{
    "data": [
        {
            "src": "[doctor] hi , andrew . how are you ?\n[patient] hey , good to see you .\n[doctor] i'm doing well , i'm doing well .\n[patient] good .\n[doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you .\n[patient] sure .\n[doctor] uh , so , andrew is a 59-year-old male with a past medical history , significant for depression , type two diabetes , and hypertension who presents today with an upper respiratory infection . so , andrew , what's going on ?\n[patient] yeah . we were doing a bit of work out in the yard in the last week or so and i started to feel really tired , was short of breath . um , we- we're not wearing masks as much at the end of the summer and i think i caught my first cold and i think it just got worse .\n[doctor] okay . all right . um , now , have you had your covid vaccines ?\n[patient] yeah , both .\n[doctor] okay . all right . and , um , do you have any history of any seasonal allergies at all ?\n[patient] none whatsoever .\n[doctor] okay . all right . and when you say you're having some shortness of breath , did you feel short of breath walking around or at rest ?\n[patient] uh , usually , it was lifting or carrying something . we were doing some landscaping , so i was carrying some heavy bags of soil and i , i got really winded . it really surprised me .\n[doctor] okay . and are you coughing up anything ?\n[patient] not yet , but i feel like that's next .\n[doctor] okay . and fevers ?\n[patient] uh , i felt a little warm , but i , i just thought it was because i was exerting myself .\n[doctor] okay . all right . and any other symptoms like muscle aches , joint pain , fatigue ?\n[patient] my elbows hurt quite a bit and my knees were pretty tired . l- like i said , i really felt some tension around my knees , but , uh , i think that was a lot to do with , uh , lifting the bags .\n[doctor] okay . all right . um , so , you know , how about , how are you doing in terms of your other medical problems , like your depression ? how are you doing with that ? i know we've , you know , talked about not putting you on medication for it because you're on medication for other things . what's going on ?\n[patient] i- it's been kind of a crazy year and a half . i was a little concerned about that but , for the most part , i've been , been doing well with it . my , my wife got me into barre classes , to help me relax and i think it's working .\n[doctor] okay . all right , great . and , and in terms of your diabetes , how are you doing watching your , your diet and your sugar intake ?\n[patient] uh , i've been monitoring my sugar levels while i am going to work during the week . uh , not so , uh , if its saturday or sunday i usually don't remember . uh , the diet's been pretty good for the most part , except for , you know , some house parties and things like that . but , uh , been good for the most part .\n[doctor] okay and have they been elevated at all since this episode of your-\n[patient] no .\n[doctor] okay . and then , how , lastly , for your high blood pressure , have you been monitoring your blood pressures at home ? did you buy the cuff like i suggested ?\n[patient] uh , same thing . during the while i'm going to work, i'm regular about monitoring it, but if its a saturday or sunday, not so much . but , uh , it's , it's been under control .\n[doctor] but you're taking your medication ?\n[patient] yes .\n[doctor] okay . all right . well , you know , i know that , you know , you've endorsed , you know , the shortness of breath and some joint pain . um , how about any other symptoms ? nausea or vomiting ? diarrhea ?\n[patient] no .\n[doctor] anything like that ?\n[patient] no .\n[doctor] okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so , your vital signs here in the office look quite good .\n[patient] mm-hmm .\n[doctor] you know , everything's looking normal , you do n't have a fever , which is really good . um , i'm just gon na go ahead and listen to your heart and your lungs and , kind of , i'll let you know what i hear , okay ?\n[patient] sure .\n[doctor] okay . so , on your physical exam , you know , your heart sounds nice and strong . your lungs , you do have scattered ronchi bilaterally on your lung exam . uh , it clears with cough . um , i do notice a little bit of , um , some edema of your lower extremities and you do have some pain to palpation of your elbows bilaterally . um , so , let's go ahead , i want to look at some of your results , okay ?\n[patient] mm-hmm .\n[doctor] hey , dragon . show me the chest x-ray .\n[doctor] so , i reviewed the results of your chest x-ray and everything looks good . there's no airspace disease , there's no pneumonia , so that's all very , very good , okay ?\n[patient] good .\n[doctor] hey , dragon . show me the diabetic labs .\n[doctor] and here , looking at your diabetic labs , you know , your hemoglobin a1c is a little elevated at eight .\n[patient] mm-hmm .\n[doctor] i'd like to see that a little bit better , around six or seven , if possible .\n[patient] mm-hmm .\n[doctor] um , so let's talk a little bit about my assessment and my plan for you .\n[patient] mm-hmm .\n[doctor] so , for your first problem , this upper respiratory infection , i believe you , you have a viral syndrome , okay ? we'll go ahead and we'll send a covid test , just to make sure that you do n't have covid .\n[patient] mm-hmm .\n[doctor] uh , but overall , i think that , um , you know , this will resolve in a couple of days . i do n't think you have covid , you do n't have any exposures , that type of thing .\n[patient] mm-hmm .\n[doctor] so , i think that this will improve . i'll give you some robitussin for your cough and i would encourage you take some ibuprofen , tylenol for any fever , okay ?\n[patient] you got it .\n[doctor] 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 ...\n[patient] mm-hmm .\n[doctor] . refer you to psychotherapy , if you think that that would be helpful .\n[patient] mm-hmm .\n[doctor] would you like that ?\n[patient] u- u- um , maybe not necessarily . maybe in a , uh , few months we'll check on that .\n[doctor] okay . all right .\n[doctor] for your third problem , your type two diabetes , i want to go ahead and increase your metformin to 1000 milligrams , twice daily .\n[patient] mm-hmm .\n[doctor] and i'm gon na get an- another hemoglobin a1c in four months , okay ?\n[patient] okay , sure .\n[doctor] hey , dragon . order a hemoglobin a1c .\n[doctor] and lastly , for your high blood pressure , it looks like you're doing a really good job managing that . i want to go ahead and continue you on the , um , lisinopril , 20 milligrams a day .\n[patient] mm-hmm .\n[doctor] and i'm gon na go ahead and order a lipid panel , okay ?\n[patient] sure .\n[doctor] do you need a refill of the lisinopril ?\n[patient] actually , i do .\n[doctor] okay . hey , dragon . order lisinopril , 20 milligrams daily .\n[doctor] so , the nurse will be in , she'll help you , uh , make a follow-up appointment with me . i want to see you again in about four months .\n[patient] okay .\n[doctor] let me know if your symptoms worsen and we can talk more about it , okay ?\n[patient] you got it .\n[doctor] all right . hey , dragon . finalize the note .",
            "tgt": "CHIEF COMPLAINT\n\nUpper respiratory infection.\n\nHISTORY OF PRESENT ILLNESS\n\nAndrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection.\n\nThe patient reports that he has been doing a bit of work out in the yard in the last week or so. He started to feel really tired and short of breath. The patient denies coughing up anything, but he feels like he will soon be coughing up phlegm. He denies having a fever, but he felt a little warm. He attributed this to exerting himself. He reports that his elbows hurt quite a bit. He notes his knees were pretty tired and he felt some tension around his knees. The patient attributes these symptoms to lifting heavy bags. He has not been wearing a mask as much recently. He believes that he caught his first cold and his symptoms have worsened. He has had both of his COVID vaccinations.\n\nHe denies any history of seasonal allergies.\n\nRegarding his depression, he states it has been a crazy year and a half. He was a little concerned about that, but for the most part, he has been doing well with it. His wife got him into barre classes and this has been relaxing.\n\nRegarding his diabetes, he has been monitoring his sugar levels while he is at work, but is not as consistent on Saturdays and Sundays. His diet has been pretty good for the most part, except for some house parties. They have not been elevated since his respiratory symptoms began.\n\nThe patient has been monitoring his blood pressure at home. He reports that he is very regular with monitoring his blood pressure during the week, though less consistently on weekends. He reports his blood pressure has been under control. He has continued to utilize lisinopril 20 mg, daily.\n\nThe patient denies nausea, vomiting, diarrhea.\n\nREVIEW OF SYSTEMS\n\n\u2022 Constitutional: Denies fever.\n\u2022 Cardiovascular: Endorses dyspnea on exertion.\n\u2022 Respiratory: Endorses shortness of breath and cough.\n\u2022 Gastrointestinal: Denies nausea or diarrhea.\n\u2022 Musculoskeletal: Endorses bilateral elbow and knee pain.\n\u2022 Psychiatric: Endorses depression.\n\nPHYSICAL EXAMINATION\n\n\u2022 Respiratory: Scattered rhonchi bilaterally, clears with cough.\n\u2022 Cardiovascular: No murmurs, gallops, or rubs. No extra heart sounds.\n\u2022 Musculoskeletal: Edema in the bilateral lower extremities. Pain to palpation of the bilateral elbows.\n\nRESULTS\n\nX-ray of the chest is unremarkable. No airspace disease. No signs of pneumonia.\n\nHemoglobin A1c is elevated at 8.\n\nASSESSMENT AND PLAN\n\nAndrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection.\n\nUpper respiratory infection.\n\u2022 Medical Reasoning: I believe he has contracted a viral syndrome. His chest x-ray was unremarkable and he has received both doses of the COVID-19 vaccination.\n\u2022 Additional Testing: We will obtain a COVID-19 test to rule this out.\n\u2022 Medical Treatment: I recommend he use Robitussin for cough, as well as ibuprofen or Tylenol if he develops a fever.\n\nDepression.\n\u2022 Medical Reasoning: He has been practicing barre classes and is doing well overall.\n\u2022 Medical Treatment: I offered medication or psychotherapy, but the patient opted to defer at this time.\n\nDiabetes type 2.\n\u2022 Medical Reasoning: His blood glucose levels have been well controlled based on home monitoring, but his recent hemoglobin A1c was elevated.\n\u2022 Additional Testing: We will repeat a hemoglobin A1c in 4 months.\n\u2022 Medical Treatment: We will increase his metformin to 1000 mg twice daily.\n\nHypertension.\n\u2022 Medical Reasoning: He has been compliant with lisinopril and his blood pressures have been well controlled based on home monitoring.\n\u2022 Additional Testing: We will order a lipid panel.\n\u2022 Medical Treatment: He will continue on lisinopril 20 mg once daily. This was refilled today.\n\nFollow up: I would like to see him back in approximately 4 months.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.",
            "file": "D2N088-virtassist"
        },
        {
            "src": "[doctor] hi andrea , how are you ?\n[patient] i'm doing well . how are you ?\n[doctor] doing well . uh , so i know the nurse told you about dax . i'd like to tell dax a little bit about you . okay ?\n[patient] okay .\n[doctor] so , andrea is a 52-year-old female with a past medical history significant for rheumatoid arthritis , atrial fibrillation , and reflux who presents today for her annual exam . so andrea , it's been a year since i saw you . how are you doing ?\n[patient] i'm doing well . so , i've been walking like you told me to and , um , exercising and doing yoga , and that's actually helped with my arthritis a lot , just the- the constant movement . so , i have n't had any joint pain recently .\n[doctor] okay . good . so , no- no issues with any stiffness or pain or flare ups over the last year ?\n[patient] no .\n[doctor] okay . and i know that we have you on the methotrexate , are you still taking that once a week ?\n[patient] yes , i am .\n[doctor] okay . and any issues with that ?\n[patient] no .\n[doctor] no . okay . and then in terms of your a-fib , how are you doing with that ? are you having any palpitations ? or , i know that you've kind of been in and out of it over the past , you know , year or so .\n[patient] yeah . i've still been having palpitations . the- the last one i had was about a week ago . i've noticed that when i start to get stressed , um , they start to flare up again . so , i've been trying meditation , trying running with my dog to try and relieve the stress but it has n't really been working .\n[doctor] yeah . i- i know that you had called , um , last month and we- we did that event monitor for you , uh , which we'll take a look at in a few minutes . okay ?\n[patient] okay .\n[doctor] um , how about um , your reflux ? you know , we had placed you on the protonix , uh , has that helped ? and i know that you were gon na do some dietary modifications .\n[patient] yeah . i cut out soda and that- that's helped- seemed to help , and the medication's been helping too . i have n't had a flare up in over , i think , five months .\n[doctor] okay . all right . um , so , you know , i know that you did the review of systems sheet when you checked in and , you know , you had- you know , you endorsed the palpitations and you had some nasal congestion . any other symptoms ? you know , chest pain , shortness of breath , nausea or vomiting ?\n[patient] no , nothing like that . just the nasal- nasal congestion because of my allergies .\n[doctor] okay . all right . okay . well , i'd like to go ahead and do a quick physical exam , okay ?\n[patient] okay .\n[doctor] all right . hey dragon , show me the vital signs . okay . so , you're in- here in the office today , it looks like , you know , your heart rate's really good today . it's- it's nice and controlled so that's good . um , i'm just gon na take a look into your heart and lungs and- and i'll let you know what i find . okay ?\n[patient] okay .\n[doctor] okay . so , on physical examination , um , you know , everything looks really good . on your heart examination , i do appreciate a slight 2/6 systolic- systolic ejection murmur , um , which we've heard in the past so i'm not worried at that . you're in the- a nice regular rate and rhythm at this time . your lungs are nice and clear . on your right elbow , i do notice some edema and some erythema . does it hurt when i press it ?\n[patient] yeah , it does a bit .\n[doctor] okay . so , she has pain to palpation of the right elbow . um , and you have no lower extremity edema , okay ? um , so i wan na go ahead and just take a look at some of your results . okay ?\n[patient] okay .\n[doctor] hey dragon , show me the event- event monitor results . okay . so , you know , this is the results of your event monitor which shows that , you know , you're in and out of a-fib , you have what we call a conversion pause . you know , you're in a-fib , you pause , and then you go back to regular rhythm . so , we'll talk about that , okay ?\n[patient] okay .\n[doctor] hey dragon , show me the autoimmune panel . so , looking here at your autoimmune panel , everything looks good , it looks like you're- you know , everything is well controlled with your rheumatoid arthritis on the methotrexate . okay ? so , let me just go over a little bit about my assessment and my plan for you . okay ?\n[patient] okay .\n[doctor] so for your first problem , your rheumatoid arthritis , again , everything looks good . i wan na just continue you on the methotrexate 2.5 mg , once weekly . um , and uh , if you need a referral back to see the rheumatologist , let me know , but i think everything seems stable now . do you need a refill of the methotrexate ?\n[patient] yes , i do .\n[doctor] okay . hey dragon , order methotrexate , 2.5 mg once weekly . for your second problem , the atrial fibrillation . so , you're going in and out of a-fib and i'd like to just keep you in normal sinus rhythm . so , i wan na go ahead and refer you to cardiology for a cardiac ablation which just maps out where that rhythm is coming from and burns it so it does n't come back . okay ? you're young , we wan na keep you in a normal rhythm and , being that you're going in and out of a-fib , i think that's what we should do . okay ?\n[patient] okay .\n[doctor] hey dragon , order a referral to cardiology . and for your last problem , the reflux , you know , i wanna- i want you to just continue on the protonix , 40 mg a day . continue with your dietary modifications , you know , avoiding coffee and spicy foods , that type of thing . okay ? and then let me know if you have any other issues with that , okay ?\n[patient] will do .\n[doctor] any questions ?\n[patient] no , i do n't .\n[doctor] okay . all right . it was good to see you .\n[patient] good seeing you .\n[doctor] hey dragon , finalize the note .",
            "tgt": "CHIEF COMPLAINT\n\nAnnual exam.\n\nHISTORY OF PRESENT ILLNESS\n\nAndrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen.\n\nThe patient states she is doing well. She has been walking, exercising, and doing yoga, which has helped with her arthritis. She denies issues with stiffness, pain, or flare ups over the last year. The patient has continued utilizing methotrexate 2.5 mg once a week and denies issues with that.\n\nIn terms of her atrial fibrillation, she endorses continued palpitations. The last episode she had was about 1 week ago. She has noticed that when she starts to get stressed they start to flare up again. She has tried meditation and running with her dog for stress relief, however these have not been helpful. The patient had called last month and had an event monitor done.\n\nRegarding her GERD, she has continued to utilize Protonix 40 mg a day. The patient has cut out soda, which seemed to help. She has not had a flare up in over 5 months.\n\nThe patient endorses nasal congestion because of her allergies. She denies chest pain, shortness of breath, nausea, and vomitting.\n\nREVIEW OF SYSTEMS\n\n\u2022 Ears, Nose, Mouth and Throat: Endorses nasal congestion from allergies.\n\u2022 Cardiovascular: Denies chest pain or dyspnea. Endorses palpitations.\n\u2022 Respiratory: Denies shortness of breath.\n\u2022 Musculoskeletal: Denies joint pain.\n\nPHYSICAL EXAMINATION\n\n\u2022 Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.\n\u2022 Cardiovascular: Regular rate and rhythm. Slight 2/6 systolic ejection murmur.\n\u2022 Musculoskeletal: No lower extremity edema. Edema and erythema of the right elbow. Pain to palpation of the right elbow.\n\nRESULTS\n\nEvent monitor: Positive for conversion pause.\n\nAutoimmune panel: Normal. Well controlled rheumatoid arthritis.\n\nASSESSMENT AND PLAN\n\nAndrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen.\n\nRheumatoid arthritis.\n\u2022 Medical Reasoning: The patient has remained active and has been compliant with methotrexate once weekly. Her recent autoimmune panel was normal.\n\u2022 Medical Treatment: She will continue on methotrexate 2.5 mg once weekly. This was refilled today.\n\u2022 Specialist Referrals: If she needs a referral back to the rheumatologist, she will let me know.\n\nAtrial fibrillation.\n\u2022 Medical Reasoning: She continues to experience episodes of palpitations. Her most recent episode was about 1 week ago. She is in normal sinus rhythm today, but her recent cardiac event monitor demonstrated a conversion pause.\n\u2022 Specialist Referrals: We will refer her to cardiology for a cardiac ablation.\n\nGERD.\n\u2022 Medical Reasoning: She has been compliant with dietary modifications and denies any episodes in approximately 5 months.\n\u2022 Medical Treatment: Continue on Protonix 40 mg daily.\n\u2022 Patient Education and Counseling: She could continue with dietary modifications and avoid known dietary triggers.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N089-virtassist"
        },
        {
            "src": "[doctor] hi , albert . how are you ?\n[patient] hey , good to see you .\n[doctor] it's good to see you too . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you .\n[patient] sure .\n[doctor] so , albert is a 62-year-old male , with a past medical history significant for depression , type 2 diabetes , and kidney transplant , who is here today for emergency room follow-up .\n[patient] mm-hmm .\n[doctor] so , i got a notification that you were in the emergency room , but , but what were you there for ?\n[patient] well , i , uh , i was n't really , uh , staying on top of my , uh , blood sugar readings , and i felt kinda woozy over the weekend . and i was little concerned , and my wife wanted to take me in and just have me checked out .\n[doctor] okay . and , and was it , in fact , high ?\n[patient] yeah , it was .\n[doctor] okay . did you ... were you admitted to the hospital ?\n[patient] uh , no .\n[doctor] okay . all right . and , uh , are you ... did they see a reason , as to why it was elevated ?\n[patient] uh , yeah . my mother was actually in the hospital the last week. she had a bit of a fall and had to do a hip replacement. she's feeling better now but we have been just grabbing meals at the cafeteria or picking up fast food on our way home and i just really was n't monitoring what i was eating .\n[doctor] okay . that's sorry to hear . and are you feeling better now ?\n[patient] uh , actually , when we got home from the , uh , f- from the visit , i felt a lot better .\n[doctor] okay . and since then , have you been following your diet pretty closely ?\n[patient] yes .\n[doctor] okay . 'cause we do n't wan na end up in the hospitaltoo\n[patient] no .\n[doctor] all right . um , okay . and , so , before that happened , how are you doing with your diet ?\n[patient] uh , during the week , i've been fine , 'cause i've been very busy . on the weekends , doing things . you're seeing people . you're having people over . it's , i- not , not as consistent on the weekend .\n[doctor] okay . all right . um , is there a way that you think that that can improve ?\n[patient] uh , s- stop eating .\n[doctor] okay . all right . well , let's talk about your , your kidney transplant . how are-\n[patient] mm-hmm .\n[doctor] . you doing ? you're taking immunotherapy meds ?\n[patient] yes .\n[doctor] okay .\n[patient] yeah . i've , i've been pretty diligent about it , following doctor's orders , so it's been , it's been pretty good so far .\n[doctor] okay . and , and y- the last time i saw that you saw dr. reyes , was about three weeks ago , and everything seemed to be fine .\n[patient] that's correct .\n[doctor] your kidney function is good .\n[patient] yes .\n[doctor] okay . all right . and in terms of your depression , how are you , how are you doing ?\n[patient] and it's been about a , a tough , ugh , year-and-a-half or so , but i've been pretty good with it . i , i have my moments , but i- as long as i find some time to relax , at least in the afternoon , then , then it seems to work out okay .\n[doctor] okay . so , i know that we've kind of talked about holding off on medical therapy-\n[patient] mm-hmm .\n[doctor] . 'cause you're on so many other meds .\n[patient] mm-hmm .\n[doctor] um , is that something that you wan na revisit , or do you wan na look into therapy , or do you think anything's needed right now ?\n[patient] uh , i think i probably wan na shy away from any therapy . my , my wife got me into meditation recently and , and , uh , i , i find that relaxing . so , i think i'd like to continue that , at least for a couple more months and see how it goes .\n[doctor] okay . all right . that sounds good . all right . well , i know the nurse did a quick review of systems with you , when you-\n[patient] mm-hmm .\n[doctor] . checked in . do you have any symptoms , any chest pain or shortness of breath ?\n[patient] none whatsoever .\n[doctor] lightheadedness ? dizziness ?\n[patient] no .\n[doctor] no ? okay . um , and i just wan na go ahead and do a quick physical exam .\n[patient] mm-hmm .\n[doctor] hey , dragon . show me the vital signs .\n[doctor] so , looking here right now , your vital signs look great . you know , your pulse ox is great . your h- your blood pressure and heart rate are right where they should be .\n[patient] mm-hmm .\n[doctor] so , i'm gon na just check you out , and i'm gon na let you know what i find . okay ?\n[patient] sure .\n[doctor] okay . so , on your physical exam , everything looks really good . um , you do n't appear in any distress at this time . i do n't appreciate any carotid bruits . your heart , on your heart exam , i do hear that slight 2/6 systolic ejection murmur , but we heard that in the past .\n[patient] mm-hmm .\n[doctor] your lungs sound nice and clear , but i notice , you know , 1+ , uh , edema in your lower extremities . okay ?\n[patient] mm-hmm .\n[doctor] um , so , let's go ahead . i wan na look at some of your results . okay ?\n[patient] sure .\n[doctor] hey , dragon . show me the glucose .\n[doctor] so , right now , your blood sugar is about 162 . have you eaten before you came in here ?\n[patient] i did not .\n[doctor] okay . all right . um , hey , dragon . show me the diabetes labs .\n[doctor] okay . i'm looking at your diabetes labs . you know , your hemoglobin a1c is about 8 , and that's a , that's a little high .\n[patient] mm-hmm .\n[doctor] so , not only , you know , have your blood sugars , were they high that one day , they were , they've been a little elevated .\n[patient] mm-hmm .\n[doctor] so , we'll talk about , you know , how to go ahead and , and fix that . okay ?\n[doctor] so , let me talk a little bit about my assessment and my plan for you .\n[patient] mm-hmm .\n[doctor] so , for your first problem , this hyperglycemia , you know , i wan na go ahead and increase your lantus to 20 units at night . okay ? i want you to continue your monitor your blood sugar and let me know how they're running 'cause we might have to adjust that further .\n[patient] mm-hmm .\n[doctor] okay ? um , and i wan na order another hemoglobin a1c in a couple months . hey , dragon . order a hemoglobin a1c .\n[doctor] for your next problem , your depression , i think you're doing a great job with your current strategies with the meditation . we will hold off on medication or therapy at this time , and you know to call me if you need anything , right ?\n[patient] mm-hmm .\n[doctor] okay . and for your third problem , your kidney transplant , your kidney function looks stable . uh , i'm gon na just have you go back to dr. reyes , to manage all of your immunosuppression medications .\n[patient] okay .\n[doctor] um , and then , he knows to reach out to me if he needs anything . okay ?\n[patient] you got it .\n[doctor] all right . well , the nurse will be in soon to check you out . okay ?\n[patient] perfect .\n[doctor] hey , dragon . finalize the note .",
