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med_intent_classification

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hi . my name is dr. edwards . nice to meet you .
[ "Chitchat" ]
[ "Null" ]
2,900
okay . and any issues with that ?
[ "Personal History" ]
[ "Subjective" ]
2,901
okay . and , h- how are you feeling now ? are you still in the same amount of pain ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,902
eugene walker , n- date of birth 4/14/1960 . he's a 61-year-old male who presents today , uh , for a routine follow-up with chronic medical conditions . of note , the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 1/22/2013 . regarding his blood work from 4/10/2021 , the patient's alkaline phosphatate- phosphatase , excuse me , was elevated to 156 . his lipid panel showed elevated total cholesterol of 247 , hdl of 66 , ldl of 166 , and triglycerides at 74 . the patient's tsh was normal at 2.68 . his cbc was unremarkable . his most recent vitamin d level was at the high end of normal at 94 . good morning , mr. walker . how are you doing ? i mean , it's been a crazy year .
[ "Personal History", "Greetings" ]
[ "Subjective" ]
2,903
okay , so on exam , everything seems to be good . your heart , i hear a slight two out of six systolic ejection murmur , and your lungs sound nice and clear , and you do n't have any lower extremity edema . um , your ... you do have some pain to palpation of the , of the sinuses here , so i think you do have a little bit of congestion there . let's go ahead and look at some of your results , okay ? hey , dragon , show me the ekg . so they did an ekg before you came in today .
[ "Physical Examination" ]
[ "Objective" ]
2,904
okay alright yeah i'm not really sure what it looks like but okay as long as you're taking it so that's good and how about your diet are you watching your are you watching your salt intake
[ "Personal History" ]
[ "Subjective" ]
2,905
okay and then when you use it at that time does it help
[ "Therapeutic History" ]
[ "Subjective" ]
2,906
okay , great . and how about any swelling in the legs at all ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,907
do you have any children or have you ever been pregnant
[ "Other Socials" ]
[ "Subjective" ]
2,908
alright in the meantime i'm gon na prescribe some medication for now let's try meloxicam and try to get some of the swelling down i want you to ice it and also keep that that ankle elevated do you have a job where you can elevate your ankle regularly
[ "Medication" ]
[ "Plan" ]
2,909
so you know it's good
[ "Vegetative History" ]
[ "Subjective" ]
2,910
hey , dragon , show me the left elbow x-ray . hey , dragon , show me the elbow x-ray . hey , dragon , show me the left arm x-ray . okay , so , in reviewing the results of your left arm x-ray , there's no evidence of any elbow fracture , which is not surprising , okay ? hey , dragon , show me the endoscopy results . hey , dragon , show me the endoscopy . okay , well , your recent endoscopy showed that you ... hey , dragon , show me the endoscope . all right , so here it looks like , you know ... your endoscopy results look like you had an episode of gastritis . that's for your , your peptic ulcer disease , and so everything , you know ... you took your , your protonix , and i think everything resolved at that point , okay .
[ "Radiology Examination" ]
[ "Objective" ]
2,911
okay okay so lem me ask you some questions so what kind of symptoms were you having that prompted you your doctor to do the tests
[ "Personal History" ]
[ "Subjective" ]
2,912
alright
[ "Chitchat" ]
[ "Null" ]
2,913
okay okay severe positive pain to extension okay so can you turn your head from side to side does that hurt
[ "Physical Examination" ]
[ "Objective" ]
2,914
hi jerry , how are you doing ?
[ "Greetings" ]
[ "Subjective" ]
2,915
the hepatomegaly means the liver is enlarged .
[ "Physical Examination" ]
[ "Objective" ]
2,916
okay . um , it looks like you had a history of atopic eczema in your past ?
[ "Personal History" ]
[ "Subjective" ]
2,917
no pain with palpation to the right side okay i'm just gon na push down on your feet can you push back up on my hands
[ "Acute Symptoms" ]
[ "Subjective" ]
2,918
all right , so take advantage of that . you've got ta start moving the finger . you're not going to tear anything or break a bone , uh , because your intensors , extensors are intact . but your collateral ligaments are intact , so you've got a stiff , sore finger . i'm going to try to help as much as i can with this soreness part , and then you have to do all the stiff part .
