DATEXIS/med_intent_classification · Datasets at Hugging Face

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good afternoon alexis i understand you're having some issues with your hand	[ "Acute Symptoms", "Greetings" ]	[ "Subjective" ]	1,500
okay . so , i know that we've had you on the norvasc and we had to increase your dose , so you're on 10 milligrams a day now . and what are your blood pressures running at home ? you c- ... like , have they been like over 150 ?	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	1,501
mm-hmm alright and did you say whether the pain was getting worse	[ "Acute Symptoms" ]	[ "Subjective" ]	1,502
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 .	[ "Medication" ]	[ "Plan" ]	1,503
okay how about the outside	[ "Physical Examination" ]	[ "Objective" ]	1,504
really ?	[ "Acute Symptoms" ]	[ "Subjective" ]	1,505
okay , great . and go ahead and bend forward and then come back up . and that does n't bother you ?	[ "Physical Examination" ]	[ "Objective" ]	1,506
okay , and have you had any other symptoms ? have you had any fever-	[ "Acute Symptoms", "Vegetative History" ]	[ "Subjective" ]	1,507
. you know , it looks like they got all of that and everything's fine .	[ "Lab Examination" ]	[ "Objective" ]	1,508
okay , so she has pain with flexion and extension of the left elbow . there's a palpable right ... or s- ... palpable left radial pulse . okay , um , so let's go over ... i just wan na take a look at some of your results , okay ?	[ "Physical Examination" ]	[ "Objective" ]	1,509
sounds good i'll be back in a couple of minutes	[ "Chitchat" ]	[ "Null" ]	1,510
a week okay alright alright so we will take a look i'll do a physical exam of your knee in a second but i do want to check up you do have a past medical history of hypertension i'm seeing here you're on twenty milligrams of lisinopril when you came in today your blood pressure was a little bit high it was one fifty over seventy so have you been taking your medications regularly	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	1,511
do you need a refill of the lisinopril ?	[ "Discussion", "Medication" ]	[ "Plan" ]	1,512
okay . was the onset gradual or sudden ?	[ "Personal History" ]	[ "Subjective" ]	1,513
your kidney function is good .	[ "Personal History" ]	[ "Subjective" ]	1,514
doctor: you're welcome thanks so much donna	[ "Chitchat" ]	[ "Null" ]	1,515
mm-hmm	[ "Personal History" ]	[ "Subjective" ]	1,516
so that's , you're doing well with that ?	[ "Therapeutic History" ]	[ "Subjective" ]	1,517
okay that's awesome so like how about about how long are your walks	[ "Other Socials" ]	[ "Subjective" ]	1,518
no okay and have you ever had a tick bite before	[ "Personal History" ]	[ "Subjective" ]	1,519
do you have any questions for me ?	[ "Discussion" ]	[ "Plan" ]	1,520
no it's not at north point	[ "Chitchat" ]	[ "Null" ]	1,521
okay now do you have any weakness	[ "Vegetative History" ]	[ "Subjective" ]	1,522
this is what i'm , um , i'm going to do . i'm going to put , print out your prescriptions , so you can shop around at the pharmacies and see if you can find better prices .	[ "Discussion", "Medication" ]	[ "Plan" ]	1,523
okay . uh , sleeping okay at night ?	[ "Vegetative History" ]	[ "Subjective" ]	1,524
so , we'll talk about that . i wan na just look at some of your results , okay ?	[ "Chitchat" ]	[ "Null" ]	1,525
. here is normal , so that's , that's very encouraging . um , i know that they had the echocardiogram , so let's look at that . hey , dragon , show me the echocardiogram . okay . so , looking at this , you know , you do have a little bit of a , a low pumping function of your heart , which , you , you know , can happen and we'll have to look into that , okay ?	[ "Physical Examination" ]	[ "Objective" ]	1,526
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 .	[ "Medication", "Other Treatments", "Drug History" ]	[ "Plan" ]	1,527
. and i wan na go ahead and order another hemoglobin a1c in a couple weeks , or , i'm sorry , a couple months .	[ "Follow-up", "Diagnostic Testing" ]	[ "Plan" ]	1,528
alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that	[ "Discussion", "Medication", "Diagnostic Testing", "Reassessment" ]	[ "Assessment", "Plan" ]	1,529