            "tgt": "CHIEF COMPLAINT\n\nER follow-up.\n\nHISTORY OF PRESENT ILLNESS\n\nAlbert Powell is a 62-year-old male with a past medical history significant for depression, type 2 diabetes, and kidney transplant. He is here today for an emergency room follow-up.\n\nThe patient states he was not staying on top of his blood sugar readings and felt \" woozy \" over the weekend. His wife was concerned that his levels were elevated and wanted to take him to the emergency room. He was not admitted to the hospital. He reports that his mother is in the hospital and he has been eating poorly. He was not monitoring his blood sugars and what he was eating. When they got home from the visit he felt a lot better. Since then, he has been following his diet pretty closely. He continues Lantus insulin at bedtime.\n\nRegarding his kidney transplant and has been doing pretty well. The patient has been pretty diligent about taking immunotherapy medication and following orders. The last time he saw Dr. Reyes was about 3 weeks ago and everything seemed to be fine.\n\nRegarding his depression, the patient states it has been about a year and a half, but he has been pretty good with that. He has his moments, but as long as he finds some time to relax in the afternoon and then it seems to work out. He thinks he would probably want to continue that at least for a couple more months and see how it goes. His wife got him into meditation recently and he finds that relaxing so he feels he would like to continue that for a couple more months and see how it goes.\n\nThe patient denies any chest pain, shortness of breath, lightheadedness or dizziness.\n\nREVIEW OF SYSTEMS\n\n\u2022 Cardiovascular: Denies chest pain or dyspnea.\n\u2022 Respiratory: Denies shortness of breath.\n\u2022 Neurological: Denies lightheadedness or dizziness.\n\u2022 Psychiatric: Endorses depression.\n\nPHYSICAL EXAMINATION\n\n\u2022 Constitutional: in no apparent distress.\n\u2022 Neck: No carotid bruits appreciable.\n\u2022 Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.\n\u2022 Cardiovascular: Grade 2/6 systolic ejection murmur.\n\u2022 Musculoskeletal: 1+ edema in the bilateral lower extremities.\n\nRESULTS\n\nFasting glucose is elevated at 162.\nHemoglobin A1c is elevated at 8.\n\nASSESSMENT AND PLAN\n\nAlbert Powell is a 62-year-old male with a past medical history significant for depression, type 2 diabetes, and kidney transplant. He is here today for an emergency room follow-up.\n\nHyperglycemia.\n\u2022 Medical Reasoning: He was recently seen in the emergency department with elevated blood glucose levels. He admits to dietary indiscretion prior to this, but has since improved his diet. His recent blood glucose level was 162, and his recent hemoglobin A1c was 8.\n\u2022 Additional Testing: Repeat hemoglobin A1c in a few months.\n\u2022 Medical Treatment: Increase Lantus to 20 units at night.\n\u2022 Patient Education and Counseling: I advised him to continue monitoring his blood glucose levels at home and report those to me, as we may need to make further adjustments to his medication.\n\nDepression.\n\u2022 Medical Reasoning: He reports personal stressors over the past year and a half but is doing well overall. He recently started meditating.\n\u2022 Medical Treatment: He should continue his current management strategies. We will hold off on medication and therapy at this time.\n\u2022 Patient Education and Counseling: The patient was encouraged to contact me if he needs anything.\n\nStatus post renal transplant.\n\u2022 Medical Reasoning: His kidney function appears stable and he has been compliant with his immunotherapy medications.\n\u2022 Medical Treatment: Continue seeing Dr. Reyes for management of his immunosuppression medication.\n\u2022 Patient Education and Counseling: He knows to reach out to me if he needs anything.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N090-virtassist"
        },
        {
            "src": "[doctor] hi jerry , how are you doing ?\n[patient] hi , good to see you .\n[doctor] good to see you as well . um , so i know that the nurse told you about dax . i'd like to tell dax about you .\n[patient] sure .\n[doctor] jerry is a 54 year old male with a past medical history , significant for osteoporosis and multiple sclerosis who presents for an annual exam . so jerry , what's been going on since the last time i saw you ?\n[patient] uh , we have been traveling all over the country . it's been kind of a stressful summer . kinda adjusting to everything in the fall and so far it's been good , but ah , lack of sleep , it's been really getting to me .\n[doctor] okay . all right . and have you taken anything for the insomnia . have you tried any strategies for it .\n[patient] i've tried everything from melatonin to meditation to , uh , t- stretching out every morning when i get up . nothing really seems to help though .\n[doctor] okay . all right .\n[doctor] in terms of your osteoporosis , i know we have you on fosamax , any issues with your joints , any issues like-\n[patient] no .\n[doctor] no broken bones recently ?\n[patient] no .\n[doctor] no , nothing like that ?\n[patient] no .\n[doctor] okay . and then in terms of your multiple sclerosis , when was the last time you saw the neurologist ?\n[patient] uh , about six months ago .\n[doctor] okay and you're taking the medication ?\n[patient] yes .\n[doctor] okay . and any issues with that ?\n[patient] none whatsoever .\n[doctor] and any additional weakness ? i know you were having some issues with your right leg , but that seems to have improved or ?\n[patient] yes a lingering issue with my knee surgery . but other than that it's been fine .\n[doctor] okay .\n[patient] pretty , pretty strong , n- nothing , nothing out of the ordinary .\n[doctor] okay . all right , well i know you did a review of systems sheet when you checked in .\n[patient] mm-hmm .\n[doctor] and you were endorsing that insomnia . any other issues , chest pain , shortness of breath , anything ?\n[patient] no .\n[doctor] all right . well lets go ahead and do a quick physical exam .\n[patient] mm-hmm .\n[doctor] hey dragon , show me the vital signs . so your vital signs here in the office they look really good . i'm just going to listen to your heart and lungs and let you know what i find .\n[patient] sure .\n[doctor] okay . on physical examination everything looks good . you know your lungs are nice and clear . your heart sounds good . you know you do have some weakness of your lower extremities . the right is about 4 out of 5 , the left is about 3 out of 5 . but you reflexes are really good so i'm , i'm encouraged by that . and you do have some , you know , arthritic changes of the right knee .\n[patient] mm-hmm .\n[doctor] um , so let's go over some of your results , okay ?\n[patient] sure .\n[doctor] 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 . do you need a refill on that ?\n[patient] actually i do .\n[doctor] 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 ?\n[patient] you got it .\n[doctor] any questions ?\n[patient] not at this point , no .\n[doctor] okay , great . hey dragon , finalize the note .",
            "tgt": "CHIEF COMPLAINT\n\nAnnual exam.\n\nHISTORY OF PRESENT ILLNESS\n\nJerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam.\n\nThe patient states he has been traveling all over the country. He notes it has been a stressful summer and adjusting to everything in the fall.\n\nThe patient reports a lack of sleep. He has tried melatonin, meditation, and stretching every morning, but nothing has helped.\n\nFor treatment of his osteoporosis, he is on Fosamax. He denies any issues with his joints. He denies any recent broken bones.\n\nRegarding his multiple sclerosis, he last saw the neurologist 6 months ago. He is taking his medication and denies any issues with this. Previously, he experienced right leg weakness, however, this has resolved.\n\nHe does have some lingering issues with his right knee after previous surgery, but nothing out of the ordinary.\n\nThe patient denies any chest pain or shortness of breath.\n\nREVIEW OF SYSTEMS\n\n\u2022 Cardiovascular: Denies chest pain or dyspnea.\n\u2022 Respiratory: Denies shortness of breath.\n\u2022 Musculoskeletal: Endorses right knee discomfort.\n\u2022 Neurological: Endorses insomnia.\n\nPHYSICAL EXAMINATION\n\n\u2022 Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.\n\u2022 Musculoskeletal: Weakness in the lower extremities, 4/5 on the right and 3/5 on the left. Reflexes are good. Arthritic changes in the right knee.\n\nRESULTS\n\nX-ray of the right knee demonstrates some arthritic changes.\n\nASSESSMENT\n\nJerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam.\n\nPLAN\n\nOsteoporosis.\n\u2022 Medical Reasoning: The patient is doing well with Fosamax.\n\u2022 Medical Treatment: Continue Fosamax 1 tab per week. Eleven refills were ordered today.\n\nMultiple Sclerosis.\n\u2022 Medical Reasoning: The patient is experiencing weakness of the bilateral lower extremities. He has been seeing his neurologist on a consistent basis and has been compliant with medication.\n\u2022 Medical Treatment: He will continue to follow up with his neurologist and comply with his medication regimen.\n\nRight knee arthritis.\n\u2022 Medical Reasoning: The patient recently underwent knee surgery. A recent right knee x-ray demonstrated some arthritic changes.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N091-virtassist"
        },
        {
            "src": "[doctor] hello , mrs . martinez . good to see you today .\n[patient] hey , dr . gomez .\n[doctor] hey , dragon , i'm here seeing mrs . martinez . she's a 43-year-old female . why are we seeing you today ?\n[patient] um , my arm hurts right here . kind of toward my wrist . this part of my arm .\n[doctor] so you have pain in your distal radius ?\n[patient] yes .\n[doctor] how did that happen ?\n[patient] um , i was playing tennis , and when i went to hit , um , i was given a , a backhand , and when i did , i m- totally missed the ball , hit the top of the net but the pole part . and , and it just jarred my arm .\n[doctor] okay . and did it swell up at all ? or-\n[patient] it did . it got a ... it had a little bit of swelling . not a lot .\n[doctor] okay . and , um , did , uh , do you have any numbness in your hand at all ? or any pain when you move your wrist ?\n[patient] a little bit when i move my wrist . um , no numbness in my hand .\n[doctor] okay . do you have any past medical history of anything ?\n[patient] um , yes . allergic , um , l- i have allergies . and so i take flonase .\n[doctor] okay . and any surgeries in the past ?\n[patient] yes . i actually had a trauma of , um , a stabbing of , um ... i actually fell doing lawn work-\n[doctor] okay .\n[patient] on my rake .\n[doctor] okay .\n[patient] yeah .\n[doctor] i was wondering where you were going to go with that .\n[patient] yeah .\n[doctor] okay . great . so , let's take a look at , uh , the x-ray of your arm . hey dragon , let's see the x-ray . okay , looking at your x-ray , i do n't see any fractures , uh , do n't really see any abnormalities at all . it looks essentially normal . great . let me examine you .\n[patient] okay .\n[doctor] does it hurt when i press on your arm here ?\n[patient] yes .\n[doctor] okay . how about when i bend your arm ?\n[patient] yes .\n[doctor] okay . that's pretty tender , ?\n[patient] mm-hmm .\n[doctor] how about when i go backwards like that ?\n[patient] not as much .\n[doctor] and how about when i flex like this ?\n[patient] a little .\n[doctor] but mostly when i do that type of motion ?\n[patient] yes .\n[doctor] okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again .\n[patient] okay .\n[doctor] okay , great . hey dragon , go ahead and order the procedures , and the medications as discussed . why do n't you come with me . dragon you can finalize the note .\n[patient] thank you .",
            "tgt": "CC:\n\nRight arm pain.\n\nHPI:\n\nMs. Martinez is a 43-year-old female who presents today for an evaluation of right arm pain after she hitting her arm on a pole while playing tennis. She had mild swelling at the time. There is pain with motion. She denies any numbness or tingling in her hand. She has a past medical history of allergies and takes Flonase.\n\nEXAM\n\nExamination of the left wrist shows tenderness over the distal radius and pain with flexion of the wrist and thumb.\n\nRESULTS\n\nX-rays of the left wrist show no obvious signs of acute fracture or other abnormality.\n\nIMPRESSION\n\nRight wrist sprain.\n\nPLAN\n\nAt this point, I discussed the diagnosis and treatment options with the patient. I have recommended ice and anti-inflammatory medications. I am prescribing Motrin, 800 mg to take 3 times a day with food. She will follow up with me in 1 week or as needed.\n",
            "file": "D2N092-virtassist"
        },
        {
            "src": "[doctor] hey lawrence . how are you ?\n[patient] hey , good to see you .\n[doctor] it's good to see you too . so , i know the nurse told you about dax .\n[patient] mm-hmm .\n[doctor] i'd like to tell dax a little bit about you .\n[patient] sure .\n[doctor] so , lawrence is a 62-year-old male , with a past medical history significant for type i diabetes , congestive heart failure , depression , and reflux , who presents with complaints of shortness of breath . so lawrence , what's been going on ? wh- what's wrong with your breathing ?\n[patient] uh , i , i've noticed that i've been swelling up a little bit . i think a lot of it has to do with going to some house parties , eating some salty foods . i feel really lethargic .\n[doctor] okay . all right . and when you get short of breath , are you short of breath when you're just sitting here ? do you feel short of breath when you're walking ?\n[patient] it's something like walking up a flight of stairs i'll actually feel it .\n[doctor] okay . all right . now , um , how long has this been going on for ?\n[patient] probably about 10 days .\n[doctor] okay . all right . and you said you're noticed some swelling in your legs ?\n[patient] a little bit .\n[doctor] okay . do you have problems lying flat in bed ?\n[patient] um , i'm a little uncomfortable when i wake up in the morning and i feel pretty stiff . and , and , like , it takes me a little while to adjust to walking when i get up .\n[doctor] okay . all right . do you ever wake up acutely short of breath at night ?\n[patient] um , it happened once , probably about a week ago , but it has n't happened since . so i have n't been that concerned about it .\n[doctor] okay . all right . in terms of your , your diabetes , how are you doing with that ? i know you're on the insulin pump .\n[patient] mm-hmm .\n[doctor] um , are your blood sugars okay ? have you noticed a spike in them recently ?\n[patient] um , i have n't . i've been pretty good about monitoring it so i ... during the working week , i stay on top of that . but on saturdays or sundays we're so busy i forget to monitor it . but i have n't seen anything spike .\n[doctor] okay . and i remember your affinity for chocolate bars , so ...\n[patient] guilty as charged . i love chocolate bars .\n[doctor] okay . all right . so , in terms of your depression , how are you doing with that ?\n[patient] uh , it's been a crazy year and a half . um , i've tried some natural solutions . in the summer i did stretches outdoors every morning , which was great , but now the weather changed and , uh , you know , i've got ta find some alternatives . i'm not ready to try any medications just yet , so-\n[doctor] okay .\n[patient] . i'm open to some suggestions .\n[doctor] okay . we'll talk about that .\n[patient] sure .\n[doctor] and then in terms of your reflux , how are you doing ? i know we had you on the omeprazole .\n[patient] mm-hmm .\n[doctor] you were making some lifestyle modifications , cutting back on your red bull and caffeine .\n[patient] yeah .\n[doctor] alcohol intake has been ... how's that been ?\n[patient] tough during the holiday season , but i'm , i'm better .\n[doctor] okay . all right . and no issues with your depression ? you do n't want to hurt yourself or anyone else ?\n[patient] no . no . absolutely not .\n[doctor] okay , all right . well , let's go ahead . i know you did a review of system sheet when you checked in and you endorsed the shortness of breath .\n[patient] mm-hmm .\n[doctor] any other symptoms ? chest pain , fever , chills , cough ?\n[patient] no .\n[doctor] um , belly pain ?\n[patient] no .\n[doctor] okay . let's go ahead . i want to move on to a physical exam .\n[patient] mm-hmm .\n[doctor] hey , dragon ? show me the vital signs . so here in the office , you know , your vital signs look good . your , your pulse ox ... that's your oxygenation level ... looks good . so i'm encouraged by that with you just sitting here , okay ? i'm gon na go ahead and do another , uh , just check you over . i'll let you know what i find .\n[patient] mm-hmm .\n[doctor] okay . all right . so , on your exam things look okay . so , i do n't appreciate any jugular venous distension or any carotid bruits on your neck exam . on your heart exam , i do appreciate a slight 3 out of 6 systolic ejection murmur . on your lung exam , i do appreciate some crackles , bilaterally , at the bases . and on your lower extremity exam i do appreciate 1+ pitting edema . so what does all that mean ? so , i do think that you're retaining some fluid . it's probably from some of the dietary indiscretion .\n[patient] mm-hmm .\n[doctor] but i wan na go ahead and look at some of the results , okay ? i had the nurse do a chest x-ray on you before we came in , okay ? hey , dragon ? show me the test x-ray . so i reviewed the results of your chest x-ray and it looks good . there's no e- evidence of any airspace disease , but that does n't mean that you still ca n't be retaining some fluid , okay ?\n[patient] okay .\n[doctor] hey , dragon ? show me the labs . and your labs look okay . you know , you do n't have an elevated white blood cell count so i'm not really concerned about infection . we saw the chest x-ray , there's no pneumonia , so that's good .\n[patient] mm-hmm .\n[doctor] 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 day .\n[patient] mm-hmm .\n[doctor] if your weight is n't going down , uh , or if it's going up i want you to call me . certainly , if you get more short of breath at rest i want you to go ahead and call me or call 911-\n[patient] mm-hmm .\n[doctor] . and go into the emergency room . you might need some intravenous diuretics .\n[patient] mm-hmm .\n[doctor] okay ? for your second problem of your type i diabetes , um , let's go ahead ... i wan na order a hemoglobin a1c for , um , uh , just in a , like a month or so , just to see if we have to make any adjustments . and i want you to follow up with your endocrinologist . okay ? and i also want to make sure that you have a recent eye exam . all right ? uh , for your third problem of your depression , let's go ahead and refer you to psychiatry , just for some , um , like , talk therapy to help you through that . okay ?\n[patient] sure .\n[doctor] no medications . and for your fourth problem of your reflux , let's go ahead and continue you on the omeprazole , 20 milligrams a day . do you have any questions , lawrence ?\n[patient] not at this point .\n[doctor] okay . um , uh , again , i want you to call me if you have any problems with your breathing , okay ?\n[patient] you got it .\n[doctor] hey , dragon ? finalize the notes ...",
            "tgt": "CHIEF COMPLAINT\n\nShortness of breath.\n\nHISTORY OF PRESENT ILLNESS\n\nLawrence Walker is a 62-year-old male with a past medical history significant for type 1 diabetes, congestive heart failure, depression, and reflux, who presents with complaints of shortness of breath.\n\nThe patient states he has had some shortness of breath and mild leg swelling which he thinks has to do with eating some salty foods at some house parties recently. His shortness of breath is primarily with exertion such as walking up the stairs. This has been going on for about 10 days now. He woke from sleep once with shortness of breath about a week ago. He also notes discomfort lying flat in bed and musculoskeletal stiffness in the morning. He states that it takes him a little while to get up.\n\nRegarding his type 1 diabetes, he is using his insulin pump. He has been consistently monitoring his blood sugars during the working week, but notes that he checks less on the weekends, due to being busy. He is trying to avoid sugar but admits to an affinity for chocolate bars.\n\nRegarding his depression, he states that it has been a crazy year and a half. He has tried some natural solutions. In the summer, he did daily outdoor stretching, which was great; but now that the weather has changed, he needs to find some alternatives. He is not ready to try any medications. He denies suicidal and homicidal ideation.\n\nRegarding his GERD, he is taking his omeprazole. He has made some lifestyle modifications like cutting back on his red bull intake and other caffeine. Reducing his alcohol intake has been tough during the holiday season, but he is getting better about this.\n\nThe patient denies chest pain, fever, chills, cough, and abdominal pain.\n\nREVIEW OF SYSTEMS\n\n\u2022 Constitutional: Denies fevers, chills.\u00a0 Endorses fatigue.\n\u2022 Cardiovascular: Denies chest pain. Endorses dyspnea on exertion.\n\u2022 Respiratory: Denies coughor wheezing. Endorses shortness of breath..\n\u2022 Musculoskeletal: Endorses lower extremity edema.\n\u2022 Psychiatric: Endorses depression.\n\nPHYSICAL EXAMINATION\n\n\u2022 Neck: No carotid bruits appreciable. No jugular venous distention.\n\u2022 Respiratory: Rales are heard bilaterally at lung bases.\n\u2022 Cardiovascular: 3/6 systolic ejection murmur.\n\u2022 Musculoskeletal: 1+ pitting bilateral lower extremity edema.\n\nRESULTS\n\nChest x-ray did not show any evidence of airspace disease.\n\nLabs were all within normal limits, including the WBC.\n\nASSESSMENT\n\nLawrence Walker is a 62-year-old male with a past medical history significant for type 1 diabetes, congestive heart failure, depression, and reflux, who presents with complaints of shortness of breath.\n\nPLAN\n\nAcute heart failure exacerbation.\n\u2022 Medical Reasoning: The patient is retaining fluid. He has noticed increased fluid retention following dietary indiscretion. He has experienced dyspnea on exertion for the past 10 days.\n\u2022 Medical Treatment: Initiate Lasix 40 mg a day.\n\u2022 Patient Education and Counseling: I advised the patient to monitor and log his daily weights. He will contact me if these continue to increase. He was instructed to call me or 911 if he experiences dyspnea at rest.\n\nType 1 diabetes.\n\u2022 Medical Treatment: This is currently stable with use of an insulin pump.\n\u2022 Additional Testing: I will order a hemoglobin A1c in 1 month.\n\u2022 Medical Treatment: He will continue the insulin pump. The patient will follow up with his endocrinologist.\n\u2022 Patient Education and Counseling: I encouraged the patient to have an eye exam.\n\nDepression.\n\u2022 Medical Reasoning: The patient has been doing well with outdoor stretching. He continues to decline the use of medications for this issue.\n\u2022 Medical Treatment: I will refer him to psychiatry as his current management strategy is unsustainable due to the change in season.\n\u2022 Patient Education and Counseling: We will defer initiating medication at this time.\n\nAcid reflux.\n\u2022 Medical Reasoning: His symptoms are stable with medication.\n\u2022 Medical Treatment: Continue omeprazole 20 mg a day.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan. his endo",
            "file": "D2N093-virtassist"
        },
        {
            "src": "[doctor] hey , ms. james . nice to meet you .\n[patient] nice to meet you , dr. cooper . how are you ?\n[doctor] i'm well . hey , dragon , i'm seeing ms. james . she's a 42-year-old female , and what brings you in today ?\n[patient] i hurt my , uh , finger when i was skiing this past weekend .\n[doctor] really ?\n[patient] yeah . yeah , so , um , i was going down hill , double diamonds , uh , double black diamonds , and i just lost control , and i , you know , flipped down a few ways , but , uh , somewhere along the way , i , i jammed my , my index finger on something . i'm not sure what .\n[doctor] okay . so this happened last saturday , you said ?\n[patient] it was saturday , yes .\n[doctor] okay . so about five days of this right index finger pain .\n[patient] mm-hmm .\n[doctor] have you taken any medicine for it ?\n[patient] i took some ibuprofen . um , did n't really seem to help .\n[doctor] okay . have you iced it or put a splint on it ?\n[patient] no .\n[doctor] okay . and what would you rate your pain ?\n[patient] it's about a seven .\n[doctor] a seven out of 10 pain . um , and no other injuries while you went down this double black diamond ?\n[patient] no , interestingly enough , this is the only one .\n[doctor] okay . well , i guess you escaped ... i mean ...\n[patient] could have been much worse .\n[doctor] could have been much worse , yes . so , um , do you have any medical problems ?\n[patient] um ... yeah , i'm ... i have chronic constipation .\n[doctor] do you take any medicine for it ?\n[patient] miralax .\n[doctor] and does that help ?\n[patient] seems to flow nicely .\n[doctor] good for you .\n[doctor] um ... have you ever had any surgeries before ?\n[patient] yes , i had my appendix out when i was seven .\n[doctor] okay . um , let's look at your x-ray together . hey , dragon , show me the last x-ray . all right . so looking at your right hand here , and that index finger looks great . so all the joints , bones are in the right places , no fractures , so you've got a normal right hand x-ray . um , let's go ahead and check your finger out . now does it hurt when i push on your finger like this ?\n[patient] yes .\n[doctor] does it hurt when i pull your finger like this ?\n[patient] yes .\n[doctor] does it hurt when i squeeze over this joint here ?\n[patient] yes . please do n't do that .\n[doctor] does it hurt when i squeeze over this ?\n[patient] yes .\n[doctor] 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 antiinflammatory called mobic . you'll take 15 milligrams once a day . i'll prescribe 14 of those for you . and i want you to come back and see me in two weeks , and let's make sure it's all healed up and if we need to start any hand therapy at that point , then we can . do you have any questions for me ?\n[patient] no questions . thank you .\n[doctor] you're welcome . hey , dragon , order the medications and procedures mentioned . and why do n't you come with me , and we'll get you checked out ?\n[patient] okay .\n[doctor] hey , dragon , finalize the report .",
            "tgt": "CC:\n\nRight index finger pain.\n\nHPI:\n\nMs. James is a 42-year-old female who presents today for an evaluation of right index finger pain. She states she injured it while skiing. She states she fell and jammed her finger. She took Ibuprofen on but it did not help her. She denies any icing it or wearing a splint. She rates her pain 7/10.\n\nCURRENT MEDICATIONS:\n\nMiraLAX\n\nPAST MEDICAL HISTORY:\n\nChronic constipation\n\nPAST SURGICAL HISTORY:\n\nAppendectomy at age 7.\n\nEXAM\n\nExamination of the right hand reveals pain to palpation of the MCP and DIP joints.\n\nRESULTS\n\nX-rays of the right index finger show no obvious signs of fracture.\n\nIMPRESSION\n\nRight index finger DIP joint sprain.\n\nPLAN\n\nAt this point, I discussed the diagnosis and treatment options with the patient. I have recommended a splint. A prescription is provided for Mobic 15 mg once a day, dispense 14. She will follow up with me in 2 weeks for a repeat evaluation. If she is unimproved, we will consider hand therapy at that time. All questions were answered.\n",
            "file": "D2N094-virtassist"
        },
        {
