DATEXIS/aci_bench_intent_annotated · Datasets at Hugging Face

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doctor: well , come have a seat here and lay back so i can examine you . patient: okay .	D2N028	26	[ "Physical Examination" ]	[ "Objective" ]	well , come have a seat here and lay back so i can examine you .	800
doctor: i'm gon na start by listening to your belly with my steth- stethoscope . and i hear bowel sounds in all four quadrants . patient: what does that mean ? is everything okay ?	D2N028	27	[ "Physical Examination" ]	[ "Objective" ]	i'm gon na start by listening to your belly with my steth- stethoscope . and i hear bowel sounds in all four quadrants .	801
doctor: it just means that i can hear little noises in all areas of your belly , which means your bowels are active and working . patient: okay , good .	D2N028	28	[ "Physical Examination" ]	[ "Objective" ]	it just means that i can hear little noises in all areas of your belly , which means your bowels are active and working .	802
doctor: so now , i'm going to push on your upper and lower abdomen . let me know if you have any pain . patient: it hurts a little when you push right there on the left side , near my belly button .	D2N028	29	[ "Physical Examination" ]	[ "Objective" ]	so now , i'm going to push on your upper and lower abdomen . let me know if you have any pain .	803
doctor: okay . i do feel stool in your lower colon , which would coincide with constipation , but i also feel a slight enlargement of your liver here on the upper right side . have you had any lab work done recently ? patient: yes , i have a physical about four months ago and they ... i had blood drawn then .	D2N028	30	[ "Physical Examination" ]	[ "Objective" ]	okay . i do feel stool in your lower colon , which would coincide with constipation , but i also feel a slight enlargement of your liver here on the upper right side . have you had any lab work done recently ?	804
doctor: okay . and did your primary care physician say anything about the lab results ? patient: he said i had some very slightly elevated liver enzymes , but we would recheck them in about six months .	D2N028	31	[ "Lab Examination" ]	[ "Objective" ]	okay . and did your primary care physician say anything about the lab results ?	805
doctor: and you remember what enzymes were elevated , alt , ast , alp ? patient: he said the alt and the ast were elevated .	D2N028	32	[ "Lab Examination" ]	[ "Objective" ]	and you remember what enzymes were elevated , alt , ast , alp ?	806
doctor: and do you take any medications , either prescription or over-the-counter ? patient: i take crestor and olmesartan daily and then tylenol for occasion- occasional pain .	D2N028	33	[ "Therapeutic History" ]	[ "Subjective" ]	and do you take any medications , either prescription or over-the-counter ?	807
doctor: and how frequently do you take the tylenol ? patient: hardly ever . maybe once a month .	D2N028	34	[ "Therapeutic History" ]	[ "Subjective" ]	and how frequently do you take the tylenol ?	808
doctor: and do you consume alcohol ? patient: uh , yes , but only a couple of beers after working in the yard on saturdays .	D2N028	35	[ "Drug History" ]	[ "Subjective" ]	and do you consume alcohol ?	809
doctor: okay . and no previous history of heavy alcohol or drug use ? patient: nope .	D2N028	36	[ "Drug History" ]	[ "Subjective" ]	okay . and no previous history of heavy alcohol or drug use ?	810
doctor: and have you had any recent issues with excessive bruising or bleeding ? patient: nope .	D2N028	37	[ "Personal History" ]	[ "Subjective" ]	and have you had any recent issues with excessive bruising or bleeding ?	811
doctor: and how about any issues with your ankles or feet swelling ? patient: no .	D2N028	38	[ "Personal History" ]	[ "Subjective" ]	and how about any issues with your ankles or feet swelling ?	812
doctor: okay . i'm gon na take a look at your eyes and skin . i do n't see any jaundice . patient: what would cause that ?	D2N028	39	[ "Physical Examination" ]	[ "Objective" ]	okay . i'm gon na take a look at your eyes and skin . i do n't see any jaundice .	813
doctor: issues with your liver . let me take a quick listen to your heart and lungs . patient: okay .	D2N028	40	[ "Physical Examination" ]	[ "Objective" ]	issues with your liver . let me take a quick listen to your heart and lungs .	814
doctor: lungs are clear , bilateral heart sounds are normal , no murmurs , gallops , or rubs noted . patient: that's good .	D2N028	41	[ "Physical Examination" ]	[ "Objective" ]	lungs are clear , bilateral heart sounds are normal , no murmurs , gallops , or rubs noted .	815
doctor: yes . the rest of your physical exam is normal other than what seems to be an increased stool burden in your colon and a slight hepatomegaly . patient: what's that ?	D2N028	42	[ "Physical Examination" ]	[ "Objective" ]	yes . the rest of your physical exam is normal other than what seems to be an increased stool burden in your colon and a slight hepatomegaly .	816
doctor: increase stool burden means that there's a lot of stool sitting in your colon . patient: and that's the constipation , right ? but what about the other thing ?	D2N028	43	[ "Physical Examination" ]	[ "Objective" ]	increase stool burden means that there's a lot of stool sitting in your colon .	817
doctor: the hepatomegaly means the liver is enlarged . patient: but you said mine was slightly enlarged ?	D2N028	44	[ "Physical Examination" ]	[ "Objective" ]	the hepatomegaly means the liver is enlarged .	818
doctor: correct . patient: so what does that mean ?	D2N028	45	[ "Physical Examination" ]	[ "Objective" ]	correct .	819
doctor: well , let's talk about what we found and then some possible next steps if you're in agreement . patient: okay .	D2N028	46	[ "Chitchat" ]	[ "Null" ]	well , let's talk about what we found and then some possible next steps if you're in agreement .	820
doctor: so as i said , the hepatomegaly means your liver is enlarged . patient: could that be why my stomach is hurting and i'm having issues with the constipation and diarrhea ?	D2N028	47	[ "Acute Assessment" ]	[ "Assessment" ]	so as i said , the hepatomegaly means your liver is enlarged .	821
doctor: no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat . and we can get you started right away on a fiber supplement that should help with that . patient: so what about my liver ? why is it enlarged ?	D2N028	48	[ "Medication", "Acute Assessment" ]	[ "Assessment", "Plan" ]	no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat . and we can get you started right away on a fiber supplement that should help with that .	822
doctor: well , there are many reasons why people can have an elevated liver enzymes and also enlarged liver . some possible causes are certain medications that can be toxic to liver , alcohol abuse , fatty liver disease , hepatitis , cirrhosis , and other liver diseases like wilson's disease . patient: so what do i need to do ?	D2N028	49	[ "Discussion", "Drug History" ]	[ "Plan" ]	well , there are many reasons why people can have an elevated liver enzymes and also enlarged liver . some possible causes are certain medications that can be toxic to liver , alcohol abuse , fatty liver disease , hepatitis , cirrhosis , and other liver diseases like wilson's disease .	823
doctor: well , i think since it's been about four months since your blood work was done , we should check your liver enzymes in addition to a few other labs . patient: okay . and then what ?	D2N028	50	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	well , i think since it's been about four months since your blood work was done , we should check your liver enzymes in addition to a few other labs .	824
doctor: we will get those drawn today and then depending upon the results you may need an ultrasound of your liver . i think we need to talk about your medications too . patient: which medications ?	D2N028	51	[ "Discussion" ]	[ "Plan" ]	we will get those drawn today and then depending upon the results you may need an ultrasound of your liver . i think we need to talk about your medications too .	825
doctor: crestor , how long have you been taking that ? patient: about 18 months .	D2N028	52	[ "Discussion", "Medication", "Therapeutic History" ]	[ "Subjective", "Plan" ]	crestor , how long have you been taking that ?	826
doctor: okay . well , crestor is one of the medications that can cause liver toxicity so it may be a good idea to discuss other alternatives . patient: should i talk to my primary care or can you change it ?	D2N028	53	[ "Discussion", "Medication" ]	[ "Plan" ]	okay . well , crestor is one of the medications that can cause liver toxicity so it may be a good idea to discuss other alternatives .	827
doctor: i would recommend calling your primary care and discuss that with him since he follows you for your blood pressure and cholesterol . patient: okay . i'll call him this afternoon .	D2N028	54	[ "Discussion" ]	[ "Plan" ]	i would recommend calling your primary care and discuss that with him since he follows you for your blood pressure and cholesterol .	828
doctor: great . i also think we should go ahead and get you scheduled for a liver ultrasound . if your blood work looks good , then we can always cancel that . patient: okay . when do you think i'll be able to get the ultrasound done ?	D2N028	55	[ "Diagnostic Testing" ]	[ "Plan" ]	great . i also think we should go ahead and get you scheduled for a liver ultrasound . if your blood work looks good , then we can always cancel that .	829
