DATEXIS/med_intent_classification · Datasets at Hugging Face

text stringlengths 6 3.62k	intents listlengths 1 9	sections listlengths 1 4	__index_level_0__ int64 0 3.89k
i i know you're scared but we'll be right here with you the whole way	[ "Chitchat" ]	[ "Null" ]	900
okay for your	[ "Chitchat" ]	[ "Null" ]	901
yeah okay	[ "Chitchat" ]	[ "Null" ]	902
you know , you could be a little happy to see me . i do n't know . um , but let's look at some of the readings . hey , dragon ? show me the blood pressure readings . yeah , so , they've been a , running a little high over the past couple months .	[ "Physical Examination" ]	[ "Objective" ]	903
for your next problem , your depression , you know , it sounds like you're doing well with that , but again , i'm happy to start on a med- , a medical regiment or ...	[ "Medication", "Reassessment" ]	[ "Assessment", "Plan" ]	904
alright this this is a no judgment zone i there i'm working through some things in my head to make sure that i give you the best care that we need right i'm making a plan as we move along you mentioned that the pain has been getting worse have you done anything or tried anything that's worked in the past	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	905
great .	[ "Personal History" ]	[ "Subjective" ]	906
alright so let's take a let's take a peek at your knee here	[ "Physical Examination" ]	[ "Objective" ]	907
okay . do you have any chest pain ?	[ "Acute Symptoms" ]	[ "Subjective" ]	908
okay . so how has your weight been .	[ "Vegetative History" ]	[ "Subjective" ]	909
alright how is your diet	[ "Personal History" ]	[ "Subjective" ]	910
there is a lot of salt and pizza and you know and you're gon na have to be able to avoid all the other salty foods as well so and i know that's hard but it's very important for your heart to be able to function at it's best right and you wan na be able to get out and walk you know walk take those walks again at the park and then you know do your photography so in order to do that we're gon na have to really cut back on those okay	[ "Other Treatments" ]	[ "Plan" ]	911
all right . anything else we can discuss today ?	[ "Discussion" ]	[ "Plan" ]	912
okay . and when was your last pap smear ?	[ "Acute Symptoms" ]	[ "Subjective" ]	913
okay so i know you mentioned tylenol	[ "Therapeutic History" ]	[ "Subjective" ]	914
okay so your partner is here with you today and reports that he is also having pain when you are standing up	[ "Acute Symptoms" ]	[ "Subjective" ]	915
i'd like to see that a little bit better , around six or seven , if possible .	[ "Lab Examination" ]	[ "Objective" ]	916
okay are you still taking your medication because i see you're on twenty milligrams of lisinopril	[ "Therapeutic History", "Personal History" ]	[ "Subjective" ]	917
yeah i would yeah you can elevate your leg stay off your stay off your leg you know if you have any kids have them work out in the yard instead of you just to to for a couple of weeks it's a good thing if you want to do that	[ "Discussion" ]	[ "Plan" ]	918
excuse me i feel rejected right now why why would you say something like that it's fine but you know i i like it when you're not here either because that means that you're doing a good job so let's see about like getting your knee fixed up but i want to talk about some of the other issues that you have first so we know that you have hypertension right and i discussed maybe you getting a blood pressure cuff because i needed you to measure those a bit more regularly did you get the cuff	[ "Personal History" ]	[ "Subjective" ]	919
yeah i say the same thing to my husband okay well let's go ahead i wanted you to just do a quick physical exam so i'm gon na be calling out some of my exam findings and i'm gon na let you know what they mean when i'm done okay so looking here at your vital signs you know you do n't have a fever here in the office which is good your temperature is ninety eight . four on your blood pressure it seems like you are doing a pretty good job monitoring your blood pressure your blood pressure is right where it should be it's about one twenty five over sixty two which is good your heart rate is nice and slow in the eighties and your oxygenation is fine it's ninety seven percent on room air so all of that is is really good now on on your facial exam i'm just pressing on your face here do you have any pain to palpation	[ "Physical Examination" ]	[ "Objective" ]	920
okay very good alright and then you said you were you've taken some tylenol for that and you said it did help a little bit or did n't sorry	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	921
i am , thank you . you too . you're looking great . how have you been feeling ?	[ "Personal History" ]	[ "Subjective" ]	922
okay . so , about four days ago ?	[ "Acute Symptoms" ]	[ "Subjective" ]	923
okay do you	[ "Chitchat" ]	[ "Null" ]	924
