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|---|---|---|---|---|---|---|
doctor: all right . i do too . all right , well any questions or anything else we can discuss today ? patient: no , i think i'm all set .
|
D2N030
| 41
|
[
"Chitchat"
] |
[
"Null"
] |
all right . i do too . all right , well any questions or anything else we can discuss today ?
| 900
|
doctor: all right , good . all right , well have a good rest of your day and just give us a call if you need anything else . patient: all right , thank you . you have a good day too .
|
D2N030
| 42
|
[
"Chitchat"
] |
[
"Null"
] |
all right , good . all right , well have a good rest of your day and just give us a call if you need anything else .
| 901
|
doctor: all right .
|
D2N030
| 43
|
[
"Chitchat"
] |
[
"Null"
] |
doctor: all right .
| 902
|
doctor: sophia brown . date of birth , 3/17/1946 . this is a new patient visit . she's here to establish care for a history of dcis . we'll go over the history with the patient . hello , ms. brown . patient: hi . yes , that's me .
|
D2N031
| 0
|
[
"Personal History",
"Greetings"
] |
[
"Subjective"
] |
sophia brown . date of birth , 3/17/1946 . this is a new patient visit . she's here to establish care for a history of dcis . we'll go over the history with the patient . hello , ms. brown .
| 903
|
doctor: wonderful . i'm doctor stewart . it's lovely to meet you . patient: you as well .
|
D2N031
| 1
|
[
"Chitchat"
] |
[
"Null"
] |
wonderful . i'm doctor stewart . it's lovely to meet you .
| 904
|
doctor: so , you've come to see me today because you had a right breast lumpectomy last year . is that right ? patient: yes . on january 20th , 2020 .
|
D2N031
| 2
|
[
"Personal History"
] |
[
"Subjective"
] |
so , you've come to see me today because you had a right breast lumpectomy last year . is that right ?
| 905
|
doctor: okay . and how have you been since then ? any problems or concerns ? patient: no , i'm feeling good . i do my self breast exams religiously now and have n't felt anything since .
|
D2N031
| 3
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . and how have you been since then ? any problems or concerns ?
| 906
|
doctor: perfect . i want to back up and go over your history so i can make sure everything in your chart is correct and i do n't miss anything . so , i'll tell you what we have in your chart from your other providers and you tell me if anything is wrong or missing . sound good ? patient: sounds good .
|
D2N031
| 4
|
[
"Personal History"
] |
[
"Subjective"
] |
perfect . i want to back up and go over your history so i can make sure everything in your chart is correct and i do n't miss anything . so , i'll tell you what we have in your chart from your other providers and you tell me if anything is wrong or missing . sound good ?
| 907
|
doctor: great . so , i have that you were found to have a calcification in your right breast during a mammogram in october 2019 . was that just a normal screening mammogram , or was it done because you felt a lump ? patient: it was just a normal one you're supposed to get every so often .
|
D2N031
| 5
|
[
"Personal History"
] |
[
"Subjective"
] |
great . so , i have that you were found to have a calcification in your right breast during a mammogram in october 2019 . was that just a normal screening mammogram , or was it done because you felt a lump ?
| 908
|
doctor: i see . and then it looks like you had an ultrasound of your right breast on november 3rd , 2019 , which revealed a mass at the two o'clock position , 11 centimeters from the nipple in the retroareolar region . the report states the mass was point four by two by three centimeters . patient: yes , that sounds right . hard to remember now , though .
|
D2N031
| 6
|
[
"Personal History",
"Radiology Examination"
] |
[
"Subjective",
"Objective"
] |
i see . and then it looks like you had an ultrasound of your right breast on november 3rd , 2019 , which revealed a mass at the two o'clock position , 11 centimeters from the nipple in the retroareolar region . the report states the mass was point four by two by three centimeters .
| 909
|
doctor: yep , definitely . based on those results , they decided to do an ultrasound-guided core needle biopsy on december 5th , 2019 . pathology results during that biopsy came back as grade two , er positive , pr positive , dcis , or ductal carcinoma in situ . patient: yes . unfortunately .
