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|---|---|---|---|---|---|---|
doctor: um i do n't think i ordered it but i could . your last a1c was 5.5 in march . patient: all righty . | D2N025 | 17 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | um i do n't think i ordered it but i could . your last a1c was 5.5 in march . | 700 |
doctor: so your blood sugar is a little bit high , it was 169 today but that kind of depends on what you ate and you were n't fasting for the blood check so i might have to repeat that test for pre-op , but i do n't think we need to do it today . patient: all righty that sounds good . | D2N025 | 18 | [
"Lab Examination"
] | [
"Objective"
] | so your blood sugar is a little bit high , it was 169 today but that kind of depends on what you ate and you were n't fasting for the blood check so i might have to repeat that test for pre-op , but i do n't think we need to do it today . | 701 |
doctor: i checked your magnesium level because sometimes you uh urinate out magnesium with the water pills but it was normal at 1.7 and your blood pressure is also looking good . patient: okay great . that all sounds awesome . | D2N025 | 19 | [
"Lab Examination"
] | [
"Objective"
] | i checked your magnesium level because sometimes you uh urinate out magnesium with the water pills but it was normal at 1.7 and your blood pressure is also looking good . | 702 |
doctor: all right let's take a quick listen . use my general physical exam template . and take a couple of deep breaths for me . your lungs sound pretty good to me so keep doing what you're doing . um uh , like i said , i think you're doing good overall but let's just talk about a few things . patient: all righty . | D2N025 | 20 | [
"Physical Examination"
] | [
"Objective"
] | all right let's take a quick listen . use my general physical exam template . and take a couple of deep breaths for me . your lungs sound pretty good to me so keep doing what you're doing . um uh , like i said , i think you're doing good overall but let's just talk about a few things . | 703 |
doctor: so we often like to keep people with heart problems on magnesium and get their levels up to around the 2-ish range . yours is a little bit less than 2 and we want that 2-ish range because it can help stabilize the heart muscle . so i might recommend putting you on magnesium supplement . it's supposed to be twic... | D2N025 | 21 | [
"Other Treatments"
] | [
"Plan"
] | so we often like to keep people with heart problems on magnesium and get their levels up to around the 2-ish range . yours is a little bit less than 2 and we want that 2-ish range because it can help stabilize the heart muscle . so i might recommend putting you on magnesium supplement . it's supposed to be twice a day ... | 704 |
doctor: great . now before surgery we'll have to get you off your clopidogrel for a week beforehand . patient: yes , okay , i have everything written down on my phone , and i have a letter taped to the side of my bed to remind me . | D2N025 | 22 | [
"Discussion",
"Medication"
] | [
"Plan"
] | great . now before surgery we'll have to get you off your clopidogrel for a week beforehand . | 705 |
doctor: perfect ! we will give you a reminder as well . we will also need to complete a pre-op check within two weeks of your surgery during the first or second week of june . patient: okay , i'll put that down . | D2N025 | 23 | [
"Follow-up"
] | [
"Plan"
] | perfect ! we will give you a reminder as well . we will also need to complete a pre-op check within two weeks of your surgery during the first or second week of june . | 706 |
doctor: you might also have to repeat an ekg before surgery which we could do today . i know i'm sure it feels like you're doing , you're always doing ekgs . um we do n't need to any x-rays of your chest because you had one recently , and we do n't need any more blood work because we did that today . patient: yeah , i ... | D2N025 | 24 | [
"Diagnostic Testing"
] | [
"Plan"
] | you might also have to repeat an ekg before surgery which we could do today . i know i'm sure it feels like you're doing , you're always doing ekgs . um we do n't need to any x-rays of your chest because you had one recently , and we do n't need any more blood work because we did that today . | 707 |
doctor: lastly , once we get your knee surgery , um we , we should think about getting you a colonoscopy . we can do it here locally because you have medicare . do you have private insurance also ? patient: yeah , i have both . | D2N025 | 25 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | lastly , once we get your knee surgery , um we , we should think about getting you a colonoscopy . we can do it here locally because you have medicare . do you have private insurance also ? | 708 |
doctor: okay so yes , you can get it , your colonoscopy , wherever you'd like . patient: okay , well my husband's insurance may be running out . might we be able to get the procedure done sooner ? maybe in the next 30 days ? is that okay ? | D2N025 | 26 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | okay so yes , you can get it , your colonoscopy , wherever you'd like . | 709 |
