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hey dragon , show me the blood pressure . okay , so here in the office today it is a little bit elevated , okay ? so your blood pressure is a little bit high . so the results , um , do show that . um , hey dragon , show me the labs . okay , so good news is is your- your labs are all essentially normal , so the results ...
[ "Discussion", "Follow-up", "Medication", "Lab Examination", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
3,800
and then your third problem was your carpal tunnel . that seems to be doing well . if you notice any tingling or any changes or you get some of those symptoms back , just let me know . okay ?
[ "Discussion", "Follow-up", "Reassessment" ]
[ "Assessment", "Plan" ]
3,801
all right . so , we'll try the spironolactone and schedule a followup in two weeks to check your blood pressure and electrolytes . uh , if the new med does n't work , the next up is going to be the resistant hypertension clinic .
[ "Discussion", "Follow-up", "Referral", "Medication" ]
[ "Plan" ]
3,802
doctor: mr. roberts presents with resistant hypertension . he's on three meds and maximum dose . i have added spironolactone to his regiment . we will need to monitor his potassium and sodium . he will have a metabolic panel and blood pressure check in two weeks . uh , next medication would be carvedilol , uh , which i...
[ "Acute Assessment", "Medication", "Diagnostic Testing", "Follow-up", "Discussion" ]
[ "Assessment", "Plan" ]
3,803
doctor: you're welcome , and have a good rest of your day . so review of symptoms is positive for diarrhea , nausea , and abdominal pain . assessment and plan . brittany edwards is a pleasant female with ibs and functional abdominal pain , aggravated by high stress , poor eating habits , and poor sleeping habits . i've...
[ "Vegetative History", "Personal History", "Medication", "Other Treatments", "Reassessment", "Follow-up" ]
[ "Subjective", "Assessment", "Plan" ]
3,804
doctor: all righty , so ros is constitutional significant for impaired ability to carry out daily functions . negative for fever or unintentional weight loss . gu is significant for urinary incontinence and wearing a diaper . negative for genital sores , decreased or painful output . neurological significant for contin...
[ "Personal History", "Vegetative History", "Physical Examination", "Radiology Examination", "Reassessment", "Lab Examination" ]
[ "Subjective", "Objective", "Assessment" ]
3,805
amanda taylor , birth date october 31st 1949 . patient is a 72 year old woman who comes for followup for hypertension . her history includes significant alcohol use disorder and mi- mild hypercholesterolemia . at last visit on april 16th her blood pressure was 130 over 90 . after presenting at 150 over 100 she was pres...
[ "Greetings", "Therapeutic History", "Drug History" ]
[ "Subjective" ]
3,806
all right , well everything looks good . you can go ahead and sit up miss taylor . all right , so the good news is everything is looking okay . i think we both agree if you were able to stop drinking your blood pressure would cease to be an issue for you .
[ "Discussion", "Other Treatments", "Reassessment" ]
[ "Assessment", "Plan" ]
3,807
doctor: miss taylor is drinking alcohol four to five days per week to excess . no tobacco , no substance abuse , skin is moist , good trigger . on exam she is alert , pleasant , in no acute distress . she is not diabetic , there is no tremor , no cva tenderness , chest clear to percussion and auscultation , unlabored b...
[ "Drug History", "Personal History", "Physical Examination", "Acute Assessment", "Reassessment", "Medication", "Follow-up", "Discussion" ]
[ "Subjective", "Objective", "Assessment", "Plan" ]
3,808
you'll hear me talk through your exam , so that i can get it all documented . uh- ? use my general physical exam template . pelvic exam demonstrates no external lesions . normal labia majora and labia minora . normal physiological discharge , with normal color and smell . ms. ross , i'm going to touch you , now . you'l...
[ "Physical Examination", "Discussion", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,809
okay . so i think we'll set that up for you now . we'll also do an x-ray on that knee . i can send you for a physical therapy , and if nothing is helping , then we really might need to get a surgery consult to see what we can do with that knee .
[ "Referral", "Diagnostic Testing", "Other Treatments" ]
[ "Plan" ]
3,810
yep . once we're done talking here , and as far as the edema in your legs , uh , we'll take an x-ray to look for the cause , but there is a lot you can do as well . the compression socks are a good start . um , and also , do you eat a lot of salt ?