doctor: hopefully , within the next two weeks . you will receive a call from the radiology scheduling this afternoon to get it set up . patient: okay . and then what happens ?	D2N028	56	[ "Discussion" ]	[ "Plan" ]	hopefully , within the next two weeks . you will receive a call from the radiology scheduling this afternoon to get it set up .	830
doctor: when i get the results from the test , i will contact you . and depending upon what we find , we'll come up with our next steps . patient: and when should i see you again ?	D2N028	57	[ "Discussion" ]	[ "Plan" ]	when i get the results from the test , i will contact you . and depending upon what we find , we'll come up with our next steps .	831
doctor: uh , let's schedule an appointment when you check out to return in four weeks . we'll discuss how you're doing with the fiber supplement and your constipation and review test results to determine if we need to do further testing on your liver . patient: okay . is there anything else i can do to help with these issues ?	D2N028	58	[ "Follow-up", "Diagnostic Testing" ]	[ "Plan" ]	uh , let's schedule an appointment when you check out to return in four weeks . we'll discuss how you're doing with the fiber supplement and your constipation and review test results to determine if we need to do further testing on your liver .	832
doctor: definitely refrain from drinking any alcohol , increase your water intake to at least 48 ounces a day in addition to taking the fiber supplement to help with your constipation . and be mindful of eating foods that you were sensitive to so you can avoid the bouts of diarrhea . patient: okay . and i'll talk to my primary care about my crestor .	D2N028	59	[ "Medication", "Other Treatments", "Drug History" ]	[ "Plan" ]	definitely refrain from drinking any alcohol , increase your water intake to at least 48 ounces a day in addition to taking the fiber supplement to help with your constipation . and be mindful of eating foods that you were sensitive to so you can avoid the bouts of diarrhea .	833
doctor: excellent . and do you have any other questions for me ? patient: i do n't think so .	D2N028	60	[ "Chitchat" ]	[ "Null" ]	excellent . and do you have any other questions for me ?	834
doctor: great . so remember when you check out the front desk , schedule follow-up appointment with me for four weeks and then go to the lab to get your blood work drawn . patient: okay . sounds good .	D2N028	61	[ "Follow-up", "Diagnostic Testing" ]	[ "Plan" ]	great . so remember when you check out the front desk , schedule follow-up appointment with me for four weeks and then go to the lab to get your blood work drawn .	835
doctor: and expect a call from radiology scheduling about setting up your ultrasound . patient: all right . thanks , dr. edwards .	D2N028	62	[ "Diagnostic Testing" ]	[ "Plan" ]	and expect a call from radiology scheduling about setting up your ultrasound .	836
doctor: thank you , mr. allen .	D2N028	63	[ "Chitchat" ]	[ "Null" ]	doctor: thank you , mr. allen .	837
doctor: next patient is sophia jackson , mrnr472348 . she's a 57 year old female who is here for a surgical consult . her dermatologist referred her . she biopsied a 0.7 millimeter lesion which was located on right inferior back . pathology came back as melanoma . mrs. jackson , it's good to meet you . patient: likewise , wish it were under better circumstances .	D2N029	0	[ "Personal History", "Greetings" ]	[ "Subjective" ]	next patient is sophia jackson , mrnr472348 . she's a 57 year old female who is here for a surgical consult . her dermatologist referred her . she biopsied a 0.7 millimeter lesion which was located on right inferior back . pathology came back as melanoma . mrs. jackson , it's good to meet you .	838
doctor: yeah , i hear your dermatologist sent you to me 'cause she found a melanoma ? patient: yes , that's what the biopsy said .	D2N029	1	[ "Personal History" ]	[ "Subjective" ]	yeah , i hear your dermatologist sent you to me 'cause she found a melanoma ?	839
doctor: okay and when did you first notice the spot ? patient: my mom noticed it when i was visiting her last month .	D2N029	2	[ "Personal History" ]	[ "Subjective" ]	okay and when did you first notice the spot ?	840
doctor: i see . and so you went to the dermatologist on april 10th to get it checked out , right ? patient: yes , i wanted to be extra cautious because skin cancer does run in my family .	D2N029	3	[ "Personal History" ]	[ "Subjective" ]	i see . and so you went to the dermatologist on april 10th to get it checked out , right ?	841
doctor: well i'm really glad you took it seriously and got it checked . who in your family has had skin cancer , and do you know if it was melanoma or was it basal cell or squamous cell ? patient: my mom and her sister , i think they both had melanoma .	D2N029	4	[ "Family History" ]	[ "Subjective" ]	well i'm really glad you took it seriously and got it checked . who in your family has had skin cancer , and do you know if it was melanoma or was it basal cell or squamous cell ?	842
doctor: okay . do you have any other types of cancer in the family , like breast or ovarian ? patient: my grandfather had pancreatic cancer .	D2N029	5	[ "Family History" ]	[ "Subjective" ]	okay . do you have any other types of cancer in the family , like breast or ovarian ?	843
doctor: okay , and was that your mom or dad's father ? patient: mother's .	D2N029	6	[ "Family History" ]	[ "Subjective" ]	okay , and was that your mom or dad's father ?	844
doctor: okay . and , um , have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ? patient: no , this was the first time i've been to a dermatologist . um , but my primary care doctor looks over all of my moles every year at my physical and has n't said , um , he's concerned about any of 'em before .	D2N029	7	[ "Personal History" ]	[ "Subjective" ]	okay . and , um , have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ?	845
doctor: good- good . uh , let's go over your medical history from your chart . i have that you're not taking any medications and do n't have any health problems listed , but that you're allergic to augmentin , is that right ? patient: yes , that's correct .	D2N029	8	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	good- good . uh , let's go over your medical history from your chart . i have that you're not taking any medications and do n't have any health problems listed , but that you're allergic to augmentin , is that right ?	846
doctor: okay , and for social history can you tell me what you do for work ? patient: i own an auto repair shop .	D2N029	9	[ "Other Socials" ]	[ "Subjective" ]	okay , and for social history can you tell me what you do for work ?	847
doctor: okay and have you ever been a smoker ? patient: yeah , i still smoke from time to time . i started that awful habit in my teens and it's hard to break , but i'm trying .	D2N029	10	[ "Vegetative History" ]	[ "Subjective" ]	okay and have you ever been a smoker ?	848
doctor: i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ? patient: i had gall bladder and appendix .	D2N029	11	[ "Personal History" ]	[ "Subjective" ]	i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ?	849
doctor: okay , great , we can get your chart up to date now , thank you . and other than the melanoma , how has your health been , any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ? patient: no , i've been feelin' great .	D2N029	12	[ "Personal History", "Vegetative History" ]	[ "Subjective" ]	okay , great , we can get your chart up to date now , thank you . and other than the melanoma , how has your health been , any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ?	850
doctor: good . well let me take a look at your back here where they did the biopsy if you do n't mind . patient: sure .	D2N029	13	[ "Physical Examination" ]	[ "Objective" ]	good . well let me take a look at your back here where they did the biopsy if you do n't mind .	851
doctor: okay , i'm gon na describe it in medical jargon what i'm seeing here , so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ? patient: okay , that's fine .	D2N029	14	[ "Chitchat" ]	[ "Null" ]	okay , i'm gon na describe it in medical jargon what i'm seeing here , so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ?	852
doctor: all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam . okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further . patient: okay , i should n't worry too much then ?	D2N029	15	[ "Physical Examination", "Diagnostic Testing" ]	[ "Objective", "Plan" ]	all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam . okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further .	853
doctor: no , i have a low suspicion that it will show anything . patient: okay , good .	D2N029	16	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	no , i have a low suspicion that it will show anything .	854
