DATEXIS/med_intent_classification · Datasets at Hugging Face

text stringlengths 6 3.62k	intents listlengths 1 9	sections listlengths 1 4	__index_level_0__ int64 0 3.89k
hi , james , how are you ?	[ "Greetings" ]	[ "Subjective" ]	1,300
doctor: okay . come with me , we'll get you checked out . hey dragon , finalize the note .	[ "Chitchat" ]	[ "Null" ]	1,301
so logan is a 58 year old male , with a past medical history significant for diabetes type 2 , hypertension , osteoarthritis , who presents today with some back pain .	[ "Acute Symptoms", "Personal History" ]	[ "Subjective" ]	1,302
uh , you're gon na hear me talk throughout your exam , just so i can make sure i get everything documented .	[ "Chitchat" ]	[ "Null" ]	1,303
alright so did the tylenol help	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	1,304
right i want you you can talk about those things yes	[ "Chitchat" ]	[ "Null" ]	1,305
how are you doing ?	[ "Personal History" ]	[ "Subjective" ]	1,306
okay and you've never injured that right elbow before	[ "Personal History" ]	[ "Subjective" ]	1,307
okay . and all right , let's go ahead do a quick physical exam . hey , dragon , show me the vitals . so looking here at your vital signs today , um , they look really good . so i'm just gon na go ahead and take a listen to your heart and lungs .	[ "Physical Examination" ]	[ "Objective" ]	1,308
thc gummies	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	1,309
okay . and then in terms of your multiple sclerosis , when was the last time you saw the neurologist ?	[ "Personal History" ]	[ "Subjective" ]	1,310
understood . okay . are you taking your medications regularly ?	[ "Therapeutic History" ]	[ "Subjective" ]	1,311
and was everything all right after that ?	[ "Acute Symptoms" ]	[ "Subjective" ]	1,312
please use my general exam template , all right . just take a few breaths .	[ "Chitchat" ]	[ "Null" ]	1,313
okay , all right . and any , have you passed out at all , or anything like that ? any weight loss ?	[ "Acute Symptoms", "Vegetative History" ]	[ "Subjective" ]	1,314
right .	[ "Discussion", "Medication" ]	[ "Plan" ]	1,315
doctor: alright great	[ "Chitchat" ]	[ "Null" ]	1,316
so hitting the car in front of you all made that finger go backwards ?	[ "Acute Symptoms" ]	[ "Subjective" ]	1,317
okay and does the ibuprofen help with that pain	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	1,318
those are huge words it's okay so let me tell you what like what all this means and what we're gon na do like for my assessment and plan so for your problem of chronic lumbar back pain based on your symptoms your exam and reviewing your mri that's consistent with a herniated disk at the l4 l5 with radiculopathy what this means is that one of your disks that sits between your spinal vertebrae is bulging out and this bulge is pinching on some nerves that's why you feel the tingling in your leg alright so that it's also why you felt pain when i pushed on that area so i'm gon na recommend some a spinal injection with a strong anti-inflammatory medication called a corticosteroid right i think you said that you had one before but i think this is something	[ "Discussion", "Medication", "Acute Assessment" ]	[ "Assessment", "Plan" ]	1,319
okay now do you have other symptoms such as weight loss constipation vomiting or issues with urination	[ "Vegetative History" ]	[ "Subjective" ]	1,320
okay well that that sounds like a good plan we can definitely help you out with that alright so i'm gon na do a quick physical exam on you looks like your blood pressure is a little bit elevated and i think that's probably because you're in pain and that's understandable everything else looks fine so on pressing on your abdomen does that hurt	[ "Physical Examination" ]	[ "Objective" ]	1,321
it's good to see you as well . so i know that the nurse told you about dax . i'd like to tell dax a little bit about you .	[ "Chitchat" ]	[ "Null" ]	1,322
yeah , let's plan to talk again in six weeks . so if you stop at the desk on your way out today , they're going to get you set up for a telemedicine visit . and that visit'll just be to check in and see how you're doing and make sure things are progressing okay .	[ "Follow-up" ]	[ "Plan" ]	1,323
