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med_intent_classification

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okay so bilateral maxillary sinus tenderness alright and i'm just gon na take a look at in your mouth if you can open up okay so i do see some do have some erythema of the pharynx and the tonsils are symmetrical i do n't appreciate any exudates now i'm just checking your neck and i do appreciate some anterior cervical ...
[ "Physical Examination", "Discussion", "Medication", "Other Treatments", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
2,200
yes , you're absolutely right , that was a bad year . that was my first fall here and i was really alarmed . well that explains why at that time your numbers were a little bit lower and today they look better . here's what i think , so you'll have kaiser currently , correct ?
[ "Other Socials" ]
[ "Subjective" ]
2,201
okay . let me put that into the system , and then downstairs they can do the ultrasound .
[ "Chitchat" ]
[ "Null" ]
2,202
okay . all right . and in terms of your high blood pressure , do you know when you had the chest pain if your blood pressure was very high ? did they say anything in the emergency room ?
[ "Personal History" ]
[ "Subjective" ]
2,203
hi i'm great thanks for asking
[ "Greetings" ]
[ "Subjective" ]
2,204
elizabeth , how are you ?
[ "Greetings" ]
[ "Subjective" ]
2,205
that will be fine i know you love walking the trails i know you like looking at the flowers because i think you you plant a lot of flowers as well do n't you especially around this time
[ "Other Socials" ]
[ "Subjective" ]
2,206
okay alright have you taken anything for the pain yet
[ "Acute Symptoms", "Other Socials" ]
[ "Subjective" ]
2,207
okay . next patient is ashley james , date of birth 12/27/2006 . ashley is a 14-year-old female , uh , who was previously healthy , now here for evaluation of abnormal renal ultrasound with an atrophic right kidney . hi . good afternoon , ashley . how are you doing ?
[ "Personal History", "Greetings" ]
[ "Subjective" ]
2,208
excellent . he's doing excellent . next let's- let's check out those ears .
[ "Physical Examination" ]
[ "Objective" ]
2,209
okay alright so i'm gon na go ahead and do my physical exam i'll be calling up my findings as i run through it if you have any questions please let me know alright so with your vital signs your blood pressure looks pretty decent we have it like one thirty three over seventy so that's fine your heart rate looks good you...
[ "Physical Examination" ]
[ "Objective" ]
2,210
yes , amino acids are what make up the protein , which is in any food you eat , with any protein . so , meats , dairy , nuts , any of that sort of thing .
[ "Discussion" ]
[ "Plan" ]
2,211
so can you tell me about that how are you doing
[ "Acute Symptoms" ]
[ "Subjective" ]
2,212
okay . yeah , i , i see that we have you on the norvasc . and so are you taking it at home ? is it running high , or ...
[ "Therapeutic History" ]
[ "Subjective" ]
2,213
mm-hmm
[ "Acute Symptoms" ]
[ "Subjective" ]
2,214
-i guess , you know , i guess they're high now so how are you feeling since then ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,215
okay . that's pretty tender , ?
[ "Physical Examination" ]
[ "Objective" ]
2,216
okay alright did you pass out
[ "Personal History" ]
[ "Subjective" ]
2,217
seven days ago okay yeah your right knee still looks a little swollen for seven days ago so i'm gon na go ahead and now i also see that you're diabetic and that you take five hundred milligrams of metformin twice a day are you still you're still on that medication is that correct
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
2,218
hmm , okay .
[ "Personal History" ]
[ "Subjective" ]
2,219
take care .
[ "Chitchat" ]
[ "Null" ]
2,220
okay . and no other symptoms since then ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,221
okay and are you waking up at night to go to the bathroom does it impact your sleep
[ "Vegetative History" ]
[ "Subjective" ]
2,222
okay , i'll make that adjustment .
[ "Family History" ]
[ "Subjective" ]
2,223
okay , and how about a cough ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,224
okay good . well i think we have our game plan .
[ "Chitchat" ]
[ "Null" ]
2,225
alright no problem any other questions
[ "Discussion" ]
[ "Plan" ]
2,226
. fever , chills ?
[ "Vegetative History" ]
[ "Subjective" ]
2,227
alright
[ "Chitchat" ]
[ "Null" ]
2,228
yeah i i really do n't like nick saving i'm so i'm super happy that that the dogs pulled it out
[ "Chitchat" ]
[ "Null" ]
2,229
okay and how about with family or friends have you been able to turn to anyone
[ "Other Socials" ]
[ "Subjective" ]
2,230
i think i would go ahead and go back to twice a day , every day , with the doxycycline .
[ "Discussion", "Medication" ]
[ "Plan" ]
2,231
did you have any other any other problems any other injuries that that went along with this or
[ "Personal History" ]
[ "Subjective" ]
2,232
all right , and relax for me . good . all right , and bend . good . that looks good . um , the incision looks nice .
