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okay alright so let me go ahead and do a quick physical exam on you so i reviewed your vitals and everything looks good and on general appearance you appear to be in no distress no jaundice on the skin on your heart exam you have a nice regular rhythm rate regular rate and rhythm with a grade two out of six systolic ej... | [
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"Objective",
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] | 3,700 |
okay okay so lem me do a quick physical examination so i looked at your vitals when you came in today and your blood pressure it's still high it's one sixty nine over seventy four your heart rate was eighty eight and your oxygenation was ninety eight percent so those are all fairly good except that blood pressure's a l... | [
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hmmm okay understood alright well listen let's go ahead and examine you okay so so on your physical exam your physical exam is pretty normal unremarkable for the most part and you know few things a few exceptions so first of all on your heent exam your eye exam your extraocular motions are intact without pain you have ... | [
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yeah that that just right but also let's set up an appointment in four weeks and i wan na see you back in four weeks if it's not if the headache is not better within the next few days with this flexeril then you can give us a call and and get back in later this week or early next but definitely if things get worse give... | [
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okay well that's great to hear that you're getting back in the gym that will be good for your long term health too you know helping to maintain that type two diabetes you know those are really great strategies talking about gym for stress relief and and you know we have other products as well that you can use for an ad... | [
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so let's talk a little bit about your exam here okay i'm gon na go ahead and do a quick physical exam and i reviewed your vitals and everything looks good including your oxygen saturation blood pressure for today was one twenty eight over eighty eight heart rate was sixty eight respirations were sixteen and your pulse ... | [
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okay great so let's go ahead and do a i just wan na take a look here i reviewed your vitals and overall they look good your blood pressure is one twenty over seventy your your heart rate is sixty and your respiratory rate is fourteen those are all phenomenal numbers as i listened to your heart it is at a regular and a ... | [
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i did okay okay so i do feel the mass on the left side but everything else looks good and on abdominal exam there is slight tenderness to palpation of the left lower quadrant no rebounding or guarding on vaginal exam there are no external lesions on the labia the vaginal vault is within normal limits the cervix is pink... | [
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okay alright tenderness to palpation of the midfoot and positive piano key test of the first and second metatarsals alright it's also warm to touch alright so on your neurovascular exam of your right foot your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light ... | [
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yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today... | [
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alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tinnitus on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflamma... | [
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no no no no no so that means like everything is normal right but i feel like you you you have some tenderness and inflammation over your kidney so that has to be expected because you do have a kidney stone so i did review the results of your ct and it does show a stone that's measuring point five centimeters located in... | [
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there is no pain to palpation of the right foot there is associated granulation tissue and some slight purulent discharge from the wound okay so what does all that mean that just means that you have this ulcer that's you know fairly sizable with i think we need to do some good wound care on it let's talk a little bit a... | [
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sure understood alright and for your last issue your coronary artery disease continue with your statin and i will talk to your cardiologist in case you need a procedure to see if you're cleared from a medical standpoint okay | [
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a little bit alright so on your exam of your abdomen there is mild pain and tenderness to palpation of the abdomen there's no rebound or guarding there is cva located near your flank tenderness on the right so that means that everything looks good but you do have what seems to be some inflammation of your kidney okay s... | [
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okay yeah i i want you to to drink try drink as much as possible just to see if we can get you hydrated and pass the stone what i'm gon na do is i'm gon na prescribe you ibuprofen eight hundred milligrams you can take that as needed for pain i know you said you were in that much pain just in case it does start to move ... | [