[ "Discussion", "Medication", "Other Treatments", "Diagnostic Testing" ]
[ "Plan" ]
3,811
okay that's that's no problem so you are positive for murphy's signs but i do n't appreciate any peritoneal signs so let's talk a little bit about your results that i reviewed before you came in today so your abdominal ultrasound shows multiple gallstones present in the gallbladder and i do appreciate some mild thicken...
[ "Physical Examination", "Discussion", "Other Treatments", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,812
okay alright well looking at your vital signs here in the office you do n't have any fever your blood pressure looks quite good it's about one twenty two over seventy six your heart rate is appropriate at eighty two beats per minute and your oxygenation is ninety five percent on room air on your cervical spine exam the...
[ "Physical Examination", "Acute Assessment", "Other Treatments", "Referral", "Radiology Examination", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
3,813
okay alright well let me let me examine you here in a second and we'll think about you know what we need to do especially with your coughing and your shortness of breath okay so nita i'm i'm examining you now let's pretend i did my exam i'm just gon na verbalize some of my findings so i can put it into my chart okay an...
[ "Physical Examination", "Discussion", "Diagnostic Testing", "Reassessment", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,814
alright for the second problem for the diabetes since your blood sugar is running a little bit high once you get over this i'm blood sugars running a little bit high once we get you over this hump of the shortness of breath and get this diagnosed i'm gon na go ahead and order another hemoglobin a1c today we will probab...
[ "Discussion", "Follow-up", "Medication", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
3,815
a hundred percent yeah you know like i one of the things that i struggle with is like are eggs good for you or bad for you you know like with cholesterol i feel like it changes every other year or something like that so you're right there may be some pieces of information that we do need to update and and you know over...
[ "Discussion", "Physical Examination", "Other Treatments" ]
[ "Objective", "Plan" ]
3,816
absolutely that's awesome and so it'll be like a a movie like coming soon to a shelf near you that's great for your second problem right we have this longstanding diabetes i want to increase your metformin to a thousand milligrams twice a day i know that you're saying you're having a hard time keeping up with that so i...
[ "Follow-up", "Referral", "Medication", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
3,817
your x-ray honestly looks great in that i do n't see any kind of fracture or bony abnormality so that's what makes me think that this is like a tendon related thing right so in reviewing your x-ray like it it does support the the the assessment and plan that i have given you i
[ "Discussion", "Radiology Examination" ]
[ "Objective", "Plan" ]
3,818
okay okay so lem me talk a little bit about my impression and plan so for that low back pain i believe you have a musculoskeletal low back strain i'm going to order a low back x-ray so we'll order that and get that done as an outpatient i do n't expect to see anything significant but it's gon na tell me how those joint...
[ "Reassessment", "Discussion", "Diagnostic Testing", "Acute Assessment", "Other Treatments", "Referral", "Medication" ]
[ "Assessment", "Plan" ]
3,819
okay the patient has a positive varus test there is full range of motion there is a negative lachman sign the patient does on cardiovascular exam the patient does have a palpable dorsalis pedis and posterior tibialis pulse okay well let's just i wan na talk a little bit about i had the nurse do an x-ray on you and i lo...
[ "Physical Examination", "Acute Assessment", "Other Socials", "Referral", "Radiology Examination", "Medication" ]
[ "Subjective", "Objective", "Assessment", "Plan" ]
3,820
yeah okay okay great not great so yeah go ahead and sit up for me so dennis my diagnosis is achilles tendinitis and it's really from overuse when we see this frequently when somebody starts to you know get in and train aggressively for an event i'm unfortunately i'm gon na have to ask you to stop training for a a week ...
[ "Discussion", "Medication", "Referral", "Acute Assessment" ]
[ "Assessment", "Plan" ]
3,821
okay so we did a x-ray of your right foot before you came in and it showed no evidence of osteomyelitis that means that there is no bone infection which is really good so let me just talk a little about my assessment and plan of your your foot so you do have that diabetic foot ulcer so what i'm gon na do is i'm going t...
[ "Discussion", "Radiology Examination", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,822
alright so your vital signs look good you know so i'm glad that it looks like you're tolerating your medication pretty well on your neck exam i do n't appreciate any jugular venous distention so and then on top of that i'm not i do n't appreciate any carotid bruits so i'm not feeling anything like too concerning on you...
