you are n't having any difficulty swallowing , though . how's your weight been ? pretty stable ? patient: i'd say pretty stable , although i have n't had much of an appetite for the past two months . i have been under a lot of work stress .
D2N181
17
[ "Vegetative History" ]
[ "Subjective" ]
okay . it's reassuring that you are n't having any difficulty swallowing , though . how's your weight been ? pretty stable ?
4,553
doctor: what do you do for work ? patient: i'm a paralegal .
D2N181
18
[ "Other Socials" ]
[ "Subjective" ]
what do you do for work ?
4,554
doctor: okay . and any family history of gi issues ? patient: um , my grandmother had esophageal cancer .
D2N181
19
[ "Family History" ]
[ "Subjective" ]
okay . and any family history of gi issues ?
4,555
doctor: on your mom or dad's side ? patient: mom's side . and my mom had some issues like acid reflux , and she was taking some medication that coats the lining of your stomach .
D2N181
20
[ "Family History" ]
[ "Subjective" ]
on your mom or dad's side ?
4,556
doctor: okay . have you ever had an upper endoscopy ? patient: i think maybe when i was younger .
D2N181
21
[ "Personal History" ]
[ "Subjective" ]
okay . have you ever had an upper endoscopy ?
4,557
doctor: but not in the last 10 years ? patient: no .
D2N181
22
[ "Personal History" ]
[ "Subjective" ]
but not in the last 10 years ?
4,558
doctor: have you ever tried any medication other than omeprazole ? patient: um , at one point i was on omeprazole and ranititine -dine . it did help . but other than that , those are the only medications i have taken .
D2N181
23
[ "Therapeutic History" ]
[ "Subjective" ]
have you ever tried any medication other than omeprazole ?
4,559
doctor: okay . have a seat here , and let me listen to your heart and lungs , and then we can talk about a plan for you . patient: okay .
D2N181
24
[ "Physical Examination" ]
[ "Objective" ]
okay . have a seat here , and let me listen to your heart and lungs , and then we can talk about a plan for you .
4,560
doctor: so normal physical exam per my new patient template , except for well-healed abdominal surgical scars noted . what's the surgical scar here on your abdomen from ? patient: i always forget about that surgery . i had it when i was a baby . my mom said my intestines were twisted , so i had to have surgery when i w...
D2N181
25
[ "Physical Examination" ]
[ "Objective" ]
so normal physical exam per my new patient template , except for well-healed abdominal surgical scars noted . what's the surgical scar here on your abdomen from ?
4,561
doctor: hm , gotcha . okay . so let's talk about what you have going on . from what you've told me , it sounds like you've had a several-year history of gerd , which is the medical term for acid reflux . and recently your symptoms have been poorly controlled with the omeprazole , 40 milligrams twice daily . you've been...
D2N181
26
[ "Discussion", "Personal History", "Medication", "Reassessment" ]
[ "Subjective", "Assessment", "Plan" ]
hm , gotcha . okay . so let's talk about what you have going on . from what you've told me , it sounds like you've had a several-year history of gerd , which is the medical term for acid reflux . and recently your symptoms have been poorly controlled with the omeprazole , 40 milligrams twice daily . you've been having ...
4,562
doctor: and you've identified trigger foods like spicy foods , carbonated bev- beverages , citrus , and tomato-based foods , but you have n't cut these foods out of your diet completely yet . so the first thing i'd try is changing your diet because these foods can exacerbate your gerd , even though you're taking the pp...
D2N181
27
[ "Other Treatments", "Reassessment" ]
[ "Assessment", "Plan" ]
and you've identified trigger foods like spicy foods , carbonated bev- beverages , citrus , and tomato-based foods , but you have n't cut these foods out of your diet completely yet . so the first thing i'd try is changing your diet because these foods can exacerbate your gerd , even though you're taking the ppi .
4,563
doctor: great . so stress is another trigger that we need to address . high stress can cause worsening of your symptoms . patient: yeah , stress and anxiety are definitely big problems for me .
D2N181
28
[ "Discussion" ]
[ "Plan" ]
great . so stress is another trigger that we need to address . high stress can cause worsening of your symptoms .