doctor: so assuming that the ultrasound is normal , the treatment for you melanoma is to cut out the area where the lesion was . with lesions that are 0.7 millimeters or less , um , and that's what we recommend , and yours was exactly 0.7 millimeters . if it were any bigger , we would have had to do a more complex surgery . but what i recommend for you is what we call a wide local incision , excuse me , excision , meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision . patient: okay , that is fine with me , i ca n't see back there anyways .	D2N029	17	[ "Other Treatments" ]	[ "Plan" ]	so assuming that the ultrasound is normal , the treatment for you melanoma is to cut out the area where the lesion was . with lesions that are 0.7 millimeters or less , um , and that's what we recommend , and yours was exactly 0.7 millimeters . if it were any bigger , we would have had to do a more complex surgery . but what i recommend for you is what we call a wide local incision , excuse me , excision , meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision .	855
doctor: yeah , your wife can tell you what it looks like and she may need to help care for the incision at it , as it heals . um , but since we're , we are n't doing the more complex surgery , i actually do n't need to see you back unless you want to check in with me or have any problems . however , it is very important that you continue to follow up with your dermatologist regularly so she can monitor you . uh , your dermatologist will check that this one does n't come back , but she'll also check for other lesions that look suspicious . uh , unfortunately , since you've had one melanoma , you're at a higher risk of developing another one somewhere else . patient: yeah , she did say she wants to see me back .	D2N029	18	[ "Discussion", "Follow-up" ]	[ "Plan" ]	yeah , your wife can tell you what it looks like and she may need to help care for the incision at it , as it heals . um , but since we're , we are n't doing the more complex surgery , i actually do n't need to see you back unless you want to check in with me or have any problems . however , it is very important that you continue to follow up with your dermatologist regularly so she can monitor you . uh , your dermatologist will check that this one does n't come back , but she'll also check for other lesions that look suspicious . uh , unfortunately , since you've had one melanoma , you're at a higher risk of developing another one somewhere else .	856
doctor: good , and i'm sure she's already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight . patient: yeah , she definitely went over that , um , several times with me .	D2N029	19	[ "Medication" ]	[ "Plan" ]	good , and i'm sure she's already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight .	857
doctor: good . other than that , i think that's all for me . um , we'll get you set up for the ultrasound , the procedure . do you have any questions for me ? patient: um , no i ca n't think of any at this time .	D2N029	20	[ "Diagnostic Testing" ]	[ "Plan" ]	good . other than that , i think that's all for me . um , we'll get you set up for the ultrasound , the procedure . do you have any questions for me ?	858
doctor: okay , my nurse will be in to get you scheduled , so sit tight . it was very good to meet you . patient: thank you , nice to meet you as well .	D2N029	21	[ "Chitchat" ]	[ "Null" ]	okay , my nurse will be in to get you scheduled , so sit tight . it was very good to meet you .	859
doctor: please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border . for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin . primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance . after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .	D2N029	22	[ "Physical Examination", "Diagnostic Testing", "Acute Assessment", "Other Treatments" ]	[ "Objective", "Assessment", "Plan" ]	doctor: please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border . for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin . primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance . after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .	860
doctor: donna torres , date of birth , 08/01/1980 . hi donna ! how are you ? patient: i'm good . how about you ?	D2N030	0	[ "Personal History", "Greetings" ]	[ "Subjective" ]	donna torres , date of birth , 08/01/1980 . hi donna ! how are you ?	861
doctor: i'm doing well , thank you . and so , i saw that dr. brown put you on buspar . have you been on that before ? patient: no , that's new .	D2N030	1	[ "Therapeutic History" ]	[ "Subjective" ]	i'm doing well , thank you . and so , i saw that dr. brown put you on buspar . have you been on that before ?	862
doctor: okay . how is it working for you ? patient: my anxiety is going good now , thankfully . i'm serious , it was brutal in november and december . finally , i was like , " i can not do this . " i have no idea why it happened . dr. ward did put me on singulair , and she did say we need to be careful because singulair can cause anxiety . so i'm not sure if that was the issue or what .	D2N030	2	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	okay . how is it working for you ?	863
doctor: mm . okay . patient: and it would , um , start usually during the day , at work .	D2N030	3	[ "Personal History" ]	[ "Subjective" ]	mm . okay .	864
doctor: well , that's good , that things have settled . i do wonder if some of what you are dealing with is hormonal , and that's why i was asking . 'cause you were on the progesterone , and i feel like you were having some irritability back then too . patient: i did .	D2N030	5	[ "Therapeutic History" ]	[ "Subjective" ]	well , that's good , that things have settled . i do wonder if some of what you are dealing with is hormonal , and that's why i was asking . 'cause you were on the progesterone , and i feel like you were having some irritability back then too .	865
doctor: and that was before we started the progesterone . patient: yes .	D2N030	6	[ "Personal History" ]	[ "Subjective" ]	and that was before we started the progesterone .	866
doctor: so i know we started it for regulating your periods , but perhaps it helped with this also . patient: yeah . and before , in november and december , i noticed that the week before my period , my anxiety would go through the roof . which then , i knew my period was coming . then it turned into my anxiety spiking just at random times .	D2N030	7	[ "Personal History" ]	[ "Subjective" ]	so i know we started it for regulating your periods , but perhaps it helped with this also .	867
doctor: hmm , okay . patient: and it seemed like it was for no reason .	D2N030	8	[ "Personal History" ]	[ "Subjective" ]	hmm , okay .	868
doctor: but november and december you were on the progesterone at that time . patient: yes .	D2N030	9	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	but november and december you were on the progesterone at that time .	869
doctor: all right . so not really a link there , all right . patient: yeah , i do n't know .	D2N030	10	[ "Personal History" ]	[ "Subjective" ]	all right . so not really a link there , all right .	870
doctor: yeah , i do n't know either . um , sometimes with the aging process , that can happen too . patient: i figured maybe that's what it was .	D2N030	11	[ "Personal History" ]	[ "Subjective" ]	yeah , i do n't know either . um , sometimes with the aging process , that can happen too .	871
doctor: and we did go through the golive in november and december , so that can be pretty stressful also . patient: yeah , and at work , that's when i first started to lead the process of delivering the results to patients with covid . in the beginning of the whole pandemic , patients would have to wait nine days before they'd get their results . and then we opened the evaluation centers and the covid clinic . so i think it just took a toll on me .	D2N030	12	[ "Personal History", "Other Socials" ]	[ "Subjective" ]	and we did go through the golive in november and december , so that can be pretty stressful also .	872
doctor: yeah , i can absolutely see that . patient: yeah , and then i was feeling selfish because i was n't even on the front lines . i mean , i was supporting people , sure , but i was n't in the icu . so i felt selfish and guilty . i mean , hands down , the physicians and nurses were in the thick of it and there i was , having anxiety . and it felt ridiculous .	D2N030	13	[ "Other Socials" ]	[ "Subjective" ]	yeah , i can absolutely see that .	873
doctor: well , honestly , you feel how you feel and what you were doing was n't easy as well , so ... but let's see . i need to just put this dax back to work . all right , so no other issues whatsoever ? patient: no .	D2N030	14	[ "Acute Symptoms" ]	[ "Subjective" ]	well , honestly , you feel how you feel and what you were doing was n't easy as well , so ... but let's see . i need to just put this dax back to work . all right , so no other issues whatsoever ?	874
doctor: have you lost weight ? patient: no , but i stopped taking the camila birth control . my hunger level was at a new high . i mean , i was eating constantly . i felt like , " what is going on ? "	D2N030	15	[ "Acute Symptoms", "Vegetative History" ]	[ "Subjective" ]	have you lost weight ?	875
doctor: all right . patient: and now i am feeling better .	D2N030	16	[ "Acute Symptoms" ]	[ "Subjective" ]	all right .	876
doctor: okay , that's good . and your masked face , though , it does look thinner . patient: well , the past six months i have lost some weight .	D2N030	17	[ "Acute Symptoms" ]	[ "Subjective" ]	okay , that's good . and your masked face , though , it does look thinner .	877