as you know , you've had dcis which we'll list in my note as stage zero , er/pr positive , invasive ductal carcinoma of the right breast . your status post-lumpectomy with removal of five lymph nodes that were benign . you also had , um , radiation therapy but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy and your mammogram in january , 2021 was also negative for recurrence and malignancy . so , based on all of that , we can just continue to observe you .	[ "Follow-up", "Reassessment" ]	[ "Assessment", "Plan" ]	925
okay and that'll be on the box when i call it in . you can put the wixela off to the side , but do n't throw it away just in case the alvesco does n't work well for you .	[ "Medication" ]	[ "Plan" ]	926
okay okay alright well hopefully we can get you to feeling better okay so i want to do a quick physical exam really check that knee out so your vital signs look good they they look alright your temperature is ninety eight . two your pulse is seventy two respirations are sixteen blood pressure is one twenty two over seventy so that looks fine i'm gon na go ahead and take a listen to your heart and lungs so on your heart exam it's a nice regular rate and rhythm but i appreciate a slight two over six systolic ejection murmur at the left base here on your lung exam your lungs are clear to auscultation bilaterally okay now let's take a quick look at that knee so does it hurt when i press on it	[ "Physical Examination" ]	[ "Objective" ]	927
alright any other questions	[ "Discussion" ]	[ "Plan" ]	928
it's an organic acid found in plants , that when digested , it binds to minerals that stones are formed from . foods like spinach , chocolate , beets , rhubarb and soy products .	[ "Discussion", "Other Treatments" ]	[ "Plan" ]	929
okay . i think that covers it . hop up here and let me take a look at you . okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes . in the result section , note that her ecog performance status today is zero . do you have ... did you have radiation after the lumpectomy ?	[ "Personal History", "Physical Examination" ]	[ "Subjective", "Objective" ]	930
issues with your liver . let me take a quick listen to your heart and lungs .	[ "Physical Examination" ]	[ "Objective" ]	931
well i'm glad that you're taking the first steps to quit smoking would you tell me a little bit more about your history of smoking	[ "Drug History" ]	[ "Subjective" ]	932
okay you measure it at home you you you measure your blood pressure at home	[ "Personal History" ]	[ "Subjective" ]	933
okay alright well let me let me go ahead and check you out	[ "Physical Examination" ]	[ "Objective" ]	934
so we're gon na put you on a medicine called combivent . okay , you're gon na do two puffs twice a day . it's gon na help open up your lungs . it's an inhaler .	[ "Medication" ]	[ "Plan" ]	935
any joint pain or muscle aches ?	[ "Vegetative History" ]	[ "Subjective" ]	936
yeah okay well we will we will try to look check and see what's going on there okay so so what kind of so have you you've done any fun activities that now that you know it's getting warm out	[ "Other Socials" ]	[ "Subjective" ]	937
um , belly pain ?	[ "Vegetative History" ]	[ "Subjective" ]	938
hi betty how are you i i read in the medical records that you ended you did end up having a heart attack they ended up putting a stent in your right coronary artery how are you doing	[ "Personal History", "Greetings" ]	[ "Subjective" ]	939
uh , now , there's two halves of it . so it's a partial tear of one half of a whole tendon . that's not that important , and the other one is just fine .	[ "Radiology Examination" ]	[ "Objective" ]	940
okay , and just for the chart , is there anyone , anybody else exposed to him who has been sick ?	[ "Other Socials" ]	[ "Subjective" ]	941
and so they added another blood pressure medication also how are you doing with that are you feeling a little bit better	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	942
i'm not gon na know that for sure or if there is other things going on in there but i think getting an mri scan to look at what you may have done inside there i'm pretty suspicious though that you may have injured that ligament if that's the only thing you did very rarely is this gon na need surgery okay so this may be something we wan na get you into a brace here get you into some therapy and get all your motion back and get your strength back and then maybe check it back in a in a few weeks and see because a lot of times those ligaments can tighten back up it's it's odd for just an isolated posterior ligament to need surgery	[ "Diagnostic Testing", "Other Treatments" ]	[ "Plan" ]	943
thank you .	[ "Other Socials" ]	[ "Subjective" ]	944
do you have any questions ?	[ "Discussion" ]	[ "Plan" ]	945
hi jeremy how are you the medical assistant told me that you injured your back	[ "Acute Symptoms", "Chitchat" ]	[ "Subjective" ]	946
doctor: alright great thanks	[ "Chitchat" ]	[ "Null" ]	947
does it happen on its own or there are certain things that trigger it	[ "Acute Symptoms" ]	[ "Subjective" ]	948