hey brandon you know glad to see you in here today i see on your chart that you're experiencing some neck pain could you tell me a bit about what happened	[ "Acute Symptoms", "Greetings" ]	[ "Subjective" ]	1,324
so , i know the nurse told you about dax . i'd like to tell dax a little bit about you .	[ "Chitchat" ]	[ "Null" ]	1,325
hmmm okay does the pain radiate anywhere like down to your arm up to your shoulder or anywhere else	[ "Acute Symptoms" ]	[ "Subjective" ]	1,326
okay alright and do you notice that pain radiates anywhere or moves you know any or anywhere	[ "Vegetative History" ]	[ "Subjective" ]	1,327
okay , all right . and are you taking your medication , are you taking the lisinopril ?	[ "Therapeutic History" ]	[ "Subjective" ]	1,328
all right . and i'll rewrite your instructions here .	[ "Chitchat" ]	[ "Null" ]	1,329
okay . um , so how frequently have you been getting or having a bowel movement on normal days ?	[ "Acute Symptoms" ]	[ "Subjective" ]	1,330
do n't weigh all so speaking of eating let's talk a little bit about your diet i see here on your chart that you're a type two diabetic and it looked like that you were gon na handle that with diet and exercise let's talk about that a little bit	[ "Personal History" ]	[ "Subjective" ]	1,331
and do you check your blood sugars every morning at home	[ "Personal History" ]	[ "Subjective" ]	1,332
alright so let's just continue with ibuprofen you can take you know six hundred to eight hundred milligrams every eight hours as needed i wan na go ahead and put you in a brace that's gon na help your knee feel a bit more supported okay and let's go ahead and i'm hoping that we can get this mri done in you know the next couple days and then we can have a conversation about what needs to be done now you said that you are are are you know obviously a very active active mom any other exercise or anything else that that i should be aware of that you do just wondering in terms of which kind of graft we would use to fix this with your with your acl being injured	[ "Follow-up", "Medication", "Diagnostic Testing" ]	[ "Plan" ]	1,333
alright sounds good we will get the nurse come in and she will take care of you and i will see you in two weeks	[ "Follow-up" ]	[ "Plan" ]	1,334
. for the next , uh , at least just three to four weeks .	[ "Discussion" ]	[ "Plan" ]	1,335
hey , dragon . show me the chest x-ray . so , i reviewed the results of your chest x-ray and everything looks good . there's no airspace disease , there's no pneumonia , so that's all very , very good , okay ?	[ "Radiology Examination" ]	[ "Objective" ]	1,336
okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again .	[ "Follow-up", "Medication", "Acute Assessment" ]	[ "Assessment", "Plan" ]	1,337
all right , well just let your knees just op- relax and open . how's the itching or discomfort ? are you still using the cream ?	[ "Physical Examination", "Therapeutic History" ]	[ "Subjective", "Objective" ]	1,338
nice have you been into the new home depot that they just opened down the street here	[ "Chitchat" ]	[ "Null" ]	1,339
mm-hmm .	[ "Acute Symptoms" ]	[ "Subjective" ]	1,340
and then i also wan na go ahead and prescribe meloxicam fifteen milligrams once a day	[ "Medication" ]	[ "Plan" ]	1,341
okay so how how are you feeling on your chemo see you're on a combination of sysplatin and a topicide you had your last dose a few days ago any nausea any fatigue from that	[ "Therapeutic History" ]	[ "Subjective" ]	1,342
how's your back pain ?	[ "Acute Symptoms" ]	[ "Subjective" ]	1,343
are you serious	[ "Chitchat" ]	[ "Null" ]	1,344
okay ? um , how about your epilepsy , any seizures recently ?	[ "Acute Symptoms", "Personal History" ]	[ "Subjective" ]	1,345
doctor: alright great	[ "Chitchat" ]	[ "Null" ]	1,346
okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct	[ "Personal History" ]	[ "Subjective" ]	1,347
you're welcome .	[ "Chitchat" ]	[ "Null" ]	1,348
okay . no chest pains or pressure or tightness ?	[ "Acute Symptoms", "Vegetative History" ]	[ "Subjective" ]	1,349