doctor: okay , good . um , anything else going on ? patient: no .	D2N030	18	[ "Acute Symptoms" ]	[ "Subjective" ]	okay , good . um , anything else going on ?	878
doctor: all right . so your pap was in 2019 . i do n't think that we need to repeat that because it was negative/negative . um , have you ever had an abnormal pap ? patient: not with you , but i did around 2009 , and then i had to be seen every six months for a while . and then i had a normal pap .	D2N030	19	[ "Personal History" ]	[ "Subjective" ]	all right . so your pap was in 2019 . i do n't think that we need to repeat that because it was negative/negative . um , have you ever had an abnormal pap ?	879
doctor: all right , well , let's just repeat it then . patient: yeah , that's fine with me , to be safe .	D2N030	20	[ "Diagnostic Testing" ]	[ "Plan" ]	all right , well , let's just repeat it then .	880
doctor: okay . i know it sounds superstitious , but i feel like with all the immunocompromising , the pressure , the stress that people's bodies have been under , and the potential for getting covid or the vaccine ... i have actually seen some , um , an increase in abnormal paps in people who have been fine for a while . so that's why i figure let's just check . patient: okay . i fight the vaccine fight every day at home because my husband is n't ready to get it . same with my daughter . she shares the same worries as her dad in how it'll impact her when she gets older .	D2N030	21	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	okay . i know it sounds superstitious , but i feel like with all the immunocompromising , the pressure , the stress that people's bodies have been under , and the potential for getting covid or the vaccine ... i have actually seen some , um , an increase in abnormal paps in people who have been fine for a while . so that's why i figure let's just check .	881
doctor: have you had the vaccine ? patient: yes , i have . and so has my son . he , um , has had his first already .	D2N030	22	[ "Therapeutic History" ]	[ "Subjective" ]	have you had the vaccine ?	882
doctor: okay . well , you know , you can only do what you can do . patient: yeah , i agree .	D2N030	23	[ "Chitchat" ]	[ "Null" ]	okay . well , you know , you can only do what you can do .	883
doctor: all right . well , let's complete your exam . patient: all right .	D2N030	24	[ "Chitchat" ]	[ "Null" ]	all right . well , let's complete your exam .	884
doctor: so let's take a deep breath . and again . all right , you can breathe normally . all right , and take one more deep breath . okay , now i'm gon na touch your neck . go ahead and swallow . perfect . and just place your hand above your head . okay , i do feel some little bumps . patient: yeah , but they're not as big as they were .	D2N030	25	[ "Physical Examination" ]	[ "Objective" ]	so let's take a deep breath . and again . all right , you can breathe normally . all right , and take one more deep breath . okay , now i'm gon na touch your neck . go ahead and swallow . perfect . and just place your hand above your head . okay , i do feel some little bumps .	885
doctor: mm-hmm . okay , in this breast it does feel a little bit denser . does it hurt at all ? patient: it does , where your left hand just was .	D2N030	26	[ "Physical Examination" ]	[ "Objective" ]	mm-hmm . okay , in this breast it does feel a little bit denser . does it hurt at all ?	886
doctor: okay , right here ? patient: yeah , down here . but whenever i breastfed , it was always sore there too . i had a clog and something else . the lumps do feel smaller , but they are still there , unfortunately .	D2N030	27	[ "Physical Examination" ]	[ "Objective" ]	okay , right here ?	887
doctor: yeah , they are . uh , well now i do n't know , because if it was the progesterone , they would've gone away . patient: yeah .	D2N030	28	[ "Physical Examination" ]	[ "Objective" ]	yeah , they are . uh , well now i do n't know , because if it was the progesterone , they would've gone away .	888
doctor: all right , well just let your knees just op- relax and open . how's the itching or discomfort ? are you still using the cream ? patient: yes , and i actually need to get that refilled for the first time ever .	D2N030	29	[ "Physical Examination", "Therapeutic History" ]	[ "Subjective", "Objective" ]	all right , well just let your knees just op- relax and open . how's the itching or discomfort ? are you still using the cream ?	889
doctor: okay , great . all right , looks good . patient: good .	D2N030	31	[ "Physical Examination" ]	[ "Objective" ]	okay , great . all right , looks good .	890
doctor: you can go ahead and sit up . patient: thank you .	D2N030	32	[ "Physical Examination" ]	[ "Objective" ]	you can go ahead and sit up .	891
doctor: all right , so typically the lumps would often just shrink up pretty quickly after you've had one or two cycles , and you've had two cycles so far . so i think let's just keep monitoring them for now . patient: okay . and what could that mean ?	D2N030	33	[ "Discussion" ]	[ "Assessment", "Plan" ]	all right , so typically the lumps would often just shrink up pretty quickly after you've had one or two cycles , and you've had two cycles so far . so i think let's just keep monitoring them for now .	892
doctor: well , so just like people have an increased risk of breast cancer , there's also an increased risk for breast issues . you know what i mean ? so for example , cysts and lumps and fibroadenomas , those are all benign things . they're annoying and require some workup , but they're all benign . patient: and i'm- i'm just worried because i'm almost 40 and my mom was almost 45 when she was diagnosed with breast cancer . so i mean , i know there's nothing i can do about it , but it's just i feel like , uh , we had it under control and now it is n't .	D2N030	34	[ "Discussion" ]	[ "Plan" ]	well , so just like people have an increased risk of breast cancer , there's also an increased risk for breast issues . you know what i mean ? so for example , cysts and lumps and fibroadenomas , those are all benign things . they're annoying and require some workup , but they're all benign .	893
doctor: well , i would n't say that . i mean , i feel like we're at a point where we have a good cadence for you having surveillance on things , and i think you are more aware of your breasts than ever before , and things actually have n't changed . patient: yeah .	D2N030	35	[ "Discussion" ]	[ "Plan" ]	well , i would n't say that . i mean , i feel like we're at a point where we have a good cadence for you having surveillance on things , and i think you are more aware of your breasts than ever before , and things actually have n't changed .	894
doctor: so those are all good things . patient: okay .	D2N030	36	[ "Discussion" ]	[ "Plan" ]	so those are all good things .	895
doctor: because , um , if it was cancer , we'd actually , we would see some change . patient: we would ? okay , thank you for explaining that .	D2N030	37	[ "Discussion" ]	[ "Plan" ]	because , um , if it was cancer , we'd actually , we would see some change .	896
doctor: yeah . so i know it's annoying and distressing , but i think that's where we're at . it's annoying that you have the breast issue , and it's annoying that we have to follow them . patient: yeah , i agree there .	D2N030	38	[ "Discussion" ]	[ "Plan" ]	yeah . so i know it's annoying and distressing , but i think that's where we're at . it's annoying that you have the breast issue , and it's annoying that we have to follow them .	897
doctor: um , but the only extra that i could po- , uh , potentially do , is we could get a breast specialist on the team and have you start to follow with them . and one of the advantages there is that they sometimes will do an ultrasound as an extension of their physical exam , in the office , to check out it- check it out on their own . uh , they also have a lot more experience and more willingness to sometimes perform procedures earlier , if they think it needs , um , if they think it needs to be done . and i think they tend to be much quicker than , you know , like radiology as to biopsy it . patient: okay . i'll do whatever you think i should .	D2N030	39	[ "Diagnostic Testing" ]	[ "Plan" ]	um , but the only extra that i could po- , uh , potentially do , is we could get a breast specialist on the team and have you start to follow with them . and one of the advantages there is that they sometimes will do an ultrasound as an extension of their physical exam , in the office , to check out it- check it out on their own . uh , they also have a lot more experience and more willingness to sometimes perform procedures earlier , if they think it needs , um , if they think it needs to be done . and i think they tend to be much quicker than , you know , like radiology as to biopsy it .	898
doctor: all right . well , i think since you're feeling worried , let's go ahead and we can get them on board . i'll send out a referral and they will call you within the next couple of business days to schedule . patient: okay , i think that sounds great .	D2N030	40	[ "Follow-up" ]	[ "Plan" ]	all right . well , i think since you're feeling worried , let's go ahead and we can get them on board . i'll send out a referral and they will call you within the next couple of business days to schedule .	899