okay , great . and how's your knee doing that's the other issue we've been , kind of , following ? you had some surgery done for that ?	[ "Personal History" ]	[ "Subjective", "Assessment" ]	1,530
and then we can we can get the brace fitted to you today we are not gon na look at a big big custom kind of expensive brace we will just put because it may just be temporary	[ "Discussion", "Other Treatments" ]	[ "Plan" ]	1,531
okay . um , hey dragon , order a western blot pcr for lyme . okay . all right . well we'll go ahead and , um , the nurse will come in soon and she'll set you up with these tests , okay ?	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	1,532
good . so , you do the shot , and it's going to take about three to five days before it starts feeling better . and then probably over the next couple of weeks , it'll start feeling even better .	[ "Discussion", "Medication" ]	[ "Plan" ]	1,533
alright	[ "Chitchat" ]	[ "Null" ]	1,534
okay . and are they soft stools or formed stools ?	[ "Acute Symptoms" ]	[ "Subjective" ]	1,535
okay . let me take a look at your face here . i'm gon na describe for the transcriptionist what i'm seeing . you're fitzpatrick skin type iv , meaning you're not going to burn , you're going to sun tan , um , essentially , iv to v. and then on bilateral medial cheeks , there are a few really faint erythematous papules and just maybe a little bit of redness around and underneath your nostrils . so you're right , it's not totally gone .	[ "Physical Examination" ]	[ "Objective" ]	1,536
um , how are you doing with that ? i know that you told dr. gutierrez-	[ "Personal History" ]	[ "Subjective" ]	1,537
doctor: hey dragon , finalize the note .	[ "Chitchat" ]	[ "Null" ]	1,538
okay . and are your stools , like , dark or charry or black looking ?	[ "Vegetative History" ]	[ "Subjective" ]	1,539
all right . so , on physical examination , you know , everything looks good . your heart sounds good . your lungs sound good . you know , on your abdominal exam , you do have some pain to your right upper quadrant when i press on it , um , and there's no rebound or guarding and there's no peritoneal signs and your right knee does show a little bit of , uh , an effusion there and there's , uh , some slight pain to palpation and some decreased range of motion . so what does that mean , you know ? that means that you have some findings on your belly exam that concern me about your gall bladder , okay ? so , we'll have to look into that and then , um , your right knee looks a little swollen , but you know , we know you have some arthritis there , okay ?	[ "Physical Examination" ]	[ "Objective" ]	1,540
okay i'm gon na do some maneuvers and i'm gon na just gon na call out my findings on this okay on your right knee exam no ecchymosis or edema no effusion no pain to palpation of the of the left medial knee is there any decreased range of motion do you feel you feel like you're you're able to fully move that as you should the same as the other knee	[ "Physical Examination" ]	[ "Objective" ]	1,541
so i was asking which beach did you did you go to when you hurt your foot	[ "Other Socials" ]	[ "Subjective" ]	1,542
all right . well , for physical exam , please use the regular template . all right , please just breathe normally . great . and now take a few deep breaths for me . all right . do you feel okay ? are you feeling any dizziness or anything ?	[ "Physical Examination" ]	[ "Objective" ]	1,543
okay . um , so four days of right middle finger pain-	[ "Acute Symptoms" ]	[ "Subjective" ]	1,544
next patient is randy gutierrez . date of birth , 8/10/2020 . please use review of symptoms . all text to write . physical exam , auto text uri . hello , how are you doing today ?	[ "Greetings" ]	[ "Subjective" ]	1,545
hi , james , how are you ?	[ "Greetings" ]	[ "Subjective" ]	1,546
all right . call me if anything happens , okay ?	[ "Chitchat" ]	[ "Null" ]	1,547
doctor: alright thanks	[ "Chitchat" ]	[ "Null" ]	1,548
okay , good . so , um ... i know my nurse did a review of systems before you came in . there were really no significant issues . you have a history of chronic back pain , that's been doing well ?	[ "Personal History" ]	[ "Subjective" ]	1,549