[ "Physical Examination", "Discussion", "Referral", "Medication", "Other Treatments", "Radiology Examination", "Diagnostic Testing", "Reassessment", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,823
no i mean every so often the stents can become narrowed again but you know that's why you're seeing me your cardiologist so that i can follow you for that now if you start to have symptoms again of any chest pain like you had before or any shortness of breath when you start to exert yourself i want you to tell me and w...
[ "Referral", "Medication", "Diagnostic Testing" ]
[ "Plan" ]
3,824
okay that's okay yeah i certainly can help you with that now managing your diabetes is also going to play an important role in your coronary artery disease which it sounds like you already know that which is really good so i will put in another referral for diabetic education for you how are you doing watching your swe...
[ "Referral", "Vegetative History" ]
[ "Subjective", "Plan" ]
3,825
okay yeah that's really high so we want it to be about six so you you do have some work to do with your diet
[ "Other Treatments", "Lab Examination" ]
[ "Objective", "Plan" ]
3,826
so let's just go over a little bit about my assessment and and plan for you going forward so for your first problem of your coronary artery disease i think you're doing really well i wan na go ahead and refer you for cardiac rehab just so that you can be more active and have some confidence in in exercising again okay ...
[ "Referral", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
3,827
and then for your third problem of your diabetes i am gon na go ahead and order another hemoglobin a1c and i'm gon na put that referral in for the dietitian to give you some dietary education and i'm gon na go ahead and talk with your primary care physician about your your insulin regimen okay
[ "Referral", "Medication", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
3,828
yeah well better to stay on the flovent daily and then just use the albuterol if you need it but if you stay on the flovent daily it will decrease the frequency of those attacks so yeah alright well let's go ahead and examine you okay so on your physical exam it's pretty normal for the most part unremarkable but i i'll...
[ "Physical Examination", "Discussion", "Follow-up", "Medication", "Other Treatments", "Diagnostic Testing", "Reassessment", "Acute Assessment", "Drug History" ]
[ "Objective", "Assessment", "Plan" ]
3,829
okay yeah that's that's really good yeah so i that's that's pretty good so what we're gon na do we're gon na get a a1c just to see you know that range and it's possibility we can we can you know lower that metformin dosage but we will do that after your visit then we will take a look at that so lem me go ahead and will...
[ "Medication", "Diagnostic Testing", "Vegetative History" ]
[ "Subjective", "Plan" ]
3,830
alright so your right elbow exam shows you have pain to palpation of the olecranon area of the posterior elbow you do have mild pain with flexion and extension but you do have also normal range of motion at that elbow so we we did do an x-ray before you came in and luckily nothing's broken no fracture no bony abnormali...
[ "Discussion", "Medication", "Other Treatments", "Radiology Examination", "Diagnostic Testing", "Reassessment", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,831
now i did review the results of your echocardiogram which shows a preserved ef of fifty five percent abnormal diastolic filling and also mild to moderate mitral regurgitation so what all that means let me go ahead and tell you about my assessment and plan so for your first problem of your you know congestive heart fail...
[ "Medication", "Other Treatments", "Radiology Examination", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
3,832
i'm sorry so you definitely there is some tenderness to palpation and anterolaterally in the soft tissue there is no laxity on anterior drawer and inversion stress and there is no bony tenderness on palpation of the foot now i'm just gon na take a look at your right foot here just to make sure it's still intact here so...
[ "Physical Examination", "Acute Assessment", "Other Treatments", "Radiology Examination" ]
[ "Objective", "Assessment", "Plan" ]
3,833
okay well i'm sorry to hear that okay so that's that's helpful information though okay let's go ahead and do physical exam on you there julie i'm gon na go ahead and take a look at your vital signs looks like your blood pressure looks good so that's good now on your heart exam i do n't appreciate any murmur rubs or gal...
[ "Physical Examination", "Referral", "Other Treatments", "Diagnostic Testing", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
3,834
okay alright well certainly you know i looked at your ekg that did we did in the office when you came in the ekg i do n't see any signs of a heart attack or anything like that so i'm you know we should definitely talk about the plan for this chest pain in a few minutes but right now the good news is i do n't see any si...
[ "Personal History", "Therapeutic History", "Lab Examination" ]
[ "Subjective", "Objective" ]
3,835
so let me examine you elizabeth for a second for the because we're running out of time here for a second so i'm gon na go ahead and do my exam we got ta just did my magical exam and i'm gon na go ahead and verbalize some of my findings just so i can get it documented in my note okay and i'll explain things as we go alo...
