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med_intent_classification

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and it should normalize , but it's too soon to do it now . um , but maybe if i put some labs in you could come in in two to three weeks ?
[ "Discussion", "Diagnostic Testing", "Follow-up" ]
[ "Plan" ]
1,900
you are okay alright now i wan na go ahead and just move on to a quick physical exam okay i'm gon na be calling out some of my exam findings and i'm gon na let you know what that means when i'm done okay alright i do have to do a rectal exam i apologize i'm just gon na be calling it out what what i what i appreciate okay so on your heart exam i do appreciate a slight three out of six systolic ejection murmur hurt at the left base on your lung exam your lungs are clear to auscultation bilaterally on your abdominal exam your abdomen is nontender and nondistended i do n't appreciate any masses or any rebound or guarding on your prostate exam i do appreciate an enlarged prostate i do n't appreciate any masses on physical exam so what what does that mean billy so that ultimately means that you know everything looks good you know you have that little heart murmur which i believe you you've had in the past but we're gon na go ahead and look into that you know your prostate seems a little bit enlarged to me on physical exam so let's talk about how we can go about and and remedy that okay so for your first problem of this you know difficulty urinating i wan na go ahead and just order some routine labs i wan na get a a psa that kind of that ultimately kinda looks for prostate cancer issues which i do n't think you have because we did n't really appreciate that on physical exam i wan na go ahead and we can try to start you on what we call flomax zero point four milligrams once a day you should take it at night because it can cause people to get a little bit dizzy if they take it in the morning so i would take it at night and i wan na go ahead and refer you to a urologist just to look into this more so we can go ahead and and get this problem solved for you okay i'm also gon na go ahead and just order some routine blood tests just to make sure that we are not missing anything do you have any questions about that and i wan na go ahead and order a urinalysis and a urine culture
[ "Physical Examination", "Discussion", "Medication", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
1,901
okay and so does that help at all
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
1,902
okay now tell me how are you doing with your with your heart when was the last time you saw doctor moore the cardiologist i know that you had the the stent placed in your right coronary artery about what was that twenty eighteen
[ "Personal History" ]
[ "Subjective" ]
1,903
so , hannah is a , uh , 52-year-old female here for evaluation of a high blood sugar . so , hannah , what ha- what happened ? i heard you were in the emergency room with a high blood sugar .
[ "Personal History" ]
[ "Subjective" ]
1,904
i'd like to tell dax about you-
[ "Chitchat" ]
[ "Null" ]
1,905
okay , good .
[ "Chitchat" ]
[ "Null" ]
1,906
and your knees , and i'll let you know what i find , okay ?
[ "Physical Examination" ]
[ "Objective" ]
1,907
okay how about at night is it bothering you at night also
[ "Acute Symptoms" ]
[ "Subjective" ]
1,908
i see . anyone in your family have any history of diseases ?
[ "Family History" ]
[ "Subjective" ]
1,909
okay . and i do like to keep patients overnight . it's just going to be for one night in the hospital . and we just wan na make sure your pain is controlled , make sure you're not nauseated , all of that stuff . some patients wan na go home that same day . but you know that some people get nauseated , and the last thing that i want is for you to be vomiting at home alone without the , the support here at the facility .
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
1,910
any history of something like multiple sclerosis or any brain tumors that you know
[ "Personal History" ]
[ "Subjective" ]
1,911
okay have you had any kind of trauma to that foot
[ "Personal History" ]
[ "Subjective" ]
1,912
okay . hey , dragon , order a refill of prozac , 20 milligrams daily . from a ... for your next problem , the lobectomy , i think , you know , i do n't think we need to do any more workup of that . it seems like you're exercising a lot . your breathing function is fine . so , uh , i , i do n't think you need to follow up with the surgeon anymore . and then for your last problem , your hypertension .
[ "Discussion", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
1,913
inside of your knee alright and are you able to bear weight on that leg matthew
[ "Acute Symptoms" ]
[ "Subjective" ]
1,914
all right . so what i'm thinking is , let's go ahead and schedule you for an echocardiogram . it's a very common test and it just takes a picture of your heart . and it'll let me see how well your heart is actually working .
[ "Diagnostic Testing" ]
[ "Plan" ]
1,915
okay and have they been elevated at all since this episode of your-
[ "Personal History" ]
[ "Subjective" ]
1,916
so let's wait those six months . you can keep using uh , the mederma scar gel twice a day . massage and scar gel will help for the scars . um , you can put it on other scars too , if you need .