all right . thank you ms. taylor . i'll be right back for your exam . i want to look up that medication you mentioned for your nerve pain .	[ "Chitchat" ]	[ "Null" ]	1,550
okay . and anyone else sick as far as you know ?	[ "Family History" ]	[ "Subjective" ]	1,551
i'm sorry	[ "Discussion" ]	[ "Plan" ]	1,552
and then , um , i'm gon na put you in a finger splint and have you come back in two weeks to get a follow-up x-ray . any questions for me ?	[ "Discussion", "Diagnostic Testing", "Follow-up", "Other Treatments" ]	[ "Plan" ]	1,553
all right , how about here ?	[ "Physical Examination" ]	[ "Objective" ]	1,554
okay alright and are you checking your blood sugars pretty regularly	[ "Personal History" ]	[ "Subjective" ]	1,555
okay , and ... and how about .. and how about , um , any fever or chills ?	[ "Vegetative History" ]	[ "Subjective" ]	1,556
okay , so no issues with the migraine ?	[ "Personal History" ]	[ "Subjective" ]	1,557
and that is the wixela that you're not taking . so on average per week , how many days of the week do you use one puff in the morning and one puff at night ?	[ "Therapeutic History" ]	[ "Subjective" ]	1,558
okay so yeah i know you keep having these recurrent kidney stones so i definitely think we can get you a referral to urology just to check up on that and also wan na do some labs as well	[ "Referral", "Diagnostic Testing" ]	[ "Plan" ]	1,559
okay , perfect . so , stay put for me now . i'm going to go see if they have discount samples , and bring you that prescription . and then , i'm going to order the labs for next time .	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	1,560
one and where in your foot was was it	[ "Personal History" ]	[ "Subjective" ]	1,561
okay let's consider having you start seeing a therapist i think that would be a good place to start	[ "Referral" ]	[ "Plan" ]	1,562
okay alright and then things like lung infections or pneumonia do you have any previous history of that	[ "Personal History" ]	[ "Subjective" ]	1,563
okay . all right . and do you have any history or any back problems before ?	[ "Personal History" ]	[ "Subjective" ]	1,564
no headaches ? no belly pain ?	[ "Acute Symptoms" ]	[ "Subjective" ]	1,565
how do you see your last name	[ "Chitchat" ]	[ "Null" ]	1,566
so that's just , uh , what we call a proton pump inhibitor which , uh , helps decrease the amount of acid secreted within your stomach .	[ "Discussion" ]	[ "Plan" ]	1,567
yeah okay now i i just have a couple questions about that are you using a an electronic blood pressure recorder or do you have somebody help you at home	[ "Personal History" ]	[ "Subjective" ]	1,568
alright now i want you to weigh yourself though everyday and then call me if you gain like three pounds in two days okay	[ "Discussion", "Follow-up" ]	[ "Plan" ]	1,569
okay . the nurse will be in soon . it was good to see you .	[ "Discussion" ]	[ "Plan" ]	1,570
five months alright do you remember which antibiotics you were on	[ "Therapeutic History" ]	[ "Subjective" ]	1,571
they usually do anybody who chooses to engage in physics for the rest of their life i question their choices it's fine okay but are you when you're like while you are at school like has anybody been sick i know like with you know covid has been going around but like have you noticed anybody like that sick all the time around you	[ "Other Socials" ]	[ "Subjective" ]	1,572
okay alright i just wan na get like a few more details do you like work out regularly was this for fun or for like an exercise class	[ "Other Socials" ]	[ "Subjective" ]	1,573
okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt	[ "Physical Examination" ]	[ "Objective" ]	1,574
okay alright let's see take anything for it okay well let's see let's just do a quick physical exam here so so your now your vitals those look alright your no fever you're at ninety seven . nine your heart rate is sixty four sounds healthy respirations are sixteen blood pressure is one ten over seventy four your o2 sat looks good at you know ninety eight percent so look real healthy there and so i'm just gon na do a quick physical exam so i do appreciate some edema and some ecchymosis around surrounding your knee your right you said right knee right	[ "Physical Examination" ]	[ "Objective" ]	1,575