alright so looking here at your appointment notes it says you're you're here you think you have a kidney stone you had some in the past so we're gon na take a look at that and then you also have a past medical history of hypertension and diabetes we want to take a look at those as well so first thing what's going on with your kidneys you as what how long ago have you been feeling pain and and how's all that	[ "Personal History" ]	[ "Subjective" ]	1,350
all right-y . okay . and it also looks like ashley has seen a gi and a geneticist , where they did n't find anything sig ... clinically significant mutations on the panel that they did .	[ "Personal History" ]	[ "Subjective" ]	1,351
okay good so tell me what conditions what kind of conditions run in your family like is there do you have hypertension diabetes or	[ "Family History" ]	[ "Subjective" ]	1,352
okay alright so you said you were raking leaves and now it's been kind of that weather outside for cleaning out the yard have you been doing a lot of yard work lately	[ "Other Socials" ]	[ "Subjective" ]	1,353
okay . do you have any questions ?	[ "Discussion" ]	[ "Plan" ]	1,354
so i see here that you looks like you hurt your left foot here where you were playing soccer can you tell me a little bit more about what happened	[ "Acute Symptoms" ]	[ "Subjective" ]	1,355
all right . um , and how about from a diabetes standpoint ? how ... how's your blood sugar been running ? especially now that you kind of have this , like , acute thing going on ? have your blood sugars been okay ?	[ "Personal History" ]	[ "Subjective" ]	1,356
okay so you have left side low back pain	[ "Therapeutic History" ]	[ "Subjective" ]	1,357
okay . hey , dragon , uh , sharon brooks is a 48 year old female here for right finger pain . all right . so , tell me what happened .	[ "Acute Symptoms" ]	[ "Subjective" ]	1,358
okay . and no chest pain while you were , you know , doing exercises in pt for your knee ?	[ "Personal History" ]	[ "Subjective" ]	1,359
okay . well it will certainly help your blood pressure if you're able to stop drinking .	[ "Vegetative History" ]	[ "Subjective" ]	1,360
we'll get we'll get to that too	[ "Chitchat" ]	[ "Null" ]	1,361
so dennis is a 57 -year-old male today complaining of shortness of breath he has also got a history of diabetes high blood pressure and history of asthma so dennis tell me what's going on how're you doing	[ "Acute Symptoms", "Personal History", "Greetings" ]	[ "Subjective" ]	1,362
okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here	[ "Personal History" ]	[ "Subjective" ]	1,363
that sounds fun but i'm i'm sad as you hurt your knee doing it so for your knee pain are you are you able to bear weight on that leg the left leg	[ "Acute Symptoms" ]	[ "Subjective" ]	1,364
okay and which knee are we talking about	[ "Acute Symptoms" ]	[ "Subjective" ]	1,365
okay so and you're using motrin for for ibuprofen for for the pain well let me go ahead and take a take a look here at your is it both hands or just your right hand	[ "Physical Examination" ]	[ "Objective" ]	1,366
okay . and you rate the pain to range from two through seven out of 10 ?	[ "Acute Symptoms" ]	[ "Subjective" ]	1,367
alright okay so do you have any more questions before i send my nurse in	[ "Discussion" ]	[ "Plan" ]	1,368
i'm so sorry to hear that .	[ "Family History" ]	[ "Subjective" ]	1,369
alright you know let's give it a couple of weeks and let's give it two weeks and then call me back and we'll get you an mri if it's still not improving	[ "Follow-up", "Diagnostic Testing" ]	[ "Plan" ]	1,370
doctor: all right . hey , dragon , finalize the note .	[ "Chitchat" ]	[ "Null" ]	1,371
also your recent labs showed an elevated alkaline phosphatase level at 156 . now this could be related to your liver but most likely related to your bone health . we're going to check a few labs today .	[ "Lab Examination" ]	[ "Objective" ]	1,372
all right . do you ever drink alcohol ?	[ "Drug History" ]	[ "Subjective" ]	1,373
can you take a big breath randy .	[ "Physical Examination" ]	[ "Objective" ]	1,374
okay good .	[ "Chitchat" ]	[ "Null" ]	1,375
yeah . what's a long bike ride to you ?	[ "Personal History" ]	[ "Subjective" ]	1,376