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okay i'm gon na do a quick physical exam now your vitals look good and i would like to do a focused exam of your right foot the there is some bruising on the bottom part of your foot and on the top part as well and i do appreciate the associated swelling and i also recognize that you do have tenderness to palpation for... | [
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you're right keep it in the family okay so speaking of family do you have do you or anyone have a history of seasonal allergies | [
"Personal History",
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"Subjective"
] | 3,717 |
so i reviewed your vitals and you appear to be breathing a little fast your respiratory rate is twenty but but your oxygen is you're satting kind of fine at ninety nine percent on room air so i'm not too worried about that on for on your heart exam i do you have a regular rate and regular rhythm i do not appreciate any... | [
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okay and i'm feeling a little bit of bone spur here as well let me let me get an x-ray | [
"Acute Symptoms",
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and so you you've got some arthritis in there we we call this hallux rigidus and treatment for this to start off with we we put an insert in your shoe called an orthotic and we give you a little bit of anti-inflammatory medication or like a drug called meloxicam you only have to take it once a day | [
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alright so why do n't we go ahead and do a quick physical exam on you here i just want to take a look at you your vital signs look good i'm glad to see you're tolerating the medication well i'm gon na go ahead and feel your neck here i do n't appreciate any jugular venous distention and there are no carotid bruits on y... | [
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it's really hard to do with actual patient so in terms of the asthma i think we could try a daily medication since it looks like you might be having a little bit of allergies maybe we can try some singulair mm-hmm and start with that once you are on that daily and you can continue to use the albuterol inhaler those sid... | [
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and we will do some screening questionnaires and and then follow up in a couple weeks on that too | [
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okay now if it's okay with you i would like to do a quick physical exam i reviewed your vitals and everything looks good blood pressure was one eighteen over seventy two heart rate was fifty eight respiratory rate was fourteen you are afebrile and you had an o2 saturation of ninety nine percent on room air on your hear... | [
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okay okay yeah so you do have some decreased range of motion in that right knee now i'm just gon na sit here and and lay you back and i'm gon na pull on your knee and twist your knee a little bit okay you currently there is a negative varus and valgus stress test that's really important so here's what i'm thinking for ... | [
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okay negative murphy's sign no peritoneal signs no rebound your on examination of the lungs they sound clear to auscultation bilaterally i do n't see any rash no lesion no bruising your eyes seem equal and reactive to light so all of these things sound pretty decent so let's talk about like the results that i got for y... | [
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so let's let's talk a little bit about my physical exam if it's okay with you i'm gon na do a quick physical exam on you your vitals look stable by the way a little elevated i know you're in pain on a focused exam of your left ankle now i do appreciate that there is ecchymosis or bruising over the lateral malleolus and... | [
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malleolus associated with swelling there is tenderness to palpation of the anterior laterally in the soft tissue there is no laxity on the anterior drawer and inversion stress there is no bony tenderness on palpation of the foot on your neurovascular exam of your right foot there your capillary refill is less than thre... | [
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okay alright yeah that's always a struggle i certainly understand but you know really important with your diabetes just to prevent some of the complications like kidney failure and eye problems and just keep your sugar under balance so i'll order another hemoglobin a1c today we'll check that again today and and you kno... | [
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exactly so your neck exam has no jvd there is no bruits that i can hear your lung exam no rales no wheezing on your heart exam you do have a two over six systolic ejection murmur you had that in the past so i'm not too worried about that otherwise regular rate and rhythm on your heart exam on your on your on your belly... | [
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alright so pain on dorsiflexion but not on plantar flexion plantar flexion okay alright so what we are gon na do right now i think i'm gon na look at your x-rays but when i when i look at the results of your x-ray i do not appreciate any fracture what i am noticing is the development of a little bit of arthritis and th... | [