doctor: um i can put it in right now for , uh , for county for the next 30 days , and they might be able to get you in within the next few weeks . it should not take , it should not make you ineligible for the surgery . in other words completing a colonoscopy would not delay your surgery . patient: okay , good . | D2N025 | 27 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | um i can put it in right now for , uh , for county for the next 30 days , and they might be able to get you in within the next few weeks . it should not take , it should not make you ineligible for the surgery . in other words completing a colonoscopy would not delay your surgery . | 710 |
doctor: so let me see . i've been doing one of two things at every one , and everyone is great so it depends more on timing availability of their or for the colonoscopy . we can send you to dr. martin for the surgery who is at county surgical services down here or the other option is valley medical , and they do it at ... | D2N025 | 28 | [
"Discussion",
"Diagnostic Testing",
"Referral",
"Other Treatments"
] | [
"Plan"
] | so let me see . i've been doing one of two things at every one , and everyone is great so it depends more on timing availability of their or for the colonoscopy . we can send you to dr. martin for the surgery who is at county surgical services down here or the other option is valley medical , and they do it at springfi... | 711 |
doctor: i think either direction they're good technicians of the colon . patient: okay , yeah whatever you can get me in , that works great . | D2N025 | 29 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | i think either direction they're good technicians of the colon . | 712 |
doctor: so i'll call around . now if you get that done and they tell you 10 years then you'll be good to go . patient: great , thank you . | D2N025 | 30 | [
"Chitchat"
] | [
"Null"
] | so i'll call around . now if you get that done and they tell you 10 years then you'll be good to go . | 713 |
doctor: you're welcome . have a great day . let us know if you need anything else , okay ? patient: sounds good . | D2N025 | 31 | [
"Chitchat"
] | [
"Null"
] | you're welcome . have a great day . let us know if you need anything else , okay ? | 714 |
doctor: all right , assessment and plan . chronic chf . mixed presentation . had a exacerbation of cf , chf earlier in the spring . we switched her from a furosemide to torsemide and symptomatically she is doing a lot better . she's about 3 , 3 and a half pounds down in weight . breathing is non-labored . going to repe... | D2N025 | 32 | [
"Family History",
"Medication",
"Diagnostic Testing",
"Reassessment"
] | [
"Subjective",
"Assessment",
"Plan"
] | doctor: all right , assessment and plan . chronic chf . mixed presentation . had a exacerbation of cf , chf earlier in the spring . we switched her from a furosemide to torsemide and symptomatically she is doing a lot better . she's about 3 , 3 and a half pounds down in weight . breathing is non-labored . going to repe... | 715 |
doctor: dictating on donald clark . date of birth , 03/04/1937 . chief complaint is left arm pain . hello , how are you ? patient: good morning . | D2N026 | 0 | [
"Greetings",
"Acute Symptoms"
] | [
"Subjective"
] | dictating on donald clark . date of birth , 03/04/1937 . chief complaint is left arm pain . hello , how are you ? | 716 |
doctor: it's nice to meet you . i'm dr. miller . patient: it's nice to meet you as well . | D2N026 | 1 | [
"Chitchat"
] | [
"Null"
] | it's nice to meet you . i'm dr. miller . | 717 |
doctor: so , i hear you are having pain this arm . is that correct ? patient: that's correct . | D2N026 | 2 | [
"Acute Symptoms"
] | [
"Subjective"
] | so , i hear you are having pain this arm . is that correct ? | 718 |
doctor: okay . and it seems like it's worse at night ? patient: well , right now the hand is . | D2N026 | 3 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay . and it seems like it's worse at night ? | 719 |
doctor: mm-hmm . patient: and the thing started about two weeks ago . i woke up about two o'clock in the morning and it was just hurting something awful . | D2N026 | 4 | [
"Acute Symptoms"
] | [
"Subjective"
] | mm-hmm . | 720 |
doctor: okay , that's good . patient: so i got up , i sat on the side of the bed and held my arm down , thinking it would , like , help the circulation , but it did n't . | D2N026 | 6 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay , that's good . | 721 |
doctor: okay , i see . patient: and so , after a while , when it eased off , maybe about four , five am , i laid back down and it did n't start up again . | D2N026 | 7 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay , i see . | 722 |
