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med_intent_classification

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carolyn okay yeah you're still working a lot on the computer for work okay are you taking breaks every hour or so you know get up stand around walk stand walk around that can be helpful
[ "Other Socials" ]
[ "Subjective" ]
3,300
yeah i think that's fine for a short if it's helping the big thing right now is we want to get your strength back and your motion back get rid of the swelling that we still see here
[ "Discussion" ]
[ "Plan" ]
3,301
maybe . i do n't really see an endocrine cause for it , at least , so i would need to see the , the hyperandrogynism or high testosterone . or , a high dhea , to cause acne , or hair growth , or any of that stuff . but , the numbers are n't showing up out of range .
[ "Discussion", "Medication" ]
[ "Plan" ]
3,302
okay alright and for diagnostics so your x-ray so there's no fracture appreciated no bony abnormalities so that looks alright so let me tell you a little bit about my impression and plan with this so you have a knee contusion so for treatment we'll we need to rest that apply ice you know two three times a day for twenty minutes at a time take some nsaids or you know nonsteroidal anti- inflamma medication such as ibuprofen every six to eight hours as needed so i just wan na really get some rest with that if that does n't improve then we can go ahead and maybe come back in and we might do some physical therapy as well i do n't know i'm not sure i like this one all that well any do you have any questions on that
[ "Discussion", "Medication", "Radiology Examination", "Referral", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,303
yeah i understand how has your diet been lately
[ "Personal History" ]
[ "Subjective" ]
3,304
and we have n't put you on medication because you're on other meds and you- you have n't really wanted to do that , so what strategies are you using ?
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
3,305
and for your last problem , your high blood pressure , again , everything looks great here . um , you know , i think you're doing a really good job with that as well . i want you to continue on the lisinopril , 10 milligrams a day . and then , uh , let me know if you notice any increases in your blood pressure readings . okay ?
[ "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
3,306
okay , and any problems with your bladder or your bowels ?
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
3,307
i'm good . you're ready to get started ?
[ "Chitchat" ]
[ "Null" ]
3,308
okay . and you live with your roommate , no history of tobacco and you limit alcohol intake to less than five drinks per month .
[ "Other Socials", "Drug History" ]
[ "Subjective" ]
3,309
okay great i would like to ask you a little bit more about that had in your face do you remember how long that you had it
[ "Acute Symptoms" ]
[ "Subjective" ]
3,310
okay . is moving your shoulder uncomfortable at all ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,311
hey , dragon ? show me the vital signs . so here in the office , you know , your vital signs look good . your , your pulse ox ... that's your oxygenation level ... looks good . so i'm encouraged by that with you just sitting here , okay ? i'm gon na go ahead and do another , uh , just check you over . i'll let you know what i find .
[ "Physical Examination" ]
[ "Objective" ]
3,312
okay okay well that's good your your thompson test is negative that's a really good finding and i just wan na continue pressing here on your right from your heel when i squeeze your heel does that cause significant pain at all
[ "Physical Examination" ]
[ "Objective" ]
3,313
okay that's okay are you taking the lisinopril i think we have you on twenty milligrams a day
[ "Therapeutic History" ]
[ "Subjective" ]
3,314
hi good afternoon joseph how are you doing today
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
3,315
hi kyle how are you today
[ "Greetings" ]
[ "Subjective" ]
3,316
okay so it does sound like there might have been some direct trauma to that area now it says here that this happened about three weeks ago were you able it sounds like you were able to get up and continue but you were having some pain did you take anything at that time to help with that shoulder pain
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
3,317
wow . okay .
[ "Personal History" ]
[ "Subjective" ]
3,318
. refer you to psychotherapy , if you think that that would be helpful .
[ "Discussion", "Referral" ]
[ "Plan" ]
3,319
all right , we're going to go ahead and do the neurologic examination . let's look at the right hand first . can you feel this ?
[ "Physical Examination" ]
[ "Objective" ]
3,320
hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it does look a little elevated still , so we'll have to talk about that . so i'm just gon na listen to your heart and your lungs and we'll go from there okay ?