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so in summary after my exam , uh , looking at your knee , uh , on the x-ray and your exam , you have some tenderness over the medial meniscus , so i think you have probably an acute medial meniscus sprain right now or strain . uh , at this point , my recommendation would be to put you in a knee brace , uh , and we'll g... | [
"Follow-up",
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i want you to continue to ice it , okay . i want you to try to avoid any strenuous activity and we can go ahead and- and refer you to physical therapy- | [
"Referral",
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] | 3,733 |
all right . so , on exam , you do have some tenderness over your distal phalanx , which is the tip of your finger . there is , uh , some tenderness over that joint itself . i do n't feel any tenderness over your proximal joint or your metacarpophalangeal joint , which is right above your knuckle . uh , you have some pa... | [
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all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work . | [
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all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if you have ... | [
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doctor: all right . this is christina cooper , pleasant 65 year old female who was diagnosed with iron deficiency anemia in 12-2019 , and w- and was unable to donate blood . um , her followup blood work on 01/20/20 was revealed a low hemoglobin , stable hematocrit and normal iron labs , although ferritin was low . um ,... | [
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all right . the patient is alert , oriented to time , place , and person . affect is appropriate and speech is fluent . cranial nerve examination is grossly intact . no focal , motor , or sensory deficit in the upper or lower extremities . visual acuity and eye movements are normal . pupils are equal and reactive . vis... | [
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well there's no guarantees , but it is a possibility . i'm gon na refer you to the eye doctor for a full exam and they'll do what's called visual field test . this will map our your peripheral vision or side vision prior to surgery . and we can monitor after surgery to see if your vision is improving . | [
"Diagnostic Testing",
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doctor: you're welcome . right this way . all right . uh , in assessment , please summarize the patient's history briefly , and let's list her possible etiologies such as , uh , gerd , dyspepsia , esophagitis , musculoskeletal etiologies , and anxiety . uh , suspect she had an anxiety attack related to her job transiti... | [
"Personal History",
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doctor: you too . all right . physical exams show the well-nourished female , who is slightly fussy when examined . eyes are small appearing . she has mild hypotonia of the lower extremities in her arms . normal external female genitalia . assessment and plan . katherine is a 22-month-old former 34 and 3-week-old , twi... | [
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okay yeah we definitely need to get you to lower that salt intake get your diet a little bit better because the hope is to get you off that medication and get your blood pressure to a manageable level okay so we yeah we definitely can talk about that alright so lem me take a look at your knee i'll do a quick physical e... | [
"Physical Examination",
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] | [
"Objective",
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] | 3,742 |
okay so on your knee exam i i see that you do have pain to palpation of the medial aspect of your right knee you have some pain with flexion extension i also identify some edema around the knee and some effusion you have a little bit of fluid in there as well so prior to coming in we did do an x-ray of that right knee ... | [
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okay sorry there is tenderness of the greater tuberosity of the humerus but there is no tenderness at the sternoclavicular or acromioclavicular joints you have good hand grips alright and then now on your neurovascular exam of your left arm your capillary refill is less than three seconds and your sensation is intact t... | [
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"Objective",
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okay so no decreased range of motion negative varus and valgus test okay and so with your x-rays i reviewed the result of your left knee x-ray which showed no evidence of fracture or bony abnormality so lem me tell you a little bit about my plan so your left knee pain i think you just have some arthritis in that i want... | [
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okay okay so we are gon na go ahead if it's okay with you and start your physical exam reviewing your vitals so vitals look good especially your oxygen especially with the chemotherapy you've been getting and the cough so your oxygen looks good so i'm happy with that so now i'm just examining your neck especially with ... | [
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okay okay yeah diabetes your family your family owns that donut shop right i mean down at the end of the street | [
"Family History",
"Other Socials"
] | [
"Subjective"
] | 3,747 |