that sounds like it hurt .	[ "Acute Symptoms" ]	[ "Subjective" ]	1,377
okay and where exactly on your shoulder does it hurt	[ "Acute Symptoms" ]	[ "Subjective" ]	1,378
okay . all right . um , and did they have anything to say ? i have n't gotten any reports from them , so ...	[ "Therapeutic History" ]	[ "Subjective" ]	1,379
goodness	[ "Chitchat" ]	[ "Null" ]	1,380
okay so pain with lumbar flexion and so i'm gon na have you lie down and we're gon na do i'm sorry okay and then i see that a supine straight leg test is positive alright so for your neurological exam you said that you are experiencing pain radiating down radiating down your left leg correct	[ "Physical Examination" ]	[ "Objective" ]	1,381
doctor: diagnosis will be pituitary adenoma . mr . ward is a very pleasant 52-year-old male who has benign appearing pituitary adenoma , incidentally discovered during workup for worsening headaches . he is symptomatic with clinical and radiographical evidence of optic chiasmal compression , therefor surgical intervention to excise and decompress the pituitary fossa is indicated . end of note .	[ "Acute Assessment", "Other Treatments" ]	[ "Assessment", "Plan" ]	1,382
sure sure	[ "Other Socials" ]	[ "Subjective" ]	1,383
i do n't think that's what we'll find , but we'll see .	[ "Discussion" ]	[ "Plan" ]	1,384
okay alright good so has has karen had any seizures in the past	[ "Personal History" ]	[ "Subjective" ]	1,385
okay alright and you let's see other than the the tennis you know increase in tennis activity you have n't had any trauma recently falling on it or you know felt a pop anywhere or anything like that have you	[ "Personal History", "Other Socials" ]	[ "Subjective" ]	1,386
okay , any recent fever , chills ?	[ "Vegetative History" ]	[ "Subjective" ]	1,387
hi , andrew , how are you ?	[ "Greetings" ]	[ "Subjective" ]	1,388
okay . and how'bout right there ? no ?	[ "Physical Examination" ]	[ "Objective" ]	1,389
okay . all right . so , on physical exam , you know , everything looks good . on your heart exam , i do appreciate a slight three out of six systolic ejection murmur , but we've heard that in the past .	[ "Physical Examination" ]	[ "Objective" ]	1,390
so- can you start at the beginning ? i know she's a twin , so are these your first two babies ?	[ "Personal History", "Other Socials" ]	[ "Subjective" ]	1,391
pharmacy is what i'm trying to say .	[ "Discussion", "Medication" ]	[ "Plan" ]	1,392
did that help at all	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	1,393
alright so listen to your lungs so your lungs are clear bilaterally listen to your heart so your heart exam you do still have that grade two out of six systolic ejection murmur but we know it about that before so let me take a look at your elbow so when i press right here on the back of your elbow is that painful	[ "Physical Examination" ]	[ "Objective" ]	1,394
okay . and you take uh- uh , fluocinonide for that ?	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	1,395
no , i have a low suspicion that it will show anything .	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	1,396
i do n't expect that to happen , but , you know , if it does , you have the tools . um , then you'll be seeing me for a followup . we can figure out what to do next . i would say if it's getting worse rather than better , just give me a call or send me a mychart message , okay ?	[ "Discussion", "Follow-up" ]	[ "Plan" ]	1,397
okay . hey dragon , order methotrexate , 2.5 mg once weekly . for your second problem , the atrial fibrillation . so , you're going in and out of a-fib and i'd like to just keep you in normal sinus rhythm . so , i wan na go ahead and refer you to cardiology for a cardiac ablation which just maps out where that rhythm is coming from and burns it so it does n't come back . okay ? you're young , we wan na keep you in a normal rhythm and , being that you're going in and out of a-fib , i think that's what we should do . okay ?	[ "Discussion", "Referral", "Reassessment" ]	[ "Assessment", "Plan" ]	1,398
you can take tylenol if you want .	[ "Discussion", "Medication" ]	[ "Plan" ]	1,399