yep yeah i'm i'm familiar	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	949
i know my nurse has already told you about dax . is it okay if i tell dax a little bit about you ?	[ "Chitchat" ]	[ "Null" ]	950
i would prefer you to get them done as soon as possible so when you walk out of this room there is a a blood lab right next door i need you to go ahead and do some of those draws some of them i will need you to not have eaten we are gon na do them it's called fasting and you can make sure that you have n't eaten when you do but they will the lab techs will know so you will be able to knock out most of those today	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	951
i'm gon na go ahead and order hemoglobin a1c for the future okay ?	[ "Diagnostic Testing" ]	[ "Plan" ]	952
hi russell how are you what's been going on	[ "Greetings" ]	[ "Subjective" ]	953
okay and then were you able to walk on it after the incident	[ "Acute Symptoms" ]	[ "Subjective" ]	954
yeah okay and if i come up a little bit further as i i run up that achilles tendon does that hurt	[ "Physical Examination" ]	[ "Objective" ]	955
okay alright and any other symptoms any problems with like your bladder or your bowels any incontinence or you know you feel like you ca n't go to the bathroom	[ "Vegetative History" ]	[ "Subjective" ]	956
okay okay any other questions	[ "Discussion" ]	[ "Plan" ]	957
yeah okay	[ "Chitchat" ]	[ "Null" ]	958
i see . and then it looks like you had an ultrasound of your right breast on november 3rd , 2019 , which revealed a mass at the two o'clock position , 11 centimeters from the nipple in the retroareolar region . the report states the mass was point four by two by three centimeters .	[ "Personal History", "Radiology Examination" ]	[ "Subjective", "Objective" ]	959
okay .	[ "Acute Symptoms", "Vegetative History" ]	[ "Subjective" ]	960
um , have you had any recent seizures ?	[ "Personal History" ]	[ "Subjective" ]	961
so if we send it to pick'n save or metro market ... let's see where else .	[ "Discussion", "Medication" ]	[ "Plan" ]	962
great , great . so , roy is a 50-year-old male patient who comes in with a history of depression , you had some , um , high blood pressure and some hypertension . so , tell me how have you been doing?	[ "Personal History" ]	[ "Subjective" ]	963
okay so pain with lumbar flexion and extension alright and as i raise your leg does this hurt when i raise your leg up	[ "Physical Examination" ]	[ "Objective" ]	964
all right . so on physical examination , everything looks pretty good , so on your neck exam , i do n't appreciate any carotid bruits . on your heart exam i do appreciate a slight two out of six systolic ejection murmur heard at the left base , which we've heard in the past .	[ "Acute Assessment" ]	[ "Assessment" ]	965
have you smoked	[ "Vegetative History" ]	[ "Subjective" ]	966
okay . and even when i press lightly like this ?	[ "Physical Examination" ]	[ "Objective" ]	967
okay alright and what have you taken for the pain	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	968
okay . and , um , does it hurt more in the morning when you wake up , or does it hurt more when you're walking around and that type of thing ?	[ "Acute Symptoms" ]	[ "Subjective" ]	969
yep , that's right .	[ "Discussion" ]	[ "Plan" ]	970
okay so i know you were sent here by your your pcp what was your understanding of why you were sent here	[ "Personal History" ]	[ "Subjective" ]	971
sleeping well ?	[ "Vegetative History" ]	[ "Subjective" ]	972
all right . do you have any questions ?	[ "Discussion" ]	[ "Plan" ]	973
doctor: hey dragon ? finalize the note .	[ "Chitchat" ]	[ "Null" ]	974
you're welcome . and then , um , lastly , your hyperthyroidism , uh , i see you're taking levothyroxine . and again , no change here and you can just keep taking that as you have them .	[ "Medication", "Reassessment" ]	[ "Assessment", "Plan" ]	975
alright sounds like a plan	[ "Discussion" ]	[ "Plan" ]	976
okay so if you do n't mind i'd like to go ahead and do a quick physical exam i've reviewed your vitals everything looks good there and i'm gon na do a focused exam of your left shoulder now you have limited active and passive range of motion there is some tenderness of the greater tuberosity of the humerus and there is no tenderness at the sternoclavicular or clavicular joints and you have good hand grip bilaterally neurovascular exam of your left arm your cap refill is brisk in less than three seconds and motor and sensation is intact to light touch now for review of your x-ray of that left shoulder the good news is i do n't see any fracture or bony abnormality so let me talk to you briefly about my assessment and plan okay so for your first problem of left shoulder pain your symptoms are most likely due to rotator cuff tendinopathy this means that the tendons of the muscles of that left shoulder have been injured and the injury happened to the tendons that make up or attach to the shoulder muscles i'm gon na go ahead and order an mri of your shoulder just to make sure nothing else is going on with that left shoulder i'm also going to go ahead and refer you for physical therapy for approximately six to eight weeks okay now during that time i want you to continue to take tylenol p.r.n . if your symptoms do n't improve we can then consider maybe like a steroid injection of that left shoulder which could hopefully get you some relief now do you have any questions comments or concerns about our treatment plan	[ "Physical Examination", "Discussion", "Medication", "Radiology Examination", "Referral", "Diagnostic Testing", "Acute Assessment" ]	[ "Objective", "Assessment", "Plan" ]	977