[ "Discussion", "Follow-up", "Medication" ]
[ "Plan" ]
1,917
all right . um , let's do your exam , okay ? so is it tender ... where is it mostly tender right now ?
[ "Physical Examination" ]
[ "Objective" ]
1,918
about a four okay so it's it's not too bad alright so we'll take a look at that knee in a second so we're also here to check up on your hypertension and diabetes so i'm looking here for your hypertension you're taking five milligrams of norvasc so are you taking that daily
[ "Therapeutic History" ]
[ "Subjective" ]
1,919
no okay and then so tell me when the twitch occurs do you ever notice any you know parts of her like moving or twitching
[ "Acute Symptoms" ]
[ "Subjective" ]
1,920
and no injury ? like you did n't fall or twist it or anything like that that you remember ?
[ "Acute Symptoms" ]
[ "Subjective" ]
1,921
alright well so i totally understand like baking and like the excitement of being able to give those to your family but we maybe wan na start cutting down on eating and taste testing ourselves is do you think that's something we could manage
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
1,922
so yeah we we've been down there we got some pain we we got went and got some samples and then hey while we were there we ended up deciding to put down a bunch of flooring too so i really recommend you guys if you get a chance go over there and take a look at their sales and and see if you ca n't finish your remodeled project
[ "Chitchat" ]
[ "Null" ]
1,923
so lem me take a look at your right knee .
[ "Physical Examination" ]
[ "Objective" ]
1,924
okay . and um ... do you have any numbing or tingling in your legs ?
[ "Acute Symptoms" ]
[ "Subjective" ]
1,925
so as i said , the hepatomegaly means your liver is enlarged .
[ "Acute Assessment" ]
[ "Assessment" ]
1,926
yeah . unfortunately that can happen , but we're working on discontinuing that so let's see if the bruises do go away .
[ "Discussion" ]
[ "Plan" ]
1,927
no side effects okay and then in terms of your diabetes are you watching your sugar intake
[ "Personal History" ]
[ "Subjective" ]
1,928
alright and have you taken anything for the pain
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
1,929
hi bruce , how are you ?
[ "Greetings" ]
[ "Subjective" ]
1,930
okay , and your blood sugars have been under control ?
[ "Personal History" ]
[ "Subjective" ]
1,931
okay . and then , how , lastly , for your high blood pressure , have you been monitoring your blood pressures at home ? did you buy the cuff like i suggested ?
[ "Personal History" ]
[ "Subjective" ]
1,932
yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system .
[ "Discussion", "Diagnostic Testing" ]
[ "Plan" ]
1,933
what do you feel ?
[ "Acute Symptoms" ]
[ "Subjective" ]
1,934
good afternoon , beverly . good to see you .
[ "Greetings" ]
[ "Subjective" ]
1,935
alright positive pain with flexion what about when you move it back
[ "Physical Examination" ]
[ "Objective" ]
1,936
yes . i would like to start with a topical therapy first . every morning , you will wash your face with a mild cleanser then use a moisturizer labeled , " noncomedogenic , " with sunscreen spf 30 or higher . this means it wo n't clog your pores . now , in the evening , wash your face with the same cleanser and allow it to dry . apply adapalene , 0.1 % cream , in a thin layer to the areas you generally get acne . i want you to start off using this a few nights a week and slowly work up to using it every night . if it is ... excuse me , if it is very expensive or not covered by insurance , you can try different gel over the counter . you can follow that with clean and clear persa-gel in a thin layer , or where you generally get acne . and then a noncomedogenic moisturizer . you're atopic retinoid will cause some sensitivity , so you will need to wear sunscreen when you are outside . it may also cause some dryness or irritation .
[ "Medication" ]
[ "Plan" ]
1,937
you can take tylenol
[ "Discussion", "Medication" ]
[ "Plan" ]
1,938
has this been the case over the past two years as well ?
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
1,939
okay . and did it swell up at all ? or-
[ "Acute Symptoms" ]
[ "Subjective" ]
1,940
so you mentioned you tried to quit before can you tell me a little bit about the methods that you used or or what you tried
[ "Drug History" ]
[ "Subjective" ]
1,941
okay okay and i wan na turn your wrist over here and turn your hand over and i'm gon na go ahead and tap on the right wrist on the back here does that do anything when i do that
[ "Physical Examination" ]
[ "Objective" ]
1,942
yeah , so getting that under control is really important to help prevent kidney failure , strokes , and- and things like that- that you're at high risk for with high blood pressure .