4,564
doctor: so working on that may help with your gerd . additionally , we can consider trying a different ppi since the only one you've tried up to this point is omeprazole . if you're okay with this , we can switch your omeprazole to nexium . patient: that's fine with me . i'm definitely open to trying whatever .
D2N181
29
[ "Discussion", "Medication" ]
[ "Plan" ]
so working on that may help with your gerd . additionally , we can consider trying a different ppi since the only one you've tried up to this point is omeprazole . if you're okay with this , we can switch your omeprazole to nexium .
4,565
doctor: perfect . i will send a prescription for nexium 40 milligrams twice daily to your pharmacy on file . i'll also recommend that you have a procedure called a egd , or upper endoscopy , to look for potential causes of the gerd . we'd sedate you and then pass a small camera through your mouth , down your throat , t...
D2N181
30
[ "Discussion", "Medication", "Diagnostic Testing" ]
[ "Plan" ]
perfect . i will send a prescription for nexium 40 milligrams twice daily to your pharmacy on file . i'll also recommend that you have a procedure called a egd , or upper endoscopy , to look for potential causes of the gerd . we'd sedate you and then pass a small camera through your mouth , down your throat , through y...
4,566
doctor: yeah . you can get scheduled at checkout desk . i'll have you follow up with me in the office for the egd so we can discuss the results and talk about how you're doing with the dietary , stress , and medication changes . how does all of that sound ? patient: that sounds good .
D2N181
31
[ "Follow-up" ]
[ "Plan" ]
yeah . you can get scheduled at checkout desk . i'll have you follow up with me in the office for the egd so we can discuss the results and talk about how you're doing with the dietary , stress , and medication changes . how does all of that sound ?
4,567
doctor: perfect . i will walk you to the checkout desk . be sure to call my office and let me know if anything changes or if you have problems before your egd and follow-up appointment . please insert the procedure paragraph in the plan . i suspect that she likely has gerd with underlying functional etiology as well . ...
D2N181
32
[ "Discussion", "Medication", "Diagnostic Testing", "Reassessment", "Vegetative History" ]
[ "Subjective", "Assessment", "Plan" ]
doctor: perfect . i will walk you to the checkout desk . be sure to call my office and let me know if anything changes or if you have problems before your egd and follow-up appointment . please insert the procedure paragraph in the plan . i suspect that she likely has gerd with underlying functional etiology as well . ...
4,568
doctor: . next patient is michelle king . date of birth : 05/07/1982 . please use toc template . she was admitted to district regional hospital on 06/29/2021 , and was discharged on 07/02/2021 . the patient is a 39-year-old female with history of quadriplegia due to , uh , prior spinal cord injury . she was experiencin...
D2N182
0
[ "Therapeutic History", "Personal History", "Greetings" ]
[ "Subjective" ]
. next patient is michelle king . date of birth : 05/07/1982 . please use toc template . she was admitted to district regional hospital on 06/29/2021 , and was discharged on 07/02/2021 . the patient is a 39-year-old female with history of quadriplegia due to , uh , prior spinal cord injury . she was experiencing increa...
4,569
doctor: i'm good , thanks . so , it looks like you had an infection , right ? patient: yeah . but you know , i really do n't think it was a uti .
D2N182
1
[ "Personal History" ]
[ "Subjective" ]
i'm good , thanks . so , it looks like you had an infection , right ?
4,570
doctor: it is , yeah . it listens to you and me and it does all of my documentation . it's pretty good stuff . um , tell me what's going on . patient: it is , in my humble opinion , that i was just constipated and that was what was causing my blood pressure to be so high . and i hardly pooped when i was there . then wh...
D2N182
3
[ "Personal History" ]
[ "Subjective" ]
it is , yeah . it listens to you and me and it does all of my documentation . it's pretty good stuff . um , tell me what's going on .
4,571
doctor: okay . um , and the white cell count was the only thing that i think they were kind of concerned about because it was a little high . patient: so i wondered if automatic dysreflexia can affect the white count ?