            "src": "[doctor] hi , cheryl . how are you ?\n[patient] i'm doing well . how are you ?\n[doctor] i'm doing well . so i know the nurse told you a little bit about dax . i'd like to tell dax about you .\n[patient] okay .\n[doctor] cheryl is a 34-year-old female with a past medical history significant for hypertension , who presents today with back pain . cheryl , what happened to your back ?\n[patient] so i've been walking a lot lately . i've been walking to ... 30 minutes to an hour or so a day . and all of a sudden , um , when i was walking , my , um , back just kind of seized up on me . and i do n't really know what it was . maybe i was going a little bit faster . but it just all kind of clenched .\n[doctor] okay . so you felt like , maybe like a spasm or something like that ?\n[patient] yeah .\n[doctor] okay . and how many days ago was that ?\n[patient] that was about six days ago now .\n[doctor] okay . and what have you taken for the pain ?\n[patient] i've been taking ibuprofen . um , and then i've been putting some heat on it . but it's still pretty stiff .\n[doctor] okay . all right . um , and did you have any trauma before that happened ? were you doing anything strenuous like crossfit or lifting boxes or anything like that before you went for , for the walk ?\n[patient] i have been lifting more , um , probably around three times a week . so i do n't know if it was because i was doing deadlifts that day and then walked .\n[doctor] okay .\n[patient] um , maybe i was using my back more than my legs .\n[doctor] okay . all right . and was it any particular area in your back ? was it the lower back ?\n[patient] yeah , it was .\n[doctor] okay . on one side versus the other ?\n[patient] um , kind of both equally .\n[doctor] okay . all right . and any numbing or tingling in your legs or your feet ?\n[patient] no , i have n't felt anything like that .\n[doctor] okay . any weakness in your lower extremities ?\n[patient] no .\n[doctor] okay . all right .\nand then in terms of your blood pressure , how are you doing ?\n[patient] so i got that cuff that you suggested the ... our ... the last visit , and i've been doing readings at home . and that's been looking great , too . i've been watching my diet . again , my boyfriend's been great and dieting with me so i do n't have to do it alone . and everything's been good .\n[doctor] okay . excellent . and you're taking the lisinopril ?\n[patient] yes .\n[doctor] okay . wonderful . okay . so i know you did a review of systems sheet with the nurse , and i know you endorse , you know , this back pain . um , do you have any other symptoms ? fever , chills , congestion , cough , chest pain , shortness of breath ?\n[patient] i have a little bit of nasal congestion , but that's just from my seasonal allergies .\n[doctor] okay . all right . well , let's go ahead . i want to do a quick physical exam on you .\n[patient] okay .\n[doctor] okay ? hey , dragon , show me the vital signs . so good- you know , here in the office , your vital signs look great . your blood pressure's really well controlled , which is good . so that's a good job . so i'm going to take a listen to your heart and lungs . i'm going to examine your back , and i'm going to let you know what i find . okay ?\n[patient] okay .\n[doctor] okay . all right . so on physical examination , you know , everything looks good . you know , on your heart exam , i do hear that slight two out of six systolic ejection murmur , but you've had that before . that seems stable to me . on your back exam , you do have some pain to palpation on the right lateral aspect of your lumbar spine , and you do have pain with flexion and extension as well , and you have a negative straight leg raise . so what does that mean ? so we're going to go over that . okay ? let's ... let me look at some of your results , though , first . okay ?\n[patient] okay .\n[doctor] we did an x-ray before you saw me , so let's look at that . hey , dragon , show me the back x-ray . so looking here at this x-ray of the lumbar spine , everything looks good . there's good boney alignment . there's no obvious fracture , you know , which is not surprising based on your history . okay ?\n[patient] hmm .\n[doctor] 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 back pain , i think you have a lumbar strain , and , you know , that might've happened , you know , lifting something or exercising . and so what i want to do is prescribe meloxicam , 15 milligrams once a day . uh , i want you ... you can ice the area , and you can also apply heat sometimes as well . um , you know , i'm going to refer you to physical therapy just to do some strengthening exercises of your back , um , because i do want you to continue to be able to work out and exercise . okay ?\n[patient] okay .\n[doctor] and for your last problem , your high blood pressure , again , everything looks great here . um , you know , i think you're doing a really good job with that as well . i want you to continue on the lisinopril , 10 milligrams a day . and then , uh , let me know if you notice any increases in your blood pressure readings . okay ?\n[patient] okay .\n[doctor] do you need a refill of the lisinopril ?\n[patient] yes , i do , actually .\n[doctor] okay . hey , dragon ? order lisinopril 10 milligrams po daily . okay . uh , so the nurse will be in soon , and she'll get you checked out . okay ?\n[patient] okay .\n[doctor] all right . hey , dragon ? finalize the note .",
            "tgt": "CHIEF COMPLAINT\n\nBack pain.\n\nHISTORY OF PRESENT ILLNESS\n\nMs. Ramirez is a 34-year-old female with a past medical history significant for hypertension, who presents today with back pain.\n\nThe patient reports she has been walking a lot lately, 30 minutes to an hour or so a day. While walking 6 days ago, she felt her back seize up on her. She is not sure what caused it but thinks she was walking a little faster than usual. She describes the sensation as a spasm. She has been taking ibuprofen and using heat on it but it is still pretty stiff. She denies any known trauma or injury to her back. She notes she has been weightlifting around 3 times a week. She did do deadlifts that day before her walk and thinks she may have been using her back more than her legs to lift. She locates the pain in her mid lower back. She denies any lower extremity numbness, tingling, and weakness.\n\nRegarding her hypertension, she states she has been doing readings at home and that has been looking great. She has been watching her diet which has helped. She is taking lisinopril.\n\nThe patient endorses nasal congestion, which she attributes to her seasonal allergies.\n\nREVIEW OF SYSTEMS\n\n\u2022 Ears, Nose, Mouth and Throat: Endorses nasal congestion from seasonal allergies.\n\u2022 Musculoskeletal: Endorses bilateral low back pain and stiffness.\n\u2022 Neurological: Denies numbness.\n\nPHYSICAL EXAMINATION\n\n\u2022 Cardiovascular: Slight 2/6 systolic ejection murmur, stable.\n\u2022 Musculoskeletal: Pain to palpation along the right lateral aspect of her lumbar spine. Pain with flexion and extension. Negative straight leg raise.\n\nRESULTS\n\nBack x-ray reveals good bony alignment with no obvious fracture.\n\nLabs: All within normal limits.\n\nASSESSMENT AND PLAN\n\nMs. Ramirez is a 34-year-old female with a past medical history significant for hypertension, who presents today with back pain.\n\nBack pain.\n\u2022 Medical Reasoning: She experienced a spasm-like pain in her back while walking approximately 6 days ago. She has also been lifting weights recently. Her lumbar spine x-ray was unremarkable and her recent labs were normal. I believe she has a lumbar strain.\n\u2022 Medical Treatment: We will initiate meloxicam 15 mg once daily.\n\u2022 Specialist Referrals: We will refer her to physical therapy to work on strengthening exercises.\n\u2022 Patient Education and Counseling: She may apply ice and heat to the area.\n\nHypertension.\n\u2022 Medical Reasoning: This is well controlled with lisinopril and dietary modifications based on home monitoring.\n\u2022 Medical Treatment: She will continue lisinopril 10 mg daily. This was refilled today.\n\u2022 Patient Education and Counseling: I encouraged her to continue with home monitoring and report any elevated blood pressures to me.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N095-virtassist"
        },
        {
            "src": "[doctor] um , hi mrs. anderson . right ?\n[patient] yeah . yes , doctor .\n[doctor] what brings you here today ?\n[patient] hi , doctor . um , i'm having this left shoulder pain lately , uh , and it's paining a lot .\n[doctor] okay . all right . hey , dragon . i am seeing mrs. anderson , a 44-years-old female , uh , complaining to check the left shoulder pain . um , so how long how has this lasted ?\n[patient] it's been a week , doctor . yeah .\n[doctor] a week .\n[patient] yeah .\n[doctor] um , did you take any medication yourself ?\n[patient] no , i did not take any pain medications . actually , i did . i did take a tylenol for two or three days , but then that did n't help at all . so , uh , the reason why it started or when it started to happen is-\n[doctor] yeah .\n[patient] . i was actually in gymnastics class .\n[doctor] yeah , okay .\n[patient] and , uh , i do n't know . maybe i must have toppled over into some weird position , so it started to pain since then , uh , because of a certain move .\n[doctor] okay , uh-\n[patient] i went overboard , i think . yeah .\n[doctor] all right , lem me , uh , take a quick look . uh , can you move up a little bit ? yeah .\n[patient] uh , yeah . in fact , that's hurts .\n[doctor] does that- does it hurt ?\n[patient] yeah , it does .\n[doctor] what if you move back a little bit ?\n[patient] uh , that also hurts , doctor .\n[doctor] yeah , okay .\n[patient] any kind of movement on my left shoulder actually hurts .\n[doctor] okay . all right , um , so let's ... hey , dragon . show me the last x-ray . all right , from the x-ray , it does n't look like there is any , uh , broken bone or fracture . my guess is you probably , um , hurt your joint , uh-\n[patient] uh- .\n[doctor] . a little bit .\n[patient] mm-hmm .\n[doctor] so i would , uh , suggest you continue using the pain reliever , maybe just like 600 milligram of ibuprofen three times a day and use it for a week .\n[patient] and for how long ? yes .\n[doctor] for a week .\n[patient] a week , okay .\n[doctor] and then if you ... if it's still painful , you can use , uh , ice or , um , heat pad-\n[patient] okay .\n[doctor] . 'cause that might help relieve your pain .\n[patient] okay .\n[doctor] um ...\n[patient] but i wanted you to know that i did have past surgery on my , um , left arm-\n[doctor] mm-hmm .\n[patient] . so , um , i hope that should n't matter , right ?\n[doctor] um , that does n't seem related to your pain .\n[patient] okay .\n[doctor] so ... but i would try to rest my , your left arm-\n[patient] okay .\n[doctor] . while it's healing .\n[patient] okay .\n[doctor] so , um-\n[patient] can i , uh , carry any heavy weights or-\n[doctor] no , no . definitely not .\n[patient] . anything like that ?\n[doctor] definitely not .\n[patient] okay . okay .\n[doctor] yeah , use , um , right hand-\n[patient] okay .\n[doctor] . instead-\n[patient] mm-hmm .\n[doctor] . for the next , uh , at least just three to four weeks .\n[patient] mm-hmm .\n[doctor] uh , come back to see me if the pain , you know , still there after maybe three weeks-\n[patient] sure .\n[doctor] . so we can take a further look .\n[patient] okay . sure .\n[doctor] but you should be fine-\n[patient] yeah .\n[doctor] . after just resting and regular pain reliever .\n[patient] okay . all right .\n[doctor] um-\n[patient] should we take another x-ray when i come back , if the pain does n't improve ?\n[doctor] um , maybe . let's see how you're doing in the next three weeks .\n[patient] uh .\n[doctor] hey , dragon . um , order medications and procedures as discussed . all right .\n[patient] okay .\n[doctor] um , i think that's good for today . hope you feel better soon .\n[patient] okay . thank you , doctor .\n[doctor] yeah .\n[patient] hopefully , the pain reliever , uh , ibuprofen actually helps .\n[doctor] yeah .\n[patient] yeah , and if i have more pain , can i call you ? can i fix up another appointment earlier than three weeks ?\n[doctor] um , you can also try advil .\n[patient] okay .\n[doctor] yeah , so , um ...\n[patient] yeah .\n[doctor] ale- , aleve . i mean , aleve .\n[patient] i see . okay , thank you , doctor .\n[doctor] thank you .",
            "tgt": "CC:\n\nLeft shoulder pain.\n\nHPI:\n\nMs. Anderson is a 44-year-old female who presents today for an evaluation of the left shoulder. She states that she was in gymnastics 1 week ago. The pain has been present since that time. She has pain with any type of movement of her left shoulder. She had taken Tylenol for 2 to 3 days with no improvement in her symptoms.\n\nShe has a surgical history significant for prior left upper extremity surgery.\n\nEXAM\n\nExamination of the left shoulder shows pain with range of motion.\n\nRESULTS\n\nX-rays of the left shoulder, 3 views obtained on today's visit show no obvious signs of fracture.\n\nPLAN\n\nAt this point, I discussed the diagnosis and treatment options with the patient. I have recommended taking ibuprofen 600 mg three times per day for one week. If the patient does not have relief from the ibuprofen she will take Aleve. The patient may also utilize ice or heat packs. She should rest her left arm and may not lift or carry heavy objects with her left arm. The patient should follow up in three to four weeks if the pain persists. We may repeat the left shoulder x-ray at that time.\n",
            "file": "D2N096-virtassist"
        },
        {
            "src": "[doctor] elizabeth , how are you ?\n[patient] i'm doing okay . how are you ?\n[doctor] doing okay . so i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ?\n[patient] okay .\n[doctor] all right . elizabeth is a 66-year-old female with a past medical history of significant for depression and hypertension who presents for her annual exam . so elizabeth , it's been a year since i've seen you .\n[patient] mm-hmm .\n[doctor] how are you doing ?\n[patient] i'm doing well . there's been so many events now that we've been able to get vaccinated , i've been able to see my grandkids again , go to more birthday parties , it's been fantastic .\n[doctor] yeah , i know . i've ... i mean , we've had some communication over telehealth and that type of thing , but it's not the same as being in-person , so i'm happy to see you today . now tell me a little bit about , you know , we have n't really got a chance to talk about your depression . how are you ... how are you doing with that ? i know we have n't had you on medication in the past because you're on medication for other things . what are your strategies with dealing with it ?\n[patient] so i've been going to therapy once a week for the past year . um , mostly virtually , um , but starting to get in-person . virtual was a bit of a struggle , but i feel like being in-person with someone really helps me .\n[doctor] okay . and do y- do you have a good support system at home ?\n[patient] yes , i do . i have my husband and , uh , my kids are right down the street from me , so i'm very lucky .\n[doctor] okay . all right . so that's good to hear .\n[doctor] how about your blood pressure ? did you buy the blood pressure cuff that i-\n[patient] yes .\n[doctor] . told you to ? okay . i know that we've been in communication and your blood pressures have been running okay . the last time i spoke with you , how are they doing since we last spoke ?\n[patient] they've been doing well . i've been using the cuff , um , once a day , and they seem pretty normal .\n[doctor] okay . and are you taking the lisinopril that i prescribed ?\n[patient] yes .\n[doctor] okay . great . all right . so i know that you did a review of systems sheet with the nurse when you checked in . you know , i know that you were talking about some nasal congestion . do you have any other symptoms , chest pain , shortness of breath , abdominal pain , nausea or vomiting , anything like that ?\n[patient] no .\n[doctor] no ? okay . all right . well , i wan na go ahead and do a quick physical exam , okay ?\n[patient] okay .\n[doctor] hey , dragon , show me the vital signs . so here in the office , you know , your blood pressure looks really good , as does your heart rate . so you are doing a good job managing your blood pressure . so i'm gon na take a listen to your heart and lungs , okay ?\n[patient] okay .\n[doctor] okay . so on physical examination , i do n't appreciate any carotid bruits in your neck . on your heart exam i do notice a slight 2/6 systolic ejection murmur , which we've heard in the past , so i think that's stable . your lungs in- are nice and clear , and you have some trace lower extremity edema bilaterally , so all that means is , you know , i agree , you know , maybe we should watch your diet a little bit better , okay ? but i wan na take a look at some of your results , okay ?\n[patient] okay .\n[doctor] all right . hey , dragon , show me the ekg . and the nurses did an ekg before you came in , and that looks perfectly fine , okay ? so i wan na just go ahead and talk a little about your assessment and my plan for you . so for your first problem , your depression , i think you're doing a really good job with your strategies . i do n't think ... it does n't sound to me like i need to start you on any medication at this time , unless you feel differently .\n[patient] no , i'm , i'm , good in that department .\n[doctor] for your second problem , your high blood pressure , i agree , everything looks fine here now . i wan na just continue on the lisinopril , 20 milligrams a day . and i want you to continue to watch your blood pressures as well , and if they start rising , i want you to contact me , okay ?\n[patient] okay .\n[doctor] and for your third problem , for an annual exam maintenance , you know , you're due for a mammogram , so we'll go ahead and schedule that , okay ?\n[patient] all right .\n[doctor] all right . do you have any questions ?\n[patient] um , can i take all my medicine at the same time ? does it matter ?\n[doctor] yeah . you can set an alarm so that it reminds you to take your medication . but yeah , you can , you can take them altogether .\n[patient] okay .\n[doctor] all right . hey , dragon , finalize the note .",
            "tgt": "CHIEF COMPLAINT\n\nAnnual exam.\n\nHISTORY OF PRESENT ILLNESS\n\nElizabeth Peterson is a 66-year-old female with a past medical history significant for depression and hypertension, who presents for her annual exam. It has been a year since I last saw the patient.\n\nThe patient reports that she is doing well. She has been to multiple events now that she has been able to get vaccinated for COVID-19. She reports that she has been able to see her grandchildren again and attend birthday parties.\n\nRegarding her depression, she has been going to therapy once a week for the past year. She reports that she is starting to go in person rather than virtual, which has helped even more. The patient has a good support system at home with her husband and her children live down the street.\n\nThe patient reports that her blood pressure has been doing well. She has been using the blood pressure cuff once a day and her readings seem normal. She has continued to utilize Lisinopril 20 mg daily, as prescribed.\n\nThe patient endorses nasal congestion. She denies any other symptoms of chest pain, shortness of breath, abdominal pain, nausea, or vomiting.\n\nREVIEW OF SYSTEMS\n\n\u2022 Ears, Nose, Mouth and Throat: Endorses nasal congestion.\n\u2022 Cardiovascular: Denies chest pain or dyspnea.\n\u2022 Respiratory: Denies shortness of breath.\n\u2022 Psychiatric: Endorses depression.\n\nPHYSICAL EXAMINATION\n\n\u2022 Neck: No carotid bruits appreciable.\n\u2022 Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.\n\u2022 Cardiovascular: Slight 2/6 systolic ejection murmur, stable.\n\u2022 Musculoskeletal: Trace lower extremity edema bilaterally.\n\nRESULTS\n\nElectrocardiogram stable in comparison to last year.\n\nASSESSMENT AND PLAN\n\nElizabeth Peterson is a 66-year-old female with a past medical history significant for depression and hypertension. She presents today for her annual exam.\n\nDepression.\n\u2022 Medical Reasoning: She is doing well with weekly therapy. She also has a solid support system at home.\n\u2022 Medical Treatment: Continue with therapy and current management strategies. We will defer medication at this time.\n\nHypertension.\n\u2022 Medical Reasoning: This is well controlled based on daily home monitoring. She has been compliant with lisinopril.\n\u2022 Medical Treatment: Continue lisinopril 20 mg daily.\n\u2022 Patient Education and Counseling: I advised her to continue with daily home monitoring of her blood pressures. She will contact me via the patient portal for any elevation in these readings.\n\nHealthcare maintenance.\n\u2022 Medical Reasoning: She is due for her annual mammogram.\n\u2022 Additional Testing: We will order a mammogram for her.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N097-virtassist"
        },
        {
            "src": "[doctor] all right . today i am seeing jose james . uh , date of birth 9/29/1957 . mr . james is a new patient who's having pain in his left shoulder and elbow . he fell five months ago going up a stairs , and the pain has been present since .\n[doctor] hi mr . james , i'm doctor isabella . how are you doing ?\n[patient] i'm okay . thank you .\n[doctor] that's good . that's good . tell me what's brings you in today .\n[patient] sure . so i've been having constant pain in my left shoulder and left elbow for a while , about five months or so . hurts all the time . pretty bad at times .\n[doctor] mm . that does not sound like fun . it sounds like you injured it going up the stairs ?\n[patient] yes , that's correct . it was icy , and i have to walk up a flight of stairs to my house . i stepped and my feet just went out . fell on my left side . seems like my shoulder and wrist took the brunt . it's been hurting since .\n[doctor] yeah , that does seem like a likely cause of your symptoms . anything seem to make the pain worse ?\n[patient] well , i've always hit the gym and lifted weights . i've been trying to keep with my routine of two days a week , but it's been hard . the pain is worse when i lift , and i have n't been able to lift more than 15 or 20 pounds which is very frustrating .\n[doctor] mm-hmm . i can imagine it is when you're so accustomed to your routine .\n[patient] exactly . i really enjoy my exercise , but over the past one to two weeks , i've stopped hitting the gym because the pain just was n't worth it honestly . i do keep up with my walking , though . my wife and i walk about 30 minutes almost every day . we have done this since i retired from my office job last year .\n[doctor] i do not blame you , mr . james . does anything seem to help the pain that you've tried ?\n[patient] not too much . i have iced a bit , but i have not taken anything for the pain . stopping exercise and some ice has helped a bit , but it still hurts enough for me to come to see you .\n[doctor] yeah , okay . how about any numbness or tingling ? have you felt that at any point ?\n[patient] no , doc . just pain . no tingling or numbless , numbness , thankfully .\n[doctor] understood . understood . all right . well , let's go ahead and take a look and see what's going on .\n[patient] sounds good . thank you .\n[doctor] okay . use my general physical exam template . mr . james , i'm going to gently press around your shoulder and elbow here to see where your pain might be stemming from . just let me know when it hurts .\n[patient] okay . it hurts when you press there on my elbow and here on my shoulder .\n[doctor] okay . left shoulder and elbow , tender sa space , no warmth , erythema or deformity . positive hawkins-kennedy and neer's test . normal proximal and distar , distal upper extremity strength . intact median radial ulnar sensation and abduction to 90 degrees . normal empty tan , can test . okay , mr . james , w-what i think you are dealing with is impingement syndrome of your left shoulder . i do n't think there's an additional injury or issue with your wrist , but because everything is connected , you're experiencing pain in your wrist because of your shoulder . we do see this type of issue when someone has a fall , so it's good you came to see us , you came in to see us so we could help .\n[patient] so what are the possible treatments ?\n[doctor] well , we have a few options you can try . first option would be to start with physical therapy . i would recommend two sessions per week as well as any other exercises they give you to do at home . we can start there and if that does n't improve your pain , then we could try a cortisone injection .\n[patient] i like the idea of starting with the physical therapy and have a next step if it does n't help . i am not opposed to a shot but would like to try the therapy first .\n[doctor] all right . great . i'll get a referral order , and they will call you within the next day or two to get you scheduled .\n[patient] okay .\n[doctor] mm-hmm . also , please continue to ice , especially your shoulder , and rest as much as you can .\n[patient] okay . i will .\n[doctor] give us a call or email us if you have symptoms worsen , if your symptoms worsen or do not improve with the therapy .\n[patient] will do . thank you . i appreciate your help .\n[doctor] you're welcome . have a great day .\n[patient] you too .\n[doctor] all right . assessment is impingement syndrome of left shoulder . plan discussed with patient . referral is requested for dr. martha rivera to be in physical therapy two days per week .",
            "tgt": "CHIEF COMPLAINT\n\nLeft shoulder and elbow pain.\n\nHISTORY OF PRESENT ILLNESS\n\nMr. Jose James is a 64-year-old male who presents for left shoulder and elbow pain.\n\nThe patient reports falling on his hand while going up stairs 5 months ago and has been experiencing constant pain since. He admits he was continuing to complete strength training exercises at least 2 times per week, however, he was unable to lift more than 15-20 pounds due to the pain.\n\nDuring the past 1-2 weeks, Mr. James has discontinued strength training activities. Additionally, he has iced the inflicted areas, denies taking any pain medications, and reports his pain has slightly improved but it is still rather constant. He denies tingling and numbness.\n\nThe patient walks 30-minutes most days of the week.\n\nSOCIAL HISTORY\n\nRetired last year, was an office worker.\n\nPHYSICAL EXAM\n\nMusculoskeletal\nLeft shoulder and elbow, tender subacromial space. No warmth, erythema, or deformity. Positive Hawkins-Kennedy and Neer\u2019s test. Normal proximal and distal upper extremity strength. Intact median, radial, ulnar sensation. Abduction to 90 degrees. Normal empty can test.\n\nASSESSMENT\n\n\u2022 Impingement syndrome of left shoulder\n\nJose is a 64-year-old male who was seen today for impingement syndrome of his left shoulder, likely related to a fall he incurred 5 months ago.\n\nPLAN\n\nToday I discussed conservative options for left shoulder impingement with the patient, who opted to try physical therapy 2 session per week. Cortisone injection was discussed as an option if the physical therapy does not successfully reduce his pain. Additionally, I recommended continued ice and rest.\n\nINSTRUCTIONS\n\nemail, or call if symptoms worsen or do not resolve.\n",
            "file": "D2N098-virtscribe"
        },
        {