no okay so your you know your abdominal exam is your belly is soft there is no tenderness as i i push around there now i did review the results of your recent lab work and it is consistent as as your pcp noted with an iga deficiency that's that immunoglobulin a that we talked about so let me tell you a little bit about... | [
"Physical Examination",
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"Objective",
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okay alright good to hear alright and your lower extremities show a trace edema so megan david david i'm looking at your results of your echocardiogram that you got when you were in the er and it it does show preserved ejection fraction of fifty five percent and normal diastolic filling and mild to moderate mild to mod... | [
"Medication",
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okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over yo... | [
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"Objective",
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okay i'm gon na review the results of your right foot x-ray that we did when you came in today the good news is i do n't see any evidence of osteomyelitis meaning that there is no infection of the bone so let's talk a little bit about my assessment and plan for this nonhealing diabetic foot ulcer i'm going to order a t... | [
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"Objective",
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okay there is full range of motion of the right knee and on skin examination there is evidence of a bull's-eye rash over the right knee okay so what does that mean richard so that means that you know you do have some area of some inflammation over the over the right knee where you where you have that tick bite and you ... | [
"Physical Examination",
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"Objective",
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hey dragon , show me the right knee x-ray . and here's the x-ray of your right knee , which shows some changes from arthritis , but otherwise that looks good . so let's talk a little bit about my assessment and plan . from an osteoporosis standpoint , we'll go ahead and order , you know , re- continue on the fosamax . ... | [
"Discussion",
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"Objective",
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hey dragon , order a refill of fosamax 1 tab per week , 11 refills . and then in t- , for your second problem , your multiple sclerosis i want you to go ahead and continue to see the neurologist and continue on those medications . and let me know if you need anything from that standpoint , okay ? | [
"Discussion",
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so , let's talk a little bit about , you know , my assessment and my plan for you . okay ? so , for your first problem of your shortness of breath i think that you are in an acute heart failure exacerbation . i want to go ahead and , uh , put you on some lasix , 40 milligrams a day . i want you to weigh yourself every ... | [
"Medication",
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"Assessment",
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okay . um ... so with your x-ray , and with your exam , looks like you have a sprain of your distar- distal interphalangeal joint . it's called your dip joint , of your right index finger , and so what we're gon na do for that is we're gon na put a splint on that right finger . i'm gon na give you a strong antiinflamma... | [
"Discussion",
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hey , dragon , show me the labs . and your labs that we did before you came in all look great . there's no elevated white blood cell count . there's no signs of infection . again , those are all really good . okay ? so let me go over with you about my assessment and my plan for you . so for your first problem , this ba... | [
"Medication",
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all right . so , he's just kind of getting started with this , and i think we're seeing something viral right now . often sinus infections will start out as a virus and then will become bacterial infections if left alone and does n't go away . but , i do n't think he needs any antibiotics , at least not at this point i... | [
"Acute Assessment",
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kayla ward , date of birth , 4/28/07 . mrn 3-8-4-9-2-0 . she's here for a new visit with her mother for acne located on the face , which started about two years ago and is present most every day . she has been using persa-gel and washing regularly , which is somewhat helpful . there are no associated symptoms including... | [
"Acute Symptoms",
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okay . what we typically do when we do a breast reduction consult , i'll document your symptoms , symptoms , we'll take some pictures , then , um , they get sent to the insurance company . and what they'll do is decide whether it's approved , or medically necessary , or not . but we wan na make sure we send it to the r... | [
"Discussion",
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"Subjective",
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] | 3,760 |
kelly wood . date of birth , february 15th , 1979 . established patient here for renal ultrasound because of hematuria . urine dipstick today . negative for leukocytes , nitrates , protein , ketone , bilirubin and glucose . color yellow and clear , urobilinogen 0.2 , ph 5.5 and specific gravity 1.020 . there is a trace... | [