[ "Physical Examination", "Discussion", "Referral", "Medication", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,836
and for the second problem the diabetes you know i think you're doing fairly well continue with your eye ophthalmology appointment you have for your eye exam for the diabetic retinopathy continue the metformin five hundred milligrams twice a day i'm gon na order another hemoglobin a1c today and i'm gon na have you come...
[ "Discussion", "Follow-up", "Medication", "Other Treatments", "Reassessment" ]
[ "Assessment", "Plan" ]
3,837
okay alright so patella and achilles reflexes are symmetrical alright so i received before you came in here we got an mri and so in reviewing your results it does show a disk desiccation a disk bulge with paracentral disk herniation resulting in moderate right neuroforaminal i do n't like this word neural foraminal ste...
[ "Discussion", "Medication", "Radiology Examination", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,838
alright so for your your left knee pain i believe you you have a mcl strain or a medial collateral ligament that's the inside of your knee i think when you were running with your knee she had somehow twisted it and so you strained that ligament there so for that what i want to do i'm going to give you some pain medicat...
[ "Discussion", "Medication", "Other Treatments", "Acute Assessment" ]
[ "Assessment", "Plan" ]
3,839
so on physical examination , i- i do n't appreciate any carotid bruits in your neck . your heart on your heart exam , it does show that you have a slight two out of six systolic ejection murmur . your , there , your lung exam shows nice clear lungs bilaterally and you do have some trace pitting edema to your lower extr...
[ "Physical Examination", "Reassessment" ]
[ "Objective", "Assessment" ]
3,840
and then for your second problem , uh , i want , you know , for your depression , i do n't think that we need to start you on any medication , it sounds like you're doing really well from that standpoint , but you know that you can contact me if you , if you need anything , okay ?
[ "Discussion", "Follow-up", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
3,841
so , let's look at your pulmonary function test . hey dragon , show me your , the pfts . and looking here again , these look quite good , i'm , i'm quite encouraged by that . that's , that's normal pulmonary function tests . hey dragon , show me the labs . and all of your labs here look quite good here as well so , i- ...
[ "Acute Assessment", "Lab Examination", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
3,842
for your next problem , the copd , i think you're doing great . you know , i , i do n't think that you , uh , need any further referrals at this time for that . i would just continue staying away from smoking . it does n't sound to be like you need any inhalers at this time . uh , for your third problem , your congesti...
[ "Referral", "Medication", "Reassessment", "Drug History" ]
[ "Assessment", "Plan" ]
3,843
hey dragon , show me the echocardiogram ? so this is the echocardiogram from last year , you know , you did have a slightly low pumping function of your heart at 45 % , but , uh , i- , you know , i suspected that will improve over time , and you did have some slight , what we call , mitral regurgitation , that's just a...
[ "Reassessment", "Diagnostic Testing", "Radiology Examination", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
3,844
hey dragon , show me the lipid panel . so your cholesterol , for the most part , is really good . i think you're doing a good job . uh , i do n't think you have to make any changes right now . um , hey dragon , show me the covid test . turns out you're positive for ... for covid . so the results of your po- your covid ...
[ "Reassessment", "Acute Assessment", "Lab Examination" ]
[ "Objective", "Assessment" ]
3,845
so , i know you were vaccinated . you probably have a , a , a very , um , low-level positivity . so let's talk about that . so for your first problem , uh , is your covid infection . and i think the vaccine has helped you . it seems to be very mild at this time . your oxygenation is really good . i want you to quaranti...
[ "Therapeutic History", "Acute Assessment", "Other Treatments" ]
[ "Subjective", "Assessment", "Plan" ]
3,846
it's just supportive management . uh , for your next problem , your high cholesterol , let's continue you on the crestor 20 milligrams a day , and continue to watch your ja- your , your diet and i- then i'll go ahead and order another lipid panel for six months . and , from a coronary artery bypass grafting standpoint ...
[ "Reassessment", "Diagnostic Testing", "Follow-up", "Other Treatments", "Medication" ]
[ "Assessment", "Plan" ]
3,847
okay . all right . um , hey , dragon , show me the hemoglobin a1c . so in reviewing your , that's the lab that we checked after when i saw before i walked in . it says 8.1 , which is elevated , so i think we need to do a maybe a better job with adjusting your medication . how are you doing with your diet for your diabe...