hi , james , how are you ?

[ "Greetings" ]

[ "Subjective" ]

1,300

doctor: okay . come with me , we'll get you checked out . hey dragon , finalize the note .

[ "Chitchat" ]

[ "Null" ]

1,301

so logan is a 58 year old male , with a past medical history significant for diabetes type 2 , hypertension , osteoarthritis , who presents today with some back pain .

[ "Acute Symptoms", "Personal History" ]

[ "Subjective" ]

1,302

uh , you're gon na hear me talk throughout your exam , just so i can make sure i get everything documented .

[ "Chitchat" ]

[ "Null" ]

1,303

alright so did the tylenol help

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

1,304

right i want you you can talk about those things yes

[ "Chitchat" ]

[ "Null" ]

1,305

how are you doing ?

[ "Personal History" ]

[ "Subjective" ]

1,306

okay and you've never injured that right elbow before

[ "Personal History" ]

[ "Subjective" ]

1,307

okay . and all right , let's go ahead do a quick physical exam . hey , dragon , show me the vitals . so looking here at your vital signs today , um , they look really good . so i'm just gon na go ahead and take a listen to your heart and lungs .

[ "Physical Examination" ]

[ "Objective" ]

1,308

thc gummies

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

1,309

okay . and then in terms of your multiple sclerosis , when was the last time you saw the neurologist ?

[ "Personal History" ]

[ "Subjective" ]

1,310

understood . okay . are you taking your medications regularly ?

[ "Therapeutic History" ]

[ "Subjective" ]

1,311

and was everything all right after that ?

[ "Acute Symptoms" ]

[ "Subjective" ]

1,312

please use my general exam template , all right . just take a few breaths .

[ "Chitchat" ]

[ "Null" ]

1,313

okay , all right . and any , have you passed out at all , or anything like that ? any weight loss ?

[ "Acute Symptoms", "Vegetative History" ]

[ "Subjective" ]

1,314

right .

[ "Discussion", "Medication" ]

[ "Plan" ]

1,315

doctor: alright great

[ "Chitchat" ]

[ "Null" ]

1,316

so hitting the car in front of you all made that finger go backwards ?

[ "Acute Symptoms" ]

[ "Subjective" ]

1,317

okay and does the ibuprofen help with that pain

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

1,318

those are huge words it's okay so let me tell you what like what all this means and what we're gon na do like for my assessment and plan so for your problem of chronic lumbar back pain based on your symptoms your exam and reviewing your mri that's consistent with a herniated disk at the l4 l5 with radiculopathy what this means is that one of your disks that sits between your spinal vertebrae is bulging out and this bulge is pinching on some nerves that's why you feel the tingling in your leg alright so that it's also why you felt pain when i pushed on that area so i'm gon na recommend some a spinal injection with a strong anti-inflammatory medication called a corticosteroid right i think you said that you had one before but i think this is something

[ "Discussion", "Medication", "Acute Assessment" ]

[ "Assessment", "Plan" ]

1,319

okay now do you have other symptoms such as weight loss constipation vomiting or issues with urination

[ "Vegetative History" ]

[ "Subjective" ]

1,320

okay well that that sounds like a good plan we can definitely help you out with that alright so i'm gon na do a quick physical exam on you looks like your blood pressure is a little bit elevated and i think that's probably because you're in pain and that's understandable everything else looks fine so on pressing on your abdomen does that hurt

[ "Physical Examination" ]

[ "Objective" ]

1,321

it's good to see you as well . so i know that the nurse told you about dax . i'd like to tell dax a little bit about you .

[ "Chitchat" ]

[ "Null" ]

1,322

yeah , let's plan to talk again in six weeks . so if you stop at the desk on your way out today , they're going to get you set up for a telemedicine visit . and that visit'll just be to check in and see how you're doing and make sure things are progressing okay .