"Physical Examination",
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"Subjective",
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doctor: yes , let's hope . come right this way and i'll walk you to check out . update pe abdomen . no flank pain . anti gu . normal vaginal exam . primary diagnosis is hematuria . secondary diagnosis is chronic urol ... urolithiasis . thank you . this completes mrs. wood encounter . | [
"Physical Examination",
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"Objective",
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yes . we are , we looked at your ecg taken earlier today , and we are seeing the a-fib , but it's being well controlled with the medicine , and you're taking coumadin , four milligrams , lasix at four milligrams a day , and the atenolol , you're taking that every day as well , right ? | [
"Therapeutic History",
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"Subjective",
"Objective"
] | 3,763 |
doctor: okay , awesome . all right . well , have a good rest of your day , and we'll see you soon . for physical exam , constitutional elderly otherwise no acute distress . cardiovascular normal s1 and s2 is preserved with a normal rate and regular rhythm . there is a 4/6 systolic murmur at the right upper sternal bord... | [
"Physical Examination",
"Acute Assessment",
"Reassessment",
"Diagnostic Testing",
"Follow-up",
"Therapeutic History"
] | [
"Subjective",
"Objective",
"Assessment",
"Plan"
] | 3,764 |
okay alright so i'm gon na do a physical exam for you right now your vital signs look good your pulse is okay and yeah your pulse ox is normal so that's good you do n't appear in any distress you may be might be a little bit nervous to come in and see me but looks pretty good i do not appreciate any rash on your body t... | [
"Physical Examination",
"Acute Assessment",
"Radiology Examination",
"Medication"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,765 |
okay so some tingling in your right leg alright so i know that you had an x-ray when you came in because we always do x-rays when we have our patients come in of your low back and everything looks normal from that perspective so for your back pain sounds like you probably sprained your low back so i what i want you to ... | [
"Discussion",
"Medication",
"Radiology Examination",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,766 |
okay alright that's good so before you came in we did get an x-ray of your right foot and there is no evidence of osteomyelitis that means that luckily you do n't have a bone infection so that's great i think it's just in your skin so let's talk a little bit about your assessment and plan so you do have that diabetic f... | [
"Discussion",
"Medication",
"Other Treatments",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,767 |
okay your hemoglobin a1c last time i looked at epic was about six . eight which is really good so i think you're doing a great job we had talked about you know cutting off the sweets and sugars and stuff like that and exercising so it sounds like you're you're you're doing a pretty good job with that have you seen the ... | [
"Discussion",
"Diagnostic Testing",
"Reassessment"
] | [
"Assessment",
"Plan"
] | 3,768 |
okay alright well let me examine you here for a second so i'm gon na go ahead and do my match exam and i'm just gon na verbalize some of my findings so i can put that into my record okay so your neck exam is fine there is no bruits your lungs are clear your heart exam is normal you do have a two over six systolic eject... | [
"Physical Examination",
"Discussion",
"Other Treatments",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,769 |
okay so do you mind getting up and walking for me really quickly alright so i do notice that there is a slight gait like there is a small sorry you are correcting you do have a limp i i am a little worried about that but it's probably it's probably the superficial when i'm looking at your knee i do notice some like ecc... | [
"Reassessment",
"Physical Examination",
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Referral",
"Radiology Examination",
"Medication"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,770 |
alright now let me listen to your lungs here very good so your your lungs are clear with no wheezes rales or rhonchi and let me go ahead and listen to your abdomen great your bowel sounds are present your abdomen is soft with no hepatospleno splenomegaly ca n't talk to appreciated so let me now check your musculoskelet... | [
"Physical Examination",
"Lab Examination",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,771 |
that's okay for your first problem your headaches your symptoms are concerning for what we call idiopathic intracranial hypertension and this is a condition that that you have increased pressure in the in your head in your brain without any known cause for it now patient also presents with often present with symptoms s... | [
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Referral"
] | [
"Assessment",
"Plan"
] | 3,772 |
okay alright so positive pain on lateral bending wow this is pretty this is pretty serious not serious necessarily sorry about that so i reviewed the results of your x-ray but the results show no signs of fracture or bony abnormalities but let's go ahead and talk about my assessment and plan for you i believe what you ... | [
