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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 twice a day so that's kind of annoying , but i know you're on other medicines twice a day too , so i think you'll do fine . patient: yeah , that'll be okay .
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 so that's kind of annoying , but i know you're on other medicines twice a day too , so i think you'll do fine .
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 do a lot of ekgs . i'm basically a regular . but i'm happy to do one today , no problem .
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 springfield . patient: okay , that sounds good .
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 springfield .
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 repeat ekg today but otherwise continue with her current regimen . labs checked and creatinine is appropriate . uh number 2 , pre-op examination . she is , she's having a right knee replacement end of june . also , she would like to have a colonoscopy performed which we'll try to have done at uh bartley regional , rightley regional hospital in the next month , uh , prior to a change in her insurance . this is just a screening colonoscopy that she is overdue for . no family history of colon cancer . uh the next one is diabetes . a1c is 5.1 on the last check so no need for further a1c today . she may need another one prior to her surgery next month though . thanks .
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 repeat ekg today but otherwise continue with her current regimen . labs checked and creatinine is appropriate . uh number 2 , pre-op examination . she is , she's having a right knee replacement end of june . also , she would like to have a colonoscopy performed which we'll try to have done at uh bartley regional , rightley regional hospital in the next month , uh , prior to a change in her insurance . this is just a screening colonoscopy that she is overdue for . no family history of colon cancer . uh the next one is diabetes . a1c is 5.1 on the last check so no need for further a1c today . she may need another one prior to her surgery next month though . thanks .
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 bothered me at night . also , just so you know , i am a va and i'm one percent disabled from this leg , um , issues from my knees down to my feet .
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 , just look and turn your head as far as you can that way . great . and now , as far as you can towards that wall . uh , does that seem to bother you at all ? patient: no . well , actually , i do feel a little strain .
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 look and turn your head as far as you can that way . great . and now , as far as you can towards that wall . uh , does that seem to bother you at all ?
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 to be potential for a disc to be pushing on a nerve . and now , what i do n't have is an mri , which would show me , uh , kind of exactly where the nerve roots are getting pinched off . patient: i see .
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 potential for a disc to be pushing on a nerve . and now , what i do n't have is an mri , which would show me , uh , kind of exactly where the nerve roots are getting pinched off .
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 off . it can often help alleviate your symptoms , and i do need to get an mri of your neck . um , i know we have had one of your lower back , but i need one of your neck to see exactly where the roots are getting pinched off . so , what i can do is tentatively set you up for an epidural , but before you do that , we do need to get that mri so i can see right where i need to put the medicine for your epidural . uh , what do you think of that ? patient: i think that sounds good to me .
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 . it can often help alleviate your symptoms , and i do need to get an mri of your neck . um , i know we have had one of your lower back , but i need one of your neck to see exactly where the roots are getting pinched off . so , what i can do is tentatively set you up for an epidural , but before you do that , we do need to get that mri so i can see right where i need to put the medicine for your epidural . uh , what do you think of that ?
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 . sound good ? patient: sounds good . for the last couple of nights , though , my neck has not been bothering me .
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 going on , because probably this is something that will likely flare up again . patient: yeah , it , it has been for the last week , so , i understand .
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 on , because probably this is something that will likely flare up again .
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 . sounds good .
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 and sensation is per the template . uh , upper and lower extremities . musculoskeletal , he is non-tender over his cervical spine . he does have mildly restricted cervical exte- extension . right and left lateral rotation which is symmetric , which gives him mild lateral neck pain but no radi- radicular pain . spurling's maneuver is benign . paragraph , diagnostics . cervical x-ray 6421 . cervical x-ray reveals significant disc degeneration at c56 , and to a lower extent c45 and c34 . significant lower lumbar facet arthropathy c67 and c7-t1 is difficult to visualize in the current x-rays . paragraph , impression . number one , left upper extremity neuropathy suspicious for cervical radicularopathy . possible contribution of peripheral neuropathy . number two , neck pain in the setting of arthritis disc degeneration . paragraph , plan . i suspect that this is a flare of cervical radicularopathy . i'm going to set him up for a cervical mri , and we'll tentatively plan for a left c7-t1 epidural afterwards , although the exact location will be pending the mri results . he'll continue his home exercise program as well as twice a day gabapentin . we'll follow up with him afterwards to determine his level of relief . he denies any blood thinners .