|
D2N031
| 7
|
[
"Personal History",
"Radiology Examination"
] |
[
"Subjective",
"Objective"
] |
yep , definitely . based on those results , they decided to do an ultrasound-guided core needle biopsy on december 5th , 2019 . pathology results during that biopsy came back as grade two , er positive , pr positive , dcis , or ductal carcinoma in situ .
| 910
|
doctor: i know . scary stuff . but you had a lumpectomy on january 20th , 2020 , which removed the eight millimeter tumor and margins were negative . the pathology confirmed dcis . looks like they also removed 5 lymph nodes , which , thankfully , were negative for malignancy . that's great ! patient: yeah , i was definitely very relieved .
|
D2N031
| 8
|
[
"Personal History"
] |
[
"Subjective"
] |
i know . scary stuff . but you had a lumpectomy on january 20th , 2020 , which removed the eight millimeter tumor and margins were negative . the pathology confirmed dcis . looks like they also removed 5 lymph nodes , which , thankfully , were negative for malignancy . that's great !
| 911
|
doctor: and your last mammogram was in january 2021 ? and that was normal . patient: yes .
|
D2N031
| 9
|
[
"Personal History"
] |
[
"Subjective"
] |
and your last mammogram was in january 2021 ? and that was normal .
| 912
|
doctor: okay . so , i feel like i have a good grasp of what's been going on with you now . and you're here today to establish care with me so i can continue to follow you and make sure you're doing well , right ? patient: yes . fingers crossed .
|
D2N031
| 10
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . so , i feel like i have a good grasp of what's been going on with you now . and you're here today to establish care with me so i can continue to follow you and make sure you're doing well , right ?
| 913
|
doctor: definitely . we'll keep a close eye on you and take good care of you . patient: okay , sounds good .
|
D2N031
| 11
|
[
"Chitchat"
] |
[
"Null"
] |
definitely . we'll keep a close eye on you and take good care of you .
| 914
|
doctor: i have a few more questions for you . when was your last colonoscopy ? patient: i had one in 2018 and , if i remember correctly , i had one polyp and that was removed and it was n't cancerous .
|
D2N031
| 12
|
[
"Personal History"
] |
[
"Subjective"
] |
i have a few more questions for you . when was your last colonoscopy ?
| 915
|
doctor: okay , yes , i see that report now . one polyp in the sigmoid colon which had a benign tubular adenoma . okay . and when was your last menstrual period ? patient: gosh . it was probably around 30 years ago .
|
D2N031
| 13
|
[
"Vegetative History"
] |
[
"Subjective"
] |
okay , yes , i see that report now . one polyp in the sigmoid colon which had a benign tubular adenoma . okay . and when was your last menstrual period ?
| 916
|
doctor: okay . do you have children ? patient: i do . i have five .
|
D2N031
| 14
|
[
"Other Socials"
] |
[
"Subjective"
] |
okay . do you have children ?
| 917
|
doctor: ah , big family then . that's nice . patient: yes . and they're all having kids of their own now , so it's getting even bigger .
|
D2N031
| 15
|
[
"Chitchat"
] |
[
"Null"
] |
ah , big family then . that's nice .
| 918
|
doctor: i bet . sounds like fun . patient: it is .
|
D2N031
| 16
|
[
"Chitchat"
] |
[
"Null"
] |
i bet . sounds like fun .
| 919
|
doctor: did you have any other pregnancies that were miscarriages or terminations ? patient: really , i did not .
|
D2N031
| 17
|
[
"Vegetative History"
] |
[
"Subjective"
] |
did you have any other pregnancies that were miscarriages or terminations ?
| 920
|
doctor: okay . so for the record , that's g5 p5 . and now that you're post-menopausal , are you currently or have you ever been on hormone replacement therapy ? patient: my primary care doctor gave me the option years ago but i decided against it .
|
D2N031
| 18
|
[
"Therapeutic History"
] |
[
"Subjective"
] |
okay . so for the record , that's g5 p5 . and now that you're post-menopausal , are you currently or have you ever been on hormone replacement therapy ?
| 921
|
doctor: okay . and on your review systems form , you indicated that you've not had any recent weight loss or gain , headaches , bone pain , urinary symptoms , or blood in the stools . but you did indicate that you have some back pain , joint pain , and high cholesterol . tell me some more about those . patient: okay . so i've seen doctors for all of those . they've said , excuse me , the back and knee pain are age-related . and the cholesterol is a fairly new diagnosis , but i am working on exercise and cutting back on fatty foods to see if i can get it lower without any medication .