perfect excellent okay and how is your blood pressure been i know we watching it your blood pressure today looks pretty good it's about one seventy over i'm sorry one twenty over seventy you're taking norvasc any issues with that any do you need any refills or anything	[ "Discussion", "Medication" ]	[ "Plan" ]	1,576
okay . and any pain when you go pee ?	[ "Acute Symptoms" ]	[ "Subjective" ]	1,577
and you've lost a lot of the cartilage	[ "Acute Assessment" ]	[ "Assessment" ]	1,578
um i can put it in right now for , uh , for county for the next 30 days , and they might be able to get you in within the next few weeks . it should not take , it should not make you ineligible for the surgery . in other words completing a colonoscopy would not delay your surgery .	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	1,579
okay , well , that's fair .	[ "Vegetative History" ]	[ "Subjective" ]	1,580
. it is high . so , there is something that we can do for that . so , let's go ahead and we'll put you on ... so , my impression of you is that your , your blood pressure is high and the norvasc is n't controlling it . and , you know , we can definitely get it under better control . so , what i would like to do is prescribe you coreg 25 milligrams , twice a day . and that will help bring your blood pressure down , okay ?	[ "Discussion", "Acute Assessment", "Medication" ]	[ "Subjective", "Assessment", "Plan" ]	1,581
now when you were in the other room you completed a breathing test , correct ?	[ "Physical Examination" ]	[ "Objective" ]	1,582
okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago .	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	1,583
okay sorry i got a text and	[ "Chitchat" ]	[ "Null" ]	1,584
your lungs are nice and clear and you do have uh one plus non-pitting edema bilaterally in your lower extremities . so what does all that mean ? it just means i heard a little sound in your heart , which you know is n't anything clinically significant . we had looked into that last year .	[ "Acute Assessment" ]	[ "Assessment" ]	1,585
alright were you able to continue playing	[ "Acute Symptoms" ]	[ "Subjective" ]	1,586
okay so let's let's try with this one see what happens hopefully you remember i need you to start writing down these car crashes that this is becoming a thing but you know it's okay so let's let's say maybe you had a	[ "Personal History" ]	[ "Subjective" ]	1,587
generally the shot is given about once a month , it can also be given as a daily pill , but the shot does tend to work a bit better .	[ "Discussion", "Medication" ]	[ "Plan" ]	1,588
i have a few more questions for you . when was your last colonoscopy ?	[ "Personal History" ]	[ "Subjective" ]	1,589
yes and your pain can be explained by multiple things but thankfully it's not a broken neck is that okay	[ "Acute Assessment" ]	[ "Assessment" ]	1,590
okay have you do have you ever like played sports before or had like a sports accident before	[ "Personal History" ]	[ "Subjective" ]	1,591
okay what about your right hand any problems with that hand	[ "Personal History" ]	[ "Subjective" ]	1,592
mm . okay .	[ "Personal History" ]	[ "Subjective" ]	1,593
yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ?	[ "Chitchat" ]	[ "Null" ]	1,594
ow alright and let me have you bend it straighten it it's painful	[ "Physical Examination" ]	[ "Objective" ]	1,595
so rachel is a 48-year-old female here for shortness of breath . she has a history of depression , smoking , and chronic back pain . so tell me about this shortness of breath .	[ "Acute Symptoms", "Drug History" ]	[ "Subjective" ]	1,596
chest pain	[ "Vegetative History" ]	[ "Subjective" ]	1,597
let's look at your x-rays . uh , they look good . so here's what you got going on in there . uh , it looks good . everything's lined up nicely . um , that's looking at it from the front . and this is looking at it from the side . and then this was underneath your kneecap , but we did n't do anything there . but things looks great .	[ "Radiology Examination" ]	[ "Objective" ]	1,598
absolutely	[ "Vegetative History" ]	[ "Subjective" ]	1,599