doctor: mm-hmm , okay . patient: um . i went back to sleep but for several nights this happened , like , over and over . so , i finally went to see the doctor , and i do n't really recall her name . | D2N026 | 8 | [
"Acute Symptoms"
] | [
"Subjective"
] | mm-hmm , okay . | 723 |
doctor: okay . yeah , i think i know who you're talking about , though . patient: um , she's the one who sent me to you , so , i , i would , i would think so . but when i went to her after the third time it happened and she checked me out , she said it was most likely coming from a pinched nerve . | D2N026 | 9 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay . yeah , i think i know who you're talking about , though . | 724 |
doctor: probably . uh , do you notice that moving your neck or turning your head seems to bother your arm ? patient: uh , no . | D2N026 | 10 | [
"Acute Symptoms"
] | [
"Subjective"
] | probably . uh , do you notice that moving your neck or turning your head seems to bother your arm ? | 725 |
doctor: okay . is moving your shoulder uncomfortable at all ? patient: no . | D2N026 | 11 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay . is moving your shoulder uncomfortable at all ? | 726 |
doctor: and do you notice it at other times besides during the night ? patient: um , some days . if it bothers me at night , then the day following , it usually will bother me some . | D2N026 | 12 | [
"Acute Symptoms"
] | [
"Subjective"
] | and do you notice it at other times besides during the night ? | 727 |
doctor: okay . and do you just notice it in the hand , or does it seem to be going down the whole arm ? patient: well , it starts there and goes all the way down the arm . | D2N026 | 13 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay . and do you just notice it in the hand , or does it seem to be going down the whole arm ? | 728 |
doctor: okay . have you noticed any weakness in your hand at all ? patient: uh , yes . | D2N026 | 14 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay . have you noticed any weakness in your hand at all ? | 729 |
doctor: okay . like , in terms of gripping things ? patient: yeah . | D2N026 | 15 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay . like , in terms of gripping things ? | 730 |
doctor: really ? patient: yeah . it does n't work properly . or , it works very rarely . | D2N026 | 17 | [
"Acute Symptoms"
] | [
"Subjective"
] | really ? | 731 |
doctor: gotcha . and did i hear that she gave you some prednisone and some oral steroids , or ? patient: uh , well , she gave me some numbing medicine . it helped a little bit . the other two were a neck pill and gabapentin . uh , you should have my full list in your notes , though . since then it has n't really bother... | D2N026 | 18 | [
"Therapeutic History"
] | [
"Subjective"
] | gotcha . and did i hear that she gave you some prednisone and some oral steroids , or ? | 732 |
doctor: okay . is it neuropathy ? patient: uh , yep . | D2N026 | 19 | [
"Therapeutic History"
] | [
"Subjective"
] | okay . is it neuropathy ? | 733 |
doctor: gotcha . that is good to know . all right , well , let's go ahead and take a look . patient: okay . | D2N026 | 20 | [
"Therapeutic History"
] | [
"Subjective"
] | gotcha . that is good to know . all right , well , let's go ahead and take a look . | 734 |
doctor: all right . so , to start , i'm gon na have you do something for me . uh , just go ahead and tilt your chin as far as you can down to your chest . okay , good . and now , go the other way , tilting your chin up as far as you can . now , does that seem to bother you at all ? okay . and now , come back to normal ... | D2N026 | 21 | [
"Physical Examination"
] | [
"Objective"
] | all right . so , to start , i'm gon na have you do something for me . uh , just go ahead and tilt your chin as far as you can down to your chest . okay , good . and now , go the other way , tilting your chin up as far as you can . now , does that seem to bother you at all ? okay . and now , come back to normal , just l... | 735 |
doctor: okay . so , you feel it in the neck a little bit ? patient: yeah , just a little strain . | D2N026 | 22 | [
"Physical Examination"
] | [
"Objective"
] | okay . so , you feel it in the neck a little bit ? | 736 |
doctor: okay . uh , now squeeze my fingers as hard as you can with both hands . great . now , hold your arms like this . patient: okay . | D2N026 | 23 | [
"Physical Examination"
] | [
"Objective"
] | okay . uh , now squeeze my fingers as hard as you can with both hands . great . now , hold your arms like this . | 737 |
doctor: and i'm going to try to strain your arms and try to keep them as stiff as you can . do n't let me strain it . okay , good . good . now , when i , i'm just touching your hands like this . does it seem to feel about the same in both hands ? patient: uh , yes . | D2N026 | 24 | [
"Physical Examination"
] | [
"Objective"
] | and i'm going to try to strain your arms and try to keep them as stiff as you can . do n't let me strain it . okay , good . good . now , when i , i'm just touching your hands like this . does it seem to feel about the same in both hands ? | 738 |