|
D2N031
| 19
|
[
"Acute Symptoms",
"Vegetative History"
] |
[
"Subjective"
] |
okay . and on your review systems form , you indicated that you've not had any recent weight loss or gain , headaches , bone pain , urinary symptoms , or blood in the stools . but you did indicate that you have some back pain , joint pain , and high cholesterol . tell me some more about those .
| 922
|
doctor: okay . and your primary care doctor is following you for that , right ? patient: that's correct .
|
D2N031
| 20
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . and your primary care doctor is following you for that , right ?
| 923
|
doctor: okay . for medications , i have that you take coq10 , vitamin d , vitamin c , fish oil , and elderberry fruit . is that all right ? patient: yes , and that's all .
|
D2N031
| 21
|
[
"Therapeutic History"
] |
[
"Subjective"
] |
okay . for medications , i have that you take coq10 , vitamin d , vitamin c , fish oil , and elderberry fruit . is that all right ?
| 924
|
doctor: okay . so for your medical history , it's high cholesterol and stage 0 er/pr positive invasive ductal carcinoma of the right breast . any surgeries other than the lumpectomy ? patient: i did have my tubes tied after my last baby , but that's all .
|
D2N031
| 22
|
[
"Personal History"
] |
[
"Subjective"
] |
okay . so for your medical history , it's high cholesterol and stage 0 er/pr positive invasive ductal carcinoma of the right breast . any surgeries other than the lumpectomy ?
| 925
|
doctor: okay . and how about family history ? patient: my mom had non-hodgkin's lymphoma and my dad had prostate cancer and heart disease , but i think that's it .
|
D2N031
| 23
|
[
"Family History"
] |
[
"Subjective"
] |
okay . and how about family history ?
| 926
|
doctor: all right . any family history of breast cancer ? patient: none .
|
D2N031
| 24
|
[
"Family History"
] |
[
"Subjective"
] |
all right . any family history of breast cancer ?
| 927
|
doctor: did any of your children have medical issues or siblings with medical problems ? patient: i do not have any siblings and , thankfully , my children are all healthy .
|
D2N031
| 25
|
[
"Family History"
] |
[
"Subjective"
] |
did any of your children have medical issues or siblings with medical problems ?
| 928
|
doctor: wonderful . do you have any history of smoking , illicit drug use , heavy alcohol consumption ? patient: no drugs . i do drink socially , but never more than that . and i used to smoke , but really , everybody did back then and i probably quit about 30 years ago .
|
D2N031
| 26
|
[
"Drug History"
] |
[
"Subjective"
] |
wonderful . do you have any history of smoking , illicit drug use , heavy alcohol consumption ?
| 929
|
doctor: excellent . i have that you're allergic to penicillin . any other allergies ? patient: nope , just penicillin .
|
D2N031
| 27
|
[
"Personal History"
] |
[
"Subjective"
] |
excellent . i have that you're allergic to penicillin . any other allergies ?
| 930
|
doctor: okay . i think that covers it . hop up here and let me take a look at you . okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes . in the result section , note that her ecog performance status today is zero . do you have ... did you have radiation after the lumpectomy ? patient: i did . we also talked about endocrine therapy , but i decided against that .
|
D2N031
| 28
|
[
"Personal History",
"Physical Examination"
] |
[
"Subjective",
"Objective"
] |
okay . i think that covers it . hop up here and let me take a look at you . okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes . in the result section , note that her ecog performance status today is zero . do you have ... did you have radiation after the lumpectomy ?
| 931
|
doctor: okay . so your exam looks good , no masses , just some skin changes from that radiation . now , let's go over the plan for you . patient: okay , sounds good .
|
D2N031
| 29
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . so your exam looks good , no masses , just some skin changes from that radiation . now , let's go over the plan for you .