okay so the inside of your right elbow okay	[ "Acute Symptoms" ]	[ "Subjective" ]	978
and , that's because of the new job and all that ?	[ "Other Socials" ]	[ "Subjective" ]	979
okay well alright well let's go ahead and do a quick physical exam on you here let me look at your vital signs okay i reviewed your vitals they they overall they look good take a listen to your heart real quick alright and your heart exam i hear regular rate and rhythm with no murmurs and on your musculoskeletal exam i have seen you and walk around here and you do have normal gait alright now i'm gon na have you do some movements on your legs here okay	[ "Physical Examination" ]	[ "Objective" ]	980
around ten okay yeah that that's that's definitely pretty high yeah you definitely if your if your pcp has n't gotten created treatment plan for you definitely need to go back and see them so you can get that controlled alright so let me do a quick physical exam on your foot here today your vital signs look normal you do n't have a fever so let me just take a look at your foot so on your foot exam there is a one by two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint there is some redness some drainage present you have some edema around it there is fluid like you said that's coming out of it i do n't see any necrosis you do n't have any odor and i do n't appreciate any bony exposure so it pretty much is like you said it's it's red it's swollen i think you have an infection in there as well so when i touch it does that hurt	[ "Physical Examination" ]	[ "Objective" ]	981
besides when you go out heavy drinking right	[ "Drug History", "Vegetative History" ]	[ "Subjective" ]	982
and then hold off until i see you again before you start back any of your old products . um , if it's starting to flair again , um , if it's just a little bit , you can try just doing the tacrolimus for a couple days , to see if that's enough . if it's not , then restart the dy- doxycycline as well .	[ "Medication" ]	[ "Plan" ]	983
alright so does that pain radiate anywhere or like where would you say it is in your shoulder	[ "Acute Symptoms" ]	[ "Subjective" ]	984
okay , good . so you- you should not be breastfeeding while you're on that medication .	[ "Vegetative History" ]	[ "Subjective" ]	985
yeah yeah there are some really nice senior routes here in boston is n't there like	[ "Chitchat" ]	[ "Null" ]	986
okay cinnamon rolls can be kind of hard like do you for your cakes do you do you use fondant you know to like do any of the decorations	[ "Vegetative History" ]	[ "Subjective" ]	987
it certainly could be contributing to that it certainly could be a factor that we need to look at so	[ "Personal History" ]	[ "Subjective" ]	988
hey alan i good to see you today so i looked here my appointment notes and i see that you're coming in you had some shoulder pain left shoulder pain for the last three weeks so how you doing is it is it gotten any better	[ "Acute Symptoms", "Greetings" ]	[ "Subjective" ]	989
okay .	[ "Family History" ]	[ "Subjective" ]	990
yeah that sounds painful and so when did this occur	[ "Acute Symptoms" ]	[ "Subjective" ]	991
no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat . and we can get you started right away on a fiber supplement that should help with that .	[ "Medication", "Acute Assessment" ]	[ "Assessment", "Plan" ]	992
okay . and , how about your diet ? are you watching your diet ?	[ "Personal History" ]	[ "Subjective" ]	993
not ready to quit ?	[ "Vegetative History" ]	[ "Subjective" ]	994
okay and have you had any back surgeries or back problems in the past or this is kind of the first time	[ "Personal History" ]	[ "Subjective" ]	995
michelle king , date of birth 01/05/1986 , mrnq27631 . new patient visit for acid reflux . past medical history of anxiety and seasonal allergies . hello , are you mrs. king ?	[ "Acute Symptoms", "Personal History", "Greetings" ]	[ "Subjective" ]	996
um , hi mrs. anderson . right ?	[ "Greetings" ]	[ "Subjective" ]	997
i want you to quit smoking , but we've had this battle before .	[ "Discussion", "Other Treatments" ]	[ "Plan" ]	998
we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better .	[ "Discussion", "Referral", "Medication" ]	[ "Plan" ]	999