doctor: okay . all right . so , i do agree with betty . uh , more than likely , this seems like it would be coming from your neck . that's the most common reason that causes what , what you're experiencing . and i looked at an x-ray of your neck , and you do seem to have a lot of arthritis there , and there does seem t... | D2N026 | 25 | [
"Radiology Examination",
"Acute Assessment"
] | [
"Objective",
"Assessment"
] | okay . all right . so , i do agree with betty . uh , more than likely , this seems like it would be coming from your neck . that's the most common reason that causes what , what you're experiencing . and i looked at an x-ray of your neck , and you do seem to have a lot of arthritis there , and there does seem to be pot... | 739 |
doctor: so , gabapentin can help a little bit with the nerve pain , and what i would like to do is potentially set you up for an epidural . and what that is is it , it's a focused anti-inflammatory medicine , excuse me , that works behind the nerve roops that , nerve roots that we are thinking might be getting squished... | D2N026 | 26 | [
"Medication",
"Diagnostic Testing"
] | [
"Plan"
] | so , gabapentin can help a little bit with the nerve pain , and what i would like to do is potentially set you up for an epidural . and what that is is it , it's a focused anti-inflammatory medicine , excuse me , that works behind the nerve roops that , nerve roots that we are thinking might be getting squished off . i... | 740 |
doctor: okay , good . and just to confirm , do you take any blood thinners ? i do n't think i saw any on your medicine list . patient: uh , no , i do n't . | D2N026 | 27 | [
"Therapeutic History"
] | [
"Subjective"
] | okay , good . and just to confirm , do you take any blood thinners ? i do n't think i saw any on your medicine list . | 741 |
doctor: okay , good . and what i would have you do is continue with the gabapentin . um , are you taking 300 or 100 ? patient: um , not sure . my lady friend helps me handle this stuff . | D2N026 | 28 | [
"Medication",
"Therapeutic History"
] | [
"Subjective",
"Plan"
] | okay , good . and what i would have you do is continue with the gabapentin . um , are you taking 300 or 100 ? | 742 |
doctor: okay . um , so whatever you are doing you can just keep doing it , and i'm going to set you up for the epidural and imaging study , um , just so i know right where to put the medicine . and i will follow up with you after s- um , that's in . we can do the shot , just to make sure your arm is feeling better . so... | D2N026 | 30 | [
"Discussion",
"Medication",
"Diagnostic Testing",
"Follow-up"
] | [
"Plan"
] | okay . um , so whatever you are doing you can just keep doing it , and i'm going to set you up for the epidural and imaging study , um , just so i know right where to put the medicine . and i will follow up with you after s- um , that's in . we can do the shot , just to make sure your arm is feeling better . sound good... | 743 |
doctor: okay . s- um , so , presumably what's happening , then , is when you're sleeping your neck is kind of gets off-tilt , uh , kilter , and it compresses the nerve roots there . now , if you think you're doing fine , we could hold off , but at the very la- least , i'd like to update that mri of yours and see what's... | D2N026 | 31 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | okay . s- um , so , presumably what's happening , then , is when you're sleeping your neck is kind of gets off-tilt , uh , kilter , and it compresses the nerve roots there . now , if you think you're doing fine , we could hold off , but at the very la- least , i'd like to update that mri of yours and see what's going o... | 744 |
doctor: okay . all right . well , do you want to do that work-up and do the epidural , or do you think you're doing fine and you want to wait ? patient: well , my hand is still bothering me . | D2N026 | 32 | [
"Discussion"
] | [
"Plan"
] | okay . all right . well , do you want to do that work-up and do the epidural , or do you think you're doing fine and you want to wait ? | 745 |
doctor: okay . so , you're saying your neck is not bothering you but the hand is . okay . so then , let's just stick with the plan . mri of the neck , so we can see where the nerve roots may be compressed , that's giving your hand the issue . and then , we're going to set you up with the epidural . patient: okay . soun... | D2N026 | 33 | [
"Discussion",
"Medication",
"Diagnostic Testing"
] | [
"Plan"
] | okay . so , you're saying your neck is not bothering you but the hand is . okay . so then , let's just stick with the plan . mri of the neck , so we can see where the nerve roots may be compressed , that's giving your hand the issue . and then , we're going to set you up with the epidural . | 746 |
doctor: all right . so , keep going with the gabapentin . i will order the imaging of your neck , and the shot will hopefully help some with those symptoms in your hand , and then we'll follow up afterwards . patient: all right . is the mri today ? | D2N026 | 34 | [