| 932
|
doctor: as you know , you've had dcis which we'll list in my note as stage zero , er/pr positive , invasive ductal carcinoma of the right breast . your status post-lumpectomy with removal of five lymph nodes that were benign . you also had , um , radiation therapy but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy and your mammogram in january , 2021 was also negative for recurrence and malignancy . so , based on all of that , we can just continue to observe you . patient: okay . that sounds great . and when do i come back in to see you ?
|
D2N031
| 30
|
[
"Follow-up",
"Reassessment"
] |
[
"Assessment",
"Plan"
] |
as you know , you've had dcis which we'll list in my note as stage zero , er/pr positive , invasive ductal carcinoma of the right breast . your status post-lumpectomy with removal of five lymph nodes that were benign . you also had , um , radiation therapy but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy and your mammogram in january , 2021 was also negative for recurrence and malignancy . so , based on all of that , we can just continue to observe you .
| 933
|
doctor: in a year , but you should have another mammogram in april of 2022 before you come back to see me . patient: okay , i can do that .
|
D2N031
| 31
|
[
"Discussion",
"Follow-up",
"Diagnostic Testing"
] |
[
"Plan"
] |
in a year , but you should have another mammogram in april of 2022 before you come back to see me .
| 934
|
doctor: wonderful . i'm glad to see you doing so well . do you have any questions or concerns i can address for you today ? patient: i do n't think so .
|
D2N031
| 32
|
[
"Discussion"
] |
[
"Plan"
] |
wonderful . i'm glad to see you doing so well . do you have any questions or concerns i can address for you today ?
| 935
|
doctor: okay , great . my nurse will be in shortly to discharge you . take care ! patient: you as well .
|
D2N031
| 33
|
[
"Chitchat"
] |
[
"Null"
] |
okay , great . my nurse will be in shortly to discharge you . take care !
| 936
|
doctor: good morning ms. reyes ! patient: good morning .
|
D2N032
| 0
|
[
"Greetings"
] |
[
"Subjective"
] |
good morning ms. reyes !
| 937
|
doctor: how are you doing ma'am ? patient: i'm doing well doctor , how are you ?
|
D2N032
| 1
|
[
"Chitchat"
] |
[
"Null"
] |
how are you doing ma'am ?
| 938
|
doctor: i am fine thank you . so you've been having some problems with your right hip ? patient: yeah .
|
D2N032
| 2
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
i am fine thank you . so you've been having some problems with your right hip ?
| 939
|
doctor: okay , and where are you hurting ? can you show me ? patient: right in the groin area .
|
D2N032
| 3
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay , and where are you hurting ? can you show me ?
| 940
|
doctor: okay , and this has been going on since february 2020 ? patient: yeah .
|
D2N032
| 4
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay , and this has been going on since february 2020 ?
| 941
|
doctor: okay . and is it worse with movement ? patient: well when it catches and i almost fall , yeah .
|
D2N032
| 5
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . and is it worse with movement ?
| 942
|
doctor: okay . so it kinda grabs you ? patient: yeah .
|
D2N032
| 6
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . so it kinda grabs you ?
| 943
|
doctor: okay , and this all started when you were walking ? patient: well , walking around the infusion room .
|
D2N032
| 7
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay , and this all started when you were walking ?
| 944
|
doctor: okay , so now it hurts whenever you move ? patient: it hurts when i pivot .
|
D2N032
| 9
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay , so now it hurts whenever you move ?
| 945
|
doctor: okay . so if you pivot then it hurts , got it . um ... patient: anything can sometimes do it . sometimes it wo n't though , and sometimes it'll do it several times in a row .
|
D2N032
| 10
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . so if you pivot then it hurts , got it . um ...
| 946
|
doctor: several times in a row , okay . patient: and sometimes i fall .
|
D2N032
| 11
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
several times in a row , okay .
| 947
|
doctor: okay . and you rate the pain to range from two through seven out of 10 ? patient: yeah , that's correct .
|
D2N032
| 12
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . and you rate the pain to range from two through seven out of 10 ?
| 948
|
doctor: okay . and are you experiencing fever or chills ? patient: no .
|
D2N032
| 13
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . and are you experiencing fever or chills ?
| 949
|
doctor: okay . and any tingling or numbness ? patient: no .
|
D2N032
| 14
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . and any tingling or numbness ?