good afternoon alexis i understand you're having some issues with your hand

[ "Acute Symptoms", "Greetings" ]

[ "Subjective" ]

1,500

okay . so , i know that we've had you on the norvasc and we had to increase your dose , so you're on 10 milligrams a day now . and what are your blood pressures running at home ? you c- ... like , have they been like over 150 ?

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

1,501

mm-hmm alright and did you say whether the pain was getting worse

[ "Acute Symptoms" ]

[ "Subjective" ]

1,502

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 .

[ "Medication" ]

[ "Plan" ]

1,503

okay how about the outside

[ "Physical Examination" ]

[ "Objective" ]

1,504

really ?

[ "Acute Symptoms" ]

[ "Subjective" ]

1,505

okay , great . and go ahead and bend forward and then come back up . and that does n't bother you ?

[ "Physical Examination" ]

[ "Objective" ]

1,506

okay , and have you had any other symptoms ? have you had any fever-

[ "Acute Symptoms", "Vegetative History" ]

[ "Subjective" ]

1,507

. you know , it looks like they got all of that and everything's fine .

[ "Lab Examination" ]

[ "Objective" ]

1,508

okay , so she has pain with flexion and extension of the left elbow . there's a palpable right ... or s- ... palpable left radial pulse . okay , um , so let's go over ... i just wan na take a look at some of your results , okay ?

[ "Physical Examination" ]

[ "Objective" ]

1,509

sounds good i'll be back in a couple of minutes

[ "Chitchat" ]

[ "Null" ]

1,510

a week okay alright alright so we will take a look i'll do a physical exam of your knee in a second but i do want to check up you do have a past medical history of hypertension i'm seeing here you're on twenty milligrams of lisinopril when you came in today your blood pressure was a little bit high it was one fifty over seventy so have you been taking your medications regularly

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

1,511

do you need a refill of the lisinopril ?

[ "Discussion", "Medication" ]

[ "Plan" ]

1,512

okay . was the onset gradual or sudden ?

[ "Personal History" ]

[ "Subjective" ]

1,513

your kidney function is good .

[ "Personal History" ]

[ "Subjective" ]

1,514

doctor: you're welcome thanks so much donna

[ "Chitchat" ]

[ "Null" ]

1,515

mm-hmm

[ "Personal History" ]

[ "Subjective" ]

1,516

so that's , you're doing well with that ?

[ "Therapeutic History" ]

[ "Subjective" ]

1,517

okay that's awesome so like how about about how long are your walks

[ "Other Socials" ]

[ "Subjective" ]

1,518

no okay and have you ever had a tick bite before

[ "Personal History" ]

[ "Subjective" ]

1,519

do you have any questions for me ?

[ "Discussion" ]

[ "Plan" ]

1,520

no it's not at north point

[ "Chitchat" ]

[ "Null" ]

1,521

okay now do you have any weakness

[ "Vegetative History" ]

[ "Subjective" ]

1,522

this is what i'm , um , i'm going to do . i'm going to put , print out your prescriptions , so you can shop around at the pharmacies and see if you can find better prices .

[ "Discussion", "Medication" ]

[ "Plan" ]

1,523

okay . uh , sleeping okay at night ?

[ "Vegetative History" ]

[ "Subjective" ]

1,524

so , we'll talk about that . i wan na just look at some of your results , okay ?

[ "Chitchat" ]

[ "Null" ]

1,525

. here is normal , so that's , that's very encouraging . um , i know that they had the echocardiogram , so let's look at that . hey , dragon , show me the echocardiogram . okay . so , looking at this , you know , you do have a little bit of a , a low pumping function of your heart , which , you , you know , can happen and we'll have to look into that , okay ?

[ "Physical Examination" ]

[ "Objective" ]

1,526

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 .

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

[ "Plan" ]

1,527

. and i wan na go ahead and order another hemoglobin a1c in a couple weeks , or , i'm sorry , a couple months .