doctor: well , come have a seat here and lay back so i can examine you . patient: okay .

D2N028

26

[ "Physical Examination" ]

[ "Objective" ]

well , come have a seat here and lay back so i can examine you .

800

doctor: i'm gon na start by listening to your belly with my steth- stethoscope . and i hear bowel sounds in all four quadrants . patient: what does that mean ? is everything okay ?

D2N028

27

[ "Physical Examination" ]

[ "Objective" ]

i'm gon na start by listening to your belly with my steth- stethoscope . and i hear bowel sounds in all four quadrants .

801

doctor: it just means that i can hear little noises in all areas of your belly , which means your bowels are active and working . patient: okay , good .

D2N028

28

[ "Physical Examination" ]

[ "Objective" ]

it just means that i can hear little noises in all areas of your belly , which means your bowels are active and working .

802

doctor: so now , i'm going to push on your upper and lower abdomen . let me know if you have any pain . patient: it hurts a little when you push right there on the left side , near my belly button .

D2N028

29

[ "Physical Examination" ]

[ "Objective" ]

so now , i'm going to push on your upper and lower abdomen . let me know if you have any pain .

803

doctor: okay . i do feel stool in your lower colon , which would coincide with constipation , but i also feel a slight enlargement of your liver here on the upper right side . have you had any lab work done recently ? patient: yes , i have a physical about four months ago and they ... i had blood drawn then .

D2N028

30

[ "Physical Examination" ]

[ "Objective" ]

okay . i do feel stool in your lower colon , which would coincide with constipation , but i also feel a slight enlargement of your liver here on the upper right side . have you had any lab work done recently ?

804

doctor: okay . and did your primary care physician say anything about the lab results ? patient: he said i had some very slightly elevated liver enzymes , but we would recheck them in about six months .

D2N028

31

[ "Lab Examination" ]

[ "Objective" ]

okay . and did your primary care physician say anything about the lab results ?

805

doctor: and you remember what enzymes were elevated , alt , ast , alp ? patient: he said the alt and the ast were elevated .

D2N028

32

[ "Lab Examination" ]

[ "Objective" ]

and you remember what enzymes were elevated , alt , ast , alp ?

806

doctor: and do you take any medications , either prescription or over-the-counter ? patient: i take crestor and olmesartan daily and then tylenol for occasion- occasional pain .

D2N028

33

[ "Therapeutic History" ]

[ "Subjective" ]

and do you take any medications , either prescription or over-the-counter ?

807

doctor: and how frequently do you take the tylenol ? patient: hardly ever . maybe once a month .

D2N028

34

[ "Therapeutic History" ]

[ "Subjective" ]

and how frequently do you take the tylenol ?

808

doctor: and do you consume alcohol ? patient: uh , yes , but only a couple of beers after working in the yard on saturdays .

D2N028

35

[ "Drug History" ]

[ "Subjective" ]

and do you consume alcohol ?

809

doctor: okay . and no previous history of heavy alcohol or drug use ? patient: nope .

D2N028

36

[ "Drug History" ]

[ "Subjective" ]

okay . and no previous history of heavy alcohol or drug use ?

810

doctor: and have you had any recent issues with excessive bruising or bleeding ? patient: nope .

D2N028

37

[ "Personal History" ]

[ "Subjective" ]

and have you had any recent issues with excessive bruising or bleeding ?

811

doctor: and how about any issues with your ankles or feet swelling ? patient: no .

D2N028

38

[ "Personal History" ]

[ "Subjective" ]

and how about any issues with your ankles or feet swelling ?

812

doctor: okay . i'm gon na take a look at your eyes and skin . i do n't see any jaundice . patient: what would cause that ?

D2N028

39

[ "Physical Examination" ]

[ "Objective" ]

okay . i'm gon na take a look at your eyes and skin . i do n't see any jaundice .

813

doctor: issues with your liver . let me take a quick listen to your heart and lungs . patient: okay .

D2N028

40

[ "Physical Examination" ]

[ "Objective" ]

issues with your liver . let me take a quick listen to your heart and lungs .

814

doctor: lungs are clear , bilateral heart sounds are normal , no murmurs , gallops , or rubs noted . patient: that's good .

D2N028

41

[ "Physical Examination" ]

[ "Objective" ]

lungs are clear , bilateral heart sounds are normal , no murmurs , gallops , or rubs noted .

815

doctor: yes . the rest of your physical exam is normal other than what seems to be an increased stool burden in your colon and a slight hepatomegaly . patient: what's that ?

D2N028

42

[ "Physical Examination" ]

[ "Objective" ]

yes . the rest of your physical exam is normal other than what seems to be an increased stool burden in your colon and a slight hepatomegaly .

816

doctor: increase stool burden means that there's a lot of stool sitting in your colon . patient: and that's the constipation , right ? but what about the other thing ?

D2N028

43

[ "Physical Examination" ]

[ "Objective" ]

increase stool burden means that there's a lot of stool sitting in your colon .

817

doctor: the hepatomegaly means the liver is enlarged . patient: but you said mine was slightly enlarged ?

D2N028

44

[ "Physical Examination" ]

[ "Objective" ]

the hepatomegaly means the liver is enlarged .

818

doctor: correct . patient: so what does that mean ?

D2N028

45

[ "Physical Examination" ]

[ "Objective" ]

correct .

819

doctor: well , let's talk about what we found and then some possible next steps if you're in agreement . patient: okay .

D2N028

46

[ "Chitchat" ]

[ "Null" ]

well , let's talk about what we found and then some possible next steps if you're in agreement .

820

doctor: so as i said , the hepatomegaly means your liver is enlarged . patient: could that be why my stomach is hurting and i'm having issues with the constipation and diarrhea ?

D2N028

47

[ "Acute Assessment" ]

[ "Assessment" ]

so as i said , the hepatomegaly means your liver is enlarged .

821

doctor: no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat . and we can get you started right away on a fiber supplement that should help with that . patient: so what about my liver ? why is it enlarged ?

D2N028

48

[ "Medication", "Acute Assessment" ]

[ "Assessment", "Plan" ]

no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat . and we can get you started right away on a fiber supplement that should help with that .

822

doctor: well , there are many reasons why people can have an elevated liver enzymes and also enlarged liver . some possible causes are certain medications that can be toxic to liver , alcohol abuse , fatty liver disease , hepatitis , cirrhosis , and other liver diseases like wilson's disease . patient: so what do i need to do ?

D2N028

49

[ "Discussion", "Drug History" ]

[ "Plan" ]

well , there are many reasons why people can have an elevated liver enzymes and also enlarged liver . some possible causes are certain medications that can be toxic to liver , alcohol abuse , fatty liver disease , hepatitis , cirrhosis , and other liver diseases like wilson's disease .

823

doctor: well , i think since it's been about four months since your blood work was done , we should check your liver enzymes in addition to a few other labs . patient: okay . and then what ?

D2N028

50

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

well , i think since it's been about four months since your blood work was done , we should check your liver enzymes in addition to a few other labs .

824

doctor: we will get those drawn today and then depending upon the results you may need an ultrasound of your liver . i think we need to talk about your medications too . patient: which medications ?

D2N028

51

[ "Discussion" ]

[ "Plan" ]

we will get those drawn today and then depending upon the results you may need an ultrasound of your liver . i think we need to talk about your medications too .

825

doctor: crestor , how long have you been taking that ? patient: about 18 months .

D2N028

52

[ "Discussion", "Medication", "Therapeutic History" ]

[ "Subjective", "Plan" ]

crestor , how long have you been taking that ?

826

doctor: okay . well , crestor is one of the medications that can cause liver toxicity so it may be a good idea to discuss other alternatives . patient: should i talk to my primary care or can you change it ?

D2N028

53

[ "Discussion", "Medication" ]

[ "Plan" ]

okay . well , crestor is one of the medications that can cause liver toxicity so it may be a good idea to discuss other alternatives .

827

doctor: i would recommend calling your primary care and discuss that with him since he follows you for your blood pressure and cholesterol . patient: okay . i'll call him this afternoon .