| 950
|
doctor: and have you had any problems with your bowel or bladder ? patient: no .
|
D2N032
| 15
|
[
"Vegetative History"
] |
[
"Subjective"
] |
and have you had any problems with your bowel or bladder ?
| 951
|
doctor: okay . and if you stay still , do you feel better ? patient: yes , but i do n't want to stay still .
|
D2N032
| 16
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay . and if you stay still , do you feel better ?
| 952
|
doctor: i understand , no problem . and for past medical history , do you have anything going on ? patient: i've had a lot of surgeries . i've had pcl , i had infertility , a gall bladder removed , but that's it .
|
D2N032
| 17
|
[
"Personal History"
] |
[
"Subjective"
] |
i understand , no problem . and for past medical history , do you have anything going on ?
| 953
|
doctor: okay . and for family history , it looks like there's high blood pressure , diabetes , thyroid disease , heart disease , kidney disease and gastric ulcers . for your current medications , it does n't look like you're taking anything at this time . and you're allergic to percocet , vicodin and regulin . and it looks like you've had intentional weight loss ? patient: yes , i've lost 110 pounds .
|
D2N032
| 18
|
[
"Family History",
"Personal History",
"Therapeutic History"
] |
[
"Subjective"
] |
okay . and for family history , it looks like there's high blood pressure , diabetes , thyroid disease , heart disease , kidney disease and gastric ulcers . for your current medications , it does n't look like you're taking anything at this time . and you're allergic to percocet , vicodin and regulin . and it looks like you've had intentional weight loss ?
| 954
|
doctor: that is awesome . and how did you do that ? patient: with weight watchers .
|
D2N032
| 19
|
[
"Personal History"
] |
[
"Subjective"
] |
that is awesome . and how did you do that ?
| 955
|
doctor: that's great . patient: mm-hmm .
|
D2N032
| 20
|
[
"Chitchat"
] |
[
"Null"
] |
that's great .
| 956
|
doctor: and how many months have you been participating in weight watchers ? patient: i started in 2018 , and i've been at my current weight for a little over a year .
|
D2N032
| 21
|
[
"Other Socials",
"Vegetative History"
] |
[
"Subjective"
] |
and how many months have you been participating in weight watchers ?
| 957
|
doctor: that is awesome . patient: yeah , thank you .
|
D2N032
| 22
|
[
"Chitchat"
] |
[
"Null"
] |
that is awesome .
| 958
|
doctor: yeah , very good , and congratulations . and so , for social history , it looks like you work at an infusion center ? patient: yes , over at .
|
D2N032
| 23
|
[
"Other Socials"
] |
[
"Subjective"
] |
yeah , very good , and congratulations . and so , for social history , it looks like you work at an infusion center ?
| 959
|
doctor: okay . and you live with your roommate , no history of tobacco and you limit alcohol intake to less than five drinks per month . patient: that's correct .
|
D2N032
| 24
|
[
"Other Socials",
"Drug History"
] |
[
"Subjective"
] |
okay . and you live with your roommate , no history of tobacco and you limit alcohol intake to less than five drinks per month .
| 960
|
doctor: all right . well let's go ahead and take a look at your hip . patient: okay .
|
D2N032
| 25
|
[
"Physical Examination"
] |
[
"Objective"
] |
all right . well let's go ahead and take a look at your hip .
| 961
|
doctor: please use my general physical exam template . physical exam . ms. reyes is a pleasant 56-year-old woman who is five feet , six inches in height , weighing 169 pounds . blood pressure is 115 over 75 . pulse rate is 67 . ankles , no ankle edema is noted , no calf tenderness . okay , ms. reyes , can you go ahead and stand up for me please and take a couple of steps ? great . patient: okay .
|
D2N032
| 26
|
[
"Physical Examination"
] |
[
"Objective"
] |
please use my general physical exam template . physical exam . ms. reyes is a pleasant 56-year-old woman who is five feet , six inches in height , weighing 169 pounds . blood pressure is 115 over 75 . pulse rate is 67 . ankles , no ankle edema is noted , no calf tenderness . okay , ms. reyes , can you go ahead and stand up for me please and take a couple of steps ? great .