            "src": "[doctor] next patient is randy gutierrez . date of birth , 8/10/2020 . please use review of symptoms . all text to write . physical exam , auto text uri .\n[doctor] hello , how are you doing today ?\n[patient_guest] we're okay , thank you .\n[doctor] that's good to hear . so , how many days has randy been feeling sick ?\n[patient_guest] well , i would say it started around supper time last night .\n[doctor] last night , okay , and what's been going on ?\n[patient_guest] well , he started to get a runny nose .\n[doctor] okay , and is he stuffy too ?\n[patient_guest] yeah . yeah .\n[doctor] okay , and have you noticed , is his mucous clear right now ?\n[patient_guest] it is , it is right now , yes .\n[doctor] okay . and , does he also have a cough ?\n[patient_guest] yes , but it's not barky .\n[doctor] and does he act like he has a sore throat or is he pulling on his ears ?\n[patient_guest] well , i know he's been pulling on his ears , yeah .\n[doctor] okay .\n[patient_guest] you know , he also , he's also been going crazy rubbing at his nose too .\n[doctor] okay . and , any fever you've noticed ?\n[patient_guest] i checked his rectal temperature and it was 100.3 .\n[doctor] okay . so , a little bit of a low-grade fever there , definitely . and , how was his appetite ? did he eat last night ?\n[patient_guest] yes , he did . yeah .\n[doctor] and how about this morning ? did he eat his breakfast ?\n[patient_guest] uh , this morning he ate about seven ounces from the bottle .\n[doctor] okay .\n[patient_guest] and then he got another bottle , and he barely ate that . um , i offered him cereal and he would n't eat that either .\n[doctor] okay .\n[patient_guest] so , he varies i guess .\n[doctor] how is his energy ? does he seem like he wants to take more naps , or does he have pretty good energy ?\n[patient_guest] mmm , it seems like he's irritable .\n[doctor] irritable because he is n't feeling good ?\n[patient_guest] yeah . he is energetic , but it seems like he ca n't go to sleep , like , he's fighting it really hard .\n[doctor] okay , and just for the chart , is there anyone , anybody else exposed to him who has been sick ?\n[patient_guest] yes , his older sister's been sick .\n[doctor] thank you .\n[patient_guest] we also had a play date with my nephew , who i learned later had a sinus infection .\n[doctor] and what medication have you tried for him ? anything at all ?\n[patient_guest] um , i've been doing the saline mist in his nose .\n[doctor] good , good . that's a good choice .\n[patient_guest] i did give him tylenol really early this morning because he was warm when i took the sleeper off of him , and we had the ac on in the house , but his whole body was sweating .\n[doctor] i see . and , any other medications ?\n[patient_guest] we did put some baby vick's on his feet last night to try and help him breathe . and , i also used the humidifier .\n[doctor] okay . that's good .\n[patient_guest] okay . okay .\n[doctor] so , there was another thing i wanted to bring up since we're here . it appears that his cradle cap has gotten a little worse . what are you using on it ?\n[patient_guest] i've been using the cradle cap brush , and then i use regular aveno shampoo .\n[doctor] is it a dandruff shampoo ?\n[patient_guest] no , i do n't think so .\n[doctor] okay , thank you . well , let's complete his exam and then we'll talk about the next steps .\n[patient_guest] okay , sounds good .\n[doctor] can you take a big breath randy .\n[patient_guest] where's mama ?\n[doctor] do n't forget to breathe little one . okay . let's try the front too .\n[patient_guest] yeah , it's okay buddy .\n[doctor] excellent . he's doing excellent . next let's- let's check out those ears .\n[patient_guest] okay .\n[doctor] let's try to make sure you do n't tip all the way over .\n[patient_guest] dino , you're doing so good .\n[doctor] all right . ears look okay . we're going to slide you forward so you do n't bump your head when i lay you down .\n[patient_guest] hey , you're- hey you're okay . you're okay .\n[doctor] okay , you can go ahead and sit him back up if you like .\n[patient_guest] all right . thank you .\n[doctor] 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 in time . um , keep up with the fluids , rest , and i would watch him very carefully for a barking cough . if he does get a barky cough , then that tends to be a little bit more significant and a little more severe . so , if he develops a barky cough , i want you to give him a half a teaspoon of his sister's medicine .\n[doctor] you know , i'm almost tempted to give you some of the medicine because they're probably sharing the same virus .\n[patient_guest] okay .\n[doctor] actually , i will . i'll go ahead and just give you some as well .\n[patient_guest] okay . okay .\n[doctor] but , if he does n't become barky , you do n't have to use it . it only works for the barky cough .\n[patient_guest] mm-hmm , got it .\n[doctor] okay . we'll do the same thing with him , as long as nothing gets worse , and we'll see him back in one week . so , it wo n't get rid of a regular cough . he can use zarbee's , but use the dose for kids under a year of age . so , if you wan na get some of that , you can definitely try that for him , it can help out a little bit with the regular cough .\n[patient_guest] i do have a question . do you or do you not give honey to babies ?\n[doctor] yes , that's a great question . you do n't give honey to kids under a year , instead , you can give them agave , which is a different type of nectar . um , now you can give honey to his older sister , that is okay , but for him , it would not be very good because his stomach acid's not good enough to break down the botulism spores . so , it'd cause him harm . um , you should look at the package of say , honey nut cheerios . it says right on there to not give it to a baby .\n[patient_guest] okay .\n[doctor] now , whether that would really hurt a baby , i am unsure , but it has real honey in it . so , no honey for him , but agave is definitely fine .\n[patient_guest] okay . so , zarbee's for the stuffy nose .\n[doctor] yes , zarbee's .\n[patient_guest] and then you said , uh , which medicine to give him just in case ?\n[doctor] i'm gon na give him the same medicine as his sister , and just hang onto it , um , just to watch and see . if this was a monday and we had a whole week to watch , i would say to just call us if things got worse , um , but since , um , if it's gon na be the weekend , and things might worsen tonight or tomorrow night , i'd rather you have just what you need on hand .\n[patient_guest] okay .\n[doctor] right , does that make sense ?\n[patient_guest] yeah , yeah . that makes sense .\n[doctor] okay , great . and that way you do n't have to share , um , with his sister .\n[patient_guest] right , okay .\n[doctor] and since he's about half her size , we'll do half the dose , which is a half a teaspoon .\n[patient_guest] okay . will this information all be in the papers ?\n[doctor] yes . and so , if he ends up starting the medicine , just give him a half a teaspoon for five days .\n[patient_guest] okay .\n[doctor] yeah , that's the only thing it wo n't say is , \" as needed , \" or anything like that .\n[patient_guest] mm-hmm , understood , thank you .\n[doctor] you're welcome .\n[patient_guest] and the cradle cap ?\n[doctor] what i would do is use something like either head & shoulder's , or selsun blue , or nizoral ad . now , do n't get the extra strength stuff , just use the regular strength . um , cradle cap , it's just basically a fancy way of saying dandruff . so , those shampoos will help get rid of it . it's not an immediate thing 'cause they , um , they are all dead scales , and you still have to brush them off . so , continue to use the soft brush and some baby oil , or something that will help get the scales out , and those shampoos will actually help to prevent it as well . use it two times per week , not every day , but maybe twice a week .\n[doctor] so , two days between shampooing , use what you normally use any other time . and then , often , within six weeks or so , you'll notice that the-the cradle cap is just , um , not coming back anymore . but , he has to be careful because it's not ph balanced for eyes . so , just make sure when you're rinsing his hair you avoid his eyes .\n[patient_guest] okay . okay .\n[doctor] all right . and , if it keeps getting worse , definitely let us know .\n[patient_guest] okay . sounds good .\n[doctor] good . and , since they do n't have covid-19 , you can go right ahead and check out .\n[patient_guest] okay . and both appointments in the week ?\n[doctor] correct . we'll see you all then . bye randy , feel better .\n[patient_guest] all right , great . thank you so much .\n[doctor] you are welcome , and have a good rest of your day .",
            "tgt": "CHIEF COMPLAINT\n\nCough, nasal congestion, and rhinorrhea.\n\nHISTORY OF PRESENT ILLNESS\n\nRandy Gutierrez is a 9-month-old male who is being evaluated today for a cough, nasal congestion, and rhinorrhea. He is accompanied by his mother.\n\nSymptoms began yesterday around dinnertime with clear nasal drainage, pulling on his ears bilaterally, and rubbing his nose frequently. He does not have a barky cough or a sore throat. His rectal temperature was 100.3 degrees. The patient did consume a 7 ounce bottle this morning, but mostly denied the next offered bottle and declined cereal. He is irritable and having trouble falling asleep, described \u201clike he is fighting it\u201d.\n\nThe patient has been exposed to an older sister who is sick and a cousin who has a sinus infection.\n\nTreatment has included saline nasal spray, Tylenol, baby Vick's, and a humidifier. When the patient aroused this morning, he was warm to the touch. When his sleeper was removed, he was quite sweaty despite the air conditioner being on.\n\nThe patient's dandruff is also worsening. The only tried treatment is Aveeno shampoo.\n\nSOCIAL HISTORY\n\nOlder sister.\n\nCURRENT MEDICATIONS\n\nTylenol PRN.\n\nPHYSICAL EXAM\n\nTemperature 100.3 degrees.\n\nEars, Eyes, Nose, Throat\nNasal congestion, clear mucus, rhinorrhea. Bilateral pulling of ears, no sore throat or hoarseness.\n\nRespiratory\nPositive for cough.\n\nASSESSMENT\n\n\u2022 Viral infection\n\u2022 Dandruff\n\nPLAN\n\nViral infection\nThe patient presents with a viral infection and does not need antibiotics currently. I advised continuation of fluids, rest. Additionally, I suggested trying Zarbee\u2019s for children under 1 years old. If a croup cough develops, the patient will receive a 0.5 teaspoon.\n\nI also provided counseling to the mother to avoid giving honey to the patient for his first year of life due to botulism spores.\n\nDandruff\nThe patient is experiencing worsening symptoms of dandruff. I recommended Head and Shoulders shampoo, Selsun Blue, or Nizoral A-D 2 times per week, combined with his usual shampoo. I counseled the mother that she should be careful not to get the shampoo in the patient eyes and to not use the extra strength shampoos. Additionally, he may also use baby oil and a soft brush on the area.\n\nINSTRUCTIONS\n\nReturn in one week for a re-check.\n",
            "file": "D2N099-virtscribe"
        },
        {
            "src": "[doctor] 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 itching , bleeding , or pain . no additional past medical history . she lives with her parents and sister . they have a dog , bird , and bunnies . she is in 7th grade . she plays basketball and volleyball and tap . she wears sunscreen in the summer , spf 30 . no additional family history . hi kayla , i'm dr. juan price . i hear you are starting to get some acne on the face . how about the chest and back ?\n[patient] it's not too bad .\n[doctor] so , it's not bad on the chest or back . you've used some over the counter items like washes and persa-gel ?\n[patient] yeah .\n[doctor] do those seem to be helping ?\n[patient] yes , i think so , a little bit .\n[doctor] good . what's your skin care routine like now ?\n[patient] do you wan na know , like , the things i currently use ?\n[doctor] yes . what do you do for your acne in the morning ? and then what do you do at nighttime ?\n[patient] i wash my face , more like i wipe it down in the morning . then at night i use an elf facial cleanser called the super clarity cleanser . i finish with a toner and then the persa-gel .\n[doctor] when you say , \" wipe your face in the morning , \" do you use a product or just water ?\n[patient] mm , just water and a washcloth , really . if i feel really greasy , sometimes i'll use the elf cleanser in the morning , too .\n[doctor] okay . and is today a good day , bad day , or an average day for you ?\n[patient] mm , i would say it's probably a good day for me , of course , since i'm here , right ?\n[doctor] acne is always good when you come to see the doctor . do you find that your acne flares with your periods ?\n[patient] no , not really .\n[doctor] and do you get a regular period ?\n[patient] yup .\n[doctor] how long have you been getting a regular period ?\n[patient] mm , i think about two years .\n[doctor] okay .\n[patient_guest] the biggest flare , probably , was when she started school sports in the fall , just with all the sweating .\n[doctor] yup , that will do it . is there anything else that you've noticed , mrs. ward ?\n[patient_guest] no . kayla really has been doing a good job with the facial care regimen . it just does n't seem to help as much as we wanted .\n[doctor] got it . okay . well , let's take a look then . full exam is performed today , except for under the underwear and under the bra . multiple benign nevi on the trunk and extremities . scattered skin colored papules . open and closed comedones . and erythmateous papules on the face , primarily on the forehead and with also some on the central cheeks and chin . the chest and back are relatively spared . and the remainder of the examination is normal . so , what i'm seeing from your exam today is mild to moderate acne , mostly comodonal with small inflammatory component .\n[patient] okay , so is there anything we can do to help it ?\n[doctor] yes . i would like to start with a topical therapy first . every morning , you will wash your face with a mild cleanser then use a moisturizer labeled , \" noncomedogenic , \" with sunscreen spf 30 or higher . this means it wo n't clog your pores . now , in the evening , wash your face with the same cleanser and allow it to dry . apply adapalene , 0.1 % cream , in a thin layer to the areas you generally get acne . i want you to start off using this a few nights a week and slowly work up to using it every night . if it is ... excuse me , if it is very expensive or not covered by insurance , you can try different gel over the counter . you can follow that with clean and clear persa-gel in a thin layer , or where you generally get acne . and then a noncomedogenic moisturizer . you're atopic retinoid will cause some sensitivity , so you will need to wear sunscreen when you are outside . it may also cause some dryness or irritation .\n[patient] okay , i can do that .\n[doctor] you also have multiple benign moles on your arms , legs , back and abdomen . this means they all look normal with no worrisome features . we will see if you have any progress over the next six months and follow up at that time .\n[patient] okay , that sounds good . thank you .\n[doctor] do you have any questions for me ?\n[patient] no , i do n't think so .\n[doctor] okay . if you have questions or concerns before your next visit , please call the office .\n[patient] thank you , doctor , we will .",
            "tgt": "CHIEF COMPLAINT\n\nNew acne evaluation.\n\nHISTORY OF PRESENT ILLNESS\n\nKayla Ward is a 15-year-old female who presents for new patient evaluation of acne located on the face. She is accompanied by her mother today.\n\nKayla states her acne started approximately 2 years ago and it is present almost every day. The patient\u2019s mother notes that the most significant acne flares started in the fall when she was playing school sports. It does not tend to flare with her periods. Kayla reports that today is a good day for her acne. She denies any significant acne present on the chest or back. There are no associated symptoms, including no itching, bleeding, or pain.\n\nThe patient has been washing her face regularly. Her acne regimen includes washing her face in the morning with Persa-Gel and at night e.l.f. SuperClarify Cleanser along with toner and Persa-Gel. This regimen is somewhat helpful. She wears sunscreen in the summer SPF 30.\n\nSOCIAL HISTORY\n\nLives with parents and sister. They have a dog, bird, and rabbits in the home. She is in the 7th grade and active in basketball, volleyball, and tap dancing.\n\nFAMILY HISTORY\n\nNo significant family medical history.\n\nPHYSICAL EXAM\n\nIntegumentary\nFull exam is performed today except for under the underwear and under the bra. There are multiple benign nevi on the trunk and extremities. Scattered skin-colored papules, open and closed comedones, and erythematous papules on the face, primarily on the forehead, with also some on the central cheeks and chin. The chest and back are relatively spared. The remainder of examination is normal.\n\nASSESSMENT\n\n\u2022 Comedonal acne.\n\u2022 Multiple benign melanocytic nevi of upper and lower extremities and trunk.\n\nKayla Ward is a 15-year-old female seen today for new acne evaluation. Full skin examination revealed mild to moderate comedonal acne with a small inflammatory component and multiple benign melanocytic nevi of upper and lower extremities and trunk.\n\nPLAN\n\nComedonal acne.\nWe discussed the diagnosis, etiology, and treatment options. I recommend starting with topical therapy first. The patient was instructed to wash face every morning with a mild cleanser, then use a non-comedogenic moisturizer with sunscreen SPF 30 of higher. In the evening, wash face with same mild cleanser and allow to dry. Apply a thin layer of topical retinoid, Retin-A 0.1% gel, to acne prone areas. Start off using a few nights a week, slowly work up to using every night. If it is very expensive or not covered by insurance, you can try Differin gel over the counter. Your topical retinoid will cause sun sensitivity, so you will need to wear sunscreen when you are outside. It may also cause some dryness or irritation.\n\nMultiple benign melanocytic nevi of upper and lower extremities and trunk.\nReassurance given moles are normal in appearance and have no concerning characteristics. Will continue to monitor for progression or changes in 6 months.\n\nINSTRUCTIONS\n\nFollow recommended cleaning regimen.\nStart Retin-A 0.1% topical gel, apply to acne prone areas, titrate as instructed.\nFollow up in 6 months.\n",
            "file": "D2N100-virtscribe"
        },
        {
            "src": "[doctor] patient is julia jones , date of birth 5/16/1996 . she is a new breast reduction consult . hello , how are you doing today ? i'm dr. gonzalez . it's nice to meet you .\n[patient] nice to meet you , ma'am . how are you ?\n[doctor] i'm doing good , thank you . so you're here to discuss a breast reduction , correct ?\n[patient] yes . that's right .\n[doctor] okay . perfect . let me just get logged in , here . have you met with anyone before about a breast reduction ?\n[patient] no , i have n't .\n[doctor] okay . and how long have you been considering this ?\n[patient] it's probably been about six or seven years . but i mean , it's always been in the back of my mind .\n[doctor] well , i perform a lot of breast reduction surgeries , pretty much every week , so it is a very common procedure .\n[patient] okay , that's reassuring .\n[doctor] yeah . so what i wan na do first is just get a little bit of history about the sort of symptoms that you're having . and then i'll do a quick exam .\n[patient] okay . that sounds good .\n[doctor] and then we'll talk more about the surgery and what it entails . and , um , at this point , who is your insurance provider ?\n[patient] i have blue cross blue shield . well , actually , my husband just accepted a new job , and i will be on his plan , uh , which i believe is not going to be blue cross , but it may be changing .\n[doctor] 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 right insurance . do you know when you'll be on the new plan ?\n[patient] most likely july .\n[doctor] okay . so we may just wait until july to submit for approval at that time .\n[patient] okay .\n[doctor] so regarding your symptoms , do you experience back pain ?\n[patient] well , i've been going to the chiropractor for a few years . i do have a lotta pain here and here . but i do n't know if it's all from my breasts or not . it gets painful and builds up . so i think i could attribute it to my breasts , when i'm working at my desk all day .\n[doctor] okay . and in your neck and your upper back . and how long has this been going on ? would you say five years , 10 years , or even since puberty ?\n[patient] i would say since i was in high school .\n[doctor] okay . and do you have the bra strap indentations in your shoulders ? um , i saw that you're wearing about a g cup .\n[patient] yes . i do get indentations , but i do n't really wear a regular bra that often . i mostly were a 34 e sports bra because it's more comfortable . and the others are expensive in my size .\n[doctor] yeah , i have heard that as well . and , um , have you had any children , or are you planning to have any children in the future ?\n[patient] no , i do not have any kids now . but we might plan to in the future .\n[doctor] okay . and at this time , are you experiencing any numbness or tingling in the s- in the hands or any nipple pain ?\n[patient] sometimes , yes .\n[doctor] okay . and rashes , do you get any rashes underneath your breasts ? and , and it could be from sweating .\n[patient] no , but they are always sweaty .\n[doctor] okay . and then do you feel like your activities are limited because of the size ?\n[patient] there's certain things i do when i have to hold them , like working out and any jumping or running . and it hurts .\n[doctor] and it hurts , okay . and , and you saw a chiropractor . but what about physical therapy for your back pain ? or do you take any pain medicine for it ?\n[patient] y- no , but i do take a migraine medication , propranolol .\n[doctor] that's okay . so let's see . i know that you have a history of breast cancer in your family . have you had any mammograms ? and how old was your mother when she had it ?\n[patient] mom was 40 . and they recommended me starting at age 30 for mammogram . i'm still ... i mean , i'm 25 . so i'm still a little bit young .\n[doctor] okay . and otherwise , it seems like you're really healthy ?\n[patient] yes , for the most part . i lost about 10 pounds over the past few months , and i still would like to lose about 20 more pounds .\n[doctor] congratulations . that's great . and then , um-\n[patient] thank you .\n[doctor] . so then ... you're welcome . and so do you use any tobacco , drugs , or alcohol ? and then , um , you said that you were going to school . what are you going to school for ?\n[patient] uh , i drink a little wine on occasion , and for school , i'm currently studying psychology .\n[doctor] okay , that's great . all right . so what we'll do is we'll go ahead and take a look . i'm gon na take a couple of measurements . and we'll kinda talk about the surgery afterwards . um , so go ahead and stand up for me , julia . okay . so , looking at the measurements , it looks like one breast is a little lower than the other .\n[patient] yeah .\n[doctor] okay . well , thank you so much . it looks like i have all the measurements that we need . you can go ahead and cover up now .\n[patient] okay .\n[doctor] so i think you're a great candidate for a breast reduction . when we talk about a breast reduction , what happens is that we remove the tissue out of the breast .\n[patient] okay . that's fine .\n[doctor] and we would then lift them and elevate the nipple position in order to help with your back pain , neck pain , and because i'm a plastic surgeon , of course i want them to look nice as well .\n[patient] right .\n[doctor] so typically , when you do the breast reduction , we make an incision around the nipple straight down and then underneath . and it kinda looks like , um , an anchor below . then straight down , and underneath , and through that incision , we're able to f- to lift the breast . and we'll take off any extra fat and breash- breast tissue . so that way it becomes smaller in size . and i noticed that you would like to be a b cup . so i do tell every patient we can make you as small as your blood supply allows . and what that means is we must move the nipple without cutting off any of its blood supply during the surgery .\n[patient] okay . well , thank you for explaining that .\n[doctor] you're welcome . and in your case , you'll probably be a small c. um , a b cup might be a little bit small , but we'll see once i'm doing the , the procedure for you .\n[patient] okay .\n[doctor] and typically the surgery takes about three hours . you will have drains , one in each side . and that helps prevent fluid from building up in the breast . and that stays in for about a week . and then we'll remove them in the clinic . and you'll have a clear plastic tape over your incision that should help with the scars . and , um , we've seen that patients who have lighter skin , the scars will tend to be red at first . and then it takes about a year for a scar to mature in line .\n[patient] okay . well , i'm not too worried about the scars .\n[doctor] okay . and i do like to keep patients overnight . it's just going to be for one night in the hospital . and we just wan na make sure your pain is controlled , make sure you're not nauseated , all of that stuff . some patients wan na go home that same day . but you know that some people get nauseated , and the last thing that i want is for you to be vomiting at home alone without the , the support here at the facility .\n[patient] okay , yeah , that sounds good .\n[doctor] okay . and then about 30 % of patients say that they can not breastfeed after a breast reduction , and the reason is the breast is made up of fat . and it's also made up of a gland . and the gland is what produces the milk .\n[patient] okay .\n[doctor] and so in order to reduce the size of the breast , we have to take out both the fat and the glands . so it just depends on how much is left , whether you can breastfeed in the future . and then also , the breast will change over time . if you , um , gain weight , they will get larger , things like that .\n[patient] yeah , okay .\n[doctor] and if you have children , they will change as well . they will enlarge , especially if you can breastfeed . but they'll go back down and will appear , um , a little bit deflated .\n[patient] yeah . i do n't know if i'm interested in breastfeeding .\n[doctor] okay . um , the hormones of pregnancy , though , will change the breasts , so that's just something to be aware of , and i tell all younger patients that .\n[patient] okay , yeah . absolutely .\n[doctor] and then typically nipple sensation is fine after a breast reduction , but there is a slight chance that you'll have an alteration in the nipple sensation or not have any sensation in the nipple . generally the nipple is just fine unless it is a massive reduction . and it's quite normal after surgery to be a little bit bruised , and then it just takes some time for that to go away .\n[patient] yeah , okay .\n[doctor] but other than that , you know , most patients are very happy after the breast reduction because the symptoms of the back pain , the neck pain , you can feel relief almost immediately . so do you have any questions , julia , about the process or anything like that ?\n[patient] no , not really .\n[doctor] okay . and , i do think you're a good candidate for it . and i think you'll benefit from it as well .\n[patient] good . i look forward to a relief .\n[doctor] i think you just have to do it when you are ready , when you know that you feel like it's a good time , because it is a commitment , and you will have some activity restrictions for about six weeks after surgery , uh , no heavy lifting . and i do say no driving for two to three weeks . and the drains stay in , like i said , for about a week .\n[patient] okay . well , i am ready as soon as my insurance is switched over .\n[doctor] okay . well , i think from this point , if you want to , we can take photos today , while you're here . i have all the documentation now in the note about your symptoms , and that's what the insurance company is going to look for . so thank you for answering those questions . so once we have the new provider , we'll go ahead and get that submitted . and then , when they approve it , um , what the office will do , is they'll work with you on a surgery date , and then we'll meet again right before the surgery to answer any last minute questions and go over the instructions in more detail , things like that .\n[patient] okay . well , i will notify the office as soon as i have the insurance information .\n[doctor] that sounds great . and then we can get it all in process . and it was so nice to meet you . and catherine will be right in to get your photos . julia jones is a 25 year old female with symptomatic macromastia , presenting for evaluation of breast reduction . the patient has attempted nonsurgical treatments , but the minimal relief , and is an ideal candidate for bilateral reduction mammoplasty . her minimum required resection , based on a bsa of 2.65 , with the schnur scale is 1,792 grams , which should be attainable . given her extremely large breasts and the measurements above , there is potential for using a nipple graft .\n[doctor] physical exam findings of breast , inspection reveals asymmetrical breasts with severe ptosis bilaterally . there is no nipple retraction or discharge bilaterally . no breast tenderness , masses , or axillary lymphadenopathy is palpable .",