D2N028

54

[ "Discussion" ]

[ "Plan" ]

i would recommend calling your primary care and discuss that with him since he follows you for your blood pressure and cholesterol .

828

doctor: great . i also think we should go ahead and get you scheduled for a liver ultrasound . if your blood work looks good , then we can always cancel that . patient: okay . when do you think i'll be able to get the ultrasound done ?

D2N028

55

[ "Diagnostic Testing" ]

[ "Plan" ]

great . i also think we should go ahead and get you scheduled for a liver ultrasound . if your blood work looks good , then we can always cancel that .

829

doctor: hopefully , within the next two weeks . you will receive a call from the radiology scheduling this afternoon to get it set up . patient: okay . and then what happens ?

D2N028

56

[ "Discussion" ]

[ "Plan" ]

hopefully , within the next two weeks . you will receive a call from the radiology scheduling this afternoon to get it set up .

830

doctor: when i get the results from the test , i will contact you . and depending upon what we find , we'll come up with our next steps . patient: and when should i see you again ?

D2N028

57

[ "Discussion" ]

[ "Plan" ]

when i get the results from the test , i will contact you . and depending upon what we find , we'll come up with our next steps .

831

doctor: uh , let's schedule an appointment when you check out to return in four weeks . we'll discuss how you're doing with the fiber supplement and your constipation and review test results to determine if we need to do further testing on your liver . patient: okay . is there anything else i can do to help with these issues ?

D2N028

58

[ "Follow-up", "Diagnostic Testing" ]

[ "Plan" ]

uh , let's schedule an appointment when you check out to return in four weeks . we'll discuss how you're doing with the fiber supplement and your constipation and review test results to determine if we need to do further testing on your liver .

832

doctor: definitely refrain from drinking any alcohol , increase your water intake to at least 48 ounces a day in addition to taking the fiber supplement to help with your constipation . and be mindful of eating foods that you were sensitive to so you can avoid the bouts of diarrhea . patient: okay . and i'll talk to my primary care about my crestor .

D2N028

59

[ "Medication", "Other Treatments", "Drug History" ]

[ "Plan" ]

definitely refrain from drinking any alcohol , increase your water intake to at least 48 ounces a day in addition to taking the fiber supplement to help with your constipation . and be mindful of eating foods that you were sensitive to so you can avoid the bouts of diarrhea .

833

doctor: excellent . and do you have any other questions for me ? patient: i do n't think so .

D2N028

60

[ "Chitchat" ]

[ "Null" ]

excellent . and do you have any other questions for me ?

834

doctor: great . so remember when you check out the front desk , schedule follow-up appointment with me for four weeks and then go to the lab to get your blood work drawn . patient: okay . sounds good .

D2N028

61

[ "Follow-up", "Diagnostic Testing" ]

[ "Plan" ]

great . so remember when you check out the front desk , schedule follow-up appointment with me for four weeks and then go to the lab to get your blood work drawn .

835

doctor: and expect a call from radiology scheduling about setting up your ultrasound . patient: all right . thanks , dr. edwards .

D2N028

62

[ "Diagnostic Testing" ]

[ "Plan" ]

and expect a call from radiology scheduling about setting up your ultrasound .

836

doctor: thank you , mr. allen .

D2N028

63

[ "Chitchat" ]

[ "Null" ]

doctor: thank you , mr. allen .

837

doctor: next patient is sophia jackson , mrnr472348 . she's a 57 year old female who is here for a surgical consult . her dermatologist referred her . she biopsied a 0.7 millimeter lesion which was located on right inferior back . pathology came back as melanoma . mrs. jackson , it's good to meet you . patient: likewise , wish it were under better circumstances .

D2N029

0

[ "Personal History", "Greetings" ]

[ "Subjective" ]

next patient is sophia jackson , mrnr472348 . she's a 57 year old female who is here for a surgical consult . her dermatologist referred her . she biopsied a 0.7 millimeter lesion which was located on right inferior back . pathology came back as melanoma . mrs. jackson , it's good to meet you .

838

doctor: yeah , i hear your dermatologist sent you to me 'cause she found a melanoma ? patient: yes , that's what the biopsy said .

D2N029

1

[ "Personal History" ]

[ "Subjective" ]

yeah , i hear your dermatologist sent you to me 'cause she found a melanoma ?

839

doctor: okay and when did you first notice the spot ? patient: my mom noticed it when i was visiting her last month .

D2N029

2

[ "Personal History" ]

[ "Subjective" ]

okay and when did you first notice the spot ?

840

doctor: i see . and so you went to the dermatologist on april 10th to get it checked out , right ? patient: yes , i wanted to be extra cautious because skin cancer does run in my family .

D2N029

3

[ "Personal History" ]

[ "Subjective" ]

i see . and so you went to the dermatologist on april 10th to get it checked out , right ?

841

doctor: well i'm really glad you took it seriously and got it checked . who in your family has had skin cancer , and do you know if it was melanoma or was it basal cell or squamous cell ? patient: my mom and her sister , i think they both had melanoma .

D2N029

4

[ "Family History" ]

[ "Subjective" ]

well i'm really glad you took it seriously and got it checked . who in your family has had skin cancer , and do you know if it was melanoma or was it basal cell or squamous cell ?

842

doctor: okay . do you have any other types of cancer in the family , like breast or ovarian ? patient: my grandfather had pancreatic cancer .

D2N029

5

[ "Family History" ]

[ "Subjective" ]

okay . do you have any other types of cancer in the family , like breast or ovarian ?

843

doctor: okay , and was that your mom or dad's father ? patient: mother's .

D2N029

6

[ "Family History" ]

[ "Subjective" ]

okay , and was that your mom or dad's father ?

844

doctor: okay . and , um , have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ? patient: no , this was the first time i've been to a dermatologist . um , but my primary care doctor looks over all of my moles every year at my physical and has n't said , um , he's concerned about any of 'em before .

D2N029

7

[ "Personal History" ]

[ "Subjective" ]

okay . and , um , have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ?

845

doctor: good- good . uh , let's go over your medical history from your chart . i have that you're not taking any medications and do n't have any health problems listed , but that you're allergic to augmentin , is that right ? patient: yes , that's correct .

D2N029

8

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

good- good . uh , let's go over your medical history from your chart . i have that you're not taking any medications and do n't have any health problems listed , but that you're allergic to augmentin , is that right ?

846

doctor: okay , and for social history can you tell me what you do for work ? patient: i own an auto repair shop .

D2N029

9

[ "Other Socials" ]

[ "Subjective" ]

okay , and for social history can you tell me what you do for work ?

847

doctor: okay and have you ever been a smoker ? patient: yeah , i still smoke from time to time . i started that awful habit in my teens and it's hard to break , but i'm trying .

D2N029

10

[ "Vegetative History" ]

[ "Subjective" ]

okay and have you ever been a smoker ?

848

doctor: i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ? patient: i had gall bladder and appendix .

D2N029

11

[ "Personal History" ]

[ "Subjective" ]

i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ?

849

doctor: okay , great , we can get your chart up to date now , thank you . and other than the melanoma , how has your health been , any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ? patient: no , i've been feelin' great .

D2N029

12

[ "Personal History", "Vegetative History" ]

[ "Subjective" ]

okay , great , we can get your chart up to date now , thank you . and other than the melanoma , how has your health been , any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ?

850

doctor: good . well let me take a look at your back here where they did the biopsy if you do n't mind . patient: sure .

D2N029

13

[ "Physical Examination" ]

[ "Objective" ]

good . well let me take a look at your back here where they did the biopsy if you do n't mind .

851

doctor: okay , i'm gon na describe it in medical jargon what i'm seeing here , so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ? patient: okay , that's fine .

D2N029

14

[ "Chitchat" ]

[ "Null" ]

okay , i'm gon na describe it in medical jargon what i'm seeing here , so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ?

852

doctor: all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam . okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further . patient: okay , i should n't worry too much then ?

D2N029

15

[ "Physical Examination", "Diagnostic Testing" ]

[ "Objective", "Plan" ]

all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam . okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further .

853

doctor: no , i have a low suspicion that it will show anything . patient: okay , good .

D2N029

16

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

no , i have a low suspicion that it will show anything .