"Discussion",
"Referral",
"Medication",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Assessment",
"Plan"
] | 3,773 |
okay alright sorry so that's you have mild pain with resisted extension of the right wrist as well okay otherwise normal unremarkable exam and let's talk about your results now so your right elbow x-ray today shows no acute fracture or other bony abnormality so that's good there's no malalignment or sign of joint effus... | [
"Personal History",
"Radiology Examination",
"Vegetative History"
] | [
"Subjective",
"Objective"
] | 3,774 |
okay great excellent alright so tell you what let's let's talk about my assessment and your plan here so for your first problem my assessment is is that you have acute lateral epicondylitis of your right elbow and this is also known as tennis elbow go figure right so this is due to overuse likely the increase in your y... | [
"Discussion",
"Follow-up",
"Medication",
"Referral",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Assessment",
"Plan"
] | 3,775 |
okay so on your abdomen exam of your abdomen i'm showing no tenderness to palpation of the abdomen or tenderness of the the cva either on the right side so that that's good i think that's pretty much cleared up so let's we'll talk a little bit about my assessment and plan for you and so my assessment you you did have t... | [
"Physical Examination",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,776 |
so you can you can come back in three months and we'll check up again i forgot you did tell me last time that you were having some issues with insomnia | [
"Follow-up",
"Personal History"
] | [
"Subjective",
"Plan"
] | 3,777 |
now i reviewed your vitals for today and your your blood pressure is good it's one twenty eight over eighty two your respiratory rate is sixteen and your oxygen saturation is ninety nine percent on room air which is a good thing i'm gon na take a listen to your heart here your heart is regular rate and rhythm and i do ... | [
"Physical Examination",
"Follow-up",
"Medication",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,778 |
sorry so definitely some pain with lumbar flexion and supine straight leg test is positive so on your neurological examination there is decreased sensation to light touch at the right lateral thigh at l4 dermatome okay and i'm just gon na take a look at your knees here real quick and then your your ankles so patellar a... | [
"Physical Examination",
"Discussion",
"Medication",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,779 |
that's nice very very good are you looking forward to spring are you a baseball fan are you excited by opening day | [
"Chitchat",
"Other Socials"
] | [
"Subjective"
] | 3,780 |
alright the patient has decreased range of motion there is a negative varus and valgus test there is a negative lachman sign there is a palpable dorsalis pedis and posterior tibial pulse there is otherwise no lower extremity edema so what does that what does that mean kenneth so that so that means that you essentially ... | [
"Physical Examination",
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Referral",
"Medication"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,781 |
okay if it's okay with you i'm gon na do a quick physical exam your vital signs look good today blood pressure of one twenty four over seventy six heart rate of seventy respiration rate of sixteen o2 sat on room air of ninety eight percent and you are afebrile so you do n't have a fever today i'm gon na take a quick li... | [
"Physical Examination",
"Discussion",
"Follow-up",
"Radiology Examination",
"Acute Assessment",
"Drug History",
"Other Treatments"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,782 |
okay good so i think we should probably repeat your hemoglobin a1c it sounds like you've you know you've improved your diet and it sounds like you've you're following the regimen so maybe the numbers will be better this time and we do n't have to change your medication so that will be awesome how are you doing with you... | [
"Discussion",
"Personal History",
"Therapeutic History",
"Reassessment"
] | [
"Subjective",
"Assessment",
"Plan"
] | 3,783 |
okay alright good so let me examine you now so tyler i'm examining you now i'm gon na just verbalize some of my findings your neck is fine i do n't see any swelling in your neck your thyroid feels normal i do n't feel any masses in your neck there's no lymph nodes i'm looking at your throat and that looks okay there is... | [
"Physical Examination",
"Discussion",
"Referral",
"Medication",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,784 |
okay okay i gotcha so i know you had an x-ray as you came in today and so i'm just looking at this x-ray here i'll show you on the screen right here i can turn my monitor towards you this is an ap lateral oblique and this is your right ankle so what we're looking at is a displaced lateral malleolus at the weber c level... | [
"Other Treatments",
"Radiology Examination",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,785 |
okay there is pain to palpation of the right lateral knee there is decreased flexion and extension there is a positive lachman sign there is a palpable palpable dorsalis pedis and posterior tibial pulse there is no leg edema in the ankle okay well let's just talk a little bit about you know my assessment and you know m... | [
"Acute Symptoms",
"Physical Examination",
"Therapeutic History",
"Radiology Examination",
"Diagnostic Testing",
"Reassessment"
] | [
"Subjective",