[ "Physical Examination" ]
[ "Objective" ]
2,233
so , let's continue on your current meds . i'm glad that you're figuring out what your body can handle . definitely try to keep active as that will certainly help .
[ "Discussion", "Medication" ]
[ "Plan" ]
2,234
and i'm gon na squeeze on the right side anything there
[ "Physical Examination" ]
[ "Objective" ]
2,235
um , and , uh , this should sort of take care of itself after a few days . if it's not , or it's getting worse , i want you to come back and see me over the next week .
[ "Discussion", "Follow-up" ]
[ "Plan" ]
2,236
how's life otherwise ? pretty good ? nothing new ?
[ "Other Socials" ]
[ "Subjective" ]
2,237
mm-hmm okay alright do you have any other siblings
[ "Family History" ]
[ "Subjective" ]
2,238
well sounds like you have quite a few projects going on what all what all are you doing for for your yard and
[ "Other Socials" ]
[ "Subjective" ]
2,239
good . well , what brings you in to see me today ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,240
no because you need to go back to work because you work on the computer not running so
[ "Discussion" ]
[ "Plan" ]
2,241
doctor: okay . hey , dragon , finalize the note .
[ "Chitchat" ]
[ "Null" ]
2,242
okay and do you have any nausea vomiting any fever chills
[ "Vegetative History" ]
[ "Subjective" ]
2,243
tuberosity of the humerus let's see there is no tenderness at the sternoclavicular or acro
[ "Physical Examination" ]
[ "Objective" ]
2,244
okay and have you ever injured your elbow before
[ "Personal History" ]
[ "Subjective" ]
2,245
pain with supination no pain with pronation
[ "Physical Examination" ]
[ "Objective" ]
2,246
how bad was your pain on a scale of zero to 10 ? zero being no pain and 10 being worse , as you can imagine .
[ "Personal History" ]
[ "Subjective" ]
2,247
okay alright not a problem so if you do n't mind i'm gon na go ahead and do a quick physical exam as i mentioned before your blood pressure is a little high as i listen to your heart i do like it's got a nice regular rate and rhythm i do n't appreciate any murmur when i listen to your lungs they sound clear bilaterally...
[ "Physical Examination" ]
[ "Objective" ]
2,248
all right . well , i wan na go ahead and do a quick physical exam , okay ?
[ "Physical Examination" ]
[ "Objective" ]
2,249
and then are you still on an iron supplement ? and are you using the bathroom okay ?
[ "Therapeutic History", "Vegetative History" ]
[ "Subjective" ]
2,250
for your second problem , your hypertension , i , i do n't believe it's well controlled at this time . so , i wan na go ahead and , you know , increase the norvasc up to 10 mg a day , and i wan na go ahead and order an echocardiogram and a lipid panel , okay ?
[ "Medication", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
2,251
i'm well . hey , dragon , i'm seeing ms. james . she's a 42-year-old female , and what brings you in today ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,252
okay and have you ever smoked before
[ "Drug History" ]
[ "Subjective" ]
2,253
okay and when you bend backward does it hurt
[ "Physical Examination" ]
[ "Objective" ]
2,254
you as well ms. sanchez , do take care .
[ "Chitchat" ]
[ "Null" ]
2,255
are you having any flank pain now or tenderness in your lower back ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,256
and then we will see in in a few weeks how how if you're ready to go play soccer again okay alright
[ "Chitchat" ]
[ "Null" ]
2,257
okay and would you say that worked for you
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
2,258
no okay alright and well i i wan na go ahead let me just do a quick physical exam i'm gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay alright so on your heart exam your heart sounds in a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam...
[ "Physical Examination" ]
[ "Objective" ]
2,259
hmmm i heard that's beautiful
[ "Chitchat" ]
[ "Null" ]
2,260
okay . and , um- and , in terms of your activities of daily living , are you able to exercise or anything like-
[ "Other Socials" ]
[ "Subjective" ]
2,261
yep that's correct so what we're gon na do is you said you're six days in do a ten or twelve day course so we're gon na go ahead and continue your antibiotics therapy that your pcp put you on i do want to get the culture back and then we'll make the determination as far as additional or changing that antibiotic therapy
[ "Discussion", "Medication" ]
[ "Plan" ]
2,262
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
[ "Acute Symptoms" ]
[ "Subjective" ]
2,263
they've been running in the 300's ? and tell me about your diet . have you been eating anything to spark- ... spike them up ?
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
2,264
and then , from an atrial fibrillation standpoint , your heart , even though you're in atrial fibrillation right now , is in a good rate . and we'll just continue you on your metoprolol , 25 milligrams , twice a day . do you need a refill on that ?
[ "Reassessment", "Discussion", "Medication" ]
[ "Assessment", "Plan" ]
2,265
okay . we'll determine what the next steps are if there are any , after we see her results .