i i know you're scared but we'll be right here with you the whole way

[ "Chitchat" ]

[ "Null" ]

900

okay for your

[ "Chitchat" ]

[ "Null" ]

901

yeah okay

[ "Chitchat" ]

[ "Null" ]

902

you know , you could be a little happy to see me . i do n't know . um , but let's look at some of the readings . hey , dragon ? show me the blood pressure readings . yeah , so , they've been a , running a little high over the past couple months .

[ "Physical Examination" ]

[ "Objective" ]

903

for your next problem , your depression , you know , it sounds like you're doing well with that , but again , i'm happy to start on a med- , a medical regiment or ...

[ "Medication", "Reassessment" ]

[ "Assessment", "Plan" ]

904

alright this this is a no judgment zone i there i'm working through some things in my head to make sure that i give you the best care that we need right i'm making a plan as we move along you mentioned that the pain has been getting worse have you done anything or tried anything that's worked in the past

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

905

great .

[ "Personal History" ]

[ "Subjective" ]

906

alright so let's take a let's take a peek at your knee here

[ "Physical Examination" ]

[ "Objective" ]

907

okay . do you have any chest pain ?

[ "Acute Symptoms" ]

[ "Subjective" ]

908

okay . so how has your weight been .

[ "Vegetative History" ]

[ "Subjective" ]

909

alright how is your diet

[ "Personal History" ]

[ "Subjective" ]

910

there is a lot of salt and pizza and you know and you're gon na have to be able to avoid all the other salty foods as well so and i know that's hard but it's very important for your heart to be able to function at it's best right and you wan na be able to get out and walk you know walk take those walks again at the park and then you know do your photography so in order to do that we're gon na have to really cut back on those okay

[ "Other Treatments" ]

[ "Plan" ]

911

all right . anything else we can discuss today ?

[ "Discussion" ]

[ "Plan" ]

912

okay . and when was your last pap smear ?

[ "Acute Symptoms" ]

[ "Subjective" ]

913

okay so i know you mentioned tylenol

[ "Therapeutic History" ]

[ "Subjective" ]

914

okay so your partner is here with you today and reports that he is also having pain when you are standing up

[ "Acute Symptoms" ]

[ "Subjective" ]

915

i'd like to see that a little bit better , around six or seven , if possible .

[ "Lab Examination" ]

[ "Objective" ]

916

okay are you still taking your medication because i see you're on twenty milligrams of lisinopril

[ "Therapeutic History", "Personal History" ]

[ "Subjective" ]

917

yeah i would yeah you can elevate your leg stay off your stay off your leg you know if you have any kids have them work out in the yard instead of you just to to for a couple of weeks it's a good thing if you want to do that

[ "Discussion" ]

[ "Plan" ]

918

excuse me i feel rejected right now why why would you say something like that it's fine but you know i i like it when you're not here either because that means that you're doing a good job so let's see about like getting your knee fixed up but i want to talk about some of the other issues that you have first so we know that you have hypertension right and i discussed maybe you getting a blood pressure cuff because i needed you to measure those a bit more regularly did you get the cuff

[ "Personal History" ]

[ "Subjective" ]

919

yeah i say the same thing to my husband okay well let's go ahead i wanted you to just do a quick physical exam so i'm gon na be calling out some of my exam findings and i'm gon na let you know what they mean when i'm done okay so looking here at your vital signs you know you do n't have a fever here in the office which is good your temperature is ninety eight . four on your blood pressure it seems like you are doing a pretty good job monitoring your blood pressure your blood pressure is right where it should be it's about one twenty five over sixty two which is good your heart rate is nice and slow in the eighties and your oxygenation is fine it's ninety seven percent on room air so all of that is is really good now on on your facial exam i'm just pressing on your face here do you have any pain to palpation

[ "Physical Examination" ]

[ "Objective" ]

920

okay very good alright and then you said you were you've taken some tylenol for that and you said it did help a little bit or did n't sorry

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

921

i am , thank you . you too . you're looking great . how have you been feeling ?

[ "Personal History" ]

[ "Subjective" ]

922

okay . so , about four days ago ?

[ "Acute Symptoms" ]

[ "Subjective" ]

923

okay do you

[ "Chitchat" ]

[ "Null" ]

924

as you know , you've had dcis which we'll list in my note as stage zero , er/pr positive , invasive ductal carcinoma of the right breast . your status post-lumpectomy with removal of five lymph nodes that were benign . you also had , um , radiation therapy but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy and your mammogram in january , 2021 was also negative for recurrence and malignancy . so , based on all of that , we can just continue to observe you .