            "tgt": "CHIEF COMPLAINT\n\nMacromastia.\n\nHISTORY OF PRESENT ILLNESS\n\nJulia Jones is a 25-year-old female who presents for evaluation of macromastia.\n\nMs. Jones reports this is her first visit in regard to a breast reduction and has been interested in getting a breast reduction for approximately 7 years. Currently she has Blue Cross Blue Shield insurance but will be added to her spouse\u2019s insurance plan in 07/2021.\n\nCurrent breast size is a G cup, although she primarily wears a 34 E sports bra for comfort, and desired breast size is a B or C cup. No prior pregnancies, potentially planning on pregnancies in the future, and unsure of breast feeding.\n\nThe patient endorses back and neck pain since she was in high school. Her back and neck pain has been managed by a chiropractor for a few years. She reports weight loss of 10 pounds over the past few months and would like to lose an additional 20 pounds.\n\nShe endorses the following symptoms because of her macromastia for 7 years:\n\nChronic upper back pain: Yes.\nBra strap grooving in shoulders or indentation on lateral chest wall: Occasionally.\nNeck pain: Yes.\nNipple pain or numbness: Yes.\nParesthesia of the hands or arms: Yes.\nIntertrigo, rash or yeast or other skin problems beneath breasts: Yes, persistent sweating.\nStooped posture: Yes.\nPhysical activity limited by breast size: Yes.\n\nThe patient has undergone the following therapies:\nPhysical therapy: No.\n\nSpecial bras: Yes.\nNon-narcotic pain medication: No.\nNarcotic pain medication: No.\n\nHer previous breast surgery includes:\nPrevious reconstruction: No.\n\nPAST HISTORY\n\nMedical\nSignificant for migraine headaches.\n\nFAMILY HISTORY\n\nMother with prior history of breast cancer at age 40.\n\nSOCIAL HISTORY\n\nTobacco: No prior history.\nAlcohol: Socially. One glass per week.\nDrug: No prior history.\nOccupational and Educational: Currently studying to be a psychologist.\n\nCURRENT MEDICATIONS\n\nPropranolol for migraine prevention.\n\nVITALS\n\nBSA 2.65\n\nPHYSICAL EXAM\n\nBreasts\nInspection reveals\u202fasymmetrical\u202fbreasts with severe ptosis bilaterally. There is no nipple retraction or discharge bilaterally. No breast tenderness, masses, or axillary lymphadenopathy is palpable.\n\nASSESSMENT\n\n\u2022 Macromastia.\n\nJulia Jones is a 25-year-old female with symptomatic macromastia presenting for evaluation of breast reduction. The patient has attempted non-surgical treatments with minimal relief and is an ideal candidate for bilateral reduction mammoplasty. Her minimum required resection based on a BSA of 2.65 with the Schnur scale is 1792 g, which should be attainable. Given her extremely large breasts and the measurements above, there is potential for using a free nipple graft.\n\nPLAN\n\nAn extensive discussion of breast reduction surgery was performed with the patient with consideration of the patient's age, co-morbidities, previous surgical history, body habitus, BMI, and smoking history. Surgical time, immediate recovery course, and longer term recovery course were discussed. Relief of the patient's current symptoms related to macromastia was not guaranteed though is expected to improve. Specific breast size was discussed, also not guaranteed. I explained the expected outcomes of using a free nipple graft such as an insensate nipple and an inability to breast feed. The patient understands that the decision for a free nipple graft will be made intraoperatively based on assessment of nipple perfusion.\n\nRisks and benefits of were discussed with the patient The patient understands the above risks, benefits and alternatives to surgery and wishes to proceed with bilateral reduction mammaplasty.\n\nThe patient will be switching to a different insurance policy in 07/2021. Once we get the new insurance information from the patient, we will submit it to her insurance company. If approved, she will return for preoperative counseling and consent.\n\nReturn to clinic prior to scheduled surgery date for preoperative counseling and consent.",
            "file": "D2N101-virtscribe"
        },
        {
            "src": "[doctor] 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 amount of blood in the urine and intact . renal ultrasound impression . right kidney is 10 cm in length by five centimeter wide . there are no stones , masses or hydronephrosis . the left kidney is 10.8 centimeters in length and five centimeters wide . there is a six millimeter left renal stone non-obstructing . 533 milliliters pre-void and 0 milliliters post-void . hi , mrs. wood . i see you're just finished your ultrasound .\n[patient] yes , ma'am .\n[doctor] well , it looks like you have one stone in the left kidney but it's not obstructing anything .\n[patient] i knew it had to be a kidney stone . i passed what looked like two small stones last week after i scheduled this appointment . and then for the past six weeks , i've had a few episodes of bright red urine the color of , like , cherry kool-aid . and last week , i was constantly having to pee and it hurt something terrible .\n[doctor] how bad was your pain on a scale of zero to 10 ? zero being no pain and 10 being worse , as you can imagine .\n[patient] um , at the time , i'd say an eight .\n[doctor] are you having any flank pain now or tenderness in your lower back ?\n[patient] no , after passing those stones , things have felt a lot better .\n[doctor] that's good to hear . now , it looks like you're only taking alavert 10 milligrams a day and have no drug allergies . is that correct ?\n[patient] that's right .\n[doctor] all right , let's take a look at you today . let's use my default pe . well , mrs. wood , we know that the blood in your urine was due to the kidney stones . fortunately , you passed two last week and the blood has nearly subsided . you do still have one stone in the left kidney . since it's not obstructing or causing pain , i do n't recommend any surgical intervention at this time .\n[patient] i'd like to know what i can do to stop getting these stones .\n[doctor] as we discussed last time , the formation of kidney stones can not be attributed to a particular cause . but several factors increase the risk , such as dehydration , family history , certain foods , digestive tract disease and certain medical conditions .\n[patient] yeah , i know i do n't drink near the amount of water that i should . i drink more mountain dew than anything .\n[doctor] you should drink about half of your body weight in ounces of water a day .\n[patient] so , if i weight 250 pounds , i should drink ?\n[doctor] that would be 125 ounces of water a day and you should avoid drinking sugary drinks like mountain dew .\n[patient] okay . is there any food i should n't eat ?\n[doctor] great question . you should avoid food rich in sodium oxalate and animal protein . so that would be salty , processed food because they're high in sodium . ideally , you should consume less than 1,000 milligrams of sodium a day and reduce the amount of beef , poultry , fish , and pork .\n[patient] what's oxalate ?\n[doctor] 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 .\n[patient] well , i'll do whatever it takes to try to avoid getting these stones again .\n[doctor] great . and here's a handout that you can look over . it goes over the dietary recommendations and what to avoid .\n[patient] okay , good . i like to have things in writing to help me remember .\n[doctor] perfect . well , if you have any more questions . if you do n't have any more questions , you're all set . i wo n't need to see you back until next year , as long as you do n't have any more issues like bleeding or pain . if you do have any issues , you can always call the office sooner . and if you experience any severe pain or bright red blood in your urine , you should go to the emergency room .\n[patient] all right . well , let's hope we do n't have to do either of those and i see you next year .\n[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 .",
            "tgt": "CHIEF COMPLAINT\n\nHematuria.\nChronic urolithiasis.\n\nHISTORY OF PRESENT ILLNESS\n\nMrs. Kelly Wood is a 41-year-old female established patient with chronic urolithiasis who returns in follow up for renal ultrasound due to hematuria.\n\nThe patient reports having intermittent episodes of gross hematuria over the past several months. she states she had multiple voids in one day where the color of her urine was like cherry Kool-Aid last week; then passed 2 small stone like structures. Pain at the time was 8 out of 10 on a scale of 10. she currently denies any flank pain.\n\nCURRENT MEDICATIONS\n\nAlavert 10 mg tablet once daily.\n\nALLERGIES\n\nNo known drug allergies.\n\nPHYSICAL EXAM\n\nGenitourinary: Normal vaginal exam.\n\nRESULTS\n\nRenal Ultrasound\nImpression: Right kidney is 10 cm in length by 5 cm wide. There are no stones, masses, or hydronephrosis. The left kidney is 10.8 cm in length and 5 cm wide. There is a 6 mm left renal stone, non-obstructing. 533 ml pre void and 0 ml post void.\n\nUrine Dipstick without Micro\nColor: Yellow.\nAppearance: Clear.\nLeukocytes: Negative.\nNitrate: Negative.\nUrobilinogen: 0.2 EU/dL.\nProtein: Negative.\npH: 5.5\nBlood: Trace, intact.\nSpecific gravity: 1.020\nKetone: Negative.\nBilirubin: Negative.\nGlucose: Negative.\n\nASSESSMENT\n\n\u2022 Hematuria.\n\u2022 Chronic urolithiasis.\n\nMrs. Wood presents today for renal ultrasound. The patient has had recurrent episodes of hematuria over the past few months secondary to chronic urolithiasis. Mrs. Wood reports passing two small stone like structures last week. Urinalysis today was notable for only a trace amount of blood and the renal ultrasound revealed a 6 mm non-obstructing renal stone in the left kidney.\n\nPLAN\n\nNo surgical intervention is recommended, and the patient would like to discuss urolithiasis prevention. We had a very lengthy discussion with regards to urolithiasis formation and treating the underlying cause to prevent reoccurrence and associated potential dietary factors that could be involved with urolithiasis formation.\n\nIt is recommended that the patient maintain a healthy diet; limit salt, and animal protein. she should increase fluid consumption; adequate intake is half of her body weight in ounces of water daily and avoid sugary drinks. A copy of the dietary recommendations and avoidances was provided to the patient for reference. We will continue to monitor annually with renal ultrasound unless new symptoms develop. The patient voiced understanding and agreed with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nFollow up in 1 year with renal ultrasound, sooner should symptoms arise. Should you develop sudden onset of severe pain or gross hematuria go to the emergency room.\n",
            "file": "D2N102-virtscribe"
        },
        {
            "src": "[doctor] next patient is melissa sanchez . date of birth , 9/23/1962 . mrn : 5484367 . she is being seen in office today for status post mitral valve repair done on 8/3/2020 . at her previous follow-up on 9/17 , we felt that she was doing quite well from a cardiac standpoint , and so we recommended she continue with the same medication . ecg taken on 12/26/2020 reveals atrial fibrillation with a controlled ventricular response . t-wave inversion anteriorly . compared to the previous study , there are no significant changes , and please add in the history , patient has a history of mitral regurgitation and atrial fibrillation , history of diabetes , asthma , and recurrent chest discomfort with negative cardiac workup for coronary artery disease .\n[doctor] ms. sanchez , it's good to see you again .\n[patient] yeah , it's good seeing you too dr. hughes . you look like you're doing well .\n[doctor] i am , thank you . you too . you're looking great . how have you been feeling ?\n[patient] pretty good . i'm definitely feeling better , thank goodness . i was having a rough time before surgery , um , but i think i'm overall pretty good now though .\n[doctor] okay . well , that's really good to hear . i'm glad . are you having any new symptoms right now ?\n[patient] no , not really . but , you know , i'm still getting some chest pains sometimes , and my breathing gets shallow . but , i guess i'm learning what i can and ca n't do . uh , so if i feel like that , if i'm , like , exerting myself , i slow down a bit which helps , and then when i go back to it later , i can usually finish whatever i was doing .\n[doctor] okay . so , it does go away though ? how long does an episode seem to last ?\n[patient] uh , only a few minutes i guess . then it disappears for a while . it's weird .\n[doctor] what is a while ?\n[patient] it goes away for a couple weeks . um , so when it happens , i just take the day nice and slow , i do n't push myself .\n[doctor] okay . so , maybe it's a couple times a month you feel this way ?\n[patient] yeah , just often enough for me to notice .\n[doctor] understood . okay . are you taking your medications regularly ?\n[patient] uh- . i've been trying to keep up with that . there's a lot of extra pills now , but i have a reminder app , so i do pretty well .\n[doctor] okay . that's great . and so , you're taking coumadin , right ?\n[patient] yeah , also lasix and the atenolol .\n[doctor] are you having any side effects from the medications at all ?\n[patient] not really . uh , i notice that the atenolol is making me irritable in the beginning , but i guess i've gotten used to it , does n't seem to bother me as much now .\n[doctor] okay . well , that sounds good . sounds like you're well on the mend . so , why do n't i start out , um , with the physical exam , and just check you out .\n[patient] okay .\n[doctor] you're going to hear me describe things in detail or repeat things as i go to reference later for my notes .\n[patient] okay .\n[doctor] okay then . i'm going to be using my status post template , ms. sanchez , please lie down on the table here and we'll get started . all right . can you turn your head to the left . head and neck no jvd detected . you can turn back now and just take a couple of deep breaths for me please . okay , that's good . and lungs have reduced breath , but auscultation and percussion are clear . okay . breath normally , i'm just going to listen to your heart . rhythm is irregularly irregular .\n[patient] that's a funny statement . what does that mean ?\n[doctor] yeah , it does sounds kind of weird , right ? it's when your heart does n't beat with the correct rhythm , and whatever rhythm it does n't have a pattern to it . so , it's part of the atrial fibrillation .\n[patient] wow , that sounds like a mess .\n[doctor] yeah , it's not ideal . but , many people have a-fib are able to keep it under control with medicine and lifestyle changes .\n[patient] agh , i see . that's good to know .\n[doctor] okay . so , s1 slightly accentuated , no s3 . i'm going to touch your belly , and does any of that hurt .\n[patient] nope .\n[doctor] how about there ? and your feet ?\n[patient] no , not really .\n[doctor] okay , great . and trace peripheral edema on extremities . all right ms. sanchez , you can sit up now . so , it looks like your heart valves are working well and you are recovering from the surgery nicely .\n[patient] good .\n[doctor] 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 ?\n[patient] yes . the 50 milligrams every day .\n[doctor] great . it sounds like you're well on your way to recovery .\n[patient] great .\n[doctor] so , let's continue on your current meds . i'm glad that you're figuring out what your body can handle . definitely try to keep active as that will certainly help .\n[patient] i'll do my best .\n[doctor] and that's about it . do you have any questions for me ?\n[patient] um , i do . when do i need to come back and get checked out ?\n[doctor] well , i do n't think you need to come back soon . everything from a cardio perspective is fine . so , i think let's do a followup in about six to nine months .\n[patient] all right , thank you . it was good to see you again dr. hughes .\n[doctor] you as well ms. sanchez , do take care .\n[patient] you too .",
            "tgt": "CHIEF COMPLAINT\n\nStatus post mitral valve repair.\n\nHISTORY OF PRESENT ILLNESS\n\nMrs. Melissa Sanchez is a 58-year-old female being seen today for a status post mitral valve repair, completed on 08/03/2020.\n\nOn 09/17/20 we saw Mrs. Sanchez in office, and she was doing well and thus we recommended maintaining her current medications, she is using a reminder app to stay compliant with medications.\n\nThe patient reports feeling better and overall, pretty good. She denies experiencing new symptoms. She is still having chest pain intermittently, and her breathing \u201cgets shallow\u201d which results in her \u201cslowing down\u201d and decreasing her exertion. An episode of shortness of breath and chest pains may last a few minutes and will not recur for a few weeks.\n\nPAST HISTORY\n\nMedical\nMitral regurgitation.\nAtrial fibrillation.\nDiabetes Type II.\nAsthma.\n\nSurgical\nMitral valve repair 08/03/2020.\n\nCURRENT MEDICATIONS\n\nCoumadin 4 mg daily.\nLasix 40 mg daily.\nAtenolol 50 mg daily.\n\nPHYSICAL EXAM\n\nHead and Neck\nNo JVD detected.\n\nRespiratory\nLungs have reduced breath, but auscultation and percussion are clear.\n\nCardiovascular\nRhythm is irregularly irregular, S1 slightly accentuated, no S3.\n\nMusculoskeletal\nTrace peripheral edema on extremities.\n\nRESULTS\n\nECG, 12/26/2020.\nImpression: Atrial fibrillation with a controlled ventricular response, t-wave inversion anteriorly. Compared to the previous study, there are no significant changes. I also recommended that the patient continues to be active within her limits.\n\nASSESSMENT\n\n\u2022 Status post mitral valve repair\n\nMrs. Melissa Sanchez is a 58-year-old female being seen today for a status post mitral valve repair, completed on 08/03/2020.\n\nPLAN\n\nContinue with current medications. Coumadin 4 mg daily, Lasix 40 mg daily, and Atenolol 50 mg daily.\n\nINSTRUCTIONS\n\nReturn to clinic in 6-9 months.",
            "file": "D2N103-virtscribe"
        },
        {
            "src": "[doctor] judy gomez , mrn 869723 . date of birth , 5 , 7 , 1961 . she's in office today for ongoing management of psoriatic arthritis . hello , judy , how are you doing today ?\n[patient] i'm doing good , thank you . how are you ?\n[doctor] i'm great , thanks . so how have you been since the last time ? i know the last time we were talking about decreasing your prednisone dose , correct ?\n[patient] yes . i'm just on one now and that seems to be enough .\n[doctor] aw , that's great to hear .\n[patient] yeah , there were a couple days there i took an extra one , just because there was a little extra pain in my feet . and i do have a desk job , so when i have a day off where i'm moving around a lot they do tend to hurt a bit more .\n[doctor] okay . how many times did you do that ?\n[patient] um , it was n't often , maybe once a week .\n[doctor] okay . so it sounds like we're still on track for discontinuing the prednisone . we'll do that today and you can let me know how it goes on your next visit . and how about the methotrexate , do you think that helped with your joint pain ?\n[patient] yeah , definitely . because i went to get my covid shots , um , but from the letter i got about it , it said that it could interfere with the vaccine , you know , reduce the efficacy . so i did n't take it on the week that i got the first shot .\n[doctor] okay . and what happened ?\n[patient] i felt absolutely horrible until i took it again a week later .\n[doctor] i'm sorry to hear that . and- and what did you do about the second dose ?\n[patient] well , i called into the hotline because i was in so much pain with the first one . and they said , \" no , just go ahead and take it , \" so i did .\n[doctor] okay . that's good then . we do have to keep an eye out on it since it's a high-risk medication . do you have an appointment to get your blood drawn for the next time ?\n[patient] no , they did n't give me one .\n[doctor] okay . so we can do that for you too . uhm , so what questions do you have for me , judy ?\n[patient] well , i just wanted to know why i was getting all these bruises here , so like when i bump myself . i do n't know where they're coming from .\n[doctor] okay . that's probably from the prednisone , it can increase bruising .\n[patient] okay . i did n't know that . um , i do n't even feel it when it happens , they just show up .\n[doctor] yeah . unfortunately that can happen , but we're working on discontinuing that so let's see if the bruises do go away .\n[patient] okay . that sounds good , thanks .\n[doctor] okay , judy , please , um , sit up here and i'll take a look . shoes and socks off please .\n[patient] all right .\n[doctor] all right . let me see here . okay . so where is it hurting ? in your joints right here ?\n[patient] yeah , a little . also in my feet joints as well .\n[doctor] okay . and how about when you bend the knee like this ?\n[patient] well , it hurt before we increased the methotrexate , but it's doing pretty good now .\n[doctor] okay , good . can you flex your toes please ? good range of motion . also ridges in nails , that's from the psoriasis .\n[patient] yeah . they've been like that for a long time now .\n[doctor] okay . all right , uhm , ms gomez , it looks like we're moving along with your treatment nicely . we'll stop your prednisone and continue with the methotrexate . make sure to stop by the front desk and make an appointment for the blood work , and i'll see you in three months .\n[patient] all right . it sounds good . thank you so much , it was great to see you .\n[doctor] it was great seeing you too . thank you .",
            "tgt": "CHIEF COMPLAINT\n\nPsoriatic arthritis management.\n\nHISTORY OF PRESENT ILLNESS\n\nJudy Gomez is a 61-year-old female who presents to the clinic today for ongoing management of psoriatic arthritis.\n\nMs. Gomez is currently taking methotrexate and prednisone 1 mg daily. She believes methotrexate has been relieving her joint pain.\n\nThe patient reports she has been doing well since her last visit. She has been able to decrease her prednisone dose to 1 mg daily; however, she took 2 mg for a couple of days due to increased pain in her bilateral feet.\n\nThe patient states when she received her first COVID-19 vaccine she held her methotrexate and felt \"horrible\" all week until the next Wednesday when she took it. She felt better by the end of the week. She did not hold methotrexate for her second COVID-19 vaccine.\n\nPHYSICAL EXAM\n\nMusculoskeletal: Full range of motion. Dystrophy of all the nails of the toes.\n\nASSESSMENT\n\n\u2022 Psoriatic arthritis.\n\u2022 High risk medication use.\n\nPLAN\n\nPsoriatic arthritis.\nStable on methotrexate and prednisone 1 mg daily. The patient will discontinue prednisone and continue methotrexate.\n\nINSTRUCTIONS\n\nThe patient will follow up in 3 months.\n",
            "file": "D2N104-virtscribe"
        },
        {