"Discussion",
"Medication",
"Diagnostic Testing"
] | [
"Plan"
] | all right . so , keep going with the gabapentin . i will order the imaging of your neck , and the shot will hopefully help some with those symptoms in your hand , and then we'll follow up afterwards . | 747 |
doctor: um , you probably ca n't do it today , but let me talk with roy and see how soon we can get it done . just give me a quick minute , and then roy will come in and get things scheduled as soon as we can . patient: all right . | D2N026 | 35 | [
"Chitchat"
] | [
"Null"
] | um , you probably ca n't do it today , but let me talk with roy and see how soon we can get it done . just give me a quick minute , and then roy will come in and get things scheduled as soon as we can . | 748 |
doctor: all right . well , it was nice meeting you , my friend . patient: you as well . thank you . | D2N026 | 36 | [
"Chitchat"
] | [
"Null"
] | all right . well , it was nice meeting you , my friend . | 749 |
doctor: physical exam , elderly white gentleman presents in a wheelchair . no apparent distress . per the template , down through neuro- neurologic . one plus bilateral biceps . triceps brachioradialis . reflexes bilateral all negative . follow up and take out the lower extremities . gait not assessed today . strength ... | D2N026 | 37 | [
"Acute Symptoms",
"Physical Examination",
"Personal History",
"Therapeutic History",
"Medication",
"Follow-up",
"Diagnostic Testing",
"Other Treatments"
] | [
"Subjective",
"Objective",
"Assessment",
"Plan"
] | doctor: physical exam , elderly white gentleman presents in a wheelchair . no apparent distress . per the template , down through neuro- neurologic . one plus bilateral biceps . triceps brachioradialis . reflexes bilateral all negative . follow up and take out the lower extremities . gait not assessed today . strength ... | 750 |
doctor: eugene walker , n- date of birth 4/14/1960 . he's a 61-year-old male who presents today , uh , for a routine follow-up with chronic medical conditions . of note , the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 1/22/2013 . regarding his blood work from 4/10/2021 , the p... | D2N027 | 0 | [
"Personal History",
"Greetings"
] | [
"Subjective"
] | eugene walker , n- date of birth 4/14/1960 . he's a 61-year-old male who presents today , uh , for a routine follow-up with chronic medical conditions . of note , the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 1/22/2013 . regarding his blood work from 4/10/2021 , the patient's... | 751 |
doctor: sure . go right ahead . patient: uh , well , i'm having more fatigue , but i do n't know if it's age or if it's just , you know , drained at the end of the day . but i still ride my bike . i ca n't go as fast as i used to . i'm still riding , and , you know , after a long bike ride , i'll sit down and then boom... | D2N027 | 1 | [
"Personal History"
] | [
"Subjective"
] | sure . go right ahead . | 752 |
doctor: yeah . what's a long bike ride to you ? patient: uh , 20 to 30 miles . | D2N027 | 2 | [
"Personal History"
] | [
"Subjective"
] | yeah . what's a long bike ride to you ? | 753 |
doctor: 20 to 30 miles on a road bike ? patient: yeah , road bike . i think it's a time thing . if i had more time , i would try to do my 40 miles , but i have n't done that . obviously , we're too early in the season so my typical ride is , like , 20 , 30 . in years back , i could do 40 on a good day . i can still do ... | D2N027 | 3 | [
"Personal History"
] | [
"Subjective"
] | 20 to 30 miles on a road bike ? | 754 |
doctor: yeah , i understand . patient: and tyler's my buddy . he's always nice and waits for me , but i used to be able to beat him . but now , he waits for me all the time . he's older than me and it- it kills me . | D2N027 | 4 | [
"Personal History"
] | [
"Subjective"
] | yeah , i understand . | 755 |
doctor: yeah , i can imagine that would upset me too . patient: well , the last time , you know , you found a heart thing , then . just making sure that the valve is holding out , you know ? | D2N027 | 5 | [
"Chitchat"
] | [
"Null"
] | yeah , i can imagine that would upset me too . | 756 |
doctor: right . so , when was your last stress test ? patient: it was september 9th , 2019 , because i'm eight years out from surgery , and back then , they said , you know , it's going to last eight years . and i'm at that year , so i just want to make sure . i asked dr. lewis for an echocardiogram to see how i'm doin... | D2N027 | 6 | [
"Personal History"
] | [
"Subjective"
] | right . so , when was your last stress test ? | 757 |
doctor: okay , good . do you still go down to hopkins at all ? patient: no , not at all . i just get follow-ups intermittently , here . going there is just ... it's too much stress . | D2N027 | 8 | [
"Personal History"
] | [
"Subjective"
] | okay , good . do you still go down to hopkins at all ? | 758 |
