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med_intent_classification

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doctor: hey , dragon . finalize the note .
[ "Chitchat" ]
[ "Null" ]
3,100
okay . even with the doxycycline , you can keep using the elidel .
[ "Vegetative History" ]
[ "Subjective" ]
3,101
so it was a surprise for you too ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,102
mm-hmm
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
3,103
okay also known as pictures elbow
[ "Chitchat" ]
[ "Null" ]
3,104
okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright. so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday
[ "Reassessment", "Referral", "Medication" ]
[ "Assessment", "Plan" ]
3,105
okay your appetite is unchanged alright what about your water consumption
[ "Vegetative History" ]
[ "Subjective" ]
3,106
okay , well , next time that ... that coupon should help , and it should only be about $ 3 .
[ "Discussion" ]
[ "Plan" ]
3,107
okay alright and then have you had any hospitalizations or surgeries in the past
[ "Personal History" ]
[ "Subjective" ]
3,108
hey dragon , order a pulmonary referral . hey dragon , order albuterol inhaler , two puffs every four hours , as needed for shortness of breath . and then i think from your reflux standpoint , everything seems stable and your migraines , i think that we should just continue on with the imitrex , as needed . does that sound good to you ?
[ "Reassessment", "Referral", "Medication" ]
[ "Assessment", "Plan" ]
3,109
okay . all right , and i know that you've had this also , had this history of gout . and the last episode you had was about three months ago . you had some inflammation of your toe . have you had any other issues with that ?
[ "Personal History" ]
[ "Subjective" ]
3,110
okay . um , all right . so the tretinoin , uh , usually lasts patients a couple of months . you probably have n't refilled that , right ?
[ "Discussion", "Medication" ]
[ "Plan" ]
3,111
alright so we're gon na say hope maybe that you had a car crash and we can verify this in february of this year and you've been experiencing some neck pain since then right
[ "Acute Symptoms" ]
[ "Subjective" ]
3,112
okay . we can take care of that today while you're here and then schedule a follow up appointment in three months to see how you're doing , and then receive another injection if needed .
[ "Follow-up", "Medication" ]
[ "Plan" ]
3,113
okay , great . so now let me ask you about the allergies , 'cause i know typically you'll use the zyrtec in the spring , summer and fall , correct ?
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
3,114
but the food was amazing it was the best egg plant parmer's john i've i've ever had where really super excited about going back there here very very soon
[ "Chitchat" ]
[ "Null" ]
3,115
okay excellent excellent alright and i recall you know just kinda review a few things i i think you've got an allergy to penicillin is that correct
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
3,116
okay playing basketball how often do you play basketball
[ "Other Socials" ]
[ "Subjective" ]
3,117
alright very good any questions at all
[ "Chitchat" ]
[ "Null" ]
3,118
alright
[ "Discussion" ]
[ "Plan" ]
3,119
okay good so i'm gon na go ahead and do a quick physical exam and take a look at your your shoulder so i reviewed your your vitals everything looks good with that so touch here in your shoulder so your left shoulder exam you have limited active and passive range of motion so pressure here so that there is tenderness of the greater
[ "Physical Examination" ]
[ "Objective" ]
3,120
um , and then , hey , dragon ? show me the chest x-ray . okay , good , and your chest x-ray looks fine , so we know that there's no pneumonia there .
[ "Radiology Examination" ]
[ "Objective" ]
3,121
and do the alvesco two puffs twice a day and your albuterol if you need it . the zyrtec 10 milligrams as you need it and continue to stay away from peanuts and tree nuts and i'll refill your epipen .
[ "Medication", "Other Treatments" ]
[ "Plan" ]
3,122
endometriosis
[ "Personal History" ]
[ "Subjective" ]
3,123
okay and then a couple other family history questions anybody in the family have kidney disease or significant high blood pressure
[ "Family History" ]
[ "Subjective" ]
3,124
okay and and how long has this been going on for
[ "Acute Symptoms" ]
[ "Subjective" ]
3,125
okay , all right . so , you know , let's talk a little bit about that colonoscopy . i know you had a colonoscopy about three years ago and that showed that you had some mild diverticuli- diverticulosis . um , no issues since then ?
[ "Personal History" ]
[ "Subjective" ]
3,126
okay . all right . now , um , how long has this been going on for ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,127
all right . are you aware of any family history of gi problems ?