D2N182
4
[ "Personal History" ]
[ "Subjective" ]
okay . um , and the white cell count was the only thing that i think they were kind of concerned about because it was a little high .
4,572
doctor: typically , it does n't . patient: okay .
D2N182
5
[ "Discussion" ]
[ "Plan" ]
typically , it does n't .
4,573
doctor: but , i mean , when i looked at the urine cultures that they checked , the cultures are not very impressive . patient: yeah , that's what they said .
D2N182
6
[ "Personal History" ]
[ "Subjective" ]
but , i mean , when i looked at the urine cultures that they checked , the cultures are not very impressive .
4,574
doctor: and when i go back and look , sometimes your white count is just elevated a little bit , and last year it was normal , so ... patient: hm .
D2N182
7
[ "Personal History" ]
[ "Subjective" ]
and when i go back and look , sometimes your white count is just elevated a little bit , and last year it was normal , so ...
4,575
doctor: but in saying that , you know , inflammation can do that . so , yeah , you could be backed up and inflamed . patient: yeah .
D2N182
8
[ "Personal History" ]
[ "Subjective" ]
but in saying that , you know , inflammation can do that . so , yeah , you could be backed up and inflamed .
4,576
doctor: uh , they did n't do a ct scan , they just did an x-ray . but you feel like you're back to your normal self now ? patient: yeah . i mean , i went in because i knew my blood pressure was out of control .
D2N182
9
[ "Personal History" ]
[ "Subjective" ]
uh , they did n't do a ct scan , they just did an x-ray . but you feel like you're back to your normal self now ?
4,577
doctor: mm-hmm . patient: it was giving me a headache and making me throw up . and i know , at that point , i'm at the loss of what i can do at home .
D2N182
10
[ "Personal History" ]
[ "Subjective" ]
mm-hmm .
4,578
doctor: yeah , it was good that you went in . patient: so i went in and they made me feel better , and then i went home , as you know .
D2N182
11
[ "Chitchat" ]
[ "Null" ]
yeah , it was good that you went in .
4,579
doctor: well , maybe that's all it was . patient: yeah .
D2N182
12
[ "Chitchat" ]
[ "Null" ]
well , maybe that's all it was .
4,580
doctor: so you're doing good otherwise ? patient: yes , i am .
D2N182
13
[ "Acute Symptoms" ]
[ "Subjective" ]
so you're doing good otherwise ?
4,581
doctor: good . let me take a quick listen to you . patient: okay .
D2N182
14
[ "Physical Examination" ]
[ "Objective" ]
good . let me take a quick listen to you .
4,582
doctor: all right . go ahead and take a few deep breaths . and breathe normally . now take several deep breaths . and two more . okay , good . you can relax . any pain or discomfort anywhere ? patient: nope .
D2N182
15
[ "Physical Examination" ]
[ "Objective" ]
all right . go ahead and take a few deep breaths . and breathe normally . now take several deep breaths . and two more . okay , good . you can relax . any pain or discomfort anywhere ?
4,583
doctor: great . so here are my thoughts . patient: okay .
D2N182
16
[ "Chitchat" ]
[ "Null" ]
great . so here are my thoughts .
4,584
doctor: you may recall it was extremely hot during that period leading up to you going to the hospital . i do n't know if you were inside for the most part ? patient: yeah , it was pretty hot , was n't it ? and i go out a bit , but i do tend to stay in more when it's hot .
D2N182
17
[ "Personal History" ]
[ "Subjective" ]
you may recall it was extremely hot during that period leading up to you going to the hospital . i do n't know if you were inside for the most part ?
4,585
doctor: okay . well , if you do get dehydrated even just a little bit it can lead to further , um , or worsening constipation issues . patient: mm-hmm .
D2N182
18
[ "Discussion" ]
[ "Plan" ]
okay . well , if you do get dehydrated even just a little bit it can lead to further , um , or worsening constipation issues .
4,586
doctor: i've had a lot of patients over the last couple of weeks coming in with just weird stuff , and i blame that a little bit on how hot and humid it was the last two weeks of june . so what i would do is wait a couple of weeks and then , if you could , come back in and we could do some , uh , complete blood work , ...