[ "Follow-up" ]

[ "Plan" ]

1,323

hey brandon you know glad to see you in here today i see on your chart that you're experiencing some neck pain could you tell me a bit about what happened

[ "Acute Symptoms", "Greetings" ]

[ "Subjective" ]

1,324

so , i know the nurse told you about dax . i'd like to tell dax a little bit about you .

[ "Chitchat" ]

[ "Null" ]

1,325

hmmm okay does the pain radiate anywhere like down to your arm up to your shoulder or anywhere else

[ "Acute Symptoms" ]

[ "Subjective" ]

1,326

okay alright and do you notice that pain radiates anywhere or moves you know any or anywhere

[ "Vegetative History" ]

[ "Subjective" ]

1,327

okay , all right . and are you taking your medication , are you taking the lisinopril ?

[ "Therapeutic History" ]

[ "Subjective" ]

1,328

all right . and i'll rewrite your instructions here .

[ "Chitchat" ]

[ "Null" ]

1,329

okay . um , so how frequently have you been getting or having a bowel movement on normal days ?

[ "Acute Symptoms" ]

[ "Subjective" ]

1,330

do n't weigh all so speaking of eating let's talk a little bit about your diet i see here on your chart that you're a type two diabetic and it looked like that you were gon na handle that with diet and exercise let's talk about that a little bit

[ "Personal History" ]

[ "Subjective" ]

1,331

and do you check your blood sugars every morning at home

[ "Personal History" ]

[ "Subjective" ]

1,332

alright so let's just continue with ibuprofen you can take you know six hundred to eight hundred milligrams every eight hours as needed i wan na go ahead and put you in a brace that's gon na help your knee feel a bit more supported okay and let's go ahead and i'm hoping that we can get this mri done in you know the next couple days and then we can have a conversation about what needs to be done now you said that you are are are you know obviously a very active active mom any other exercise or anything else that that i should be aware of that you do just wondering in terms of which kind of graft we would use to fix this with your with your acl being injured

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

[ "Plan" ]

1,333

alright sounds good we will get the nurse come in and she will take care of you and i will see you in two weeks

[ "Follow-up" ]

[ "Plan" ]

1,334

. for the next , uh , at least just three to four weeks .

[ "Discussion" ]

[ "Plan" ]

1,335

hey , dragon . show me the chest x-ray . so , i reviewed the results of your chest x-ray and everything looks good . there's no airspace disease , there's no pneumonia , so that's all very , very good , okay ?

[ "Radiology Examination" ]

[ "Objective" ]

1,336

okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again .

[ "Follow-up", "Medication", "Acute Assessment" ]

[ "Assessment", "Plan" ]

1,337

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

[ "Physical Examination", "Therapeutic History" ]

[ "Subjective", "Objective" ]

1,338

nice have you been into the new home depot that they just opened down the street here

[ "Chitchat" ]

[ "Null" ]

1,339

mm-hmm .

[ "Acute Symptoms" ]

[ "Subjective" ]

1,340

and then i also wan na go ahead and prescribe meloxicam fifteen milligrams once a day

[ "Medication" ]

[ "Plan" ]

1,341

okay so how how are you feeling on your chemo see you're on a combination of sysplatin and a topicide you had your last dose a few days ago any nausea any fatigue from that

[ "Therapeutic History" ]

[ "Subjective" ]

1,342

how's your back pain ?

[ "Acute Symptoms" ]

[ "Subjective" ]

1,343

are you serious

[ "Chitchat" ]

[ "Null" ]

1,344

okay ? um , how about your epilepsy , any seizures recently ?

[ "Acute Symptoms", "Personal History" ]

[ "Subjective" ]

1,345

doctor: alright great

[ "Chitchat" ]

[ "Null" ]

1,346

okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct

[ "Personal History" ]

[ "Subjective" ]

1,347

you're welcome .

[ "Chitchat" ]

[ "Null" ]

1,348

okay . no chest pains or pressure or tightness ?