854

doctor: so assuming that the ultrasound is normal , the treatment for you melanoma is to cut out the area where the lesion was . with lesions that are 0.7 millimeters or less , um , and that's what we recommend , and yours was exactly 0.7 millimeters . if it were any bigger , we would have had to do a more complex surgery . but what i recommend for you is what we call a wide local incision , excuse me , excision , meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision . patient: okay , that is fine with me , i ca n't see back there anyways .

D2N029

17

[ "Other Treatments" ]

[ "Plan" ]

so assuming that the ultrasound is normal , the treatment for you melanoma is to cut out the area where the lesion was . with lesions that are 0.7 millimeters or less , um , and that's what we recommend , and yours was exactly 0.7 millimeters . if it were any bigger , we would have had to do a more complex surgery . but what i recommend for you is what we call a wide local incision , excuse me , excision , meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision .

855

doctor: yeah , your wife can tell you what it looks like and she may need to help care for the incision at it , as it heals . um , but since we're , we are n't doing the more complex surgery , i actually do n't need to see you back unless you want to check in with me or have any problems . however , it is very important that you continue to follow up with your dermatologist regularly so she can monitor you . uh , your dermatologist will check that this one does n't come back , but she'll also check for other lesions that look suspicious . uh , unfortunately , since you've had one melanoma , you're at a higher risk of developing another one somewhere else . patient: yeah , she did say she wants to see me back .

D2N029

18

[ "Discussion", "Follow-up" ]

[ "Plan" ]

yeah , your wife can tell you what it looks like and she may need to help care for the incision at it , as it heals . um , but since we're , we are n't doing the more complex surgery , i actually do n't need to see you back unless you want to check in with me or have any problems . however , it is very important that you continue to follow up with your dermatologist regularly so she can monitor you . uh , your dermatologist will check that this one does n't come back , but she'll also check for other lesions that look suspicious . uh , unfortunately , since you've had one melanoma , you're at a higher risk of developing another one somewhere else .

856

doctor: good , and i'm sure she's already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight . patient: yeah , she definitely went over that , um , several times with me .

D2N029

19

[ "Medication" ]

[ "Plan" ]

good , and i'm sure she's already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight .

857

doctor: good . other than that , i think that's all for me . um , we'll get you set up for the ultrasound , the procedure . do you have any questions for me ? patient: um , no i ca n't think of any at this time .

D2N029

20

[ "Diagnostic Testing" ]

[ "Plan" ]

good . other than that , i think that's all for me . um , we'll get you set up for the ultrasound , the procedure . do you have any questions for me ?

858

doctor: okay , my nurse will be in to get you scheduled , so sit tight . it was very good to meet you . patient: thank you , nice to meet you as well .

D2N029

21

[ "Chitchat" ]

[ "Null" ]

okay , my nurse will be in to get you scheduled , so sit tight . it was very good to meet you .

859

doctor: please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border . for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin . primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance . after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .

D2N029

22

[ "Physical Examination", "Diagnostic Testing", "Acute Assessment", "Other Treatments" ]

[ "Objective", "Assessment", "Plan" ]

doctor: please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border . for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin . primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance . after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .

860

doctor: donna torres , date of birth , 08/01/1980 . hi donna ! how are you ? patient: i'm good . how about you ?

D2N030

0

[ "Personal History", "Greetings" ]

[ "Subjective" ]

donna torres , date of birth , 08/01/1980 . hi donna ! how are you ?

861

doctor: i'm doing well , thank you . and so , i saw that dr. brown put you on buspar . have you been on that before ? patient: no , that's new .

D2N030

1

[ "Therapeutic History" ]

[ "Subjective" ]

i'm doing well , thank you . and so , i saw that dr. brown put you on buspar . have you been on that before ?

862

doctor: okay . how is it working for you ? patient: my anxiety is going good now , thankfully . i'm serious , it was brutal in november and december . finally , i was like , " i can not do this . " i have no idea why it happened . dr. ward did put me on singulair , and she did say we need to be careful because singulair can cause anxiety . so i'm not sure if that was the issue or what .

D2N030

2

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

okay . how is it working for you ?

863

doctor: mm . okay . patient: and it would , um , start usually during the day , at work .

D2N030

3

[ "Personal History" ]

[ "Subjective" ]

mm . okay .

864

doctor: well , that's good , that things have settled . i do wonder if some of what you are dealing with is hormonal , and that's why i was asking . 'cause you were on the progesterone , and i feel like you were having some irritability back then too . patient: i did .

D2N030

5

[ "Therapeutic History" ]

[ "Subjective" ]

well , that's good , that things have settled . i do wonder if some of what you are dealing with is hormonal , and that's why i was asking . 'cause you were on the progesterone , and i feel like you were having some irritability back then too .

865

doctor: and that was before we started the progesterone . patient: yes .

D2N030

6

[ "Personal History" ]

[ "Subjective" ]

and that was before we started the progesterone .

866

doctor: so i know we started it for regulating your periods , but perhaps it helped with this also . patient: yeah . and before , in november and december , i noticed that the week before my period , my anxiety would go through the roof . which then , i knew my period was coming . then it turned into my anxiety spiking just at random times .

D2N030

7

[ "Personal History" ]

[ "Subjective" ]

so i know we started it for regulating your periods , but perhaps it helped with this also .

867

doctor: hmm , okay . patient: and it seemed like it was for no reason .

D2N030

8

[ "Personal History" ]

[ "Subjective" ]

hmm , okay .

868

doctor: but november and december you were on the progesterone at that time . patient: yes .

D2N030

9

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

but november and december you were on the progesterone at that time .

869

doctor: all right . so not really a link there , all right . patient: yeah , i do n't know .

D2N030

10

[ "Personal History" ]

[ "Subjective" ]

all right . so not really a link there , all right .

870

doctor: yeah , i do n't know either . um , sometimes with the aging process , that can happen too . patient: i figured maybe that's what it was .

D2N030

11

[ "Personal History" ]

[ "Subjective" ]

yeah , i do n't know either . um , sometimes with the aging process , that can happen too .

871

doctor: and we did go through the golive in november and december , so that can be pretty stressful also . patient: yeah , and at work , that's when i first started to lead the process of delivering the results to patients with covid . in the beginning of the whole pandemic , patients would have to wait nine days before they'd get their results . and then we opened the evaluation centers and the covid clinic . so i think it just took a toll on me .

D2N030

12

[ "Personal History", "Other Socials" ]

[ "Subjective" ]

and we did go through the golive in november and december , so that can be pretty stressful also .

872

doctor: yeah , i can absolutely see that . patient: yeah , and then i was feeling selfish because i was n't even on the front lines . i mean , i was supporting people , sure , but i was n't in the icu . so i felt selfish and guilty . i mean , hands down , the physicians and nurses were in the thick of it and there i was , having anxiety . and it felt ridiculous .

D2N030

13

[ "Other Socials" ]

[ "Subjective" ]

yeah , i can absolutely see that .

873

doctor: well , honestly , you feel how you feel and what you were doing was n't easy as well , so ... but let's see . i need to just put this dax back to work . all right , so no other issues whatsoever ? patient: no .

D2N030

14

[ "Acute Symptoms" ]

[ "Subjective" ]

well , honestly , you feel how you feel and what you were doing was n't easy as well , so ... but let's see . i need to just put this dax back to work . all right , so no other issues whatsoever ?

874

doctor: have you lost weight ? patient: no , but i stopped taking the camila birth control . my hunger level was at a new high . i mean , i was eating constantly . i felt like , " what is going on ? "

D2N030

15

[ "Acute Symptoms", "Vegetative History" ]

[ "Subjective" ]

have you lost weight ?

875

doctor: all right . patient: and now i am feeling better .

D2N030

16

[ "Acute Symptoms" ]

[ "Subjective" ]

all right .

876

doctor: okay , that's good . and your masked face , though , it does look thinner . patient: well , the past six months i have lost some weight .

D2N030

17

[ "Acute Symptoms" ]

[ "Subjective" ]

okay , that's good . and your masked face , though , it does look thinner .