doctor: okay . is there any wheezing associated with that ? patient: no , no wheezing . | D2N027 | 10 | [
"Personal History"
] | [
"Subjective"
] | okay . is there any wheezing associated with that ? | 759 |
doctor: and you're able to bike 30 miles and mostly keep up with your friend , tyler , correct ? patient: yeah . the only other thing i want to mention is it's not like i do routine testicular exams , but i know i have this little nodule on my right testicle . | D2N027 | 11 | [
"Personal History"
] | [
"Subjective"
] | and you're able to bike 30 miles and mostly keep up with your friend , tyler , correct ? | 760 |
doctor: on the testicle or the epididymis ? patient: epididymis . uh , i really do n't know . i'm not super concerned . i read a little online . just wanted to ask you . | D2N027 | 12 | [
"Personal History"
] | [
"Subjective"
] | on the testicle or the epididymis ? | 761 |
doctor: and did you have a vasectomy ? patient: no . let me pull my notes out and make sure i mentioned everything i wanted to tell you . those were the only things and it's not like my tiredness is depression or anything . i'm a pretty happy guy overall , you know ? i just know you would ask those questions . | D2N027 | 13 | [
"Personal History"
] | [
"Subjective"
] | and did you have a vasectomy ? | 762 |
doctor: what time are you going to sleep , and about how many hours do you sleep a night ? patient: um , it varies . usually , i get six to seven hours of sleep . i get out of bed some days to be at work by 7:00 , lecture , and i try to work out in the morning . i- i do n't ... i'm not ... i'm not always successful , a... | D2N027 | 14 | [
"Personal History"
] | [
"Subjective"
] | what time are you going to sleep , and about how many hours do you sleep a night ? | 763 |
doctor: okay , so you're getting six to seven hours of sleep , and has your wife ever mentioned if you snore or stop breathing at any time ? patient: i believe i snore a little bit , but she's never said anything about me not breathing . | D2N027 | 15 | [
"Vegetative History"
] | [
"Subjective"
] | okay , so you're getting six to seven hours of sleep , and has your wife ever mentioned if you snore or stop breathing at any time ? | 764 |
doctor: okay . so , you're currently taking vitamin d3 , around 5000 units on sundays , and two thous ... or 50,000 units on sundays , excuse me , and 2000s on the other six days , and then clindamycin prior to dental procedures , correct ? patient: yeah , that's right . | D2N027 | 16 | [
"Therapeutic History"
] | [
"Subjective"
] | okay . so , you're currently taking vitamin d3 , around 5000 units on sundays , and two thous ... or 50,000 units on sundays , excuse me , and 2000s on the other six days , and then clindamycin prior to dental procedures , correct ? | 765 |
doctor: have you had a covid-19 shot yet ? patient: i've received both . my first dose on january 15th , '21 and my second on february 5th , '21 . | D2N027 | 17 | [
"Therapeutic History",
"Personal History"
] | [
"Subjective"
] | have you had a covid-19 shot yet ? | 766 |
doctor: good . if you'd hop up here on the table , we're just going to do a physical exam . well , mr. walker , overall you're doing well . i'm going to order an echocardiogram and a stress test . i also recommend that you follow up with cardiology , i think dr. vincent sanchez would be a great fit for you . patient: a... | D2N027 | 18 | [
"Physical Examination",
"Diagnostic Testing",
"Acute Assessment",
"Referral"
] | [
"Objective",
"Assessment",
"Plan"
] | good . if you'd hop up here on the table , we're just going to do a physical exam . well , mr. walker , overall you're doing well . i'm going to order an echocardiogram and a stress test . i also recommend that you follow up with cardiology , i think dr. vincent sanchez would be a great fit for you . | 767 |
doctor: also your recent labs showed an elevated alkaline phosphatase level at 156 . now this could be related to your liver but most likely related to your bone health . we're going to check a few labs today . patient: you're going to have them done today ? | D2N027 | 19 | [
"Lab Examination"
] | [
"Objective"
] | also your recent labs showed an elevated alkaline phosphatase level at 156 . now this could be related to your liver but most likely related to your bone health . we're going to check a few labs today . | 768 |
doctor: yes , sir , and we will send the results through your patient portal unless something is way off then we'll give you a call . patient: sounds good . | D2N027 | 20 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | yes , sir , and we will send the results through your patient portal unless something is way off then we'll give you a call . | 769 |
doctor: now as far as your breathing , i observed the pursed lip breathing and your exhalation is low . i think you should do a pulmonary function test to further evaluate , and i'll order that as well . now the nodule in your right testicle should be evaluated by urology , and we will place that referral today , also ... | D2N027 | 21 | [