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
2,919
what kind of pain meds did you
[ "Physical Examination" ]
[ "Objective" ]
2,920
okay no i understand okay so i'm going so you said you were doing laundry
[ "Acute Symptoms" ]
[ "Subjective" ]
2,921
um , basically you want to avoid anything that puts extra pressure on your knees for a little while and it should be fine . if it's not getting any better in a couple weeks i wan na see you again , okay ? so no lunges , avoid the breaststroke . if you're comfortable, you can also do other swimming strokes where your knees are straight instead . or you can take the opportunity to have a little break .
[ "Discussion", "Follow-up" ]
[ "Plan" ]
2,922
okay alright and we do n't want you to go back to the hospital it's never a good experience so you know being in a hospital it's better to be well and be at home and watching your chiefs play now have you bought a blood pressure cuff at home i know we talked about that
[ "Personal History" ]
[ "Subjective" ]
2,923
yeah and have you ever had headaches like this before
[ "Personal History" ]
[ "Subjective" ]
2,924
okay . all right . well , it looks like also that you never smoked . that's excellent . and then no allergies to medicines that you know of , is that correct ?
[ "Personal History" ]
[ "Subjective" ]
2,925
i i have a daughter myself have have you picked out any names
[ "Chitchat" ]
[ "Null" ]
2,926
yeah okay so you do have pain on flexion and extension and when i touch the fingertips here now you said you had some numbness in your thumb and your index finger and a little bit in your your middle finger the other two fingers they feel okay or do you think that there is different than the other hand
[ "Physical Examination" ]
[ "Objective" ]
2,927
doctor: okay . great . hey , dragon , finalize the note .
[ "Chitchat" ]
[ "Null" ]
2,928
well since you've been in the hospital and and they've helped you out with some with all that how are you feeling now
[ "Acute Symptoms" ]
[ "Subjective" ]
2,929
great question . you should avoid food rich in sodium oxalate and animal protein . so that would be salty , processed food because they're high in sodium . ideally , you should consume less than 1,000 milligrams of sodium a day and reduce the amount of beef , poultry , fish , and pork .
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
2,930
okay and how about when you're sleeping at night are you able to lay flat or do you have to sit up a little bit
[ "Other Socials" ]
[ "Subjective" ]
2,931
that's great .
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
2,932
and are you still on the coreg for hypertension and the lexapro for anxiety ?
[ "Therapeutic History" ]
[ "Subjective" ]
2,933
doctor: hey , dragon . finalize the note .
[ "Chitchat" ]
[ "Null" ]
2,934
yeah okay well you know we can get you there too you know we can work on that so we we'll take we'll talk more about some tips to help achieve those goals okay
[ "Chitchat" ]
[ "Null" ]
2,935
okay that's what i was gon na ask you okay so you're able to drink water and are you able to drink any other fluids have you been able to drink any you know i do n't know juices or milk shakes or anything like that
[ "Vegetative History" ]
[ "Subjective" ]
2,936
we do know that caffeine and caffeinated beverages will do that , even sodas . um , even just the carbonation can cause that . how about tomato-based products or citrus products ?
[ "Vegetative History" ]
[ "Subjective" ]
2,937
what can i do for you today
[ "Acute Symptoms" ]
[ "Subjective" ]
2,938
hmmm okay and do you would you say it's a sharp pain stabbing pain aching throbbing how would you describe it
[ "Acute Symptoms" ]
[ "Subjective" ]
2,939
really like where
[ "Vegetative History" ]
[ "Subjective" ]
2,940
okay that i mean that's not too bad i think when you were first diagnosed you were up there in the the one eighties which was really high
[ "Acute Symptoms" ]
[ "Subjective" ]
2,941
okay alright well would you be interested in in like a referral to psychiatry or something like that so that you have someone to talk to about some of of issues because medication can help but i do i think it's important to have you know talk some of these things out
[ "Discussion", "Referral" ]
[ "Plan" ]
2,942
it's really hard to swallow okay now do you have pain every time you swallow or is it just periodically
[ "Acute Symptoms" ]
[ "Subjective" ]
2,943
so i know you said that you like to do a lot of travel
[ "Other Socials" ]
[ "Subjective" ]
2,944
hmmm well in any case what i'm gon na have to do is i'm gon na send you up for mri to take another look at this
[ "Diagnostic Testing" ]
[ "Plan" ]
2,945
no problem . what pharmacy are you using ? have you changed it or anything ?
[ "Therapeutic History", "Other Socials" ]
[ "Subjective" ]
2,946
okay . and you're using the metro cream ?