| 962
|
doctor: and can you walk on your tippy toes ? good , okay . and can you walk on your heels ? kind of a heel walk and toe walk are intact . um , go ahead and turn around please . patient: okay .
|
D2N032
| 27
|
[
"Physical Examination"
] |
[
"Objective"
] |
and can you walk on your tippy toes ? good , okay . and can you walk on your heels ? kind of a heel walk and toe walk are intact . um , go ahead and turn around please .
| 963
|
doctor: examination of the cervical spine , any pain here now ? patient: no .
|
D2N032
| 28
|
[
"Physical Examination"
] |
[
"Objective"
] |
examination of the cervical spine , any pain here now ?
| 964
|
doctor: okay , no tenderness . look at your right and your left and then over to the right , then go ahead and look up , then look down , and look straight ahead . range of motion is full in the neck without pain . spurling's test is negative . exam of the low back . any pain here ? patient: no .
|
D2N032
| 29
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay , no tenderness . look at your right and your left and then over to the right , then go ahead and look up , then look down , and look straight ahead . range of motion is full in the neck without pain . spurling's test is negative . exam of the low back . any pain here ?
| 965
|
doctor: okay . skin is intact , no midline tenderness to palpitation . go ahead and lean back . and lean to your right , to your left . does that hurt at all ? patient: no .
|
D2N032
| 30
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . skin is intact , no midline tenderness to palpitation . go ahead and lean back . and lean to your right , to your left . does that hurt at all ?
| 966
|
doctor: okay , great . and go ahead and bend forward and then come back up . and that does n't bother you ? patient: no . i did or do have several bulging discs .
|
D2N032
| 31
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay , great . and go ahead and bend forward and then come back up . and that does n't bother you ?
| 967
|
doctor: okay . but you're not hurting right now ? patient: no , the weight loss has really decreased all the pain .
|
D2N032
| 32
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . but you're not hurting right now ?
| 968
|
doctor: okay . range of motion is decreased in exertion . lateral flection without pain . any pain when i push ? patient: no .
|
D2N032
| 33
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . range of motion is decreased in exertion . lateral flection without pain . any pain when i push ?
| 969
|
doctor: okay . you can go ahead and , um , sit down please . no pain ? patient: no .
|
D2N032
| 34
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . you can go ahead and , um , sit down please . no pain ?
| 970
|
doctor: okay . sacroiliac signs are negative . examination of the hips . trochanteric is non tender . go ahead and lift your knee up , does that bother you ? patient: um , just a little bit .
|
D2N032
| 35
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . sacroiliac signs are negative . examination of the hips . trochanteric is non tender . go ahead and lift your knee up , does that bother you ?
| 971
|
doctor: okay , little bit . and then back one , probably bothers you ? patient: right there , like there , yeah .
|
D2N032
| 36
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay , little bit . and then back one , probably bothers you ?
| 972
|
doctor: okay . how about this way ? not too bad ? patient: no .
|
D2N032
| 37
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . how about this way ? not too bad ?
| 973
|
doctor: okay . range of motion is decreased in right hip with pain in the groin and internal and external rotation . okay , go ahead and keep it up , do n't let me push it down . does that hurt ? patient: right there .
|
D2N032
| 38
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . range of motion is decreased in right hip with pain in the groin and internal and external rotation . okay , go ahead and keep it up , do n't let me push it down . does that hurt ?
| 974
|
doctor: okay . resisted right hip flection causes pain in the right groin region . no tenderness is noted . do you feel me touching you all the way down ? patient: yeah .
|
D2N032
| 39
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . resisted right hip flection causes pain in the right groin region . no tenderness is noted . do you feel me touching you all the way down ?
| 975
|
doctor: okay . motor control is normal in the lower extremities . go ahead and lift your knee up . patient: okay .
|
D2N032
| 40
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . motor control is normal in the lower extremities . go ahead and lift your knee up .
| 976
|
doctor: okay , lift it up . any pain ? patient: no .
|
D2N032
| 41
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay , lift it up . any pain ?
| 977
|
doctor: okay . and this one ? patient: yeah .
|
D2N032
| 42
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay . and this one ?