[ "Acute Symptoms", "Reassessment", "Lab Examination" ]
[ "Subjective", "Objective", "Assessment" ]
3,848
okay . all right . how are you doing with your high blood pressure ?
[ "Acute Symptoms", "Reassessment" ]
[ "Subjective", "Assessment" ]
3,849
okay . so on exam , uh , your hent or your neck exam is fine . your , uh , your eyes look fine . your lungs are clear . i do hear a systolic ejection murmur , about three over six . your belly's nice and soft . no swelling in your legs or extremities right now . so let's talk about some of the issues today . all right ...
[ "Physical Examination", "Discussion", "Diagnostic Testing", "Acute Assessment", "Follow-up", "Other Treatments", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
3,850
okay , great . and for the knee , i think you're doing great with that . you know , continue with your physical exercise , with your physical therapy , uh , uh , with your normal exercise regimen . uh , if you have any issues with that , certainly give us a call .
[ "Reassessment", "Follow-up", "Other Treatments" ]
[ "Assessment", "Plan" ]
3,851
that sounds great . all right . so , let's talk just a little bit about , you know , my assessment and my plan for you . for your reflux , i want you to continue on the protonix 40 mg a day , and continue with those lifestyle modifications with the dietary stuff-
[ "Reassessment", "Discussion", "Other Treatments", "Medication" ]
[ "Assessment", "Plan" ]
3,852
there's no evidence that i'm concerned about anything at this time . hey dragon , show me the diabetes logs . so on your diabetic labs , your hemoglobin a1c is elevated . it's at eight . i'd like to see it closer to six . now some of them might be having to do with the holidays that type of thing but i still think that...
[ "Reassessment", "Discussion", "Lab Examination" ]
[ "Objective", "Assessment", "Plan" ]
3,853
so lets talk a little bit about my assessment and plan for you so for your first problem of your depression i'd like to just go ahead and refer you to uh psychiatry not for medications , but just for some talk therapy that type of thing , okay ?
[ "Acute Assessment", "Referral" ]
[ "Assessment", "Plan" ]
3,854
doctor: review of systems , please make the following changes . uh , constitutional , patient reports fatigue and weight gain . gi , um , excessive appetite and bloating . eyes , floaters . uh , cardiovascular , shortness of breath and leg swelling . endocrine , positive diabetes , always hungry . skin , nail bed trenc...
[ "Physical Examination", "Discussion", "Diagnostic Testing", "Acute Assessment", "Personal History", "Other Treatments", "Referral", "Vegetative History" ]
[ "Subjective", "Objective", "Assessment", "Plan" ]
3,855
hm , gotcha . okay . so let's talk about what you have going on . from what you've told me , it sounds like you've had a several-year history of gerd , which is the medical term for acid reflux . and recently your symptoms have been poorly controlled with the omeprazole , 40 milligrams twice daily . you've been having ...
[ "Discussion", "Personal History", "Medication", "Reassessment" ]
[ "Subjective", "Assessment", "Plan" ]
3,856
and you've identified trigger foods like spicy foods , carbonated bev- beverages , citrus , and tomato-based foods , but you have n't cut these foods out of your diet completely yet . so the first thing i'd try is changing your diet because these foods can exacerbate your gerd , even though you're taking the ppi .
[ "Other Treatments", "Reassessment" ]
[ "Assessment", "Plan" ]
3,857
doctor: perfect . i will walk you to the checkout desk . be sure to call my office and let me know if anything changes or if you have problems before your egd and follow-up appointment . please insert the procedure paragraph in the plan . i suspect that she likely has gerd with underlying functional etiology as well . ...
[ "Discussion", "Medication", "Diagnostic Testing", "Reassessment", "Vegetative History" ]
[ "Subjective", "Assessment", "Plan" ]
3,858
i've had a lot of patients over the last couple of weeks coming in with just weird stuff , and i blame that a little bit on how hot and humid it was the last two weeks of june . so what i would do is wait a couple of weeks and then , if you could , come back in and we could do some , uh , complete blood work , uh , inc...
[ "Diagnostic Testing", "Follow-up", "Referral" ]
[ "Plan" ]
3,859
yeah , i do , i do . i think there are side effects from all vaccines , so you have to go back and think about it . do you get flu shot every year ?
[ "Therapeutic History", "Discussion", "Medication" ]
[ "Subjective", "Plan" ]
3,860
doctor: next line heading will be " acute to chronic constipation " . she believes her hospitalization was more likely due to her dysreflexia , from her quadriplegia that typically occurs . she did have a lot of vital signs changes , including blood pressure fluctuations . the patient feels like she has a good bowel re...