[ "Follow-up", "Reassessment" ]

[ "Assessment", "Plan" ]

925

okay and that'll be on the box when i call it in . you can put the wixela off to the side , but do n't throw it away just in case the alvesco does n't work well for you .

[ "Medication" ]

[ "Plan" ]

926

okay okay alright well hopefully we can get you to feeling better okay so i want to do a quick physical exam really check that knee out so your vital signs look good they they look alright your temperature is ninety eight . two your pulse is seventy two respirations are sixteen blood pressure is one twenty two over seventy so that looks fine i'm gon na go ahead and take a listen to your heart and lungs so on your heart exam it's a nice regular rate and rhythm but i appreciate a slight two over six systolic ejection murmur at the left base here on your lung exam your lungs are clear to auscultation bilaterally okay now let's take a quick look at that knee so does it hurt when i press on it

[ "Physical Examination" ]

[ "Objective" ]

927

alright any other questions

[ "Discussion" ]

[ "Plan" ]

928

it's an organic acid found in plants , that when digested , it binds to minerals that stones are formed from . foods like spinach , chocolate , beets , rhubarb and soy products .

[ "Discussion", "Other Treatments" ]

[ "Plan" ]

929

okay . i think that covers it . hop up here and let me take a look at you . okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes . in the result section , note that her ecog performance status today is zero . do you have ... did you have radiation after the lumpectomy ?

[ "Personal History", "Physical Examination" ]

[ "Subjective", "Objective" ]

930

issues with your liver . let me take a quick listen to your heart and lungs .

[ "Physical Examination" ]

[ "Objective" ]

931

well i'm glad that you're taking the first steps to quit smoking would you tell me a little bit more about your history of smoking

[ "Drug History" ]

[ "Subjective" ]

932

okay you measure it at home you you you measure your blood pressure at home

[ "Personal History" ]

[ "Subjective" ]

933

okay alright well let me let me go ahead and check you out

[ "Physical Examination" ]

[ "Objective" ]

934

so we're gon na put you on a medicine called combivent . okay , you're gon na do two puffs twice a day . it's gon na help open up your lungs . it's an inhaler .

[ "Medication" ]

[ "Plan" ]

935

any joint pain or muscle aches ?

[ "Vegetative History" ]

[ "Subjective" ]

936

yeah okay well we will we will try to look check and see what's going on there okay so so what kind of so have you you've done any fun activities that now that you know it's getting warm out

[ "Other Socials" ]

[ "Subjective" ]

937

um , belly pain ?

[ "Vegetative History" ]

[ "Subjective" ]

938

hi betty how are you i i read in the medical records that you ended you did end up having a heart attack they ended up putting a stent in your right coronary artery how are you doing

[ "Personal History", "Greetings" ]

[ "Subjective" ]

939

uh , now , there's two halves of it . so it's a partial tear of one half of a whole tendon . that's not that important , and the other one is just fine .

[ "Radiology Examination" ]

[ "Objective" ]

940

okay , and just for the chart , is there anyone , anybody else exposed to him who has been sick ?

[ "Other Socials" ]

[ "Subjective" ]

941

and so they added another blood pressure medication also how are you doing with that are you feeling a little bit better

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

942

i'm not gon na know that for sure or if there is other things going on in there but i think getting an mri scan to look at what you may have done inside there i'm pretty suspicious though that you may have injured that ligament if that's the only thing you did very rarely is this gon na need surgery okay so this may be something we wan na get you into a brace here get you into some therapy and get all your motion back and get your strength back and then maybe check it back in a in a few weeks and see because a lot of times those ligaments can tighten back up it's it's odd for just an isolated posterior ligament to need surgery

[ "Diagnostic Testing", "Other Treatments" ]

[ "Plan" ]

943

thank you .

[ "Other Socials" ]

[ "Subjective" ]

944

do you have any questions ?

[ "Discussion" ]

[ "Plan" ]

945

hi jeremy how are you the medical assistant told me that you injured your back

[ "Acute Symptoms", "Chitchat" ]

[ "Subjective" ]

946

doctor: alright great thanks

[ "Chitchat" ]

[ "Null" ]

947

does it happen on its own or there are certain things that trigger it

[ "Acute Symptoms" ]

[ "Subjective" ]

948

yep yeah i'm i'm familiar

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

949

i know my nurse has already told you about dax . is it okay if i tell dax a little bit about you ?