| 978
|
doctor: and squeeze your knees together , push it out and kick your leg out straight . now go ahead and bring it back and kick it out straight again . and go ahead and lean back , keep it loose . okay , all set . you can go ahead and sit up now . patient: okay , thank you .
|
D2N032
| 43
|
[
"Physical Examination"
] |
[
"Objective"
] |
and squeeze your knees together , push it out and kick your leg out straight . now go ahead and bring it back and kick it out straight again . and go ahead and lean back , keep it loose . okay , all set . you can go ahead and sit up now .
| 979
|
doctor: you're welcome . so what i think we're dealing with is right hip degenerative joint disease . patient: okay .
|
D2N032
| 44
|
[
"Acute Assessment"
] |
[
"Assessment"
] |
you're welcome . so what i think we're dealing with is right hip degenerative joint disease .
| 980
|
doctor: and we do have some options . so first is to start some low impact exercises . i can provide you with a hand out with what exercises you can do . you should take nsaids as needed to help with the pain and discomfort , as well as use of a cane to help offload the right side . a cane will help support your painful side to help reduce the pain . patient: hmm , i do n't love that idea but i'll give it a try .
|
D2N032
| 45
|
[
"Referral"
] |
[
"Plan"
] |
and we do have some options . so first is to start some low impact exercises . i can provide you with a hand out with what exercises you can do . you should take nsaids as needed to help with the pain and discomfort , as well as use of a cane to help offload the right side . a cane will help support your painful side to help reduce the pain .
| 981
|
doctor: okay , that would be great . and we can also try a cortisone injection into the right hip joint to see if that offers any relief . patient: i would like to definitely get the injection .
|
D2N032
| 46
|
[
"Medication"
] |
[
"Plan"
] |
okay , that would be great . and we can also try a cortisone injection into the right hip joint to see if that offers any relief .
| 982
|
doctor: okay . we can take care of that today while you're here and then schedule a follow up appointment in three months to see how you're doing , and then receive another injection if needed . patient: okay , that sounds good .
|
D2N032
| 47
|
[
"Follow-up",
"Medication"
] |
[
"Plan"
] |
okay . we can take care of that today while you're here and then schedule a follow up appointment in three months to see how you're doing , and then receive another injection if needed .
| 983
|
doctor: okay . and here are the risks associated with getting the inje- injection . um , please just take a moment to review it and consent to the shot . patient: i'm good .
|
D2N032
| 48
|
[
"Discussion",
"Medication"
] |
[
"Plan"
] |
okay . and here are the risks associated with getting the inje- injection . um , please just take a moment to review it and consent to the shot .
| 984
|
doctor: great . we'll get that set up for ya . all right , well i hope things , um , feel better , and we will see you back here in three months . patient: see you . have a nice day .
|
D2N032
| 49
|
[
"Chitchat"
] |
[
"Null"
] |
great . we'll get that set up for ya . all right , well i hope things , um , feel better , and we will see you back here in three months .
| 985
|
doctor: thank you so much , you as well . deep tendon reflex is one plus throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list ? next radiographs , mr arthrogram of the right hip done june 3rd 2021 show high grade condromalacia involving the interosuperior right acetabulum with subchondral marrow edema and cyst formation . next paragraph plan . options include low impact exercise program , use of an nsaid and use of a cane to offload the right . we discussed that she'd like to proceed with the cortisone injection in right hip joint . i explained the risks of injection , including needles , sterile and covid . she understood and decided to proceed with the injection . she will follow up with me in three months for another injection if needed . end of dictation .
|
D2N032
| 50
|
[
"Radiology Examination",
"Physical Examination",
"Medication",
"Discussion",
"Follow-up"
] |
[
"Objective",
"Assessment",
"Plan"
] |
doctor: thank you so much , you as well . deep tendon reflex is one plus throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list ? next radiographs , mr arthrogram of the right hip done june 3rd 2021 show high grade condromalacia involving the interosuperior right acetabulum with subchondral marrow edema and cyst formation . next paragraph plan . options include low impact exercise program , use of an nsaid and use of a cane to offload the right . we discussed that she'd like to proceed with the cortisone injection in right hip joint . i explained the risks of injection , including needles , sterile and covid . she understood and decided to proceed with the injection . she will follow up with me in three months for another injection if needed . end of dictation .