[ "Physical Examination" ]
[ "Objective" ]
3,321
mm-hmm
[ "Discussion" ]
[ "Plan" ]
3,322
wow and how long do your symptoms normally last for
[ "Acute Symptoms" ]
[ "Subjective" ]
3,323
okay how long has that been going on for
[ "Vegetative History" ]
[ "Subjective" ]
3,324
okay great and okay you're still watching your diet and getting some exercise
[ "Personal History" ]
[ "Subjective" ]
3,325
. next patient is michelle king . date of birth : 05/07/1982 . please use toc template . she was admitted to district regional hospital on 06/29/2021 , and was discharged on 07/02/2021 . the patient is a 39-year-old female with history of quadriplegia due to , uh , prior spinal cord injury . she was experiencing increasing concerns for spasms and lightheadedness , significant constipation , and reported diaphoresis . she was evaluated in the emergency department where she was , uh , febrile and had significantly elevated white blood cell count of 23,000 . there were concerns for ongoing urinary tract infection , but she was treated with iv antibiotic therapy . she had labile blood pressure , headache , and vomiting . in the end , she slowly improved . she does have a supra-pubic catheter . cultures were obtained and reviewed . she was eventually discharged after clinical improvement of her symptoms . she presents today to follow up regarding these concerns . hi , michelle . how are you doing ?
[ "Therapeutic History", "Personal History", "Greetings" ]
[ "Subjective" ]
3,326
okay , great . um , all right . so , let's take a look .
[ "Physical Examination" ]
[ "Objective" ]
3,327
okay . all right . and any numbing or tingling in your legs or your feet ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,328
of 2020 , correct ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,329
okay . and what have you taken for the pain ?
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
3,330
great . i will definitely review that over . any other , uh , family history to be aware of ?
[ "Family History" ]
[ "Subjective" ]
3,331
okay so with your newly diagnosed ovarian cancer so how are you feeling today how are you doing
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
3,332
hi virginia how're you today
[ "Greetings" ]
[ "Subjective" ]
3,333
all right . so , the nurse will be in soon and i'll ... we'll schedule that cath for you , okay ?
[ "Chitchat" ]
[ "Null" ]
3,334
can you touch down here ?
[ "Physical Examination" ]
[ "Objective" ]
3,335
. the history , okay ?
[ "Chitchat" ]
[ "Null" ]
3,336
um , and then i'm gon na prescribe some steroids to help , also some prednisone . so let me just order those .
[ "Medication" ]
[ "Plan" ]
3,337
okay and when you say dizzy are you feeling lightheaded like you might pass out or you feeling that the world spinning around you or what
[ "Vegetative History" ]
[ "Subjective" ]
3,338
perfect . um , and then , i know that you have this history of a-fib , atrial fibrillation . have you felt your heart racing at all , recently ?
[ "Personal History" ]
[ "Subjective" ]
3,339
patient , bruce ward . date of birth 5/21/1969 . please use my neuro consult template . this is a 52-year-old male with dia- newly diagnosed pituitary lesion . the patient is seen in consultation at the request of dr. henry howard for possible surgical intervention . mr . ward presented to his primary care provider , dr. howard , on 3/1/21 complaining of worsening headaches over the past few months . he denied any trouble with headaches in the past . his past clinical history is unremarkable . worked out for worsening headaches was initiated with brain mri and serology where pituitary lesion was incidentally discovered . i personally reviewed the labs dated 3/3/21 including cbc , unes , uh , coagulation , and crp . all were normal . pituitary hormone profile demonstrates a low tsh , all other results were normal . um , i personally reviewed pertinent radiology studies including mri for the brain with contrast from 3/4/21 . the mri reveals a pituitary lesion with elevation and compression of the optic chiasm . the ventricles are normal in size and no other abnormalities are lo- are noted . hello , mr . ward . nice to meet you . i'm dr. flores .
[ "Personal History", "Greetings" ]
[ "Subjective" ]
3,340
that's great news . um , and then how's your depression doing ?
[ "Personal History" ]
[ "Subjective" ]
3,341
you're welcome i'll see you in a month
[ "Chitchat" ]
[ "Null" ]
3,342
so what what brings you into the office i do n't believe i have ever seen you before here
[ "Acute Symptoms" ]
[ "Subjective" ]
3,343
awesome that's great alright and so i see that you also we are treating you for diabetes as well and that we have you on five hundred milligrams of metformin twice a day how about that have you been taking that regularly
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
3,344
so what are your concerns about the vaccine ?
[ "Discussion", "Medication" ]
[ "Plan" ]
3,345
okay any other questions
[ "Discussion" ]
[ "Plan" ]
3,346
you're gon na be wearing the brace for about six weeks
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
3,347
how about you start taking the the increased dose in the morning and then we'll see how you do and if necessary i'll have to add a second dose in the afternoon that you can take around four o'clock in the afternoon i do n't want you to take it too late at night because then you will be going to the bathroom all night okay
[ "Discussion", "Medication" ]
[ "Plan" ]
3,348
yeah . and we'll see where you stand at that point .