[ "Acute Symptoms", "Vegetative History" ]

[ "Subjective" ]

1,349

alright so looking here at your appointment notes it says you're you're here you think you have a kidney stone you had some in the past so we're gon na take a look at that and then you also have a past medical history of hypertension and diabetes we want to take a look at those as well so first thing what's going on with your kidneys you as what how long ago have you been feeling pain and and how's all that

[ "Personal History" ]

[ "Subjective" ]

1,350

all right-y . okay . and it also looks like ashley has seen a gi and a geneticist , where they did n't find anything sig ... clinically significant mutations on the panel that they did .

[ "Personal History" ]

[ "Subjective" ]

1,351

okay good so tell me what conditions what kind of conditions run in your family like is there do you have hypertension diabetes or

[ "Family History" ]

[ "Subjective" ]

1,352

okay alright so you said you were raking leaves and now it's been kind of that weather outside for cleaning out the yard have you been doing a lot of yard work lately

[ "Other Socials" ]

[ "Subjective" ]

1,353

okay . do you have any questions ?

[ "Discussion" ]

[ "Plan" ]

1,354

so i see here that you looks like you hurt your left foot here where you were playing soccer can you tell me a little bit more about what happened

[ "Acute Symptoms" ]

[ "Subjective" ]

1,355

all right . um , and how about from a diabetes standpoint ? how ... how's your blood sugar been running ? especially now that you kind of have this , like , acute thing going on ? have your blood sugars been okay ?

[ "Personal History" ]

[ "Subjective" ]

1,356

okay so you have left side low back pain

[ "Therapeutic History" ]

[ "Subjective" ]

1,357

okay . hey , dragon , uh , sharon brooks is a 48 year old female here for right finger pain . all right . so , tell me what happened .

[ "Acute Symptoms" ]

[ "Subjective" ]

1,358

okay . and no chest pain while you were , you know , doing exercises in pt for your knee ?

[ "Personal History" ]

[ "Subjective" ]

1,359

okay . well it will certainly help your blood pressure if you're able to stop drinking .

[ "Vegetative History" ]

[ "Subjective" ]

1,360

we'll get we'll get to that too

[ "Chitchat" ]

[ "Null" ]

1,361

so dennis is a 57 -year-old male today complaining of shortness of breath he has also got a history of diabetes high blood pressure and history of asthma so dennis tell me what's going on how're you doing

[ "Acute Symptoms", "Personal History", "Greetings" ]

[ "Subjective" ]

1,362

okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here

[ "Personal History" ]

[ "Subjective" ]

1,363

that sounds fun but i'm i'm sad as you hurt your knee doing it so for your knee pain are you are you able to bear weight on that leg the left leg

[ "Acute Symptoms" ]

[ "Subjective" ]

1,364

okay and which knee are we talking about

[ "Acute Symptoms" ]

[ "Subjective" ]

1,365

okay so and you're using motrin for for ibuprofen for for the pain well let me go ahead and take a take a look here at your is it both hands or just your right hand

[ "Physical Examination" ]

[ "Objective" ]

1,366

okay . and you rate the pain to range from two through seven out of 10 ?

[ "Acute Symptoms" ]

[ "Subjective" ]

1,367

alright okay so do you have any more questions before i send my nurse in

[ "Discussion" ]

[ "Plan" ]

1,368

i'm so sorry to hear that .

[ "Family History" ]

[ "Subjective" ]

1,369

alright you know let's give it a couple of weeks and let's give it two weeks and then call me back and we'll get you an mri if it's still not improving

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

[ "Plan" ]

1,370

doctor: all right . hey , dragon , finalize the note .

[ "Chitchat" ]

[ "Null" ]

1,371

also your recent labs showed an elevated alkaline phosphatase level at 156 . now this could be related to your liver but most likely related to your bone health . we're going to check a few labs today .

[ "Lab Examination" ]

[ "Objective" ]

1,372

all right . do you ever drink alcohol ?

[ "Drug History" ]

[ "Subjective" ]

1,373

can you take a big breath randy .

[ "Physical Examination" ]

[ "Objective" ]

1,374

okay good .

[ "Chitchat" ]

[ "Null" ]

1,375

yeah . what's a long bike ride to you ?