[ "Family History" ]
[ "Subjective" ]
3,128
okay good alright have you had any chest pain
[ "Acute Symptoms" ]
[ "Subjective" ]
3,129
okay . all right . so i , i know that the nurse went over the review of systems sheet with you , and , and you endorsed some nasal congestion from the pollen , but how about any shortness of breath , cough , muscle aches ?
[ "Vegetative History" ]
[ "Subjective" ]
3,130
mm-hmm . okay . all right . well , you know , for the most part , how , you know , before all of this-
[ "Chitchat" ]
[ "Null" ]
3,131
alright so you've got neuropathy yeah that that that makes sense with the the diabetes so have you had any other symptoms like a fever chills any drainage coming from it
[ "Vegetative History" ]
[ "Subjective" ]
3,132
wow okay and what have you been doing for the the pain since then
[ "Therapeutic History" ]
[ "Subjective" ]
3,133
okay alright any loss of sensation
[ "Vegetative History" ]
[ "Subjective" ]
3,134
what happened
[ "Acute Symptoms" ]
[ "Subjective" ]
3,135
no concerns about hurting yourself or anything like that ?
[ "Vegetative History" ]
[ "Subjective" ]
3,136
let me know if your symptoms worsen and we can talk more about it , okay ?
[ "Discussion" ]
[ "Plan" ]
3,137
okay and do you remember what you were doing when the pain started
[ "Acute Symptoms" ]
[ "Subjective" ]
3,138
do you have any nausea vomiting
[ "Vegetative History" ]
[ "Subjective" ]
3,139
okay , dragon . hey dragon , go ahead and order the medications and procedures and close out the note . come on i'll bring you out to check out .
[ "Chitchat" ]
[ "Null" ]
3,140
okay . and , and y- the last time i saw that you saw dr. reyes , was about three weeks ago , and everything seemed to be fine .
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
3,141
okay , and that's not drying you out too much ?
[ "Therapeutic History" ]
[ "Subjective" ]
3,142
yeah that's that will be good if you can take your blood pressures at home and definitely track those what about any problems with shortness of breath lately
[ "Vegetative History" ]
[ "Subjective" ]
3,143
that's awesome .
[ "Chitchat" ]
[ "Null" ]
3,144
hmmm my gosh so it looks like you you went into the er and looks like they said that your ankles were swelling a little bit too and did you have some shortness of breath
[ "Acute Symptoms" ]
[ "Subjective" ]
3,145
okay so yes , you can get it , your colonoscopy , wherever you'd like .
[ "Discussion", "Diagnostic Testing" ]
[ "Plan" ]
3,146
okay alright so i just want to know i know some of my patients they have like bad ankles where they hurt the ankles all the time but have you ever injured this ankle before
[ "Personal History" ]
[ "Subjective" ]
3,147
okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything
[ "Acute Symptoms" ]
[ "Subjective" ]
3,148
mm-hmm
[ "Acute Symptoms" ]
[ "Subjective" ]
3,149
yeah i you know if i could do telehealth visits all day long i would be totally happy with that yeah and just set it home and do those so you mentioned is there anything that makes that pain feel better
[ "Acute Symptoms" ]
[ "Subjective" ]
3,150
yeah that's uh uh that's a really good question so our big and favorite one is gon na be your blood pressure right so you're right like we are seeing some some definite improvement today it was one twenty over seventy and honestly that's a great place to be so that tells me that your medication is working and that maybe we can start to evaluate a bit more your respiratory rate is completely normal so i see it here as eighteen that's wonderful you are not running a fever so ninety seven . nine and you're honestly that's within like a good enough range for me you're satting pretty well your oxygen saturation is a hundred percent again so that means that you're not experiencing any kind of difficulty getting in that oxygen to the rest of your body i do wan na say that you know pain is one of the vitals that we worry about and you're saying that at it's worst your the pain in your elbow is a seven out of ten so that's something that i'm gon na evaluate and then your pulse rate seems to be appropriate as well so those are all great do you have any questions about that so far
[ "Physical Examination" ]
[ "Objective" ]
3,151
next patient is nicole miller . date of birth is 09/18/1949 . patient was called for a follow-up with me for chronic congestive heart failure with diastolic dysfunction . bmp's been , uh , 3,000 in march , and is about six- was up to 6,000 in april . she was increasingly dyspneic . we changed her furosemide and torsemide 20 milligrams by mouth daily . uh to note , the patient is not currently on potassium supplement . her lisinopril had- has also been increased up to 10 milligrams daily in march . also did when i saw her last april . she reported being interested in having her right knee replaced this summer at east metro . it was recommended that we work to control her cardiovascular status before surgery . hey , miss miller , how are you today ?