877

doctor: okay , good . um , anything else going on ? patient: no .

D2N030

18

[ "Acute Symptoms" ]

[ "Subjective" ]

okay , good . um , anything else going on ?

878

doctor: all right . so your pap was in 2019 . i do n't think that we need to repeat that because it was negative/negative . um , have you ever had an abnormal pap ? patient: not with you , but i did around 2009 , and then i had to be seen every six months for a while . and then i had a normal pap .

D2N030

19

[ "Personal History" ]

[ "Subjective" ]

all right . so your pap was in 2019 . i do n't think that we need to repeat that because it was negative/negative . um , have you ever had an abnormal pap ?

879

doctor: all right , well , let's just repeat it then . patient: yeah , that's fine with me , to be safe .

D2N030

20

[ "Diagnostic Testing" ]

[ "Plan" ]

all right , well , let's just repeat it then .

880

doctor: okay . i know it sounds superstitious , but i feel like with all the immunocompromising , the pressure , the stress that people's bodies have been under , and the potential for getting covid or the vaccine ... i have actually seen some , um , an increase in abnormal paps in people who have been fine for a while . so that's why i figure let's just check . patient: okay . i fight the vaccine fight every day at home because my husband is n't ready to get it . same with my daughter . she shares the same worries as her dad in how it'll impact her when she gets older .

D2N030

21

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

okay . i know it sounds superstitious , but i feel like with all the immunocompromising , the pressure , the stress that people's bodies have been under , and the potential for getting covid or the vaccine ... i have actually seen some , um , an increase in abnormal paps in people who have been fine for a while . so that's why i figure let's just check .

881

doctor: have you had the vaccine ? patient: yes , i have . and so has my son . he , um , has had his first already .

D2N030

22

[ "Therapeutic History" ]

[ "Subjective" ]

have you had the vaccine ?

882

doctor: okay . well , you know , you can only do what you can do . patient: yeah , i agree .

D2N030

23

[ "Chitchat" ]

[ "Null" ]

okay . well , you know , you can only do what you can do .

883

doctor: all right . well , let's complete your exam . patient: all right .

D2N030

24

[ "Chitchat" ]

[ "Null" ]

all right . well , let's complete your exam .

884

doctor: so let's take a deep breath . and again . all right , you can breathe normally . all right , and take one more deep breath . okay , now i'm gon na touch your neck . go ahead and swallow . perfect . and just place your hand above your head . okay , i do feel some little bumps . patient: yeah , but they're not as big as they were .

D2N030

25

[ "Physical Examination" ]

[ "Objective" ]

so let's take a deep breath . and again . all right , you can breathe normally . all right , and take one more deep breath . okay , now i'm gon na touch your neck . go ahead and swallow . perfect . and just place your hand above your head . okay , i do feel some little bumps .

885

doctor: mm-hmm . okay , in this breast it does feel a little bit denser . does it hurt at all ? patient: it does , where your left hand just was .

D2N030

26

[ "Physical Examination" ]

[ "Objective" ]

mm-hmm . okay , in this breast it does feel a little bit denser . does it hurt at all ?

886

doctor: okay , right here ? patient: yeah , down here . but whenever i breastfed , it was always sore there too . i had a clog and something else . the lumps do feel smaller , but they are still there , unfortunately .

D2N030

27

[ "Physical Examination" ]

[ "Objective" ]

okay , right here ?

887

doctor: yeah , they are . uh , well now i do n't know , because if it was the progesterone , they would've gone away . patient: yeah .

D2N030

28

[ "Physical Examination" ]

[ "Objective" ]

yeah , they are . uh , well now i do n't know , because if it was the progesterone , they would've gone away .

888

doctor: all right , well just let your knees just op- relax and open . how's the itching or discomfort ? are you still using the cream ? patient: yes , and i actually need to get that refilled for the first time ever .

D2N030

29

[ "Physical Examination", "Therapeutic History" ]

[ "Subjective", "Objective" ]

all right , well just let your knees just op- relax and open . how's the itching or discomfort ? are you still using the cream ?

889

doctor: okay , great . all right , looks good . patient: good .

D2N030

31

[ "Physical Examination" ]

[ "Objective" ]

okay , great . all right , looks good .

890

doctor: you can go ahead and sit up . patient: thank you .

D2N030

32

[ "Physical Examination" ]

[ "Objective" ]

you can go ahead and sit up .

891

doctor: all right , so typically the lumps would often just shrink up pretty quickly after you've had one or two cycles , and you've had two cycles so far . so i think let's just keep monitoring them for now . patient: okay . and what could that mean ?

D2N030

33

[ "Discussion" ]

[ "Assessment", "Plan" ]

all right , so typically the lumps would often just shrink up pretty quickly after you've had one or two cycles , and you've had two cycles so far . so i think let's just keep monitoring them for now .

892

doctor: well , so just like people have an increased risk of breast cancer , there's also an increased risk for breast issues . you know what i mean ? so for example , cysts and lumps and fibroadenomas , those are all benign things . they're annoying and require some workup , but they're all benign . patient: and i'm- i'm just worried because i'm almost 40 and my mom was almost 45 when she was diagnosed with breast cancer . so i mean , i know there's nothing i can do about it , but it's just i feel like , uh , we had it under control and now it is n't .

D2N030

34

[ "Discussion" ]

[ "Plan" ]

well , so just like people have an increased risk of breast cancer , there's also an increased risk for breast issues . you know what i mean ? so for example , cysts and lumps and fibroadenomas , those are all benign things . they're annoying and require some workup , but they're all benign .

893

doctor: well , i would n't say that . i mean , i feel like we're at a point where we have a good cadence for you having surveillance on things , and i think you are more aware of your breasts than ever before , and things actually have n't changed . patient: yeah .

D2N030

35

[ "Discussion" ]

[ "Plan" ]

well , i would n't say that . i mean , i feel like we're at a point where we have a good cadence for you having surveillance on things , and i think you are more aware of your breasts than ever before , and things actually have n't changed .

894

doctor: so those are all good things . patient: okay .

D2N030

36

[ "Discussion" ]

[ "Plan" ]

so those are all good things .

895

doctor: because , um , if it was cancer , we'd actually , we would see some change . patient: we would ? okay , thank you for explaining that .

D2N030

37

[ "Discussion" ]

[ "Plan" ]

because , um , if it was cancer , we'd actually , we would see some change .

896

doctor: yeah . so i know it's annoying and distressing , but i think that's where we're at . it's annoying that you have the breast issue , and it's annoying that we have to follow them . patient: yeah , i agree there .

D2N030

38

[ "Discussion" ]

[ "Plan" ]

yeah . so i know it's annoying and distressing , but i think that's where we're at . it's annoying that you have the breast issue , and it's annoying that we have to follow them .

897

doctor: um , but the only extra that i could po- , uh , potentially do , is we could get a breast specialist on the team and have you start to follow with them . and one of the advantages there is that they sometimes will do an ultrasound as an extension of their physical exam , in the office , to check out it- check it out on their own . uh , they also have a lot more experience and more willingness to sometimes perform procedures earlier , if they think it needs , um , if they think it needs to be done . and i think they tend to be much quicker than , you know , like radiology as to biopsy it . patient: okay . i'll do whatever you think i should .

D2N030

39

[ "Diagnostic Testing" ]

[ "Plan" ]

um , but the only extra that i could po- , uh , potentially do , is we could get a breast specialist on the team and have you start to follow with them . and one of the advantages there is that they sometimes will do an ultrasound as an extension of their physical exam , in the office , to check out it- check it out on their own . uh , they also have a lot more experience and more willingness to sometimes perform procedures earlier , if they think it needs , um , if they think it needs to be done . and i think they tend to be much quicker than , you know , like radiology as to biopsy it .

898

doctor: all right . well , i think since you're feeling worried , let's go ahead and we can get them on board . i'll send out a referral and they will call you within the next couple of business days to schedule . patient: okay , i think that sounds great .

D2N030

40

[ "Follow-up" ]

[ "Plan" ]

all right . well , i think since you're feeling worried , let's go ahead and we can get them on board . i'll send out a referral and they will call you within the next couple of business days to schedule .

899