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

[ "Plan" ]

1,528

alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that

[ "Discussion", "Medication", "Diagnostic Testing", "Reassessment" ]

[ "Assessment", "Plan" ]

1,529

okay , great . and how's your knee doing that's the other issue we've been , kind of , following ? you had some surgery done for that ?

[ "Personal History" ]

[ "Subjective", "Assessment" ]

1,530

and then we can we can get the brace fitted to you today we are not gon na look at a big big custom kind of expensive brace we will just put because it may just be temporary

[ "Discussion", "Other Treatments" ]

[ "Plan" ]

1,531

okay . um , hey dragon , order a western blot pcr for lyme . okay . all right . well we'll go ahead and , um , the nurse will come in soon and she'll set you up with these tests , okay ?

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

1,532

good . so , you do the shot , and it's going to take about three to five days before it starts feeling better . and then probably over the next couple of weeks , it'll start feeling even better .

[ "Discussion", "Medication" ]

[ "Plan" ]

1,533

alright

[ "Chitchat" ]

[ "Null" ]

1,534

okay . and are they soft stools or formed stools ?

[ "Acute Symptoms" ]

[ "Subjective" ]

1,535

okay . let me take a look at your face here . i'm gon na describe for the transcriptionist what i'm seeing . you're fitzpatrick skin type iv , meaning you're not going to burn , you're going to sun tan , um , essentially , iv to v. and then on bilateral medial cheeks , there are a few really faint erythematous papules and just maybe a little bit of redness around and underneath your nostrils . so you're right , it's not totally gone .

[ "Physical Examination" ]

[ "Objective" ]

1,536

um , how are you doing with that ? i know that you told dr. gutierrez-

[ "Personal History" ]

[ "Subjective" ]

1,537

doctor: hey dragon , finalize the note .

[ "Chitchat" ]

[ "Null" ]

1,538

okay . and are your stools , like , dark or charry or black looking ?

[ "Vegetative History" ]

[ "Subjective" ]

1,539

all right . so , on physical examination , you know , everything looks good . your heart sounds good . your lungs sound good . you know , on your abdominal exam , you do have some pain to your right upper quadrant when i press on it , um , and there's no rebound or guarding and there's no peritoneal signs and your right knee does show a little bit of , uh , an effusion there and there's , uh , some slight pain to palpation and some decreased range of motion . so what does that mean , you know ? that means that you have some findings on your belly exam that concern me about your gall bladder , okay ? so , we'll have to look into that and then , um , your right knee looks a little swollen , but you know , we know you have some arthritis there , okay ?

[ "Physical Examination" ]

[ "Objective" ]

1,540

okay i'm gon na do some maneuvers and i'm gon na just gon na call out my findings on this okay on your right knee exam no ecchymosis or edema no effusion no pain to palpation of the of the left medial knee is there any decreased range of motion do you feel you feel like you're you're able to fully move that as you should the same as the other knee

[ "Physical Examination" ]

[ "Objective" ]

1,541

so i was asking which beach did you did you go to when you hurt your foot

[ "Other Socials" ]

[ "Subjective" ]

1,542

all right . well , for physical exam , please use the regular template . all right , please just breathe normally . great . and now take a few deep breaths for me . all right . do you feel okay ? are you feeling any dizziness or anything ?

[ "Physical Examination" ]

[ "Objective" ]

1,543

okay . um , so four days of right middle finger pain-

[ "Acute Symptoms" ]

[ "Subjective" ]

1,544

next patient is randy gutierrez . date of birth , 8/10/2020 . please use review of symptoms . all text to write . physical exam , auto text uri . hello , how are you doing today ?

[ "Greetings" ]

[ "Subjective" ]

1,545

hi , james , how are you ?

[ "Greetings" ]

[ "Subjective" ]

1,546

all right . call me if anything happens , okay ?

[ "Chitchat" ]

[ "Null" ]

1,547

doctor: alright thanks

[ "Chitchat" ]

[ "Null" ]

1,548

okay , good . so , um ... i know my nurse did a review of systems before you came in . there were really no significant issues . you have a history of chronic back pain , that's been doing well ?