[ "Chitchat" ]

[ "Null" ]

950

i would prefer you to get them done as soon as possible so when you walk out of this room there is a a blood lab right next door i need you to go ahead and do some of those draws some of them i will need you to not have eaten we are gon na do them it's called fasting and you can make sure that you have n't eaten when you do but they will the lab techs will know so you will be able to knock out most of those today

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

951

i'm gon na go ahead and order hemoglobin a1c for the future okay ?

[ "Diagnostic Testing" ]

[ "Plan" ]

952

hi russell how are you what's been going on

[ "Greetings" ]

[ "Subjective" ]

953

okay and then were you able to walk on it after the incident

[ "Acute Symptoms" ]

[ "Subjective" ]

954

yeah okay and if i come up a little bit further as i i run up that achilles tendon does that hurt

[ "Physical Examination" ]

[ "Objective" ]

955

okay alright and any other symptoms any problems with like your bladder or your bowels any incontinence or you know you feel like you ca n't go to the bathroom

[ "Vegetative History" ]

[ "Subjective" ]

956

okay okay any other questions

[ "Discussion" ]

[ "Plan" ]

957

yeah okay

[ "Chitchat" ]

[ "Null" ]

958

i see . and then it looks like you had an ultrasound of your right breast on november 3rd , 2019 , which revealed a mass at the two o'clock position , 11 centimeters from the nipple in the retroareolar region . the report states the mass was point four by two by three centimeters .

[ "Personal History", "Radiology Examination" ]

[ "Subjective", "Objective" ]

959

okay .

[ "Acute Symptoms", "Vegetative History" ]

[ "Subjective" ]

960

um , have you had any recent seizures ?

[ "Personal History" ]

[ "Subjective" ]

961

so if we send it to pick'n save or metro market ... let's see where else .

[ "Discussion", "Medication" ]

[ "Plan" ]

962

great , great . so , roy is a 50-year-old male patient who comes in with a history of depression , you had some , um , high blood pressure and some hypertension . so , tell me how have you been doing?

[ "Personal History" ]

[ "Subjective" ]

963

okay so pain with lumbar flexion and extension alright and as i raise your leg does this hurt when i raise your leg up

[ "Physical Examination" ]

[ "Objective" ]

964

all right . so on physical examination , everything looks pretty good , so on your neck exam , i do n't appreciate any carotid bruits . on your heart exam i do appreciate a slight two out of six systolic ejection murmur heard at the left base , which we've heard in the past .

[ "Acute Assessment" ]

[ "Assessment" ]

965

have you smoked

[ "Vegetative History" ]

[ "Subjective" ]

966

okay . and even when i press lightly like this ?

[ "Physical Examination" ]

[ "Objective" ]

967

okay alright and what have you taken for the pain

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

968

okay . and , um , does it hurt more in the morning when you wake up , or does it hurt more when you're walking around and that type of thing ?

[ "Acute Symptoms" ]

[ "Subjective" ]

969

yep , that's right .

[ "Discussion" ]

[ "Plan" ]

970

okay so i know you were sent here by your your pcp what was your understanding of why you were sent here

[ "Personal History" ]

[ "Subjective" ]

971

sleeping well ?

[ "Vegetative History" ]

[ "Subjective" ]

972

all right . do you have any questions ?

[ "Discussion" ]

[ "Plan" ]

973

doctor: hey dragon ? finalize the note .

[ "Chitchat" ]

[ "Null" ]

974

you're welcome . and then , um , lastly , your hyperthyroidism , uh , i see you're taking levothyroxine . and again , no change here and you can just keep taking that as you have them .

[ "Medication", "Reassessment" ]

[ "Assessment", "Plan" ]

975

alright sounds like a plan

[ "Discussion" ]

[ "Plan" ]

976

okay so if you do n't mind i'd like to go ahead and do a quick physical exam i've reviewed your vitals everything looks good there and i'm gon na do a focused exam of your left shoulder now you have limited active and passive range of motion there is some tenderness of the greater tuberosity of the humerus and there is no tenderness at the sternoclavicular or clavicular joints and you have good hand grip bilaterally neurovascular exam of your left arm your cap refill is brisk in less than three seconds and motor and sensation is intact to light touch now for review of your x-ray of that left shoulder the good news is i do n't see any fracture or bony abnormality so let me talk to you briefly about my assessment and plan okay so for your first problem of left shoulder pain your symptoms are most likely due to rotator cuff tendinopathy this means that the tendons of the muscles of that left shoulder have been injured and the injury happened to the tendons that make up or attach to the shoulder muscles i'm gon na go ahead and order an mri of your shoulder just to make sure nothing else is going on with that left shoulder i'm also going to go ahead and refer you for physical therapy for approximately six to eight weeks okay now during that time i want you to continue to take tylenol p.r.n . if your symptoms do n't improve we can then consider maybe like a steroid injection of that left shoulder which could hopefully get you some relief now do you have any questions comments or concerns about our treatment plan