[ "Therapeutic History", "Personal History", "Greetings" ]
[ "Subjective" ]
3,152
mm-hmm i do wan na say that like looking at your the weight we do see like maybe a five pound increase from the last time that you were here but that's completely normal right to be able like to fluctuate you know give or take five pounds so i'm not i'm not i'm not like seriously worried about it but if we do come back and notice an additional five pounds then we might have to start talking about like actually you know what let's do that right now what kind of exercise regimen are you on
[ "Physical Examination", "Other Socials" ]
[ "Subjective", "Objective" ]
3,153
sore to walk on ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,154
. with your current strategy . let's continue you on the prozac 20 milligrams a day and do you need a refill on that ?
[ "Discussion", "Medication" ]
[ "Plan" ]
3,155
i have to
[ "Discussion" ]
[ "Plan" ]
3,156
no kidding , that's great .
[ "Therapeutic History" ]
[ "Subjective" ]
3,157
hey dragon , show me the autoimmune panel . so , looking here at your autoimmune panel , everything looks good , it looks like you're- you know , everything is well controlled with your rheumatoid arthritis on the methotrexate . okay ? so , let me just go over a little bit about my assessment and my plan for you . okay ?
[ "Lab Examination" ]
[ "Objective" ]
3,158
okay and is it seem to be stuck in your throat or does it seem to go in your lungs area or are you coughing with this at all or just mostly when you're swallowing
[ "Acute Symptoms" ]
[ "Subjective" ]
3,159
i'm gon na reach out i'm gon na reach out to them now and see if they can get you in this week
[ "Chitchat" ]
[ "Null" ]
3,160
so , albert is a 62-year-old male , with a past medical history significant for depression , type 2 diabetes , and kidney transplant , who is here today for emergency room follow-up .
[ "Personal History" ]
[ "Subjective" ]
3,161
okay , all right , so it might just be from that . okay , well let's look at some of your results . hey , dragon , show me the glucose . okay , so yeah , you know i know that they just checked your blood sugar now and it was 162 and you know , what ... you know , did you eat before this ?
[ "Lab Examination" ]
[ "Objective" ]
3,162
okay . and just in general , you know , i know that we've kind of battled with your arthritis .
[ "Personal History" ]
[ "Subjective" ]
3,163
so , anna is a 44-year-old female with a past medical history significant for arthritis , gout , and reflux , who presents today for follow up of her chronic problems . so , anna , it's been probably about six months since i've seen you . how are you doing ?
[ "Personal History" ]
[ "Subjective" ]
3,164
what does it look like when it comes up ?
[ "Vegetative History" ]
[ "Subjective" ]
3,165
okay . skin is intact , no midline tenderness to palpitation . go ahead and lean back . and lean to your right , to your left . does that hurt at all ?
[ "Physical Examination" ]
[ "Objective" ]
3,166
alright we'll get a urine culture just to make sure everything is is cleared up i also want to give you a referral to referral referral to urology
[ "Referral", "Diagnostic Testing" ]
[ "Plan" ]
3,167
mm-hmm . to me , it's , you know , a lot of the stuff out there is fear and most of us health providers have gotten the vaccine . we've seen what the virus can do . i also have gotten all of my kids vaccinated .
[ "Discussion", "Medication" ]
[ "Plan" ]
3,168
okay . and any surgeries in the past ?
[ "Personal History" ]
[ "Subjective" ]
3,169
you should drink about half of your body weight in ounces of water a day .
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
3,170
okay . that area of numbness will get smaller as the nerves that innervate the skin across the knee heal .
[ "Acute Symptoms" ]
[ "Subjective" ]
3,171
what are you for her toppings on pizza
[ "Vegetative History" ]
[ "Subjective" ]
3,172
yeah . and so wh- what side of your back is it on ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,173
all right-y . please use my physical exam template . so , ashley , i'm gon na listen to your lungs and heart , if you'll just breathe normally for me . okay ?