[ "Discussion" ]
[ "Plan" ]
1,943
hi billy how are you doing the medical assistant told me that you have a cough today
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
1,944
okay alright so when i move your your kneecap does that hurt
[ "Physical Examination" ]
[ "Objective" ]
1,945
so regarding your symptoms , do you experience back pain ?
[ "Personal History" ]
[ "Subjective" ]
1,946
okay . and do you have any other symptoms with this ? do you have any other associated fatigue or fever or anything like that ?
[ "Vegetative History" ]
[ "Subjective" ]
1,947
alright when i touch are there any like decreased sensation
[ "Physical Examination" ]
[ "Objective" ]
1,948
hey , dragon , show me the hemoglobin . so , here , looking at this , you know , your hemoglobin level is 8.2. somebody like you should have a hemoglobin o- of about 13 , 14 , okay ?
[ "Lab Examination" ]
[ "Objective" ]
1,949
what about down here ?
[ "Acute Symptoms", "Physical Examination" ]
[ "Subjective", "Objective" ]
1,950
that's great .
[ "Personal History" ]
[ "Subjective" ]
1,951
okay so yeah we definitely got ta get you to to take it we could try something else just if you're having interaction with that medication what about your blood sugars are they taking those daily
[ "Personal History" ]
[ "Subjective" ]
1,952
yeah , so it ... actually ... it is actually more expensive . i think the prices fluctuate .
[ "Discussion", "Medication" ]
[ "Plan" ]
1,953
so what have you been doing for the pain since the initial insult
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
1,954
okay great great you're still using that pill box that we suggested i think you had a pretty good system going there maybe maybe you're using that app now to take to keep track of one when to take your medicine are you doing that
[ "Therapeutic History" ]
[ "Subjective" ]
1,955
doctor: okay bye good to see you i'll be in touch
[ "Chitchat" ]
[ "Null" ]
1,956
okay how about any problems with karen's sleep
[ "Vegetative History" ]
[ "Subjective" ]
1,957
that's great i think i think i remember you saying it was tricky to get that app set up but then your grandson helped you with it and those kids amazing what they can do these days right anything like that i always trust them my kids before me so hey by the way how did he do in his softball or in his in his little league tournament last month i think you said he had a big tournament coming up how did that go
[ "Other Socials" ]
[ "Subjective" ]
1,958
okay and are you still taking the lisinopril twenty milligrams once per day no actually i see we last visit we increased that to twice per day you're still taking that lisinopril twenty milligrams twice per day
[ "Therapeutic History" ]
[ "Subjective" ]
1,959
okay there is pain to palpation of the right anterior knee and i'm just gon na bend your knee up and down does that hurt at all
[ "Physical Examination" ]
[ "Objective" ]
1,960
you actually no
[ "Acute Symptoms" ]
[ "Subjective" ]
1,961
alrighty so i'll have the nurse come in and get you set up with that sling and i will see you again in about a week
[ "Follow-up" ]
[ "Plan" ]
1,962
okay . all right . um , so let's just talk a little bit about your high cholesterol . how are you doing with the diet ?
[ "Personal History" ]
[ "Subjective" ]
1,963
yes , that's a great question . you do n't give honey to kids under a year , instead , you can give them agave , which is a different type of nectar . um , now you can give honey to his older sister , that is okay , but for him , it would not be very good because his stomach acid's not good enough to break down the botulism spores . so , it'd cause him harm . um , you should look at the package of say , honey nut cheerios . it says right on there to not give it to a baby .
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
1,964
okay do you remember what caused the pain initially
[ "Acute Symptoms" ]
[ "Subjective" ]
1,965
okay alright and then are you are you a smoker or did you smoke
[ "Drug History" ]
[ "Subjective" ]
1,966
yeah , it's not ideal . but , many people have a-fib are able to keep it under control with medicine and lifestyle changes .
[ "Physical Examination" ]
[ "Objective" ]
1,967
okay . all right . well , let's go ahead and ... and look at your vital signs today . hey , dragon ? show me the blood pressure . yeah , so your blood pressure's a little high today . that's probably because you're in some pain , um , but let ... let me just take a listen to your heart and lungs , and i'll let you know what i find , okay ?
[ "Physical Examination" ]
[ "Objective" ]
1,968
yeah right so how about your high blood pressure how are you doing with that are you taking your blood pressure medication like i asked
[ "Therapeutic History", "Personal History" ]
[ "Subjective" ]
1,969
so health wise , how is everything going ?