[ "Physical Examination", "Discussion", "Medication", "Radiology Examination", "Referral", "Diagnostic Testing", "Acute Assessment" ]

[ "Objective", "Assessment", "Plan" ]

977

okay so the inside of your right elbow okay

[ "Acute Symptoms" ]

[ "Subjective" ]

978

and , that's because of the new job and all that ?

[ "Other Socials" ]

[ "Subjective" ]

979

okay well alright well let's go ahead and do a quick physical exam on you here let me look at your vital signs okay i reviewed your vitals they they overall they look good take a listen to your heart real quick alright and your heart exam i hear regular rate and rhythm with no murmurs and on your musculoskeletal exam i have seen you and walk around here and you do have normal gait alright now i'm gon na have you do some movements on your legs here okay

[ "Physical Examination" ]

[ "Objective" ]

980

around ten okay yeah that that's that's definitely pretty high yeah you definitely if your if your pcp has n't gotten created treatment plan for you definitely need to go back and see them so you can get that controlled alright so let me do a quick physical exam on your foot here today your vital signs look normal you do n't have a fever so let me just take a look at your foot so on your foot exam there is a one by two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint there is some redness some drainage present you have some edema around it there is fluid like you said that's coming out of it i do n't see any necrosis you do n't have any odor and i do n't appreciate any bony exposure so it pretty much is like you said it's it's red it's swollen i think you have an infection in there as well so when i touch it does that hurt

[ "Physical Examination" ]

[ "Objective" ]

981

besides when you go out heavy drinking right

[ "Drug History", "Vegetative History" ]

[ "Subjective" ]

982

and then hold off until i see you again before you start back any of your old products . um , if it's starting to flair again , um , if it's just a little bit , you can try just doing the tacrolimus for a couple days , to see if that's enough . if it's not , then restart the dy- doxycycline as well .

[ "Medication" ]

[ "Plan" ]

983

alright so does that pain radiate anywhere or like where would you say it is in your shoulder

[ "Acute Symptoms" ]

[ "Subjective" ]

984

okay , good . so you- you should not be breastfeeding while you're on that medication .

[ "Vegetative History" ]

[ "Subjective" ]

985

yeah yeah there are some really nice senior routes here in boston is n't there like

[ "Chitchat" ]

[ "Null" ]

986

okay cinnamon rolls can be kind of hard like do you for your cakes do you do you use fondant you know to like do any of the decorations

[ "Vegetative History" ]

[ "Subjective" ]

987

it certainly could be contributing to that it certainly could be a factor that we need to look at so

[ "Personal History" ]

[ "Subjective" ]

988

hey alan i good to see you today so i looked here my appointment notes and i see that you're coming in you had some shoulder pain left shoulder pain for the last three weeks so how you doing is it is it gotten any better

[ "Acute Symptoms", "Greetings" ]

[ "Subjective" ]

989

okay .

[ "Family History" ]

[ "Subjective" ]

990

yeah that sounds painful and so when did this occur

[ "Acute Symptoms" ]

[ "Subjective" ]

991

no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat . and we can get you started right away on a fiber supplement that should help with that .

[ "Medication", "Acute Assessment" ]

[ "Assessment", "Plan" ]

992

okay . and , how about your diet ? are you watching your diet ?

[ "Personal History" ]

[ "Subjective" ]

993

not ready to quit ?

[ "Vegetative History" ]

[ "Subjective" ]

994

okay and have you had any back surgeries or back problems in the past or this is kind of the first time

[ "Personal History" ]

[ "Subjective" ]

995

michelle king , date of birth 01/05/1986 , mrnq27631 . new patient visit for acid reflux . past medical history of anxiety and seasonal allergies . hello , are you mrs. king ?

[ "Acute Symptoms", "Personal History", "Greetings" ]

[ "Subjective" ]

996

um , hi mrs. anderson . right ?

[ "Greetings" ]

[ "Subjective" ]

997

i want you to quit smoking , but we've had this battle before .

[ "Discussion", "Other Treatments" ]

[ "Plan" ]

998

we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better .

[ "Discussion", "Referral", "Medication" ]

[ "Plan" ]

999