[ "Personal History", "Therapeutic History", "Lab Examination", "Diagnostic Testing", "Follow-up" ]
[ "Subjective", "Objective", "Assessment", "Plan" ]
3,861
doctor: okay , this is a six-week post-op meeting exam for her . her gait was antalgic with a slight limp and decreased velocity . she's not using an assistive device . right knee focused exam has a healed surgical scar , mild swelling , tenderness- tenderness . . on the area of the incision . range of motion is zero t...
[ "Physical Examination", "Radiology Examination", "Reassessment" ]
[ "Objective", "Assessment" ]
3,862
okay . i am so sorry for all of that back and forth , but glad to know that there was some light at the end of that tunnel .
[ "Acute Symptoms", "Personal History", "Chitchat" ]
[ "Subjective" ]
3,863
yes . absolutely . it sounds like this road has been very much so rough to navigate too , so we'll- we'll get you through for that . um , is ashley taking any medications daily right now ?
[ "Therapeutic History", "Chitchat" ]
[ "Subjective" ]
3,864
alright dorsiflexion is normal looks like that you have normal range of motion so that's good any pain down your legs
[ "Acute Assessment", "Other Treatments", "Radiology Examination" ]
[ "Objective", "Assessment", "Plan" ]
3,865
okay yeah it's really important to keep up with your blood pressure check that regularly i'm totally going off script and you know might want to keep a log of that as well and check your blood pressures regularly so okay well let me do a just a quick exam of your eyes if you can take off your glasses and just rest your...
[ "Physical Examination", "Discussion", "Acute Assessment", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
3,866
there is pain to palpation of the right lateral malleolus there is decreased flexion and extension of the right ankle as well as internal and external rotation there is no apparent injury to the knee or the foot okay so what does that mean jacqueline seem awfully giggling right now so what does that mean so i took a i ...
[ "Physical Examination", "Radiology Examination", "Acute Assessment" ]
[ "Objective", "Assessment" ]
3,867
yeah so for your assessment and plan i do believe you have a an acute right ankle sprain i wan na go ahead and put you in an air cast we can give you some crutches i wan na go ahead and prescribe some meloxicam fifteen milligrams once a day you should ice the area for about twenty minutes five times a day and weight-be...
[ "Discussion", "Medication", "Other Treatments", "Referral", "Diagnostic Testing", "Acute Assessment" ]
[ "Assessment", "Plan" ]
3,868
no one likes them okay well let's i wan na just go ahead and do a quick physical exam i'm just gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay so looking at your blood pressure here in the office your blood pressure looks good it's about one twenty seven over sixt...
[ "Physical Examination", "Discussion", "Medication", "Radiology Examination", "Diagnostic Testing", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
3,869
but if there's other things going on i ca n't tell you for sure that you did n't injure a meniscus too or maybe chipped some cartilage when that bone shifted so let's let's get an mri scan to look at that if that comes back with just a ligament like i'm suspecting hopefully this is something we can treat with some ther...
[ "Discussion", "Diagnostic Testing", "Other Treatments" ]
[ "Plan" ]
3,870
you do n't check them okay so yeah we can get a a glucose test today and and and just check those because that's something we want to do everyday you know just to make sure you're eating the correct amount and that your sugars are are in range to make sure that and also to make sure that our medication is is the right ...
[ "Discussion", "Medication", "Diagnostic Testing", "Vegetative History" ]
[ "Subjective", "Plan" ]
3,871
okay yeah you have i would call an equivocal murphy's sign in the right upper quadrant on your abdominal examination as well the rest of your abdomen is soft and no significant tenderness you have no tenderness in the right lower quadrant with deep palpation and you have no cva tenderness on your back exam as well and ...
[ "Physical Examination", "Referral", "Diagnostic Testing", "Acute Assessment", "Vegetative History" ]
[ "Subjective", "Objective", "Assessment", "Plan" ]
3,872
okay alright alright good yeah i i see you do n't have a fever today so that's that's good and so alright now for your second problem the migraine headaches you you do have a history of chronic migraines and and you have occasional bouts of of migraines nothing recent so let's continue the excedrin as needed over the c...