[ "Personal History" ]

[ "Subjective" ]

1,549

all right . thank you ms. taylor . i'll be right back for your exam . i want to look up that medication you mentioned for your nerve pain .

[ "Chitchat" ]

[ "Null" ]

1,550

okay . and anyone else sick as far as you know ?

[ "Family History" ]

[ "Subjective" ]

1,551

i'm sorry

[ "Discussion" ]

[ "Plan" ]

1,552

and then , um , i'm gon na put you in a finger splint and have you come back in two weeks to get a follow-up x-ray . any questions for me ?

[ "Discussion", "Diagnostic Testing", "Follow-up", "Other Treatments" ]

[ "Plan" ]

1,553

all right , how about here ?

[ "Physical Examination" ]

[ "Objective" ]

1,554

okay alright and are you checking your blood sugars pretty regularly

[ "Personal History" ]

[ "Subjective" ]

1,555

okay , and ... and how about .. and how about , um , any fever or chills ?

[ "Vegetative History" ]

[ "Subjective" ]

1,556

okay , so no issues with the migraine ?

[ "Personal History" ]

[ "Subjective" ]

1,557

and that is the wixela that you're not taking . so on average per week , how many days of the week do you use one puff in the morning and one puff at night ?

[ "Therapeutic History" ]

[ "Subjective" ]

1,558

okay so yeah i know you keep having these recurrent kidney stones so i definitely think we can get you a referral to urology just to check up on that and also wan na do some labs as well

[ "Referral", "Diagnostic Testing" ]

[ "Plan" ]

1,559

okay , perfect . so , stay put for me now . i'm going to go see if they have discount samples , and bring you that prescription . and then , i'm going to order the labs for next time .

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

1,560

one and where in your foot was was it

[ "Personal History" ]

[ "Subjective" ]

1,561

okay let's consider having you start seeing a therapist i think that would be a good place to start

[ "Referral" ]

[ "Plan" ]

1,562

okay alright and then things like lung infections or pneumonia do you have any previous history of that

[ "Personal History" ]

[ "Subjective" ]

1,563

okay . all right . and do you have any history or any back problems before ?

[ "Personal History" ]

[ "Subjective" ]

1,564

no headaches ? no belly pain ?

[ "Acute Symptoms" ]

[ "Subjective" ]

1,565

how do you see your last name

[ "Chitchat" ]

[ "Null" ]

1,566

so that's just , uh , what we call a proton pump inhibitor which , uh , helps decrease the amount of acid secreted within your stomach .

[ "Discussion" ]

[ "Plan" ]

1,567

yeah okay now i i just have a couple questions about that are you using a an electronic blood pressure recorder or do you have somebody help you at home

[ "Personal History" ]

[ "Subjective" ]

1,568

alright now i want you to weigh yourself though everyday and then call me if you gain like three pounds in two days okay

[ "Discussion", "Follow-up" ]

[ "Plan" ]

1,569

okay . the nurse will be in soon . it was good to see you .

[ "Discussion" ]

[ "Plan" ]

1,570

five months alright do you remember which antibiotics you were on

[ "Therapeutic History" ]

[ "Subjective" ]

1,571

they usually do anybody who chooses to engage in physics for the rest of their life i question their choices it's fine okay but are you when you're like while you are at school like has anybody been sick i know like with you know covid has been going around but like have you noticed anybody like that sick all the time around you

[ "Other Socials" ]

[ "Subjective" ]

1,572

okay alright i just wan na get like a few more details do you like work out regularly was this for fun or for like an exercise class

[ "Other Socials" ]

[ "Subjective" ]

1,573

okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt

[ "Physical Examination" ]

[ "Objective" ]

1,574

okay alright let's see take anything for it okay well let's see let's just do a quick physical exam here so so your now your vitals those look alright your no fever you're at ninety seven . nine your heart rate is sixty four sounds healthy respirations are sixteen blood pressure is one ten over seventy four your o2 sat looks good at you know ninety eight percent so look real healthy there and so i'm just gon na do a quick physical exam so i do appreciate some edema and some ecchymosis around surrounding your knee your right you said right knee right

[ "Physical Examination" ]

[ "Objective" ]

1,575

perfect excellent okay and how is your blood pressure been i know we watching it your blood pressure today looks pretty good it's about one seventy over i'm sorry one twenty over seventy you're taking norvasc any issues with that any do you need any refills or anything

[ "Discussion", "Medication" ]

[ "Plan" ]

1,576

okay . and any pain when you go pee ?