"Diagnostic Testing",
"Referral"
] | [
"Plan"
] | now as far as your breathing , i observed the pursed lip breathing and your exhalation is low . i think you should do a pulmonary function test to further evaluate , and i'll order that as well . now the nodule in your right testicle should be evaluated by urology , and we will place that referral today , also . | 770 |
doctor: yes , sir . now you are due for your mmr and i'm recommend you get the shingles vaccine as well . you have completed your covid-19 , so that's good . now i'm going to have , uh ... have you return in about a year for your wellness visit . we'll see you back sooner if needed after i review all those labs and tho... | D2N027 | 22 | [
"Discussion",
"Diagnostic Testing",
"Follow-up",
"Medication"
] | [
"Plan"
] | yes , sir . now you are due for your mmr and i'm recommend you get the shingles vaccine as well . you have completed your covid-19 , so that's good . now i'm going to have , uh ... have you return in about a year for your wellness visit . we'll see you back sooner if needed after i review all those labs and those other... | 771 |
doctor: great . okay , the nurse will , uh , be back in a minute to give you mmr today , and the front desk will line up a time to do the shingles vaccine next month . patient: thanks , doc . have a great day . | D2N027 | 23 | [
"Diagnostic Testing",
"Follow-up",
"Medication"
] | [
"Plan"
] | great . okay , the nurse will , uh , be back in a minute to give you mmr today , and the front desk will line up a time to do the shingles vaccine next month . | 772 |
doctor: all right , i used my general physical exam template for respiratory notate : pursed lip breathing , low exhalation phase , clear to oscillation , no wheezing . uh , genitalia notate : right testicle with two to three millimeters palpable nodule does not feel as if it will ... does not feel as if with the epidi... | D2N027 | 24 | [
"Reassessment",
"Physical Examination",
"Diagnostic Testing",
"Follow-up",
"Personal History",
"Referral",
"Medication"
] | [
"Subjective",
"Objective",
"Assessment",
"Plan"
] | doctor: all right , i used my general physical exam template for respiratory notate : pursed lip breathing , low exhalation phase , clear to oscillation , no wheezing . uh , genitalia notate : right testicle with two to three millimeters palpable nodule does not feel as if it will ... does not feel as if with the epidi... | 773 |
doctor: patrick allen . date of birth : 7/7/1977 . new patient visit . past medical history includes gerd , anxiety , depression . here for chronic abdominal pain . he had an abdominal ct on 1/23/2020 . impression is a normal ct of the ab- abdomen . hello , are you mr. allen ? patient: yes , i am . | D2N028 | 0 | [
"Acute Symptoms",
"Personal History",
"Greetings"
] | [
"Subjective"
] | patrick allen . date of birth : 7/7/1977 . new patient visit . past medical history includes gerd , anxiety , depression . here for chronic abdominal pain . he had an abdominal ct on 1/23/2020 . impression is a normal ct of the ab- abdomen . hello , are you mr. allen ? | 774 |
doctor: hi . my name is dr. edwards . nice to meet you . patient: nice to meet you . | D2N028 | 1 | [
"Chitchat"
] | [
"Null"
] | hi . my name is dr. edwards . nice to meet you . | 775 |
doctor: welcome to the gi specialty clinic . patient: thank you . | D2N028 | 2 | [
"Chitchat"
] | [
"Null"
] | welcome to the gi specialty clinic . | 776 |
doctor: did you have any problems finding us ? patient: no , i've been here with my sister once before . | D2N028 | 3 | [
"Chitchat"
] | [
"Null"
] | did you have any problems finding us ? | 777 |
doctor: good . so how can i help you today ? uh , the referral i have is for abdominal pain and diarrhea . patient: right . so i've had ... i've been having this pain right here in my stomach , like right around here . | D2N028 | 4 | [
"Acute Symptoms"
] | [
"Subjective"
] | good . so how can i help you today ? uh , the referral i have is for abdominal pain and diarrhea . | 778 |
doctor: so in the area of your mid abdomen , just below the belly button ? patient: correct . i've had the pain on and off for about two years . i finally went to the er and a ... a few months ago and they did a ct scan . | D2N028 | 5 | [
"Acute Symptoms"
] | [
"Subjective"
] | so in the area of your mid abdomen , just below the belly button ? | 779 |
doctor: i saw that . patient: yeah . they said they did n't really see anything on the scan . | D2N028 | 6 | [
"Acute Symptoms"
] | [
"Subjective"
] | i saw that . | 780 |
doctor: yes , i agree . it looked normal . patient: the problem is i'm either constipated or have explosive diarrhea . | D2N028 | 7 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | yes , i agree . it looked normal . | 781 |
doctor: is the pain there all the time ? patient: it's a nagging feeling and it just depends . sometimes it bothers me , sometimes it does n't . | D2N028 | 8 | [
"Acute Symptoms"
] | [
"Subjective"