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 and sensation is per the template . uh , upper and lower extremities . musculoskeletal , he is non-tender over his cervical spine . he does have mildly restricted cervical exte- extension . right and left lateral rotation which is symmetric , which gives him mild lateral neck pain but no radi- radicular pain . spurling's maneuver is benign . paragraph , diagnostics . cervical x-ray 6421 . cervical x-ray reveals significant disc degeneration at c56 , and to a lower extent c45 and c34 . significant lower lumbar facet arthropathy c67 and c7-t1 is difficult to visualize in the current x-rays . paragraph , impression . number one , left upper extremity neuropathy suspicious for cervical radicularopathy . possible contribution of peripheral neuropathy . number two , neck pain in the setting of arthritis disc degeneration . paragraph , plan . i suspect that this is a flare of cervical radicularopathy . i'm going to set him up for a cervical mri , and we'll tentatively plan for a left c7-t1 epidural afterwards , although the exact location will be pending the mri results . he'll continue his home exercise program as well as twice a day gabapentin . we'll follow up with him afterwards to determine his level of relief . he denies any blood thinners .
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 patient's alkaline phosphatate- phosphatase , excuse me , was elevated to 156 . his lipid panel showed elevated total cholesterol of 247 , hdl of 66 , ldl of 166 , and triglycerides at 74 . the patient's tsh was normal at 2.68 . his cbc was unremarkable . his most recent vitamin d level was at the high end of normal at 94 . good morning , mr. walker . how are you doing ? i mean , it's been a crazy year . patient: i'm doing fine , for the most part , but there are a few things i want to cover today .
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 alkaline phosphatate- phosphatase , excuse me , was elevated to 156 . his lipid panel showed elevated total cholesterol of 247 , hdl of 66 , ldl of 166 , and triglycerides at 74 . the patient's tsh was normal at 2.68 . his cbc was unremarkable . his most recent vitamin d level was at the high end of normal at 94 . good morning , mr. walker . how are you doing ? i mean , it's been a crazy year .
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 . i'm out , you know ?
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 20 but , you know , i'm tired and have to take a break when i get home .
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 doing .
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 , and now what i do is i- i do make reservations twice a week for a 5:45 swim in the morning .
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: all right .
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 . patient: sounds like i'm going to be busy getting this all checked out .
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 those other studies . do you have any other questions for me ? patient: no , doc . i think you covered it all .
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 studies . do you have any other questions for me ?
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 epididymis or variococele ; left testicle , normal ; no hernia . all other portions of the physical exam are normal default . assessment history of the aortic aneurysm repair : the patient underwent and aortic valve replacement and ascending aortic aneurysm repair on 1/20/2013 . he is doing well overall and currently asymptomatic . he is currently not seen by cardiology routinely . suggest the following up and suggested vincent sanchez as his physician . we will perform an echocardiogram , eh , slash , stress test . elevated alkaline phosphatase level . most recent cmd showed elevation at 156 . this could be related to his liver but most likely re- related to his bone health . i've ordered an alkaline phosphatase and again a gt . lung field abnormal finding on exona ... excuse me , on examination . the patient has been noted to purse his lips while breathing . he was found himself ... he has found himself feeling more fatigued at the end of the day . he does bicycle around 20 to 30 miles at a time . his exhal- exhalation phase is low on exam , and i've ordered pfts today to further ... for further evaluation . the right testicular nodule is about two to three millimeters , i've noted on the exam . there's no hernia palpable , and i have suggested reaching out to ro ... urology for a possible ultrasound . preventative health : the most recent blood work was reviewed with no significant abnormalaries ... abnormalities other than the cmv . uh , we will perform mmr titer today . i have suggested the shingles vaccine and he is fully vaccinated against covid-19 . patient will return , uh , for a follow-up in one year for a wellness visit , sooner if needed . he is to call with any questions or concerns .
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 epididymis or variococele ; left testicle , normal ; no hernia . all other portions of the physical exam are normal default . assessment history of the aortic aneurysm repair : the patient underwent and aortic valve replacement and ascending aortic aneurysm repair on 1/20/2013 . he is doing well overall and currently asymptomatic . he is currently not seen by cardiology routinely . suggest the following up and suggested vincent sanchez as his physician . we will perform an echocardiogram , eh , slash , stress test . elevated alkaline phosphatase level . most recent cmd showed elevation at 156 . this could be related to his liver but most likely re- related to his bone health . i've ordered an alkaline phosphatase and again a gt . lung field abnormal finding on exona ... excuse me , on examination . the patient has been noted to purse his lips while breathing . he was found himself ... he has found himself feeling more fatigued at the end of the day . he does bicycle around 20 to 30 miles at a time . his exhal- exhalation phase is low on exam , and i've ordered pfts today to further ... for further evaluation . the right testicular nodule is about two to three millimeters , i've noted on the exam . there's no hernia palpable , and i have suggested reaching out to ro ... urology for a possible ultrasound . preventative health : the most recent blood work was reviewed with no significant abnormalaries ... abnormalities other than the cmv . uh , we will perform mmr titer today . i have suggested the shingles vaccine and he is fully vaccinated against covid-19 . patient will return , uh , for a follow-up in one year for a wellness visit , sooner if needed . he is to call with any questions or concerns .
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