"Objective",
"Assessment",
"Plan"
] | 3,786 |
okay , so pain with flexion and extension of the right arm . uh , your abdomen is nice and soft , and there's no lower extremity edema . uh , let's go ahead and take a look at some of your labs . you know , you have a lot of arthritis for someone so young , so we had sent off that autoimmune panel . hey , dragon . show... | [
"Physical Examination",
"Medication",
"Lab Examination",
"Diagnostic Testing",
"Reassessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,787 |
hey , dragon . order meloxicam 15 milligrams once a day . and then i'd like to um , just see those- how- the x-ray show- shows up and the results of that before we refer you for any type of physical therapy , okay ? | [
"Discussion",
"Medication",
"Referral",
"Diagnostic Testing"
] | [
"Plan"
] | 3,788 |
hey , dragon , show me the hemoglobin a1c . okay , so , blood sugars have been elevated . your hemoglobin a1c is elevated as well , so that tells me your blood sugars have been a little bit out of control . you're still taking the metformin , correct ? | [
"Therapeutic History",
"Lab Examination"
] | [
"Subjective",
"Objective"
] | 3,789 |
and , i want you to check your blood sugars in the morning . i want you to call them in in about two weeks so we know what your first , um , fasting blood sugar was in the morning , and then , we'll come back and see you in about two months and see if everything has straightened out . if it has n't , then we'll talk ab... | [
"Discussion",
"Follow-up",
"Medication",
"Other Treatments"
] | [
"Plan"
] | 3,790 |
so , let's talk a little bit about my assessment and my plan for you . so for your first problem , this left elbow pain , you know , i think you have olecranon bursitis , and we're just gon na , you know , have you , you know , get a little pillow for your elbow there . it's just caused by repetitive trauma . | [
"Discussion",
"Other Treatments",
"Acute Assessment"
] | [
"Assessment",
"Plan"
] | 3,791 |
all right . so , let's go ahead and we'll do a quick physical exam . so , looking at you , you do n't appear any distress . your neck is nice and supple . your heart is irregular rate and rhythm . i do hear a slight , uh , two out of six systolic ejection murmur . your lungs are clear . i do see the scar on the left , ... | [
"Physical Examination",
"Personal History",
"Lab Examination"
] | [
"Subjective",
"Objective"
] | 3,792 |
hey , dragon , show me the creatinine . so , your kidney function looks really good . so , that's really promising after your transplant . hey , dragon , show me the ekg . and your ekg looks great , uh , perfectly normal , so that's good . um , so , my impression of you at this time ... , let me see your blood pressure... | [
"Reassessment",
"Radiology Examination",
"Lab Examination"
] | [
"Objective",
"Assessment"
] | 3,793 |
hey , dragon , order a lipid panel . hey , dragon , order a complete metabolic panel . all right . and then , um , from a transplant standpoint , everything looks fine . your kidney function looks great , so we're just gon na continue you on all of those medications .so , the nurse will come in soon and she'll help you... | [
"Diagnostic Testing",
"Medication",
"Reassessment",
"Follow-up"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,794 |
okay , great . so , you had a injury to your back when you were twisting at the birthday party . you do n't really have any pain or numbness down your legs . you have some stiffness with rotation , um , but you do n't have any evidence of a , um , what we would call a pinched nerved or radiculopathy . so , i think you ... | [
"Acute Symptoms",
"Therapeutic History",
"Acute Assessment"
] | [
"Subjective",
"Assessment"
] | 3,795 |
hey , dragon , show me the lyme titer . so you can see here , you know , in reviewing the results of your lyme titer , it is elevated . so we're gon na go ahead and do some further testing , but we're gon na , you know , we're gon na look into that , okay ? | [
"Discussion",
"Diagnostic Testing",
"Lab Examination"
] | [
"Objective",
"Plan"
] | 3,796 |
so for your second problem , your type 2 diabetes , i wan na go ahead and order a hemoglobin a1c and just this ... make sure we do n't have to make any changes to the metformin , okay ? | [
"Reassessment",
"Discussion",
"Diagnostic Testing"
] | [
"Assessment",
"Plan"
] | 3,797 |
uh , let's look at some of your labs , 'cause i know that you have the diabetes . hey dragon , show me the labs . so , here your white blood cell count is not elevated , so i'm not concerned about an infection or anything like that . um , hey dragon , show me the diabetes' labs . okay and , and your a1c is a little ele... | [
"Discussion",
"Medication",
"Lab Examination",
"Referral",
"Diagnostic Testing",
"Reassessment"
] | [
"Objective",
"Assessment",
"Plan"
] | 3,798 |
okay . hey dragon , order meloxicam 15 mg once a day . hey dragon , order a physical therapy referral . hey dragon , order an autoimmune profile . and then from a hypertension standpoint you , because your blood pressure is a little elevated today , i'd like you to continue to monitor it at home and , you know , send m... | [
"Discussion",
"Follow-up",
"Medication",
"Referral",
"Reassessment"
] | [
"Assessment",
"Plan"
] | 3,799 |
Subsets and Splits
Filtered ChitChat, Greetings, History
The query filters and retrieves specific records based on their index and intent labels, providing insight into a subset of chatty, greeting, and personal history interactions.