[ "Physical Examination" ]
[ "Objective" ]
3,174
okay your blood sugars are running below
[ "Personal History" ]
[ "Subjective" ]
3,175
do you remember the numbers that you're getting on your blood pressure readings
[ "Personal History" ]
[ "Subjective" ]
3,176
yeah okay okay roll over here on my my stretcher for me and i want you to dangle your your feet over the edge and what i wan na do is i just wan na i'm gon na squeeze your left calf first and when i do that does that hurt on your left side
[ "Physical Examination" ]
[ "Objective" ]
3,177
well that's a good question so based on what i see at this time i will we believe you have a favorable diagnosis prognosis and you're also still young and healthy which makes your prognosis even better and we do need to see a final pathology report to give you a definitive answer though okay
[ "Discussion" ]
[ "Plan" ]
3,178
okay . what type of alcohol drink do you drink when you are there ? is it a sweet drink ?
[ "Drug History" ]
[ "Subjective" ]
3,179
okay . all right . and when you say you're having some shortness of breath , did you feel short of breath walking around or at rest ?
[ "Vegetative History" ]
[ "Subjective" ]
3,180
no . okay . all right , well let me go ahead , i want to do a quick physical exam .
[ "Physical Examination" ]
[ "Objective" ]
3,181
okay , and is he stuffy too ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,182
okay okay i'm sure this is impacting that ability to to really focus on your training uh as you're going with that with that type of a pain so lem me go ahead and let's let's take a look at your your and your lower extremities here and yeah okay so roll up your pants yeah okay good now does your left leg hurt at all do you get that severe pain or is it mainly on the right
[ "Physical Examination" ]
[ "Objective" ]
3,183
okay and then lastly for the painful swallowing that you're having so the inflammation you're having it not only in your lungs but it also in your esophagus as well so what i'm gon na do is prescribe you you're taking the the prednisone i'm also gon na give you a lidocaine swish and swallow and you can do that four times a day and so that will be able to help you so you can eat immediately after taking it and it can also help so that you can continue to take food and fluids prevent dehydration and any further weight loss
[ "Medication", "Other Treatments", "Reassessment" ]
[ "Assessment", "Plan" ]
3,184
okay so both the dosepak and then also the high dose as well okay
[ "Therapeutic History" ]
[ "Subjective" ]
3,185
okay , yeah . i , you know , the nurse told me that you had called with these complaints . and i know that we have ordered some labs on you before the visit . and it did , it c- you know , your , your , your hemoglobin is your red blood cell count . and now , and that came back as a little low on the results , okay ? so , have you noticed any blood in your stools ?
[ "Acute Symptoms", "Personal History", "Vegetative History" ]
[ "Subjective" ]
3,186
right , so let's check your leg . can you straighten it , and does it hurt ?
[ "Physical Examination" ]
[ "Objective" ]
3,187
right knee okay and when did this happen
[ "Acute Symptoms" ]
[ "Subjective" ]
3,188
alright so press here in the back and your cva does that back here in
[ "Physical Examination" ]
[ "Objective" ]
3,189
i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ?
[ "Personal History" ]
[ "Subjective" ]
3,190
okay okay so you know maybe this is just a situation of like where we are on the right path but probably need to step up a few things okay
[ "Personal History" ]
[ "Subjective" ]
3,191
okay and now are you able to move that right arm for me
[ "Acute Symptoms", "Physical Examination" ]
[ "Subjective", "Objective" ]
3,192
okay alright and did you take anything at all to relieve the pain
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
3,193
all right .
[ "Acute Symptoms" ]
[ "Subjective" ]
3,194
acne is always good when you come to see the doctor . do you find that your acne flares with your periods ?
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
3,195
and we do have some options . so first is to start some low impact exercises . i can provide you with a hand out with what exercises you can do . you should take nsaids as needed to help with the pain and discomfort , as well as use of a cane to help offload the right side . a cane will help support your painful side to help reduce the pain .
[ "Referral" ]
[ "Plan" ]
3,196
it does help good very good so how often are you taking your your medication are you taking that as prescribed like daily it sounds like you missed a few times but for the most part are you taking it
[ "Therapeutic History" ]
[ "Subjective" ]
3,197
alright so looking at your vitals your blood pressure seems alright we are in like the one thirty over seventy range that's perfectly fine your respiratory rate i have you at an eighteen again pretty normal when i listen here to your heart you have a regular rate and rhythm i do n't appreciate any murmurs rubs or gallops that means your heart sounds great on your respiratory exam your lungs sound clear to auscultation bilaterally on your musculoskeletal back exam as i'm looking here i do n't notice any overlying redness or bruising on the skin when i push here on the midline of your back does it hurt
[ "Physical Examination" ]
[ "Objective" ]
3,198
okay alright great and okay so so tell me about your migraines how have they been are you still taking the sumatriptan you know as needed when when you developed migraine you have have you had a migraine recently
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
3,199