[ "Therapeutic History" ]
[ "Subjective" ]
2,947
hey , dragon ? show me the vital signs . so , looking at your vital signs here in the office , everything looks good . you know , your blood pressure and your heart rate and your oxygenation all look really good .
[ "Physical Examination" ]
[ "Objective" ]
2,948
got it . yeah , it can be a little rough , but it works .
[ "Discussion", "Medication" ]
[ "Plan" ]
2,949
yeah , there is . and it actually works on the chemicals in your brain that are causing your gut to be overly sensitive . one is called elavil , but the only drawback is that it can make you a little sleepy . how does that sound ?
[ "Discussion", "Medication" ]
[ "Plan" ]
2,950
okay . so , it sounds like you were skiing about four about days ago and you went over a mogul and got it hyper extended or got it bent backwards a little bit , ? okay . do you have any other past medical history at all ?
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
2,951
mm . that does not sound like fun . it sounds like you injured it going up the stairs ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,952
all right , so pain to palpation of the right knee . um , and decreased range of motion of the knees bilaterally . so i just wan na look at some of your results , okay ?
[ "Physical Examination" ]
[ "Objective" ]
2,953
okay alright what
[ "Chitchat" ]
[ "Null" ]
2,954
okay . have a seat here , and let me listen to your heart and lungs , and then we can talk about a plan for you .
[ "Physical Examination" ]
[ "Objective" ]
2,955
okay and then do you still have that pain that radiates down your left leg sometimes
[ "Personal History" ]
[ "Subjective" ]
2,956
okay so let's talk a little bit about that now is your is your stream is your urination stream weak
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
2,957
okay . all right . sometimes they kind of describe it as looking as like a bull's-eye .
[ "Acute Symptoms" ]
[ "Subjective" ]
2,958
i am so sorry so i mean that's really cool that you do parttery it's something that i've wanted to pick up you know but i do n't know that i have those skills yet does the pain radiate down your arm or up your shoulder or anything
[ "Acute Symptoms" ]
[ "Subjective" ]
2,959
louis is a 58-year-old male here for follow up from an emergency room visit . so , louis , what happened ?
[ "Acute Symptoms" ]
[ "Subjective" ]
2,960
that's- that's a good start on a regimen . are you checking your blood pressure at home , and if yes , what numbers are you seeing ?
[ "Personal History" ]
[ "Subjective" ]
2,961
and do you get a regular period ?
[ "Vegetative History" ]
[ "Subjective" ]
2,962
hey , dragon ? order ultram 50 milligrams every six hours as needed for pain . and i want you to push fluids and strain your urine . i know that you're familiar with that .
[ "Medication", "Acute Assessment" ]
[ "Assessment", "Plan" ]
2,963
thanks , rachel . nice , nice to meet you .
[ "Chitchat" ]
[ "Null" ]
2,964
okay . all right . so let's go ahead and do a quick physical exam . so , listening to you , um , look , or looking at you , you appear in no distress . your thyroid is a little enlarged , but non-tender . there's no carotid bruits , your heart is in irregular rate and rhythm , and your lungs are clear . your abdomen is nice and soft , and you have no edema in your lower extremities . let's go ahead and look at some of your test results .
[ "Physical Examination" ]
[ "Objective" ]
2,965
yeah . so hang tight . anna will bring that note back in to you , and we'll talk in six weeks .
[ "Follow-up" ]
[ "Plan" ]
2,966
but have you ever needed to receive a blood transfusion or blood products
[ "Personal History" ]
[ "Subjective" ]
2,967
i'm going through , uh , i'll also order another , uh , cbc on you . hey , dragon , order a complete blood count . all right . the nurse will be in soon . it's , you know , settle all that . i'll see you soon .
[ "Diagnostic Testing" ]
[ "Plan" ]
2,968
okay , all right , well it's good to see you .
[ "Chitchat" ]
[ "Null" ]
2,969
now if you do have a herniated disk we can go ahead and talk about some other treatment options maybe like an epidural steroid injection to help take down some of that inflammation
[ "Discussion", "Medication" ]
[ "Plan" ]
2,970
okay so i'm just gon na listen to your lungs here your lungs are clear bilaterally i do n't hear any wheezes or crackles listen to your heart so on your heart exam i do still hear that grade two out of six systolic ejection murmur and you already had that and so we we knew about that already so lem me look at your knee here so when i press here on the inside of your knee does that hurt
[ "Physical Examination" ]
[ "Objective" ]
2,971
okay and then any numbness or tingling in in your lower extremities or any weakness there in your legs
[ "Vegetative History" ]
[ "Subjective" ]
2,972
hey , i'm dr. sanders . it's nice to meet you .