            "src": "[doctor] patient's name is diana scott . date of birth , 12/8/1920 . the date of service is 7/9/2021 . this is a new patient note .\n[doctor] good afternoon . how are you today ?\n[patient] i'm good , thank you .\n[doctor] good . well , what brings you in to see me today ?\n[patient] well , my doctor says that i have a heart murmur .\n[doctor] okay .\n[patient] so i do n't know how big a heart murmur i have , or really even what it is .\n[doctor] okay . so how long have you had that for ? do you have any idea , or is that completely new as far as you know ?\n[patient] yeah , she said it's a new worrisome heart murmur . so of course , i'm worried as well .\n[doctor] got it . okay . and are you having any symptoms at all ?\n[patient] i do n't think so . i do n't know what symptoms i should be having .\n[doctor] okay . well , so you are 100 , so we ca n't really get around that one . so i expect that you probably do n't move quite as fast as maybe you used to ?\n[patient] no , i definitely do n't .\n[doctor] okay . and do you notice that you have any chest pain or f- feel shortness of breath ?\n[patient] no , i do n't have any chest pain . um , my problem is i have severe pains in my legs , and so she had me going for a chest x-ray , and that was just last week .\n[doctor] okay .\n[patient] and so i started taking pain pills for my legs .\n[doctor] okay , got it , for the legs . and do you feel short of breath at all ?\n[patient] if i walk too fast or too long , or if i tried to drink a whole glass of water without stopping , then yeah , i do get short of breath that way .\n[doctor] okay . and how far can you walk before you feel short of breath or sort of overly fatigued ?\n[patient] well , i do have a walker now , so i do n't know . maybe when i walk to the end of the driveway or i walk around the culdesac .\n[doctor] got it . all right .\n[patient] so it is n't that bothersome to me at all . um , maybe more if i try to overdo it .\n[doctor] okay .\n[patient] then i , um , i get short of breath if i do overdo it though .\n[doctor] okay , got it . and so how different would you say , um , that the symptoms are now compared to like six months ago or a year ago ?\n[patient] i would say probably 70 to 80 % from about six months ago . before that i did n't notice anything at all .\n[doctor] okay . so do you feel like it's mainly the leg pain that seems to limit you ?\n[patient] my legs have been severe for about a month now .\n[doctor] okay . and how about , do you feel lightheaded or dizzy at all ?\n[patient] yeah . so i do take a pill for that when it does get bad .\n[doctor] okay .\n[patient] yeah , and i do n't take it every day , only when i do feel dizzy .\n[doctor] okay . and so how about any passing out at all ?\n[patient] no .\n[doctor] okay , good . and how about irregular heartbeats ? do you ever feel like your heart is going too fast or like it skips a beat ?\n[patient] i do n't notice it at all .\n[doctor] okay , great . and how about any swelling in the legs at all ?\n[patient] yeah , my ankles swell .\n[doctor] okay . and how long has this been going on ?\n[patient] um , i would say for probably six months . but it goes up and down , and sometimes it's worse than other times .\n[doctor] okay . and how about any recent weight gain or anything else like that ?\n[patient] um , i lost a little bit of weight , but i still weigh a 120 pounds , but i normally weigh about 130 pounds .\n[doctor] mm-hmm . okay .\n[patient] um , but that's been going down gradually for about a year .\n[doctor] okay . and then how about any fevers , chills or anything else that's , that's going on that you can think of ?\n[patient] no .\n[doctor] good . so mainly it sounds like you came in , um , mostly because of the murmur . is that right ? and sort of just kind of seeing what things look like ?\n[patient] yeah , that and i feel overly tired because i take all that medication .\n[doctor] okay . and so fatigue as well . and have you ever had any testing of your heart done ?\n[patient] i'm not really sure .\n[doctor] okay . it does look like you've had a decent number of sh- , uh , surgeries here , ?\n[patient] yeah , you name it .\n[doctor] all right . well , i wo n't make you repeat them since i do have a good record . um , but just give me just a second and i'm going to enter the ones we need , okay ? all right . got them . and then , are you taking all the medicines that you went through with madison ?\n[patient] yes .\n[doctor] okay , good . and looking at your family history , it looks like maybe your brother had a heart attack . is that correct ?\n[patient] it was actually my son , not my brother .\n[doctor] okay , i'll make that adjustment .\n[patient] um , but my brother did have a stroke . but that was because he had gotten sugar diabetes , and my eldest sister did have a heart problem as well .\n[doctor] okay , i see .\n[patient] yeah , so heart problems kinda run in the family .\n[doctor] okay . all right . well , it looks like also that you never smoked . that's excellent . and then no allergies to medicines that you know of , is that correct ?\n[patient] correct .\n[doctor] all right . well , let's do a quick exam .\n[patient] all right . sounds good .\n[doctor] all right . well , for physical exam , please use the regular template . all right , please just breathe normally . great . and now take a few deep breaths for me . all right . do you feel okay ? are you feeling any dizziness or anything ?\n[patient] no , i feel fine .\n[doctor] okay , great . all right . well , that is it for the exam .\n[patient] okay .\n[doctor] all right . so what i'm thinking is , let's go ahead and schedule you for an echocardiogram . it's a very common test and it just takes a picture of your heart . and it'll let me see how well your heart is actually working .\n[patient] okay .\n[doctor] and i can order that for today . um , do you have time to complete that ? it should n't take too long .\n[patient] yes , that's fine . i have time .\n[doctor] okay , great . so we will complete that today , um , to assess your overall cardiac structure and function , as well as , uh , the valve view of where diseased .\n[patient] okay .\n[doctor] and some hospital outcomes and what we might suggest to fix that out , i'll go over that . so one possible suspicion i'm having is it's called , um , aortic stenosis , and that just means that one of your main valves of your heart has narrowed a bit and the valve does n't really open , um , quite fully . and this could just reduce or block the blood flow from your heart into the main artery of your body , and that's called the aorta , into the rest of your body .\n[patient] okay .\n[doctor] and if this is severe , then we might wan na perform a procedure called the transcatheter aortic valve replacement , or we just call it tavr . and it is a minimally invasive procedure to replace the valve .\n[patient] well , i would have to think about that . i'm not too sure i'd wan na do that , given my age of all .\n[doctor] yeah , sure , no problem . and we do n't have to make any decisions today , just , you know , wanted to go over a couple of these things . um , but sometimes we can also perform a surgical aortic valve replacement , or it's called an savr . but really , because of your age and medical history , um , unfortunately , that would n't be a good option for you .\n[patient] i see . okay . well , i guess we'll see , um , what you see from , from the , um , test .\n[doctor] yeah , agreed . okay . and , um , so couple other things real quick . so it looked like your blood pressure looked really good today . so we're not going to change your amlodipine or lisinopril . so just continue taking those as you are currently .\n[patient] okay , good .\n[doctor] and then , it also looks like you're taking about 20 milligrams of simvastatin for your lipids . and i will pr- , um , defer to your pcp . however , given you are having leg pain in both your legs , and given your age and no history of coronary artery d- , artery disease , it is possible that you might be able to stop your statin .\n[patient] really ?\n[doctor] yeah , um , possibly . he would have to evaluate you , but it is certainly something to discuss with him . so i will send over the results of the echocardiogram and also my recommendations and then you guys can talk about the statin .\n[patient] okay , that sounds great . thank you .\n[doctor] 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 .\n[patient] okay , i will .\n[doctor] all right . so we will see you back here in about three or four weeks to discuss the results and your next steps . um , and we'll , uh , take care of your echocardiogram today . um , any questions ?\n[patient] not that i can think of . thank you so much . and i think it looks good .\n[doctor] okay , awesome . all right . well , have a good rest of your day , and we'll see you soon .\n[doctor] 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 border with , uhm , mild radiation to the carotids . neurologic gait is normal for age .\n[doctor] for assessment and plan , probably one cardiac murmur . diana has a 4/6 systolic murmur at the upper right sternal border with mild radiation to the carotids . this is most likely representative of aortic stenosis , for symptoms could be due to severe aortic , aortic stenosis . however , her s2 is relatively preserved , which would be more consistent with , consistent with moderate . some of her outside records do note diastolic dysfunction , so it is possible she , she did have an echocardiogram at some point in the past . she does not appear significantly volume overloaded today .\n[doctor] her next problem is pvcs . her referral mentioned tachycardia . uh , her ekg today shows sinus rhythm with frequent pvcs , as well as an anterior septum infarct pattern . she does not have any significant palpitations and we will check an echocardiogram to assess overa- overall cardiac structure and function . depending on results as well as the severity of her aortic stenosis , we will need to consider an ischemic evaluation , or further , possibly a heart mon- monitor to assess overall burden of the pvcs . at this point , she's asymptomatic , so we will start with the echocardiogram only .\n[doctor] her next problem , hypolipidemia , is managed by her pcp . due to bilateral leg pain over the last month , considered tavr evaluation following echocardiogram . statin could be indicated .\n[doctor] and next problem , lightheadedness , dizziness . she is on meclizine for this . it is possible that some of her lightheadedness and dizziness is related to the aorta stenosis , and we will do an echocardiogram as noted above . pvcs on her ekg could be contributing , but she does not feel palpitations . we will consider a monitor , but start with the echocardiogram first as noted above . follow up three to four weeks after her echocardiogram is done to discuss results and next steps . end of dictation .",
            "tgt": "CHIEF COMPLAINT\n\nHeart murmur.\n\nHISTORY OF PRESENT ILLNESS\n\nDiana Scott is a 100-year-old female who presents today for evaluation of a heart murmur.\n\nMs. Scott has been recently diagnosed with a \u201cnew, worrisome\u201d heart murmur. She denies chest pain, syncope, palpitations, fevers, or chills. She reports shortness of breath if she walks too fast, too long, or tries to drink a whole glass of water without stopping. The patient requires a walker and can walk around her cul-de-sac or to the end of the driveway without shortness of breath. Compared to 6 months ago, her functioning has declined 20-30%. Prior to 6 months, symptoms were absent. For the past month she has been experiencing severe, bilateral leg pain, which was limiting her mobility. She did see her doctor last week who completed a chest x-ray and prescribed pain medicine. Occasionally, she feels dizzy but takes medication for this and it subsides. Her ankles have been swelling for the past 6 months, but the swelling fluctuates day to day. Her weight has been slowly decreasing over the past year, with her current weight at 120 pounds, previous weight was 130 pounds. She also reports feeling \u201coverly tired\u201d but attributes this to her polypharmacy.\n\nThe patient is unsure if she has completed any cardiovascular testing.\n\nPAST HISTORY\n\nMedical\nHyperlipidemia.\nHypertension.\nHypothyroid.\n\nSOCIAL HISTORY\n\nRequires a walker to ambulate.\n\nFAMILY HISTORY\n\nSon had a myocardial infarction.\nBrother had a stroke and has diabetes.\nOlder sister has an unknown heart problem.\nFamily is positive for heart disease.\n\nCURRENT MEDICATIONS\n\nLevothyroxine.\nLisinopril.\nSimvastatin 20 mg.\nMeclizine.\nAmlodipine.\n\nALLERGIES\n\nNo known drug allergies.\n\nPHYSICAL EXAM\n\nConstitutional\nElderly, no acute distress.\n\nCardiovascular\nNormal S1, S2 preserved, irregular rhythm and normal rate. 4/6 systolic murmur at the RUSB with mild radiation to the carotids.\n\nMusculoskeletal\nLower extremity edema\n\nNeurologic\nGait normal for age.\n\nRESULTS\n\nEKG\nImpression: Sinus rhythm with frequent PVCs as well as anterior septal infarct pattern.\n\nASSESSMENT\n\n\u2022 Cardiac murmur.\n\u2022 PVCs.\n\u2022 Hypertension.\n\u2022 Hyperlipidemia.\n\u2022 Hypothyroid.\n\u2022 Lightheadedness/dizziness.\n\nPLAN\n\nCardiac murmur\nDiana has a 4/6 systolic murmur at the RUSB with mild radiation to the carotids. This is most likely representative of aortic stenosis. She does have symptoms including a significant increase in fatigue over the last 6 months, shortness of breath, and some lightheadedness. This could be due to severe aortic stenosis, however, her S2 is relatively preserved which would be more consistent with moderate. She is unsure if she has had an echocardiogram, although some of her outside records do note diastolic dysfunction, so it is possible that she had one as some point in the past. We will order a repeat echocardiogram today to assess overall cardiac structure and function as well as valvular disease. If she does truly have severe aortic stenosis, I briefly discussed a TAVR procedure today as she is not a candidate for a surgical AVR given her age co-morbidities and frailty. She is unsure if she would be interested in this, but we will assess first with the echocardiogram and then discuss further at follow-up. She does not appear significantly volume overloaded today.\n\nPVCs\nHer referral mentions tachycardia. Her EKG today shows sinus rhythm with frequent PVCs as well as anterior septal infarct pattern. She does not have any significant palpitations. We will check an echocardiogram to assess overall cardiac structure and function. Depending on results as well as the severity of her aortic stenosis, we will need to consider an ischemic evaluation or possibly a heart monitor to assess the overall burden of PVCs. At this point, she is asymptomatic, so we will start with the echocardiogram only.\n\nHypertension\nShe is taking amlodipine and lisinopril. We will continue these as is.\n\nHyperlipidemia\nThis is managed by her PCP. She is on simvastatin 20 mg. She is having bilateral leg pain over the past month. This could be related to the simvastatin possibly and given her age, it would not be unreasonable to stop the simvastatin, but I will defer to her PCP. She has no known CAD but if we were to do a TAVR evaluation and this was discovered, a statin would be indicated.\n\nHypothyroidism\nShe takes levothyroxine for supplementation and will continue this as is.\n\nLightheadedness/dizziness\nShe is on meclizine for this. It is possible that some of her lightheadedness and dizziness are related to the aortic stenosis, and we will do an echocardiogram as noted above. She is also having some PVCs on her EKG, which could be contributing, but she does not feel palpitations. We will consider a monitor but start with the echocardiogram first as noted above.\n\nINSTRUCTIONS\n\nFollow-up in 3 to 4 weeks after her echocardiogram is done to discuss results and next steps.\n",
            "file": "D2N105-virtscribe"
        },
        {
            "src": "[doctor] hey charles i'm using this cool new recording device to help me with my documentation is that okay with you\n[patient] sure\n[doctor] awesome how are you doing today\n[patient] well i could be better you know i moved out in the city\n[doctor] about two years ago bought this big plot of land\n[patient] oh\n[doctor] i love it lots of deer round awesome\n[patient] you be hunter\n[doctor] huge hunter i love hunter yeah\n[patient] i have a refrigerator full of venison at home\n[doctor] do you\n[patient] mm-hmm\n[doctor] you want to carry share sure yeah we can switch\n[patient] nice but so the thing is i have noticed that for some reason my breathing\n[doctor] is n't what it used to be\n[patient] sure\n[doctor] yeah it's you know i i seem to catch my breath a lot more than i used to and i consider myself to be pretty healthy\n[patient] you look pretty healthy\n[doctor] thanks so do you thank you you you're feeling short of breath\n[patient] yes\n[doctor] okay is there you know is there any other symptoms that you have with that i get like you know mid shortness of breath suddenly for some reason i'm not quite sure why\n[patient] hmmm\n[doctor] eyes they're water does n't make very much sense to me\n[patient] mm-hmm\n[doctor] i always think it's allergies\n[patient] okay\n[doctor] mostly could be\n[patient] i have a dog that eyes water like that she always gets eyebugers\n[doctor] yeah i get eyebugers too\n[patient] uh\n[doctor] crazy uh the last time it happened i went to the urgent care and they gave me a nebulizer that helped\n[patient] they prescribed me an inhaler that i use now when i feel the symptoms coming on\n[doctor] okay great do you ever notice a rash with any of this\n[patient] no\n[doctor] do you have any nausea vomiting\n[patient] no\n[doctor] besides when you go out heavy drinking right\n[patient] i mean i diarrhea quite a bit once i go out\n[doctor] i understand that\n[patient] heavy drinking\n[doctor] yeah do you ever get lip or throat swelling\n[patient] no\n[doctor] have you ever had any issues with allergies in the past\n[patient] no\n[doctor] hmmm what situations do you notice the symptoms come on when is it when you're near your cat or outside the house\n[patient] i have noticed them in all three situations\n[doctor] hmmm\n[patient] in the house when the cat is n't around and outside as well\n[doctor] hmmm yeah i'm not a big cat person\n[patient] no neither\n[doctor] do you do you have any symptoms now well which is\n[patient] no\n[doctor] no no travels and no symptoms right now\n[patient] mm-hmm\n[doctor] okay\n[doctor] 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 there is no angioedema which is just swelling of your lips like you mentioned no audible stridor which is a bad noise in your airway when it gets swollen so that's good news if you just want to take a deep breath listening to your lungs on your lungs exam i do appreciate some faint expiratory wheezing bilaterally in all lung fields so i know you had a chest x-ray when you came in i'm looking at that chest x-ray right now and your pulmonary function test and they were both normal so let's talk a little bit about what i think is going on for your first problem you have newly diagnosed allergic asthma so i want you to continue the albuterol inhaler i do n't want you to wait until your symptoms flare up or are bad take it as soon as you start to feel any symptoms at all i'm gon na prescribe something else called singulair ten milligrams you might have seen some commercials for it\n[patient] hmmm\n[doctor] you take that once daily and that's gon na help decrease the occurrences of your asthma\n[patient] hmmm\n[doctor] i also am gon na proceed with allergy testing have you ever had an allergy test before\n[patient] no\n[doctor] okay we'll start with skin testing and we'll see if we can target what the triggers in hopes in hopes that we can avoid any any other management and this can be successful if we ca n't figure out what it is from that we'll have to discuss more testing in your blood and do immunotherapy so i wan na see you next week to schedule the skin testing do you have any questions for me\n[patient] should i come my cats\n[doctor] yes",
            "tgt": "CHIEF COMPLAINT\n\nShortness of breath.\n\nHISTORY OF PRESENT ILLNESS\nCharles Sullivan is a pleasant 45-year-old male who presents to the clinic today for the evaluation of shortness of breath. The onset of his symptoms began 2 years ago. He has noticed that his breathing is not what it used to be. He describes an increased need to catch his breath. The patient also reports he gets \u201cmid-shortness of breath\u201d without reason. He has been seen at an urgent care where he received a nebulizer treatment and was prescribed an inhaler, which he uses when his symptoms are present. The patient states his symptoms are aggravated by living with a cat in his house and are present even when the cat is not around or is outside. He has experienced epiphora with rheum present that he attributes to allergies. He has had diarrhea after consuming large amounts of alcohol. He denies any symptoms at this time including shortness of breath, rash, nausea, vomiting, and lip or throat swelling. The patient denies any previous issues with allergies.\n\nHe enjoys hunting.\n\nVITALS\n\nOxygen Saturation: Normal on room air.\n\nPHYSICAL EXAM\n\nCONSTITUTIONAL: In no apparent distress.\nHEAD: No angioedema.\nRESPIRATORY: No audible stridor. I do appreciate some faint expiratory wheezing bilaterally in all lung fields.\nSKIN: No rash.\n\nRESULTS\n\nA chest x-ray, obtained and reviewed today is normal.\nPulmonary function test, obtained and reviewed today is normal.\n\nASSESSMENT\n\nNewly diagnosed allergic asthma.\n\nPLAN\n\nAfter reviewing the patient's examination, radiographic findings, and pulmonary function test results today, I have had a lengthy discussion with him regarding his current symptoms. He will continue to use the albuterol inhaler; however, he should limit its use to when he is experiencing a severe flare-up of symptoms. I advised he should take it as soon as he starts to feel any symptoms at all. I have also prescribed the patient Singulair 10 mg to be taken once daily. This should help to decrease the occurrences of his asthma. I have also recommended we proceed with an allergy skin test to target what his triggers are in the hope that we can avoid any other management. If we unable to determine his allergens, then we may consider further testing or immunotherapy.\n\nINSTRUCTIONS\n\nThe patient will follow up with me in 1 week for skin testing.",
            "file": "D2N106-aci"
        },
        {
            "src": "[doctor] so bryan it's nice to see you again in the office today what's going on\n[patient] i was in my yard yesterday and i was raking leaves and i felt fine and then when i got into my house about two hours later my back started tightening up and i started getting pins and needles in my right foot\n[doctor] alright have you ever had this type of back pain before\n[patient] i had it once about three years ago but it went away after a day\n[doctor] okay and did you try anything for the pain yet did you take anything or have you have you tried icing\n[patient] put some ice on it and i tried two advils and it did n't help\n[doctor] okay does it get better when you're laying down sitting standing\n[patient] yeah i think the only thing that helped was a hot shower and it feels a little better when i sit\n[doctor] okay alright so you said you were raking leaves and now it's been kind of that weather outside for cleaning out the yard have you been doing a lot of yard work lately\n[patient] i i i normally do n't do any physical activity\n[doctor] yeah i hear you i make a i make my husband do all the yard work too so alright let me take a look at that low back if if you bend over does that hurt\n[patient] it hurts a little bit when i bend over yes\n[doctor] okay how about when you stand back up\n[patient] no pain\n[doctor] okay so no pain on extension some pain on flexion how about when i push right here on your back\n[patient] yeah that hurts\n[doctor] okay so some pain to palpation right around the l5 can i have that\n[patient] what happens when family members chime in like i'm doing right now because i actually think it was it hurts more when he stands up because i've watched him bend over but it's when he stands up that it really hurts\n[doctor] okay and and what's your relationship\n[patient] partners\n[doctor] okay so your partner is here with you today and reports that he is also having pain when you are standing up\n[patient] i've spent so many times you know who i am\n[doctor] so that's right you always come in together have you noticed anything else partner when when he is\n[patient] i'm worried about it because he is you know his pain tolerance is so high and he would n't be saying anything if it really was n't a problem because it's not at all like last week when he thought about raking leaves but did n't actually rake leaves but then his back did n't hurt as much but this time it really hurts\n[doctor] okay so you think this is more of a long term injury\n[patient] no he was just thinking about it hurting when he thought about raking but it did n't\n[doctor] okay alright and have you noticed any any prior pain with with the back\n[patient] i do n't want to take this away you better go back to talking to him\n[doctor] that's alright let's see how it turns out okay so how about if you if i push down on both your feet like this can you push back up on my hands\n[patient] can you repeat that\n[doctor] if i'm pushing down on your feet can you push push your feet back\n[patient] i\n[doctor] alright so your dorsiflexion is normal looks like pulses are equal in all extremities you said you had a little bit of a tingling sensation in which leg\n[patient] that would be my right leg\n[doctor] 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 do is let's rest it i'm going to prescribe some meloxicam have you taken that before\n[patient] i have not taken meloxicam\n[doctor] alright so i'll prescribe that i'm also gon na prescribe some physical therapy i know you said you have n't been overly active and your partner reported the same thing for a long time so we might wan na get you into some pt and hopefully get you back back in shape get you some stretches that you can do and some exercises and then you know if it's not improving i want you to send me a message and we can possibly look into see if there is anything else going on potentially an mri if it's still not improving does that sound like an okay plan\n[patient] it sounds reasonable\n[doctor] alright\n[patient] i think he should have an mri now i think he had surgery yesterday i think he should have an mri now this it's been hurting for like six hours now and she had an mri we are really worried about it\n[doctor] alright you know let's give it a couple of weeks and let's give it two weeks and then call me back and we'll get you an mri if it's still not improving\n[patient] good answer\n[doctor] alright alright hope you feel better",
            "tgt": "CHIEF COMPLAINT\n\nLow back pain.\n\nHISTORY OF PRESENT ILLNESS\n\nBryan Brooks is a pleasant 39-year-old male who presents to the clinic today for the evaluation of low back pain. He is accompanied today by his partner.\n\nApproximately 2 hours after he finished raking leaves yesterday, the patient began to feel a tightening sensation in his low back and tingling in his right foot. Prior to this, he recalls a similar episode approximately 3 years ago in which his symptoms resolved after 1 day. Ice and Advil provided no relief, but his pain is less severe when he is in a seated position and taking a hot shower helped alleviate his pain. The patient's partner reports that his pain seems to worsen when he stands up.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports low back pain.\nNeurological: Reports tingling in the right foot.\n\nPHYSICAL EXAM\n\nNEURO: Normal strength and sensation.\nMSK: Examination of the lumbar spine: No pain on extension. Some pain with flexion. Pain with palpation around L5. Dorsiflexion is normal. Pulses are equal in all extremities.\n\nRESULTS\n\nX-rays obtained and reviewed in office today were normal.\n\nASSESSMENT\n\nLow back sprain.\n\nPLAN\n\nThe examination findings and x-ray results were discussed with the patient and his partner today. I recommend we treat this conservatively with rest, meloxicam, and formal physical therapy. If he fails to improve, we can consider obtaining an MRI for further evaluation.\n\nINSTRUCTIONS\n\nThe patient will follow up in 2 weeks.",
            "file": "D2N107-aci"
        },
        {
            "src": "[doctor] hey gregory good to see you today so take a look at my notes and i see that you're here you've had a nonhealing foot ulcer so can you tell me how you're doing how long have you had it what's going on with it\n[patient] sure so i've had it for about two months now and it's recently become red and is draining so i was concerned about how it's healed\n[doctor] okay and when you when you got it would you have any trauma to your foot or it just just did it pop up all of a sudden\n[patient] i think i may have gotten it from walking barefoot on the beach\n[doctor] okay alright and i saw you you did see your pcp before you came in did they put you on antibiotics\n[patient] they did start me on some medication but i did n't i did n't pick them up from the pharmacy yet\n[doctor] okay do you know which ones that they prescribed for you\n[patient] i do n't recall the name exactly\n[doctor] do n't recall alright\n[patient] something i had taken it before\n[doctor] okay so when you what beach did you go to when you you hurt it\n[patient] i'm sorry\n[doctor] so i was asking which beach did you did you go to when you hurt your foot\n[patient] at i was at dewey beach in my ambulance\n[doctor] dewey beach wow that sounds like fun i wish i could be a mab right now but all or as lucky as i guess as you are to go to dewey beach okay so does it hurt\n[patient] it sometimes it throbs does n't i do n't have specific pain but sometimes it does feel like there is some throbbing going on and again my my biggest concern is the it started to drain and it looks a little red\n[doctor] okay\n[patient] i have n't had that before\n[doctor] okay and that makes sense alright so as far as your diabetes you know and i think that's probably a a major cause of this not being able to heal how well are how well is that controlled\n[patient] i take my medication but i do n't check my sugar all the time\n[doctor] okay do you\n[patient] i'm not really sure how\n[doctor] okay do you know what your last a1c is i'm pretty sure you doc talk to you about it\n[patient] i think they told me it was around ten\n[doctor] 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\n[patient] no i i feel like increased pressure but it's not distinct\n[doctor] 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 foot ulcer and what i wan na do is i wan na order an abi ankle brachial index just to determine the blood supply in your foot to see if we can actually heal that ulcer i'm gon na also perform a debridement here just to take off some of that dead tissue and then i'm gon na prescribe you some clindamycin you can do that four hundred milligrams you take that for seven days take that twice a day just to try to get rid of that infection which you currently do have and that will get rid of some of that that redness and and drainage that that's happening right now did your doc did your pcp give you a surgical shoe something that you would wear while this is happening\n[patient] they did n't they mentioned that you may be able to give it to me\n[doctor] okay yeah we could definitely get you a a shoe because if you wear your regular shoes that pressure on that foot can really irritate it and take you backwards so i'll get you a shoe where you can wear that for the next month you know we just wan na make sure that it does heal and then i wan na see you back again in two weeks and we can we'll possibly do another debridement at that time we'll just take a look and see how the tissue is doing so how does that sound\n[patient] that sounds great\n[doctor] alright do you have any other question\n[patient] i do if anything happens in between\n[doctor] please feel free to call the office yeah please feel free to call you call the office we can definitely get you in you know if you are having any other issues and if it's an emergency if you feel like you're getting a fever feeling well please go to the urgent care or the er if you feel getting black or anything like that but otherwise we'll see you back in two weeks\n[patient] okay sounds great thanks document\n[doctor] alright great",