[ "Discussion" ]
[ "Plan" ]
3,349
all right . so , keep going with the gabapentin . i will order the imaging of your neck , and the shot will hopefully help some with those symptoms in your hand , and then we'll follow up afterwards .
[ "Discussion", "Medication", "Diagnostic Testing" ]
[ "Plan" ]
3,350
okay alright and what part of the knee is it inside outside middle
[ "Acute Symptoms" ]
[ "Subjective" ]
3,351
you're welcome . then , what i did is , i gave you a topical antibiotic , plus i gave you the benzoyl peroxide . so , the peroxide may bleach your sheets , but , you want to make sure to take it and apply it at night , so you do n't have a reaction from the sun during the day .
[ "Discussion", "Medication" ]
[ "Plan" ]
3,352
okay . on one side versus the other ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,353
you're welcome . have a great day , have a great day ms. cooper .
[ "Chitchat" ]
[ "Null" ]
3,354
i did n't hear about that no
[ "Discussion" ]
[ "Plan" ]
3,355
wow okay are you having any headaches
[ "Vegetative History" ]
[ "Subjective" ]
3,356
doctor: thanks
[ "Chitchat" ]
[ "Null" ]
3,357
you're good today yeah you've been going through a lot lately i know you just had your treatment how how are your symptoms
[ "Acute Symptoms" ]
[ "Subjective" ]
3,358
wonderful , good to hear . and then i'm assuming you're staying away from the peanuts . uh , last year you had told me it worked with ... uh , you worked with enterprise rent-a-car and one of the cars had a lot of peanuts in it that you were cleaning out and that gave you hives , uh , when you had touched it , is that correct ?
[ "Personal History" ]
[ "Subjective" ]
3,359
okay .
[ "Personal History" ]
[ "Subjective" ]
3,360
nice to see you
[ "Chitchat" ]
[ "Null" ]
3,361
doctor: thank you .
[ "Chitchat" ]
[ "Null" ]
3,362
perfect . and then you've got the high blood pressure .
[ "Personal History" ]
[ "Subjective" ]
3,363
okay . remember , it's also the portion sizes . so i mean , if you eat a little and you feel fine , then that's okay . you have to just really watch the portions .
[ "Acute Symptoms" ]
[ "Subjective" ]
3,364
alright and it's not a long procedure it's it's relatively quick and common and you should be out of the office within an hour
[ "Discussion" ]
[ "Plan" ]
3,365
okay . the new prescription that i'm going to write is gon na be for the , uh , four milligram pill . so when you get the new one , just one pill twice a day . also , continue the metformin , okay ? blood pressure , when i rechecked it , i got 140 over 60 s- so the numbers at home are better , so we're gon na continue the combination of medications . we'll check kidney function today . for your cholesterol though , you're on the high dose of atorvastatin or lipitor to protect the arteries , so we really wan na keep you on that .
[ "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
3,366
okay . can you flex it or can you bend it ?
[ "Physical Examination" ]
[ "Objective" ]
3,367
yep i'm gon na put them into the computer and and whatever pharmacy you want yep mm-hmm
[ "Discussion", "Medication" ]
[ "Plan" ]
3,368
okay . it was good to see you .
[ "Chitchat" ]
[ "Null" ]
3,369
doctor: hey , dragon , finalize the note .
[ "Chitchat" ]
[ "Null" ]
3,370
actually it would be an upper endoscopy and a colonoscopy , but yes , likely that's the reason why .
[ "Discussion", "Diagnostic Testing" ]
[ "Plan" ]
3,371
alright so four out of five strength in the left and five out of five on the right does look like that reflexes are brisk and motor and sensory is intact in both lower extremities i do wan na review the results of your mri the mri shows a disk herniation at the level of l4 l5 vertebrae and it is associated with some nerve root impingement and what that means is the nerve is being compressed by that herniation so let me tell you a little bit about my assessment and plan okay so for the diagnosis of of acute disk herniation at l4 l5 with that nerve root impingement that's causing that pain down your leg and your lower back pain now i know you've tried nsaids in the past without relief and you've done some pt so what i'm going to do is i'm gon na recommend an epidural steroid injection and we're gon na do that today for you if you agree to it what that means is gon na place some anti-inflammatory medication right at the spot of inflammation and once that's in place i wan na refer you back to pt and we wan na strengthen that area mkay you're young and otherwise healthy i think you'll do well but it can take about two to three weeks for that injection really to take full effect so then i want you to see pt and i want you to see me again in about a month are you okay with that treatment plan
[ "Discussion", "Follow-up", "Medication", "Radiology Examination", "Referral", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,372
i'm good . uh , are you ready to get started ?