D2N182
19
[ "Diagnostic Testing", "Follow-up", "Referral" ]
[ "Plan" ]
i've had a lot of patients over the last couple of weeks coming in with just weird stuff , and i blame that a little bit on how hot and humid it was the last two weeks of june . so what i would do is wait a couple of weeks and then , if you could , come back in and we could do some , uh , complete blood work , uh , inc...
4,587
doctor: and it should normalize , but it's too soon to do it now . um , but maybe if i put some labs in you could come in in two to three weeks ? patient: sure , i can do that .
D2N182
20
[ "Discussion", "Diagnostic Testing", "Follow-up" ]
[ "Plan" ]
and it should normalize , but it's too soon to do it now . um , but maybe if i put some labs in you could come in in two to three weeks ?
4,588
doctor: great . so that appointment will let us kill a bird ... two birds with one stone since you're due to get blood work anyways for cholesterol . patient: okay .
D2N182
21
[ "Discussion", "Diagnostic Testing", "Follow-up" ]
[ "Plan" ]
great . so that appointment will let us kill a bird ... two birds with one stone since you're due to get blood work anyways for cholesterol .
4,589
doctor: and then , i just wanted to make sure that the white count is okay , because if it remains elevated then that means there's something else going on with your bowels . patient: mm-hmm .
D2N182
22
[ "Discussion", "Diagnostic Testing" ]
[ "Plan" ]
and then , i just wanted to make sure that the white count is okay , because if it remains elevated then that means there's something else going on with your bowels .
4,590
doctor: i do n't think that's what we'll find , but we'll see . patient: i mean , i knew going in that i had n't had a regular bowel movement in a while , even though i drink the miralax every day .
D2N182
23
[ "Discussion" ]
[ "Plan" ]
i do n't think that's what we'll find , but we'll see .
4,591
doctor: have i ever given you lactulose ? it would be a medicine you use in , um , conjunction with miralax . sort of a rescue type thing . patient: is that the stuff that comes in a bottle ?
D2N182
25
[ "Discussion", "Medication" ]
[ "Plan" ]
have i ever given you lactulose ? it would be a medicine you use in , um , conjunction with miralax . sort of a rescue type thing .
4,592
doctor: got it . yeah , it can be a little rough , but it works . patient: yeah .
D2N182
27
[ "Discussion", "Medication" ]
[ "Plan" ]
got it . yeah , it can be a little rough , but it works .
4,593
doctor: all right . so we have our plan . any questions ? patient: yeah , well , i would like to talk to you about covid , if we can .
D2N182
28
[ "Discussion" ]
[ "Plan" ]
all right . so we have our plan . any questions ?
4,594
doctor: sure . so where are you at when it comes to the vaccine ? patient: i am unvaccinated .
D2N182
29
[ "Therapeutic History" ]
[ "Subjective" ]
sure . so where are you at when it comes to the vaccine ?
4,595
doctor: so what are your concerns about the vaccine ? patient: well , we do n't know the side effects .
D2N182
30
[ "Discussion", "Medication" ]
[ "Plan" ]
so what are your concerns about the vaccine ?
4,596
doctor: correct , we do n't . patient: it's too soon to tell the side effects , and i'm hearing more and more reports of people getting what's now termed as " vaccine injury " .
D2N182
31
[ "Discussion", "Medication" ]
[ "Plan" ]
correct , we do n't .
4,597
doctor: right . patient: which i had never heard of before . i do n't know if it is a new term or not , but my take on the whole thing is that i'm young and healthy enough to beat it , even if my respiratory is limited . i also take a lot of vitamin c.
D2N182
32
[ "Discussion", "Medication" ]
[ "Plan" ]
right .
4,598
doctor: well , my thoughts are that you actually should be vaccinated . i think you are high risk . if you get covid it's not going to be good for you . patient: okay .
D2N182
34
[ "Discussion", "Medication" ]
[ "Plan" ]
well , my thoughts are that you actually should be vaccinated . i think you are high risk . if you get covid it's not going to be good for you .
4,599