            "tgt": "CHIEF COMPLAINT\n\nRight foot ulcer.\n\nHISTORY OF PRESENT ILLNESS\n\nGregory Hernandez is a pleasant 40-year-old male who presents to the clinic today for the evaluation of a non-healing right foot ulcer. Onset of ulcer was approximately 2 months ago after walking barefoot on the beach. He reports the ulcer has recently become red and is draining. At times he will also experience throbbing pain. He has seen his primary care physician and was prescribed antibiotics, however, he has not started them yet and does not recall the name of the medication.\n\nThe patient is a diabetic. He is taking medication for this, however, he does not monitor his blood sugar consistently. His last A1C was around 10.\n\nMEDICAL HISTORY\n\nPatient reports history of diabetes.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports right foot pain.\nSkin: Reports right foot ulcer with redness and drainage.\n\nVITALS\n\nVital signs are normal.\n\nPHYSICAL EXAM\n\nMSK: Examination of the right foot: There is a 1 x 2 inch circular wound on the dorsal aspect laterally just proximal to the 5th MTP joint. There is some redness and drainage present as well as edema. No necrosis, odor, or bony exposure. Nontender to palpation.\n\nRESULTS\n\n3 views of the right foot were taken. These reveal no evidence of osteomyelitis.\n\nASSESSMENT\n\nRight diabetic foot ulcer.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any evidence of osteomyelitis. I have recommended that we obtain an ankle brachial index to determine the blood supply in his foot. Debridement will be performed. A prescription for clindamycin 400 mg 2 times per day for 7 days will be provided as he does seem to have an infection. He will also be placed in a surgical shoe to provide increased support for the next month.\n\nINSTRUCTIONS\n\nThe patient will follow up with me in 2 weeks to assess his progress and for possible repeat debridement. He has been advised to call the office if his symptoms worsen and we will get him in sooner, however, if he starts to develop a fever or necrosis he has been instructed to go to the ER.\n",
            "file": "D2N108-aci"
        },
        {
            "src": "[doctor] so stephanie morales is a 36 -year-old female today complaining of her ankle pain and she also has a history of diabetes and high blood pressure so stephanie tell me what's going on with your ankle\n[patient] well we had a long spring and the other day we got some snow and ice i was walking to my car and i slipped and my left ankle kinda turned underneath me\n[doctor] okay and so this happened couple days ago or how many days ago\n[patient] two days ago\n[doctor] two days ago okay and so it's your left ankle and it kinda just twisted underneath you on the kind of on the inside\n[patient] yeah more on the it's more on the outside of my hips\n[doctor] and did you fall down or did you just kind of cut catch yourself\n[patient] no i fell\n[doctor] okay and were you able to get up afterwards or somebody helped you up\n[patient] i was but it was very sore and then started swelling and quite a bit of pain so it's hard to walk\n[doctor] sure have you tried anything for pain or the swelling or anything like that\n[patient] ibuprofen some ice and elevation\n[doctor] okay has that helped much or not really\n[patient] a little bit\n[doctor] okay and any pain above your ankle does it hurt on your on your calf or your lower leg at all or knee at all\n[patient] no it's mostly just the outside of my ankle\n[doctor] okay got it and no bleeding or i'm sure it's a little swollen probably\n[patient] yeah it's swollen but no bleeding\n[doctor] well i'll have you take off your shoes in a second we'll examine you in a second but since you're here and i wanted to talk about some of your other things that you know we have n't i have n't seen you in a year so let's talk about your history of diabetes as well are you taking the metformin how's your blood sugars been how how're you managing that any issues with that\n[patient] no they've been pretty stable\n[doctor] okay\n[patient] so with my diet\n[doctor] good\n[patient] so\n[doctor] you're checking your sugars regularly as well\n[patient] yes\n[doctor] 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 ophthalmologist recently for your eye exam for your diabetes checkup or no\n[patient] i am due for one of those in the next couple of weeks\n[doctor] okay alright so we'll so you do you already have an appointment or do you need to make an appointment for that\n[patient] i have an appointment\n[doctor] perfect excellent okay and how is your blood pressure been i know we watching it your blood pressure today looks pretty good it's about one seventy over i'm sorry one twenty over seventy you're taking norvasc any issues with that any do you need any refills or anything\n[patient] i need a refill on that yes\n[doctor] 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 ejection murmur you had that in the past unchanged from before so that's not really worried about that your belly exam is good on your ankle exam on your left ankle you do have some tenderness over the lateral malleolus and you do also have some tenderness over this bone here which is the fifth metatarsal so i do n't see any there is some swelling there some redness but there is some pain with valgus stressing of your ankle as well and let me turn off my phone here and also you do have otherwise normal sensation normal pulses so on your so my diagnosis for your ankle is i think you probably have an ankle sprain but i would like to order an x-ray of your ankle because you do have some tenderness over this bone and i'm sometimes worried about a fracture so i'm gon na go ahead and get an x-ray i'm gon na put you in a splint we're gon na put you in a in an air splint and i'll give you some crutches until i get the x-ray back i want you to do just avoid weightbearing just to make sure there is no fracture there i will give you some naprosyn five hundred milligrams twice a day for pain control keep it elevated put some ice on it i think those are all good things and if the x-ray shows a fracture i'm gon na go ahead and give you a call back and we'll send you to orthopedics but right now let's try this air splint if there is no fracture i will probably have you take off the air splint and do some partial weightbearing and see how it goes does that sound like a reasonable plan for you\n[patient] that's a great plan i need to get back to exercising so\n[doctor] okay\n[patient] thank you\n[doctor] perfect and for the diabetes keep the eye appointment that you already have you know continue with the metformin i'm gon na order another hemoglobin a1c today we'll check some baseline labs as well since it's been a while since we checked them and then once if you have any issues or you know give me a call we can get you into the office and for the high blood pressure i'll go ahead and refill the norvasc today you're doing a great job with that it sounds like continue to monitor that if something changes certainly call me we can get you in sooner okay\n[patient] thank you\n[doctor] sounds good sounds good good great seeing you thanks stephanie\n[patient] thank you",
            "tgt": "CHIEF COMPLAINT\n\nLeft ankle pain.\n\nMEDICAL HISTORY\n\nPatient reports history significant for type 2 diabetes and hypertension.\n\nMEDICATIONS\n\nPatient reports taking metformin and Norvasc.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports left ankle pain and swelling.\\ Denies left calf pain, lower left leg pain, or left knee pain.\n\nVITALS\n\nBlood pressure: 120/70 mmHg\n\nPHYSICAL EXAM\n\nNeurological\n- Examination: Sensation intact in left lower extremity.\n\nNeck\n- General Examination: No bruits.\n\nRespiratory\n- Auscultation of Lungs: Clear bilaterally.\n\nCardiovascular\n- Examination: Pulses are normal in left lower extremity.\n- Auscultation of Heart: 2/6 systolic ejection murmur, unchanged from previous exam.\n\nMusculoskeletal\n- Examination of the left ankle: Tender to palpation over the lateral malleolus and fifth metatarsal. Trace edema. Mild erythema. Pain with valgus stress testing.\n\nRESULTS\n\nHemoglobin A1c: 6.8\n\nASSESSMENT AND PLAN\n\n1. Left ankle pain.\n- Medical Reasoning: Given the nature of her injury, I believe this is an ankle sprain.\n- Patient Education and Counseling: I advised the patient that I will contact her with the results of her x-ray, and that if these reveal a fracture, we will put in a referral to orthopedics for further evaluation.\n- Medical Treatment: X-ray ordered to rule out fracture. We will place her in an air splint and have her ambulate with crutches to avoid weightbearing until we get the x-ray results. She will start Naprosyn 500 mg twice daily for pain control. Continue with ice and elevation.\n\n2. Diabetes type 2.\n- Medical Reasoning: This appears to be well controlled with her current regimen.\n- Patient Education and Counseling: I encouraged her to keep her appointment with ophthalmology for her diabetic eye exam.\n- Medical Treatment: We will keep her on her current dose of metformin and order a repeat hemoglobin A1c. We will also obtain a set of baseline labs.\n\n3. Hypertension.\n- Medical Reasoning: She is doing well with Norvasc.\n- Patient Education and Counseling: I encouraged her to continue with home monitoring and knows to contact the office if needed.\n- Medical Treatment: We will keep her on her current dose of Norvasc. A refill was sent for this today.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N109-aci"
        },
        {
            "src": "[doctor] okay hi wayne well i understand you're here for you've got a sore on your foot that's not healing is that right\n[patient] yes\n[doctor] so can you tell me about that how are you doing\n[patient] well i've been doing okay but i've had this wound on my right foot for a couple of weeks and it's not getting better i saw my pcp and they referred me to you i i used to see a podiatrist and a couple of years ago but they moved and i was n't able to get another one\n[doctor] okay and how long have you had the wound\n[patient] about two to three weeks\n[doctor] okay have you had any kind of trauma to that foot\n[patient] no i bought a new pair of shoes to travel with and the neuropathy i guess i did n't feel that they were too tight at first it was just a blister but it looked a lot worse now i've been putting a band-aid on it and\n[doctor] okay and so did your doctor put you on any antibiotics when they they saw your foot\n[patient] yes i finished the course yesterday the wound looked about the same though\n[doctor] okay now does it hurt\n[patient] no i ca n't feel it\n[doctor] okay now have you had any other symptoms like fever chills drainage from the wound or anything along those lines\n[patient] no but when i take my sock off sometimes it sticks to the wound even when i put a band-aid on\n[doctor] okay well are you still wearing those same shoes that cause the problem\n[patient] no i'm upset\n[doctor] i'm so upset too i love those shoes\n[patient] no i'm so upset i i love those shoes\n[doctor] okay so what kind of shoes are they\n[patient] they're hoka's\n[doctor] ah so where did you get them\n[patient] i got them at rei couple of years ago\n[doctor] they're pretty good about helping you to fit your fit you in a shoe are n't they\n[patient] yeah\n[doctor] so what do you like about them\n[patient] they are comfortable they are easy to take on and off and they provide good stability\n[doctor] that's good so you've had some issues with stability sometimes or\n[patient] yes\n[doctor] okay okay well another question i want to ask you is how is your diabetes doing\n[patient] i do n't think it's too bad my last hgb a1c was a little over eight\n[doctor] okay alright well let me just do a quick physical exam okay for vital signs your temperature is ninety eight . one your vital signs look good your heart rate is seventy two respirations sixteen blood pressure is one ten over sixty five okay so on your foot exam let's see there is a one by two inch circular wound on the dorsal aspect of the lateral right foot it is just proximal to the right fifth to the fifth mtp joint and there is some yellow slough present with minimal granulation tissue there's no surrounding erythema or cellulitis and there's no evidence of fluid collection there's no necrosis there is no odor i do not appreciate any bony exposure on on vascular exam there are palpable bilateral femoral and popliteal pulses there are no palpable dp or pt pulses but doppler signs are present okay so does this hurt when i touch it here\n[patient] no it's okay\n[doctor] okay alright so i've reviewed the results your right foot x-ray that we did before you i came in the room and this shows no evidence of osteomyelitis which means there is no evidence of bone infection so that's really good so let me tell you a little about my assessment and plan for you so for your first problem your diabetic foot ulcer so i want to order an ankle brachial index abi to determine the blood supply to your foot to see if you can heal this wound i'm also gon na perform a debridement here in the office to take off some of the dead tissue and then next i'm going to prescribe a collagenase ointment to be applied to the wound once daily and then cover with a dry sterile dressing now we will continue this until we see the wound shrinking and a nice pink tissue is present and i want you to wear a surgical shoe to take pressure off of the area okay so i do n't think any more antibiotics are needed at this time and i want to see you again in two weeks so we may need to refer you to a vascular specialist if the abi indicates your blood supply is not optimal for wound healing okay\n[patient] okay\n[doctor] okay so for your diabetes it's gon na be very important to get your diabetes under control in order to get the wound to heal so we might even go ahead and get a diabetic consult so that we can go over some some maybe some ways you can modify your diet without a being too much but maybe that can bring down your hemoglobin a1c into a little bit better level okay\n[patient] okay\n[doctor] alright do you have any other questions\n[patient] no\n[doctor] okay",
            "tgt": "HISTORY OF PRESENT ILLNESS\n\nWayne Jenkins is a pleasant 43-year-old male who presents to the clinic today for the evaluation of a right foot wound, onset 2 to 3 weeks ago. He was seen by his primary care physician who referred him to our office. His last visit with a podiatrist was 2 years ago, however they moved, and he has been unable to get another podiatrist. He denies any specific injury.\n\nThe patient purchased a new pair of shoes and was breaking them in prior to traveling. Initially, he did not feel that the shoes were too tight, however a blister formed on his right foot. The patient does have neuropathy and notes this might be why he did not notice the tightness. His blister soon became a wound and he was seen by his PCP. He was placed on a round of antibiotics, which he completed yesterday. He denies any changes to the appearance of the wound. The patient denies pain or drainage. His sock will occasionally stick to his wound, regardless of if he has a Band-Aid covering it. The patient has discontinued the use of these shoes. Occasionally, he has issues with stability, which was a primary purpose of purchasing these shoes. He denies any fever or chills.\n\nRegarding his diabetes, his last hemoglobin A1C was 8.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Denies fever and chills.\nSkin: Reports right foot wound.\nNeurological: Reports neuropathy.\n\nVITALS\n\nTemperature: 98.1.\nHeart rate: 72.\nRespiration: 16.\nBlood pressure: 110/65 mm Hg.\n\nPHYSICAL EXAM\n\nCV: Palpable bilateral femoral and popliteal pulses. No palpable DP or PT pulses but Doppler signs are present. No evidence of fluid collection.\nSKIN: On the right foot, there is a 1 x 2 inch circular wound on the dorsal aspect of the lateral right foot that is just proximal to the 5th MTP joint. There is some yellow slough present with minimal granulation tissue. No surrounding erythema or cellulitis. No necrosis. No odor.\n\nRESULTS\n\n3 views of the right foot were taken today. These reveal no evidence of osteomyelitis.\n\nASSESSMENT\n\n1. Right foot diabetic ulcer.\n2. Diabetes.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient regarding his current symptoms. I have explained to him that his x-rays did not reveal any evidence of osteomyelitis. At this time, I have recommended that we obtain an ankle brachial index ABI to determine the blood supply to his foot to see if he can heal this wound. I have also performed a debridement in the office to remove some of the dead tissue. I have prescribed a collagenase ointment to be applied to the wound 1 time daily and instructed him to cover with a dry sterile dressing. He will continue this until we see the wound shrinking and the nice pink tissue is present. I have also recommended that the patient be placed in a surgical shoe to take pressure off the area. I do not think that antibiotics are needed at this time. He may need to see a vascular specialist if the ABI indicates that his blood supply is not optimal for wound healing.\n\nRegarding his diabetes, I explained the need for controlling his diabetes and the effects this will have on wound healing. I have recommended a diabetic consultation to discuss diet modifications to bring his hemoglobin A1c to a better level.\n\nINSTRUCTIONS\n\nThe patient will follow up with me in 2 weeks to check on his progress.",
            "file": "D2N110-aci"
        },
        {
            "src": "[doctor] hey william so i see that you injured your knee could you tell me a bit about what happened\n[patient] yeah i thought it was a good idea to go to the trampoline park with my wife and heard a snap and instant pain when i was on the trampoline\n[doctor] okay alright and so do do you go to the trampoline park often\n[patient] i do n't and i think that's the issue\n[doctor] okay so this is the first time you'd ever done something like that\n[patient] yes\n[doctor] okay alright i just wan na get like a few more details do you like work out regularly was this for fun or for like an exercise class\n[patient] no it's just for fun\n[doctor] okay and do you have like a regular exercise regimen at all\n[patient] try to not consistent with it\n[doctor] okay no that's fine this is not a place of judgment i just i'm just trying to understand like if a little bit more of the background okay so we went to the trampoline park which knee where did you hurt\n[patient] my right\n[doctor] okay your right knee and so based on like your inside and outside which part hurts more\n[patient] it's kind of the outside of the knee\n[doctor] alright so the lateral aspect not a problem and you said that you heard a pop when you landed right\n[patient] yeah\n[doctor] okay have you taken anything for the pain\n[patient] just tylenol\n[doctor] alright so did the tylenol help\n[patient] not really\n[doctor] okay alright and so hmmm when does it have you tried anything else like did you ice it use heat anything like that\n[patient] no i just kinda elevated it and that was about it\n[doctor] okay that's fine and how long ago did this happen\n[patient] a week ago\n[doctor] okay alright so you put up with the pain for a week that's i'm proud of you for that\n[patient] i do n't like to come to the doctors\n[doctor] 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\n[patient] what no\n[doctor] no okay that's fine have you measured your blood pressure recently at all\n[patient] no\n[doctor] okay are you still taking your medication because i see you're on twenty milligrams of lisinopril\n[patient] yeah most days i remember\n[doctor] okay\n[patient] ra i'm not suspicious but we're just gon na go with that okay because looking at your vitals it it is of still a bit high i'm not really comfortable i see like a hundred and eighty over you know eighty and\n[doctor] that's not where we wan na be so i wonder if we might need to adjust your medication but let's talk about your diabetes how are your blood sugars\n[patient] i think they're little bit better\n[doctor] okay what makes you think that have you been taking them\n[patient] yeah i check it you know most days again kinda when i remember\n[doctor] okay how often are you checking it\n[patient] i would say four five times a week\n[doctor] okay you might wan na switch to maybe two or three times a day but you know that's something i'm glad that you are measuring are you taking your metformin\n[patient] yes\n[doctor] okay and then i think we have you on five hundred milligrams correct\n[patient] yes\n[doctor] alright how is your diet\n[patient] kinda the same as my exercise decent could be better\n[doctor] alright and okay not a problem so what is your do you are you measuring your calories at all looking at your macros are you just eating what you feel like\n[patient] yeah just trying to watch what i eat more than anything but nothing specific\n[doctor] okay and are you do you know if you're particularly focused on your salt like is it like a low salt diet\n[patient] no just trying to watch my carbs a little bit more but not counting or anything\n[doctor] alright so like is it a specific diet i just wan na make sure like are you on like the keto diet\n[patient] no\n[doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and do a quick physical exam as i mentioned before your blood pressure is a little high as i listen to your heart i do like it's got a nice regular rate and rhythm i do n't appreciate any murmur when i listen to your lungs they sound clear bilaterally i would like to look at your knee though so when i press here on the outside does it hurt\n[patient] little bit\n[doctor] okay and then when i press on the inside does it hurt\n[patient] no\n[doctor] alright can you bend your knee and straighten it\n[patient] i can i think that's all i can i can bend\n[doctor] mm-hmm alright so are you having problems walking can you bear weight\n[patient] i can but i have a little bit of a limp\n[doctor] 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 ecchymosis and edema that just means bruising and swelling along the lateral aspect of your knee i do n't notice any effusion and it looks like you have a decent range of motion but i do understand that you know you are experiencing pain with some movement okay i'm gon na go ahead and order an x-ray and when you come back we can have that discussion alright so i reviewed the results of your right knee x-ray which showed no evidence of fracture or bony abnormality so let's talk about my assessment and plan alright so for your first problem of right knee pain i think you have a lateral a lateral ligament strain i wan na prescribe some meloxicam which is gon na be fifteen milligrams daily for pain and swelling i'm gon na refer you to physical therapy to help strengthen the muscles around the area and to prevent further injury if you're still having pain we can do further imaging imaging but like this is a common injury that tends to heal on its own for your second problem with hypertension i wan na continue the lisinopril at twenty milligrams and order an echo i am concerned that we might not be getting your blood pressure to where we need it to be so we might have to do some medication modification for your third problem with diabetes i wan na order an a1c i know that you said you have been measuring your blood sugars but i think this would give us a better image of what's been happening long term and i also wan na order a lipid panel in case we need to make any adjustments to that medication as well do you have any questions\n[patient] sounds good\n[doctor] alright awesome",
            "tgt": "CHIEF COMPLAINT\n\nRight knee injury.\n\nHISTORY OF PRESENT ILLNESS\n\nWilliam Russell is a pleasant 57-year-old male who presents to the clinic today for the evaluation of a right knee injury. He has a past medical history significant for hypertension and type 2 diabetes.\n\nApproximately 1 week ago, the patient sustained an injury to his right knee while at a trampoline park. He explains that he was jumping on a trampoline when he heard a snap, followed by instant pain in the lateral aspect of his knee. This is not a common activity for him, and he admits that he is inconsistent with exercise. As far as treatment, he has been elevating his knee and taking Tylenol without significant relief of his pain. He has not tried applying heat or ice to the area.\n\nIn terms of his hypertension, the patient admits that he did not purchase a blood pressure cuff as previously recommended. While he does not monitor his blood pressures at home, he has been compliant with lisinopril 20 mg.\n\nHis diabetes appears to be stable based on home monitoring, although he is only checking his blood glucose levels 4 to 5 times per week. He does not follow any specific diet plan, but he does try to make healthier choices such as limiting his carbohydrate intake. He has also been taking his metformin 500 mg as prescribed.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports right knee pain.\n\nVITALS\n\nBlood pressure: 180/80 mmHg\n\nPHYSICAL EXAM\n\nCV: Regular rate and rhythm. No murmurs.\nRESPIRATORY:\nLungs are clear bilaterally.\nMSK: Examination of the right knee: Mild tenderness to palpation at the lateral aspect. Ecchymosis and edema along the lateral aspect. No effusion. Decent range of motion. Pain with movement.\n\nRESULTS\n\nX-rays of the right knee were obtained and reviewed. These reveal no evidence of fracture or bony abnormality.\n\nASSESSMENT\n\n1. Right knee pain, lateral ligament strain.\n2. Hypertension.\n3. Diabetes type 2.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, his symptoms appear to be consistent with a lateral ligament strain of the right knee. I am going to prescribe meloxicam 15 mg once daily for pain and swelling. I also put in a referral for physical therapy so he can work on strengthening the muscles around the area and prevent any further injury. We can consider further imaging if he continues to have pain, but I explained that this is a common injury that typically heals on it's own.\n\nFor his hypertension, I'm concerned that his blood pressure is not well controlled at this time, so we may need to modify his medication. I'm going to order an echocardiogram for further evaluation, but I want him to continue taking his lisinopril 20 mg for now.\n\nFor his diabetes, he stated that he has been measuring his blood glucose levels 4 to 5 times per week, but I want him to start measuring them 2 to 3 times per day. His hemoglobin A1c levels should provide more detail as far as his long-term progress so we will order that today. I'm also going to order a lipid panel and we can determine if any adjustments need to be made to his medication. In the meantime, he should continue taking metformin 500 mg.\n",