[ "Personal History" ]

[ "Subjective" ]

1,376

that sounds like it hurt .

[ "Acute Symptoms" ]

[ "Subjective" ]

1,377

okay and where exactly on your shoulder does it hurt

[ "Acute Symptoms" ]

[ "Subjective" ]

1,378

okay . all right . um , and did they have anything to say ? i have n't gotten any reports from them , so ...

[ "Therapeutic History" ]

[ "Subjective" ]

1,379

goodness

[ "Chitchat" ]

[ "Null" ]

1,380

okay so pain with lumbar flexion and so i'm gon na have you lie down and we're gon na do i'm sorry okay and then i see that a supine straight leg test is positive alright so for your neurological exam you said that you are experiencing pain radiating down radiating down your left leg correct

[ "Physical Examination" ]

[ "Objective" ]

1,381

doctor: diagnosis will be pituitary adenoma . mr . ward is a very pleasant 52-year-old male who has benign appearing pituitary adenoma , incidentally discovered during workup for worsening headaches . he is symptomatic with clinical and radiographical evidence of optic chiasmal compression , therefor surgical intervention to excise and decompress the pituitary fossa is indicated . end of note .

[ "Acute Assessment", "Other Treatments" ]

[ "Assessment", "Plan" ]

1,382

sure sure

[ "Other Socials" ]

[ "Subjective" ]

1,383

i do n't think that's what we'll find , but we'll see .

[ "Discussion" ]

[ "Plan" ]

1,384

okay alright good so has has karen had any seizures in the past

[ "Personal History" ]

[ "Subjective" ]

1,385

okay alright and you let's see other than the the tennis you know increase in tennis activity you have n't had any trauma recently falling on it or you know felt a pop anywhere or anything like that have you

[ "Personal History", "Other Socials" ]

[ "Subjective" ]

1,386

okay , any recent fever , chills ?

[ "Vegetative History" ]

[ "Subjective" ]

1,387

hi , andrew , how are you ?

[ "Greetings" ]

[ "Subjective" ]

1,388

okay . and how'bout right there ? no ?

[ "Physical Examination" ]

[ "Objective" ]

1,389

okay . all right . so , on physical exam , you know , everything looks good . on your heart exam , i do appreciate a slight three out of six systolic ejection murmur , but we've heard that in the past .

[ "Physical Examination" ]

[ "Objective" ]

1,390

so- can you start at the beginning ? i know she's a twin , so are these your first two babies ?

[ "Personal History", "Other Socials" ]

[ "Subjective" ]

1,391

pharmacy is what i'm trying to say .

[ "Discussion", "Medication" ]

[ "Plan" ]

1,392

did that help at all

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

1,393

alright so listen to your lungs so your lungs are clear bilaterally listen to your heart so your heart exam you do still have that grade two out of six systolic ejection murmur but we know it about that before so let me take a look at your elbow so when i press right here on the back of your elbow is that painful

[ "Physical Examination" ]

[ "Objective" ]

1,394

okay . and you take uh- uh , fluocinonide for that ?

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

1,395

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

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

1,396

i do n't expect that to happen , but , you know , if it does , you have the tools . um , then you'll be seeing me for a followup . we can figure out what to do next . i would say if it's getting worse rather than better , just give me a call or send me a mychart message , okay ?

[ "Discussion", "Follow-up" ]

[ "Plan" ]

1,397

okay . hey dragon , order methotrexate , 2.5 mg once weekly . for your second problem , the atrial fibrillation . so , you're going in and out of a-fib and i'd like to just keep you in normal sinus rhythm . so , i wan na go ahead and refer you to cardiology for a cardiac ablation which just maps out where that rhythm is coming from and burns it so it does n't come back . okay ? you're young , we wan na keep you in a normal rhythm and , being that you're going in and out of a-fib , i think that's what we should do . okay ?

[ "Discussion", "Referral", "Reassessment" ]

[ "Assessment", "Plan" ]

1,398

you can take tylenol if you want .

[ "Discussion", "Medication" ]

[ "Plan" ]

1,399