[ "Discussion" ]
[ "Plan" ]
2,266
any smoke you do n't have to tell me exactly but
[ "Vegetative History" ]
[ "Subjective" ]
2,267
you're welcome . have a great day .
[ "Chitchat" ]
[ "Null" ]
2,268
no okay
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
2,269
okay . any weakness in your lower extremities ?
[ "Vegetative History" ]
[ "Subjective" ]
2,270
that's good so you've had some issues with stability sometimes or
[ "Personal History" ]
[ "Subjective" ]
2,271
so what software do hunters use for designing and hunting their pray
[ "Chitchat" ]
[ "Null" ]
2,272
anything like that ?
[ "Vegetative History" ]
[ "Subjective" ]
2,273
okay . all right . um , and , in terms of your asthma , you just said that you were short of breath running up and down the stairs , so , um , do , how often have you been using your inhaler over the past year ?
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
2,274
yeah literally yeah
[ "Chitchat" ]
[ "Null" ]
2,275
okay alright understood okay great well then i'll see you back in a month if not before okay you take care of yourself nice seeing you
[ "Discussion", "Follow-up" ]
[ "Plan" ]
2,276
that's a fantastic day and happy birthday coming up on monday
[ "Chitchat" ]
[ "Null" ]
2,277
yeah that's very accurate you know like there are huge consequences to not taking them so if you are noticing any problems please please please please let us know how about your diet are you watching your salt intake
[ "Personal History" ]
[ "Subjective" ]
2,278
hey , dragon , show me the ecg . yeah , so in reviewing the results of your ekg , it looks the same as last year . um , you do have just blood , those changes from your chronic high blood pressure that we'll address , okay ? hey , dragon , show me the echocardiogram . and this is just the echocardiogram from just a few...
[ "Radiology Examination" ]
[ "Objective" ]
2,279
well that's good news .
[ "Chitchat" ]
[ "Null" ]
2,280
so , i know the nurse told you a little bit about dax . i'd like to tell dax about you . okay ?
[ "Chitchat" ]
[ "Null" ]
2,281
and it hurts , okay . and , and you saw a chiropractor . but what about physical therapy for your back pain ? or do you take any pain medicine for it ?
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
2,282
are you any belly pain
[ "Physical Examination" ]
[ "Objective" ]
2,283
you might also have to repeat an ekg before surgery which we could do today . i know i'm sure it feels like you're doing , you're always doing ekgs . um we do n't need to any x-rays of your chest because you had one recently , and we do n't need any more blood work because we did that today .
[ "Diagnostic Testing" ]
[ "Plan" ]
2,284
all right , well , the nurse will be in soon and she'll get you checked out , okay ?
[ "Chitchat" ]
[ "Null" ]
2,285
do you have a family history of this ?
[ "Family History" ]
[ "Subjective" ]
2,286
okay . when did these four days of chest pain occur ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,287
i'm gon na start by listening to your belly with my steth- stethoscope . and i hear bowel sounds in all four quadrants .
[ "Physical Examination" ]
[ "Objective" ]
2,288
okay alright yeah i have you on bumex cozaar and norvasc does that sound right
[ "Therapeutic History" ]
[ "Subjective" ]
2,289
okay , all right . and then i know that , uh , you know , you have this slightly reduced heart function , you know , your congestive heart failure . how have you been doing watching your salt intake ? i know that that's kind of been a struggle for you .
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
2,290
okay well you're one of the lucky ones some of my my patients that play sports they sprain their ankle seems like every other week so good for you so for that that that ankle sprain i just want to keep i want you to keep your leg elevated when you're seated and i want you to continue to ice it you can ice it let's say ...
[ "Discussion", "Medication", "Other Treatments" ]
[ "Plan" ]
2,291
at the level of l5 .
[ "Physical Examination" ]
[ "Objective" ]
2,292
judy gomez , mrn 869723 . date of birth , 5 , 7 , 1961 . she's in office today for ongoing management of psoriatic arthritis . hello , judy , how are you doing today ?
[ "Personal History", "Greetings" ]
[ "Subjective" ]
2,293
mm-hmm and help with some of the healing of your elbow
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
2,294
all right . and i just wan na really help knock it out as fast as possible , since you've been dealing with it for so long now . i would take it twice a day until it's gone , and then once a day for a week before you stop . i'll write it out like that . so twice a day until rash is gone , and then once a day for anothe...
[ "Medication" ]
[ "Plan" ]
2,295
body aches , joint pain ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,296
okay good good and then for your asthma have you had any recent asthma attacks and are you still taking the flovent twice a day and albuterol as needed for wheezing
[ "Personal History" ]
[ "Subjective" ]
2,297
okay . do you have any past medical history of anything ?
[ "Personal History" ]
[ "Subjective" ]
2,298
how long ago did that happen
[ "Acute Symptoms" ]
[ "Subjective" ]
2,299