[ "Discussion", "Medication", "Other Treatments", "Reassessment", "Drug History" ]
[ "Subjective", "Assessment", "Plan" ]
3,873
a little bit alright i'm gon na do a couple of maneuvers here so your your right knee exam shows that you do have pain to palpation of the medial aspect of that right knee also have some edema some little bit of swelling some ecchymosis as well you do have a negative varus and valgus test of my maneuvers and you know i...
[ "Physical Examination", "Medication", "Other Treatments", "Radiology Examination", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,874
alright for your diabetes i'm going to need you we got to get you to start taking your your blood sugars daily we got to keep track of those alright so i want you to take those daily we'll get a log book so you can keep track of those and bring those back and we can determine how we adjust your medications for now also...
[ "Discussion", "Follow-up", "Referral", "Medication", "Other Treatments", "Reassessment" ]
[ "Assessment", "Plan" ]
3,875
okay alright good good okay well listen let's go ahead and examine you here jerry so on your physical exam for the most part it's pretty normal and unremarkable on your heart exam you still have that grade three out of six systolic ejection murmur that's unchanged from your prior and just means yeah i'm hearing some he...
[ "Physical Examination", "Discussion", "Follow-up", "Medication", "Diagnostic Testing", "Reassessment", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,876
okay okay so you do n't have any frontal sinus tenderness no maxillary sinus tenderness it sounds like you do n't have any lymphadenopathy that would just be if your lymph nodes were tender so yeah you know let's just talk about a few things that i wan na do and then i want you to actually come in and and be seen by do...
[ "Physical Examination", "Medication", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
3,877
and then i want you to keep checking your blood pressure and i wan na order some blood tests i'd like to get some just normal blood work we'll get a hemoglobin a1c some laboratory tests things like that and and then for your diabetes i'm gon na have some diabetic education for you that i want you to be able to review i...
[ "Discussion", "Referral", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
3,878
alright no rebound no guarding that's great okay so based on my physical exam we are gon na have a couple conversations one that ct that your your primary care doctor the the one that you you question his judgment it is showing a couple things that we are a little concerned about it could be that these recurrent strep ...
[ "Discussion", "Referral", "Diagnostic Testing", "Acute Assessment" ]
[ "Assessment", "Plan" ]
3,879
well that's good so let's go ahead and do a physical exam on you real quick here okay and so i'm looking at your vital signs it looks like your blood pressure i we mentioned that today is pretty high your heart rate looks good it's with it's within normal limits here and then your oxygenation is fine so you did mention...
[ "Physical Examination", "Discussion", "Follow-up", "Medication", "Other Treatments", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,880
okay it's really gon na be important that you take your medication for your blood pressure as prescribed i'd really like to see you start doing that today and then let's let's go ahead and and let's set that that pill bottle down on the counter and see if that does n't help you remember to take that blood pressure medi...
[ "Therapeutic History", "Physical Examination" ]
[ "Subjective", "Objective" ]
3,881
yeah i'm sorry about that it it's just gon na help me check the lenses in both of your eyes so it looks like the anterior segment examination reveals posterior chamber intraocular lenses in both eyes for the right eye the cornea is clear no nvi peak hole cup to disc is . two fundus examination of the right eye shows th...
[ "Physical Examination", "Acute Assessment", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
3,882
okay that's good so let me do a quick physical exam on you just gon na check your vitals here so your vitals are normal your pulse ox is okay so everything's good with that so i'm gon na feel your neck on your neck exam i do n't appreciate any cervical lymphadenopathy no subclavicular adenopathy your heart exam regular...
[ "Physical Examination", "Medication", "Therapeutic History", "Radiology Examination", "Reassessment", "Other Treatments" ]
[ "Subjective", "Objective", "Assessment", "Plan" ]
3,883
i mean and and i for you that's that that's for patients that you know who are on them for a a long period of time right you're only gon na be on it for five days that should n't affect you too bad you might feel when you coming off of it after the five days a few muscle aches other than that you should be fine you sho...
[ "Discussion", "Medication", "Other Treatments", "Reassessment" ]
[ "Assessment", "Plan" ]
3,884
okay so on your physical exam there seems to be no tenderness to palpation of your abdomen there is cva tenderness on your your right side here and that's due to that kidney stone so we did get a a ct scan before you came in so it does show that you have a stone measuring point five centimeters in size located on the p...
[ "Physical Examination", "Discussion", "Medication", "Radiology Examination", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
3,885