[ "Personal History" ]
[ "Subjective" ]
1,970
okay and then when you do take that ibuprofen or tylenol what what's your relief level what's your pain look like then
[ "Acute Symptoms" ]
[ "Subjective" ]
1,971
all right well thanks so much and you have a great day .
[ "Chitchat" ]
[ "Null" ]
1,972
and they gave you a water pill and is that is that helping is that making you pee a lot
[ "Therapeutic History", "Vegetative History" ]
[ "Subjective" ]
1,973
mm-hmm
[ "Acute Symptoms" ]
[ "Subjective" ]
1,974
alright
[ "Chitchat" ]
[ "Null" ]
1,975
okay good
[ "Personal History" ]
[ "Subjective" ]
1,976
okay . and had you ever had that before ?
[ "Personal History" ]
[ "Subjective" ]
1,977
okay alright understood and you've not had any any fever or nausea vomiting anything like that have you or diarrhea
[ "Vegetative History" ]
[ "Subjective" ]
1,978
the adobee illustrator get it
[ "Chitchat" ]
[ "Null" ]
1,979
okay do you take any oral hormone replacement therapy
[ "Therapeutic History" ]
[ "Subjective" ]
1,980
well washington sounds nice i have n't been there but it sounds like it's pretty nice area to be in and they have a lot of maple syrup there do n't they produce a lot of maple syrup
[ "Chitchat" ]
[ "Null" ]
1,981
okay and for the third diagnosis the high blood pressure you you do have a trend i've noticed in your chart that your blood pressure's been running a little bit high several other people have documented as well i'm gon na go ahead and start you on some hydrochlorothiazide it's a pretty low dose medication to help you with your blood pressure plus it'll also help with you some of the swelling you have in your in your feet i'm gon na have you use a blood pressure cuff at home and enter your findings at epic mychart and i'll get a reading of those as well and then what when you come back in two weeks we'll keep a log of your blood pressure daily in the morning when you wake up and see how things are going and then if we need to make any adjustments to the medications we can but especially considering your history and the chest pain and the diabetes and the swelling i think starting this hydrochlorothiazide is a probably a good idea
[ "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
1,982
so are you experiencing any numbness or tingling in your arm or hand
[ "Vegetative History" ]
[ "Subjective" ]
1,983
okay and have you had any fever or chills
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
1,984
alright any any belly pain
[ "Physical Examination" ]
[ "Objective" ]
1,985
doctor: okay , great . hey dragon , finalize the note .
[ "Chitchat" ]
[ "Null" ]
1,986
that's awesome so just out of curiosity with the left foot have you experienced anything like numbness or tingling or or any strange sensation
[ "Acute Symptoms" ]
[ "Subjective" ]
1,987
okay . let's see , do you have any other medical problems that you take medicine for ?
[ "Therapeutic History", "Personal History" ]
[ "Subjective" ]
1,988
and what about the outside does that hurt as well
[ "Physical Examination" ]
[ "Objective" ]
1,989
okay and i would like to talk about your familial history here for just a second do you have any family history of lung cancer or any other type of malignancies
[ "Family History" ]
[ "Subjective" ]
1,990
okay . it's reassuring that you are n't having any difficulty swallowing , though . how's your weight been ? pretty stable ?
[ "Vegetative History" ]
[ "Subjective" ]
1,991
okay okay and in the the the form that you filled out when you came in it says that you are on ten milligrams of norvasc daily and carvedilol twenty five milligrams twice a day is those the medicines you're on
[ "Therapeutic History" ]
[ "Subjective" ]
1,992
that's not too bad you might have a little white coat syndrome you seeing me today because it's a little bit high today so you're on that two . five of norvasc have you been taking that
[ "Therapeutic History" ]
[ "Subjective" ]
1,993
alright any other questions
[ "Discussion" ]
[ "Plan" ]
1,994
and how about a loss of sensation in the genital or the rectal area
[ "Vegetative History" ]
[ "Subjective" ]
1,995
good . how is your heart burn doing ? any problems with that ?
[ "Personal History" ]
[ "Subjective" ]
1,996
okay alright so it's really gon na be really important for you to go ahead and continue to take these medications to prevent that stent from clogging again okay or prevent that stent from closing because we do n't want you to have another heart attack okay
[ "Discussion", "Medication" ]
[ "Plan" ]
1,997
uh , but i would pickup the elidel too .
[ "Discussion", "Medication" ]
[ "Plan" ]
1,998
okay well then i'll see you again in three months then kevin okay take care of yourself
[ "Follow-up" ]
[ "Plan" ]
1,999