[ "Acute Symptoms" ]

[ "Subjective" ]

1,577

and you've lost a lot of the cartilage

[ "Acute Assessment" ]

[ "Assessment" ]

1,578

um i can put it in right now for , uh , for county for the next 30 days , and they might be able to get you in within the next few weeks . it should not take , it should not make you ineligible for the surgery . in other words completing a colonoscopy would not delay your surgery .

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

1,579

okay , well , that's fair .

[ "Vegetative History" ]

[ "Subjective" ]

1,580

. it is high . so , there is something that we can do for that . so , let's go ahead and we'll put you on ... so , my impression of you is that your , your blood pressure is high and the norvasc is n't controlling it . and , you know , we can definitely get it under better control . so , what i would like to do is prescribe you coreg 25 milligrams , twice a day . and that will help bring your blood pressure down , okay ?

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

[ "Subjective", "Assessment", "Plan" ]

1,581

now when you were in the other room you completed a breathing test , correct ?

[ "Physical Examination" ]

[ "Objective" ]

1,582

okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago .

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

1,583

okay sorry i got a text and

[ "Chitchat" ]

[ "Null" ]

1,584

your lungs are nice and clear and you do have uh one plus non-pitting edema bilaterally in your lower extremities . so what does all that mean ? it just means i heard a little sound in your heart , which you know is n't anything clinically significant . we had looked into that last year .

[ "Acute Assessment" ]

[ "Assessment" ]

1,585

alright were you able to continue playing

[ "Acute Symptoms" ]

[ "Subjective" ]

1,586

okay so let's let's try with this one see what happens hopefully you remember i need you to start writing down these car crashes that this is becoming a thing but you know it's okay so let's let's say maybe you had a

[ "Personal History" ]

[ "Subjective" ]

1,587

generally the shot is given about once a month , it can also be given as a daily pill , but the shot does tend to work a bit better .

[ "Discussion", "Medication" ]

[ "Plan" ]

1,588

i have a few more questions for you . when was your last colonoscopy ?

[ "Personal History" ]

[ "Subjective" ]

1,589

yes and your pain can be explained by multiple things but thankfully it's not a broken neck is that okay

[ "Acute Assessment" ]

[ "Assessment" ]

1,590

okay have you do have you ever like played sports before or had like a sports accident before

[ "Personal History" ]

[ "Subjective" ]

1,591

okay what about your right hand any problems with that hand

[ "Personal History" ]

[ "Subjective" ]

1,592

mm . okay .

[ "Personal History" ]

[ "Subjective" ]

1,593

yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ?

[ "Chitchat" ]

[ "Null" ]

1,594

ow alright and let me have you bend it straighten it it's painful

[ "Physical Examination" ]

[ "Objective" ]

1,595

so rachel is a 48-year-old female here for shortness of breath . she has a history of depression , smoking , and chronic back pain . so tell me about this shortness of breath .

[ "Acute Symptoms", "Drug History" ]

[ "Subjective" ]

1,596

chest pain

[ "Vegetative History" ]

[ "Subjective" ]

1,597

let's look at your x-rays . uh , they look good . so here's what you got going on in there . uh , it looks good . everything's lined up nicely . um , that's looking at it from the front . and this is looking at it from the side . and then this was underneath your kneecap , but we did n't do anything there . but things looks great .

[ "Radiology Examination" ]

[ "Objective" ]

1,598

absolutely

[ "Vegetative History" ]

[ "Subjective" ]

1,599