[ "Chitchat" ]
[ "Null" ]
2,973
okay alright now what do you think caused this ulcer were you wearing some tight fitting shoes or did you have some trauma to your foot or
[ "Acute Symptoms" ]
[ "Subjective" ]
2,974
hey , dragon . order a hemoglobin a1c . and lastly , for your high blood pressure , it looks like you're doing a really good job managing that . i want to go ahead and continue you on the , um , lisinopril , 20 milligrams a day .
[ "Medication", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
2,975
okay got it and any nausea vomiting or diarrhea or anything like that with your diabetes or any side effects from your medications the metformin
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
2,976
i like it too alright are you taking the metformin twice a day
[ "Therapeutic History" ]
[ "Subjective" ]
2,977
okay do n't worry i think i can look that up in your chart i just wan na make sure that we have the story straight alright so i know that you said that you mentioned that you played basketball you know before how how like what's your activity like now
[ "Other Socials" ]
[ "Subjective" ]
2,978
were you having some dizziness and some lightheadedness ?
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
2,979
okay tell me a little bit about the pain is you said it it's after the activity but it you when you first wake up in the morning it it's it's there also
[ "Acute Symptoms" ]
[ "Subjective" ]
2,980
no , no . so , so you really need to start bending the finger right here for me , as hard as you can , and keep going , going . all right , so , so you're okay . all right , so i would say the following , that there is a partial tear in one of the two flexor tendons . there is the fdp and the fds , and the fds is the least important of the two . so the mri shows that it's the fds , the flexor digitorum superficialis , which is the least important of the two .
[ "Physical Examination", "Acute Assessment", "Radiology Examination" ]
[ "Objective", "Assessment" ]
2,981
great . um , beverly's a 24 year old female patient , and i know you have a history of type 2 diabetes and high blood pressure . correct ?
[ "Personal History" ]
[ "Subjective" ]
2,982
okay and and tell me what is your day like
[ "Other Socials" ]
[ "Subjective" ]
2,983
alright can you follow my finger with your eyes good now can you do me a favor walk across the room for me great job okay now i want you to close your eyes and reach out your arms in front of you good now keep your eyes closed can you feel me touch you here how about okay how about there
[ "Physical Examination" ]
[ "Objective" ]
2,984
okay but you do take it
[ "Therapeutic History" ]
[ "Subjective" ]
2,985
okay , great . do you mind if i do a quick exam ?
[ "Physical Examination" ]
[ "Objective" ]
2,986
okay and when you get this pain what makes it better is it stopping and just resting for a while or do you take medications or try other
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
2,987
well , let's talk about what we found and then some possible next steps if you're in agreement .
[ "Chitchat" ]
[ "Null" ]
2,988
all right . does that hurt ?
[ "Physical Examination" ]
[ "Objective" ]
2,989
i'm okay the the medical assistant told me that you had this ulcer on your foot that's been there for a couple of weeks
[ "Acute Symptoms" ]
[ "Subjective" ]
2,990
how's it been since you've had your heart attack have you been have you been doing alright
[ "Personal History" ]
[ "Subjective" ]
2,991
okay . and rashes , do you get any rashes underneath your breasts ? and , and it could be from sweating .
[ "Personal History" ]
[ "Subjective" ]
2,992
patient is pamela cook . medical record number is 123546 . she's a 36-year-old female post bilateral reduction mammoplasty on 10-10 20-20 . hey , how are you ?
[ "Personal History", "Greetings" ]
[ "Subjective" ]
2,993
have what ?
[ "Discussion" ]
[ "Plan" ]
2,994
alright that sounds good now just out of curiosity can you rate your pain for me right now zero being none ten being the worst pain you've ever been in your life
[ "Acute Symptoms" ]
[ "Subjective" ]
2,995
okay . all right , and um , any other joint pain ?
[ "Personal History" ]
[ "Subjective" ]
2,996
is that helping
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
2,997
looks like you have little bit of limited range of motion on extension not on flexion though you said it hurts right here on the inside of your elbow
[ "Physical Examination" ]
[ "Objective" ]
2,998
okay , let me examine you . does it hurt when i push on your leg like that ?
[ "Physical Examination" ]
[ "Objective" ]
2,999