] | is the pain there all the time ? | 782 |
doctor: has this been the case over the past two years as well ? patient: more recently in the past couple months , at least with the constipation and diarrhea . | D2N028 | 9 | [
"Acute Symptoms",
"Personal History"
] | [
"Subjective"
] | has this been the case over the past two years as well ? | 783 |
doctor: and before that , how are your bowel movements ? patient: they were normal . | D2N028 | 10 | [
"Personal History",
"Vegetative History"
] | [
"Subjective"
] | and before that , how are your bowel movements ? | 784 |
doctor: uh , okay . so any blood in your stool ? patient: nope . | D2N028 | 11 | [
"Vegetative History"
] | [
"Subjective"
] | uh , okay . so any blood in your stool ? | 785 |
doctor: do you feel like you have more constipation or diarrhea ? patient: probably more constipation . | D2N028 | 12 | [
"Vegetative History"
] | [
"Subjective"
] | do you feel like you have more constipation or diarrhea ? | 786 |
doctor: okay , so when you're constipated , do you not have a bowel movement or is the stool hard ? patient: i usually do n't go , but when i do , it's hard . | D2N028 | 13 | [
"Vegetative History"
] | [
"Subjective"
] | okay , so when you're constipated , do you not have a bowel movement or is the stool hard ? | 787 |
doctor: and how often do you have a bowel movement when you are constipated ? patient: about three to four times a week . it's like when i need to go to the bathroom , if i can massage it , it feels like it's moving some and i can eventually go . | D2N028 | 14 | [
"Personal History",
"Vegetative History"
] | [
"Subjective"
] | and how often do you have a bowel movement when you are constipated ? | 788 |
doctor: okay . and when you have a bowel movement , does the pain change ? patient: yeah , it gets a little better . | D2N028 | 15 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | okay . and when you have a bowel movement , does the pain change ? | 789 |
doctor: and are you eating and drinking okay ? any nausea or vomiting , heartburn or indigestion ? patient: none of that . | D2N028 | 16 | [
"Vegetative History"
] | [
"Subjective"
] | and are you eating and drinking okay ? any nausea or vomiting , heartburn or indigestion ? | 790 |
doctor: okay . so tell me about the diarrhea , how often do you get it ? patient: it kinda just depends on what i eat . i think i have a very sensitive stomach . if i eat pasta with a creamy sauce , i'm probably gon na have diarrhea . | D2N028 | 17 | [
"Personal History",
"Vegetative History"
] | [
"Subjective"
] | okay . so tell me about the diarrhea , how often do you get it ? | 791 |
doctor: okay . and it does n't happen for multiple days in a row or is it just one time ? patient: it's usually just one time and then it's over . | D2N028 | 18 | [
"Personal History",
"Vegetative History"
] | [
"Subjective"
] | okay . and it does n't happen for multiple days in a row or is it just one time ? | 792 |
doctor: and how's your weight been ? any fluctuation ? patient: nice and pretty stable , although i could stand to lose about 25 pounds . | D2N028 | 19 | [
"Vegetative History"
] | [
"Subjective"
] | and how's your weight been ? any fluctuation ? | 793 |
doctor: okay . and is there any family history of gi issues that you know of ? patient: not that i can think of . well , actually my sister does have problems with her stomach too . she has irritable bowel syndrome and that is kind of what i always thought i had even thought i've never been diagnosed with it . | D2N028 | 20 | [
"Family History"
] | [
"Subjective"
] | okay . and is there any family history of gi issues that you know of ? | 794 |
doctor: okay . and is there any family history of gi cancer or liver disease ? patient: nope . | D2N028 | 21 | [
"Family History"
] | [
"Subjective"
] | okay . and is there any family history of gi cancer or liver disease ? | 795 |
doctor: have you ever had any surgeries on your abdomen ? patient: i've never had any surgery . | D2N028 | 22 | [
"Personal History"
] | [
"Subjective"
] | have you ever had any surgeries on your abdomen ? | 796 |
doctor: okay , so your gallbladder , appendix , all those are still intact ? patient: yup . | D2N028 | 23 | [
"Personal History"
] | [
"Subjective"
] | okay , so your gallbladder , appendix , all those are still intact ? | 797 |
doctor: and have you ever had a colonoscopy ? patient: no . i thought that happen when you turn 50 . | D2N028 | 24 | [
"Personal History"
] | [
"Subjective"
] | and have you ever had a colonoscopy ? | 798 |
doctor: well , that's for colon cancer screening , but there are other reasons to have a colonoscopy , like unexplained abdominal pain and changes in bowel habits . patient: okay . | D2N028 | 25 | [
"Personal History"
] | [
"Subjective"
] | well , that's for colon cancer screening , but there are other reasons to have a colonoscopy , like unexplained abdominal pain and changes in bowel habits . | 799 |
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