[ "Chitchat" ]
[ "Null" ]
3,373
okay that's fine and how long ago did this happen
[ "Acute Symptoms" ]
[ "Subjective" ]
3,374
okay so i'm looking here i think last after your last visit you got a1c now was six . seven so it's a little bit high it's gone down a little bit since you were first diagnosed with the type two diabetes a year ago so i'm glad we're making progress with that as well alright so i'm just gon na do a quick physical exam on you before i do just wan na make sure are you having any chest pain today
[ "Physical Examination" ]
[ "Objective" ]
3,375
okay yeah i mean i think we all like to lose a little bit of weight but yeah it's a it says it's a struggle so no no chest pain or shortness of breath with this
[ "Vegetative History" ]
[ "Subjective" ]
3,376
alright
[ "Other Socials" ]
[ "Subjective" ]
3,377
yeah i want it's exactly what i want you to do i want you to use that that solution twice daily when you get that flare but then other than that just continue to use that t-gel shampoo
[ "Discussion", "Medication" ]
[ "Plan" ]
3,378
any hard spots , lumps , or bumps that you've noticed ?
[ "Personal History" ]
[ "Subjective" ]
3,379
it is , yeah . it listens to you and me and it does all of my documentation . it's pretty good stuff . um , tell me what's going on .
[ "Personal History" ]
[ "Subjective" ]
3,380
thank you . they're gon na come get your photos now , okay ?
[ "Chitchat" ]
[ "Null" ]
3,381
okay now since you are here let me just ask you a little bit about your high blood pressure did you buy the blood pressure cuff i asked you to have you been checking your blood pressure at home
[ "Personal History" ]
[ "Subjective" ]
3,382
okay and have you had any chest pain or trouble breathing along with you know your elevated blood pressure
[ "Vegetative History" ]
[ "Subjective" ]
3,383
okay . how's your family ?
[ "Chitchat" ]
[ "Null" ]
3,384
okay . and fevers ?
[ "Vegetative History" ]
[ "Subjective" ]
3,385
so there's some swelling there . and how about , uh , can you move your fingers okay ? does that hurt ?
[ "Physical Examination" ]
[ "Objective" ]
3,386
well okay well hopefully that we get you feeling better so you can start running again more than . five miles but tell me though have you noticed any swelling or redness in your knees
[ "Vegetative History" ]
[ "Subjective" ]
3,387
all right .um , and i know a few years ago , you had , had that scare with the possible lung cancer , but then they did the biopsy and , and you've been fine .
[ "Personal History" ]
[ "Subjective" ]
3,388
good , good . that's a good choice .
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
3,389
okay . so did you increase your glimepiride ?
[ "Therapeutic History" ]
[ "Subjective" ]
3,390
keflex alright so kinda does your foot hurt or is it just just the
[ "Acute Symptoms" ]
[ "Subjective" ]
3,391
so i wan na talk a little bit about , you know , my assessment and my plan for you . so for your first problem , this newly diagnosed lyme disease , i wan na go ahead and prescribe you doxycycline , 100 milligrams twice a day . you have to take it for three weeks , okay ?
[ "Discussion", "Acute Assessment", "Medication" ]
[ "Assessment", "Plan" ]
3,392
we did an x-ray before you saw me , so let's look at that . hey , dragon , show me the back x-ray . so looking here at this x-ray of the lumbar spine , everything looks good . there's good boney alignment . there's no obvious fracture , you know , which is not surprising based on your history . okay ?
[ "Radiology Examination" ]
[ "Objective" ]
3,393
so how does that that sound
[ "Discussion" ]
[ "Plan" ]
3,394
okay and then do you have any family history of gallbladder disease
[ "Family History" ]
[ "Subjective" ]
3,395
wow okay have you done anything to ease it
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
3,396
okay . do you have children ?
[ "Other Socials" ]
[ "Subjective" ]
3,397
all right . so , we will see you in two weeks then .
[ "Follow-up" ]
[ "Plan" ]
3,398
your right ankle okay and did it twist like did your ankle twist outward or did your ankle twist inward do you know
[ "Acute Symptoms" ]
[ "Subjective" ]
3,399