| 986
|
doctor: so sophia i see that you you hurt your knee tell me about what happened patient: yeah i was jumping on my kid's trampoline and i could just slipped out from under me
|
D2N033
| 0
|
[
"Acute Symptoms",
"Greetings"
] |
[
"Subjective"
] |
so sophia i see that you you hurt your knee tell me about what happened
| 987
|
doctor: my gosh one of those big trampolines in your back yard patient: yeah a pretty big one
|
D2N033
| 1
|
[
"Chitchat"
] |
[
"Null"
] |
my gosh one of those big trampolines in your back yard
| 988
|
doctor: okay which knee was it patient: my right knee
|
D2N033
| 2
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay which knee was it
| 989
|
doctor: right knee okay and when did this happen patient: about four days ago
|
D2N033
| 3
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
right knee okay and when did this happen
| 990
|
doctor: great the weather was perfect this weekend so i'm glad you at least got outside sorry to hear you got hurt okay so your right knee did you did you feel it like pop or or snap or anything when you hurt it patient: yeah i felt a little pop and then it swelled up really big afterward
|
D2N033
| 4
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
great the weather was perfect this weekend so i'm glad you at least got outside sorry to hear you got hurt okay so your right knee did you did you feel it like pop or or snap or anything when you hurt it
| 991
|
doctor: okay did you try anything for the pain patient: i took some ibuprofen and i put some ice on it
|
D2N033
| 5
|
[
"Acute Symptoms",
"Therapeutic History"
] |
[
"Subjective"
] |
okay did you try anything for the pain
| 992
|
doctor: okay did that help patient: a little bit but it's still really hard to get around
|
D2N033
| 6
|
[
"Acute Symptoms",
"Therapeutic History"
] |
[
"Subjective"
] |
okay did that help
| 993
|
doctor: alright and have you have you been able to stand on it or does that hurt too much patient: it hurts quite a bit to stand but i am able to put weight on it
|
D2N033
| 7
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
alright and have you have you been able to stand on it or does that hurt too much
| 994
|
doctor: okay alright and what part of the knee is it inside outside middle patient: kind of that inside part of my kneecap
|
D2N033
| 8
|
[
"Acute Symptoms"
] |
[
"Subjective"
] |
okay alright and what part of the knee is it inside outside middle
| 995
|
doctor: okay alright and okay so as long as you're here and then your primary care physician i'm looking through your chart and it looks like we're treating your diabetes so how you've been doing with your your diet overall are you are you keeping your sugars low patient: it's going okay i i forget to check quite a bit though
|
D2N033
| 9
|
[
"Personal History"
] |
[
"Subjective"
] |
okay alright and okay so as long as you're here and then your primary care physician i'm looking through your chart and it looks like we're treating your diabetes so how you've been doing with your your diet overall are you are you keeping your sugars low
| 996
|
doctor: yeah i understand how has your diet been lately patient: it's been pretty good
|
D2N033
| 11
|
[
"Personal History"
] |
[
"Subjective"
] |
yeah i understand how has your diet been lately
| 997
|
doctor: okay okay good good you know it's hard to stay away from the sugary foods sometimes i i enjoy ice cream regularly okay so let's do physical exam as long as you are here so i'm just gon na listen to your heart your heart sounds normal no murmurs or gallops listen to your lungs quick if you can take a deep breath lungs are clear that's good news let's take a look at that knee right knee looks like it definitely has some swelling i'm gon na do some maneuvers here does it hurt when i push you on the inside of the knee patient: yeah that hurts
|
D2N033
| 12
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay okay good good you know it's hard to stay away from the sugary foods sometimes i i enjoy ice cream regularly okay so let's do physical exam as long as you are here so i'm just gon na listen to your heart your heart sounds normal no murmurs or gallops listen to your lungs quick if you can take a deep breath lungs are clear that's good news let's take a look at that knee right knee looks like it definitely has some swelling i'm gon na do some maneuvers here does it hurt when i push you on the inside of the knee
| 998
|
doctor: okay how about the outside patient: a little bit but not as much
|
D2N033
| 13
|
[
"Physical Examination"
] |
[
"Objective"
] |
okay how about the outside
| 999
|
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