            "file": "D2N111-aci"
        },
        {
            "src": "[doctor] hey matthew i see here that you've had some back pain for a while and your pcp sent you over to see me how're you doing today\n[patient] pretty good i'm feeling pretty good do n't like the weather you know i've been sitting in the waiting area for you know thirty minutes and that definitely makes the symptoms worse\n[doctor] okay well first of all i i agree with you the weather has kinda been all over the place been hot and been cold and and and now it seems like we've had a week of pretty chilly weather hopefully that changes pretty soon so tell me a little bit about when when your back pain started and and and what happened there\n[patient] well you wan na hear the long story or kind of the short story because my back has been bothering me for a long time\n[doctor] so let's do let's do the reader's digestive version\n[patient] well i ca n't i ca n't really tie my shoes you know standing really makes it bad you know when i go to the mall it really really i do n't know all i i've just been bedridden\n[doctor] okay and i know it got real bad about a month ago that's what the report here from the pcp said but can you tell me exactly where the pain is in your lower back can you kinda point to where that's at\n[patient] yeah it's right here and you know like thirty years ago when i fell off the roof it was really really bothersome they they said maybe there was a fracture or something and you know i do n't know i just could n't play football and then i had to you know kinda try to take care of myself but you know it's it's been really bad for about a month\n[doctor] okay and then do you still have that pain that radiates down your left leg sometimes\n[patient] yeah of course yeah it goes all the way through here\n[doctor] okay and then so it looks like you pointed to your lower back area and then pointed down through your hip and down into your to your left leg can you describe that pain for me\n[patient] it's like a electrical tooth ache and it it it goes down the whole leg\n[doctor] okay and can you rate that pain for me right now zero being none ten being the worst pain you've ever been in in your life\n[patient] right now it's less bad i did n't take my medications because i wanted you to see me as as i am but it's six out of ten but when it gets really bad i'd say it's thirteen out of ten\n[doctor] okay and anything that you do make it feel better you mentioned that you know sometimes sitting or laying down anything there make that better\n[patient] yeah like i said it the only thing that seems to make it better is laying down\n[doctor] okay\n[patient] you know standing walking seems to make it worse coughing sneezing makes it worse and you know i had a friend that saw you and you know you burned some nerves or something like that and so i was just seeing if there was something that you could do to get me out of this pain and hopefully you can do it today\n[doctor] okay and then any numbness or tingling in in your lower extremities or any weakness there in your legs\n[patient] you know it it's my back that's weak and my legs are weak both of them you know coughing sneezing seem to make it worse so sorry i'm just trying to be like a typical patient because most patients they do n't answer the darn questions so you you know all this time i still have n't gotten a chief complaint out of them so i love the way that you're trying to redirect and so you know what your doctor said you had back pain and leg pain but for me the most important thing for me to capture is that it's in the hip side of the leg side of the calf goes to the big toe and so i need them to be able to give me a perfect sort of root signature so i can hone in is that four five disk seen on the mri really significant or is it on the opposite side but again i'm sorry i'm purposely trying to be in a difficult patient because some of these patients he asked them fifty different questions they wo n't answer any of them so anyway sorry about well\n[doctor] that's okay\n[patient] to explain but this is what i deal with every single day\n[doctor] absolutely\n[patient] lot of pain yeah you know what my pain is eight out of ten it goes in the back goes into the hip side of the leg side of the calf goes to the big toe my foot kinda drags when i walk i've been having to use a cane nothing seems to make it better and but very few patients will give you the perfect history and most people will start talking about you know when something happened or go back to thirty years ago and you wan na redirect them to their current symptom but the patients wo n't rarely ever tell you what the chief complaint is you you got ta pull it out of them\n[doctor] so let's take a a quick look at you here okay let's do a physical exam real quick so your vitals look good which is a good thing now on your back exam i do n't see any bony abnormalities no redness or no and no bruising present now do you have pain when i press here\n[patient] no it's right here\n[doctor] okay so positive for pain to palpation at the l4 vertebrae and if you bend forward do you have pain there\n[patient] it hurts all the time especially sitting in these run office desks\n[doctor] okay so you are positive for pain with flexion and extension of your back i'm going to go ahead and test the strength of your legs now push out against my hands for me please\n[patient] okay that's it that's all i got\n[doctor] alright so four out of five strength in the left and five out of five on the right does look like that reflexes are brisk and motor and sensory is intact in both lower extremities i do wan na review the results of your mri the mri shows a disk herniation at the level of l4 l5 vertebrae and it is associated with some nerve root impingement and what that means is the nerve is being compressed by that herniation so let me tell you a little bit about my assessment and plan okay so for the diagnosis of of acute disk herniation at l4 l5 with that nerve root impingement that's causing that pain down your leg and your lower back pain now i know you've tried nsaids in the past without relief and you've done some pt so what i'm going to do is i'm gon na recommend an epidural steroid injection and we're gon na do that today for you if you agree to it what that means is gon na place some anti-inflammatory medication right at the spot of inflammation and once that's in place i wan na refer you back to pt and we wan na strengthen that area mkay you're young and otherwise healthy i think you'll do well but it can take about two to three weeks for that injection really to take full effect so then i want you to see pt and i want you to see me again in about a month are you okay with that treatment plan\n[patient] sure sounds good\n[doctor] alright sounds good i'm gon na have the nurse come in and get you prepped and then we'll get that injection for you",
            "tgt": "HISTORY OF PRESENT ILLNESS\n\nMatthew Hill is a pleasant 44-year-old male who presents to the clinic today for the evaluation of back pain. The patient was referred from his primary care physician. The onset of his pain began 30 years ago, when he fell off of a roof. He endorses that it was very bothersome and he was unable to play football. He states that he was told that he may have a fracture at that time. The patient reports that his pain has worsened 1 month ago. He locates his pain to his lower back, which radiates into his left hip, down his left leg, on the side of his calf, and into his left big toe. The patient describes his pain as an \"electrical tooth ache\" that radiates down his entire left leg. He notes that he has to use a cane to walk as his left foot drags when he walks. He rates his pain level as a 6 to 8 out of 10, however it can get to a 13 out of 10 at its worst. He states that he did not take any medication before his appointment so it did not affect his pain during our visit. The patient notes that he was in the waiting room for 30 minutes today and states that it made his symptoms worse. His pain is aggravated by standing, ambulating, coughing, and sneezing. The patient states that he is unable to tie his shoes secondary to the pain. The patient states that his pain is alleviated by lying down. He also reports weakness in his bilateral legs and his back. The patient denies any numbness or tingling. The patient has attempted NSAIDs in the past without relief. He has also attended physical therapy.\n\nPHYSICAL EXAM\n\nCONSTITUTIONAL: Vitals look good.\nMSK: Examination of the lumbar spine: No bony abnormalities. No redness. No bruising present. Pain with palpation at the L4 vertebrae. Positive for pain with flexion and extension of the back. 4/5 strength on the left, 5/5 strength on the right. Reflexes are brisk. Motor and sensory are intact throughout the bilateral lower extremities.\n\nRESULTS\n\nThe MRI of the lumbar spine was reviewed today. It revealed a disc herniation at the level of the L4-5 vertebrae. It is associated with some nerve root impingement.\n\nASSESSMENT\n\nAcute disc herniation at L4-5 with nerve root impingement.\n\nPLAN\n\nI have recommended that we treat the patient conservatively with a epidural steroid injection and formal physical therapy. With the patient's consent, we will proceed with a epidural steroid injection into the lumbar spine today. He will follow up with me in 4 weeks to check on his progress.",
            "file": "D2N112-aci"
        },
        {
            "src": "[doctor] hi jacqueline how are you doing today\n[patient] i'm doing okay i'm just really anxious about my recent blood work that my pcp did and said that i have hepatitis c i'm just really surprised because i've been feeling fine\n[doctor] okay so were you ever told in the past that you have hepatitis c\n[patient] no never\n[doctor] okay and do do you have any history like iv drug use known that you know or do you have any known to have any like hepatitis c positive partners\n[patient] i mean like years ago i used to party a lot and even use iv drugs but i've been clean for over fifteen years now\n[doctor] okay well very good you know congratulations on that that's that's a great great achievement so tell me though how about alcohol use\n[patient] i used to drink a lot a lot more alcohol now i probably would say i drink about a beer a day\n[doctor] okay\n[patient] and maybe slightly more on the weekends but nothing like how i used to\n[doctor] okay alright how about smoking have you ever smoked\n[patient] i do smoke i'm down to one to two cigarettes a day it's just really been tough to just get rid of those two but i've cut down a lot i used to i was up to one point or a pack and a half a day\n[doctor] wow okay alright so yeah you you definitely have decreased that so that's again good for you on that one so hopefully you keep you keep that up\n[patient] thing\n[doctor] so tell me do you have any other medication conditions\n[patient] do i do i no otherwise i'm i'm feel pretty good i had my physical there was nothing else the the only thing i was telling my pcp is i do feel like tend to be really tired at the end of the day after working but otherwise i've been good\n[doctor] okay and and has work been not hard lately you've been busy it sounds like\n[patient] i know i have been busy but not really much more than usual\n[doctor] okay\n[patient] so that's why i was kind of marking because i mean i used to you know be able and be fine but i just lately have been feeling like i'm getting enough sleep but i still get very tired at the end of the day\n[doctor] okay alright well i hope you're not working too much and then you'll able to at least find some time with the family\n[patient] yeah i'm i yeah i tend to be a workaholic but yes i i am working on that\n[doctor] okay well i hope kids are doing okay\n[patient] they are thank you\n[doctor] okay good so tell me what conditions what kind of conditions run in your family like is there do you have hypertension diabetes or\n[patient] yeah all of all of the above\n[doctor] okay\n[patient] hypertension diabetes and also depression\n[doctor] okay and depression okay alright well let's go ahead and do a quick physical exam on you here i reviewed your vitals and everything there looks good so that's good and now on general appearance you appear in no distress and no jaundice on skin exam let me go ahead and listen to your heart here great on your heart exam you have a nice regular rate and rhythm with a two out of six six systolic murmur appreciate appreciated that's that has n't changed from last year so we will just continue to monitor that monitor that as well okay\n[patient] okay\n[doctor] 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 musculoskeletal exam here great i i did n't see any gait disturbance and no edema so that's great so jacqueline i did review the results of your recent blood blood work and your hcv antibody test was positive and your liver panel that was done showing an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so what that all means and let me go ahead and tell you about my assessment and plan here for your first problem of hepatitis c your initial labs are consistent with hepatitis c so based on the the once i just discussed with you there now hepatitis c is a viral infection that affects the liver so you most likely may have had it for years now so the next step that i would like to do is to confirm the diagnosis with some additional blood work that includes checking the hep c rna and also the hcv genotype okay now i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and i'm gon na do this by ordering a special ultrasound and with this information i'm gon na be able to know how to proceed as far as treatment\n[patient] okay\n[doctor] alright now i know that was a lot of information do you have any questions for me\n[patient] yeah so should i be worried about my wife and my kids should they be tested as well\n[doctor] yes so we can start with the same screening that you have had for you for all of them first okay\n[patient] okay alright so i'll make sure i'll have them set up an appointment with our our family doctor\n[doctor] okay great so if you do n't have any other questions i'm gon na have the nurse check you out and get all that scheduled and i'm gon na see you in about three weeks\n[patient] alright perfect\n[doctor] alright\n[patient] thank you\n[doctor] take care jacqueline\n[patient] okay bye\n[doctor] bye",
            "tgt": "CHIEF COMPLAINT\n\nHepatitis C.\n\nSOCIAL HISTORY\n\nPatient reports personal history of intravenous drug use over 15 years ago. She is currently smoking 1-2 cigarettes per day, previously 1 to 1.5 packs per day. She also has a history of heavy alcohol use, but now drinks approximately 1 beer per day, more on the weekends.\n\nFAMILY HISTORY\n\nPatient reports family history significant for hypertension, diabetes, and depression.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Reports fatigue.\n\nAll other systems were reviewed and are negative.\n\nVITALS\n\nVitals look good today.\n\nPHYSICAL EXAM\n\nConstitutional\n- General Appearance: in no apparent distress.\n\nRespiratory\n- Auscultation of Lungs: No wheezes, rales, or rhonchi.\n\nCardiovascular\n- Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur, unchanged.\n\nGastrointestinal\n- Examination of Abdomen: No masses or tenderness. No hepatosplenomegaly.\n- Auscultation: Bowel sounds normal.\n\nMusculoskeletal\n- Examination: No edema.\n\nIntegumentary\n- Examination: No signs of jaundice.\n\nRESULTS\n\nHCV antibody: Positive\nAST: 39\nALT: Within normal limits\nAlbumin: Within normal limits\nBilirubin, total: Within normal limits\n\nASSESSMENT AND PLAN\n\n1. Hepatitis C.\n- Medical Reasoning: Her recent blood work revealed a positive HCV antibody. She does have a history of intravenous drug use, but she has not used drugs in over 15 years.\n- Patient Education and Counseling: We discussed the nature of hepatitis C in detail. I advised the patient to have her spouse and children tested for hepatitis C as well.\n- Medical Treatment: I'm going to order additional labs including a hepatitis C RNA and HCV genotype to confirm the diagnosis, as well as a Fibroscan to assess the severity of the condition.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow up in 3 weeks.\n",
            "file": "D2N113-aci"
        },
        {
            "src": "[doctor] alright\n[patient] good morning Julie how are you doing today\n[doctor] i'm doing okay i'm just a little nervous about what's been going on with my headaches\n[patient] okay so i know you were sent here by your your pcp what was your understanding of why you were sent here\n[doctor] yeah so i actually have been someone who been struggling with headaches for years now ever since i was a teenager and they used to be around my when i would have my menstrual my menses but as i got older i noticed that it has been with that and also i can get it when i'm really stressed but recently and why i went to her is because my headaches have been getting a lot more they've just been happening a lot more frequently and a lot more severe\n[patient] okay can you tell me a little bit about them what how do they how do they feel when they come on\n[doctor] so they say mostly on my right side and it even seems like it's like behind my eye and it just like this pulsing like this really bad pulsing sensation\n[patient] okay do you notice these any activities or time of the day that makes them worse i know you said they they seem to get worse around your menstrual periods but is there any time of the day or that makes them worse\n[doctor] i i have noticed that you know i've been trying to exercise more in order to lose weight but i ca n't even really exercise for very long because i start of as soon as i start to jog i my headaches the headaches come back on a lot worse so i notice it when i'm exercising\n[patient] okay and do you seem to have any other symptoms when you get these headaches i've been having a ringing in my ears for a few months now and then what really scared me is that now i'm starting to get some blurred vision it's not all the time but it it will come and go but some blurred like on the\n[doctor] in my on the side of my vision\n[patient] okay okay and have you experienced any numbness or tingling to your hands or feet or your face\n[doctor] no i have n't\n[patient] okay so you you like to run a lot what kind of do you do you use a a good shoe you know what kind of shoes do you use for your running\n[doctor] yeah i yeah i i'm starting to get back into it i'm a big new balance person in asics so yeah those are the two brands i like to wear yeah so right now i'm using asics\n[patient] okay yeah i like to run too and i use nike\n[doctor] okay\n[patient] i used to get tumor guy but i i really kinda moved over to nike\n[doctor] hmmm\n[patient] that's good you know it is running is a great exercise\n[doctor] it is\n[patient] so have you had any let's get back to the exam here have you had a recent mri of your brain i saw one from a few years ago but as doctor white said anything about getting a more a recent mri\n[doctor] yeah she was gon na put one in but she wanted me to see you first and urgently so they have n't called me yet for the mri\n[patient] okay so that's good we i think we'll we will follow up with that mri but let's go ahead and take a do a quick physical exam here i reviewed your vitals that the the assistant collected when you came in and everything there looks good including your blood pressure you know with symptoms like that that's one of those things that i'd be concerned about\n[doctor] okay\n[patient] now on your heart exam it sounds like it's normal sinus rhythm with no murmurs rubs or gallops so that's good as i listen i'm gon na go ahead and look here in your eyes the funduscopic exam shows papilledema and that's just some of swelling behind there in the eye and this let me do a a neurological exam this will take a few minutes you get up to follow my instructions as we go through that okay on neurological exam your cranial nerves one through twelve are intact including a normal cranial reflex and just went to watch you walk across the room here\n[doctor] okay turn around come back and okay so on musculoskeletal exam your gait is normal\n[doctor] okay go ahead sorry\n[patient] 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 such as yours you know headaches worsening with activity ringing in the ears changes in your vision so i'm i'm pretty confident that that's what we're having here now why we get concerned is if the pressure continues to increase this can lead to some permanent changes in your vision so i i do wan na get a a few more tests just so we can confirm that diagnosis and the first one that we just talked about is an mri i think it's really important to get that to check for any other condition that could be contributing to your symptoms now once i have that result i'm gon na be doing also doing a spinal tap which will help me evaluate the pressure in the brain and it can also help you feel better if you do have an increased pressure by taking the decreasing the amount of that pressure just by taking a a a little bit of fluid off of that and lastly i want you to be seen by a neuro-ophthalmologist for a complete eye exam now i i know that sounds like a lot of information but i think it's really important we get that accomplished do you have any questions for me\n[doctor] yeah that is a lot and so i i'm sure i'll have more that comes up but so let's say we do all this test and it confirms what you're saying does that mean was i referred to you because that means i will need surgery\n[patient] not necessarily if you have idiopathic intracranial hypertension there are number of medications that we can try to help decrease that pressure in your brain and this will also help you have less headaches when you exercise as exercise and weight loss are also an important part of the treatment\n[doctor] okay alright alright and i'll probably add something about so is this something i'll be doing soon is this all things i'll be doing this week\n[patient] yeah that's a great question here i i'm gon na go ahead and we're gon na for the mri i'll have to get a preapproval from your insurance company i will work on that my my my team in the front office will get that preapproved and then once that's done we'll call you to help schedule that mri\n[doctor] okay alright thank you bye\n[patient] bye sorry",
            "tgt": "CHIEF COMPLAINT\n\nHeadaches.\n\nHISTORY OF PRESENT ILLNESS\n\nJulie Jenkins is a pleasant 33-year-old female who presents to the clinic today for the evaluation of headaches. The patient was referred from her primary care physician. The patient states that she was seen by Dr. White a few years ago and was going to obtain an MRI; however, Dr. White wanted her to see me first and urgently.\n\nThe onset of her headaches began when she was a teenager. Initially, her headaches appeared during menses, however she now experiences them more frequently and with more severity. Her pain is aggravated by physical activities. The patient states that she has been trying to exercise more in order to lose weight, however she is unable to exercise for prolonged periods of time secondary to the headaches. The patient locates her pain to the right side of her head and behind her eye. She describes her pain as a pulsing sensation. She also reports intermittent ringing in her ears for the last few months. Additionally, she reports intermittent blurred vision on the lateral aspect of her vision. She denies any numbness or tingling in her hands, feet, or face.\n\nThe patient enjoys running and wears either New Balance or Asics shoes.\n\nREVIEW OF SYSTEMS\n\nNeurological: Reports headaches. Denies numbness or tingling in her hands, feet, or face.\n\nVITALS\n\nVitals are within normal limits.\n\nPHYSICAL EXAM\n\nCV: Normal head rhythm with no murmurs, rubs, or gallops.\nNEURO: Cranial nerves I through XII are intact distally, including a normal cranial reflex.\nMSK: Gait is normal.\nFunduscopic exam: Positive for papilledema.\n\nASSESSMENT\n\nHeadaches, concern for idiopathic intracranial hypertension.\n\nPLAN\n\nAfter reviewing the patient's examination today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have recommended that we obtain an urgent MRI of the brain to evaluate for any other condition that could be contributing to her symptoms. We will contact her to schedule this after approved by insurance. Once the MRI results are available for review and further discussion, I will also perform a spinal tap to evaluate the pressure in the brain. I have also advised her to be seen by a neuro ophthalmologist for a complete eye exam. Questions were invited and answered today. The patient agrees to the treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow up with me once the MRI results are available for review and further recommendations.",
            "file": "D2N114-aci"
        },
        {
            "src": "[doctor] alright so hey it's nice to see you jack i know you've been experiencing some neck pain could you tell me what happened\n[patient] yeah so i was in a a car accident\n[doctor] mm-hmm\n[patient] and i hit in the back and like my my neck went forward and my head went forward really quick and so i've been having some pain ever since\n[doctor] okay and so with this pain how long ago was the car accident\n[patient] that was about a week ago\n[doctor] okay with this pain like on a scale of one to ten how severe is it\n[patient] i would say it's about a seven\n[doctor] okay\n[patient] it's not a constant pain but like whenever i move my head which is like a lot i i feel it\n[doctor] alright so where exactly is it on the side on the back\n[patient] it's in the back of my neck\n[doctor] okay has anything made it better\n[patient] i mean i've tried some ibuprofen that helped a little bit but not too much\n[doctor] mm-hmm\n[patient] just about five out of ten\n[doctor] mm-hmm alright and did you say whether the pain was getting worse\n[patient] i mean it's been staying the same it just gets worse when i'm moving my neck\n[doctor] okay are you able to turn your neck from side to side\n[patient] mostly but there is there is pain with it\n[doctor] okay and then do you have headaches\n[patient] yeah i had i had a couple early on\n[doctor] uh uh\n[patient] i have had it lately\n[doctor] okay and so does the pain move anywhere like your upper back your shoulder\n[patient] no it just stays on monday\n[doctor] okay and then any kind of hearing any kind of hearing problems visual disturbances\n[patient] no\n[doctor] okay have you do have you ever like played sports before or had like a sports accident before\n[patient] yeah i played football\n[doctor] okay\n[patient] years ago but i i did n't have any issues with my neck though\n[doctor] okay and then when you got in the car accident did you end up going to the emergency room\n[patient] no i mean i i know that going to the emergency room that like the english rides like five hundred bucks so i did n't want to do that\n[doctor] i understand i understand okay was there any like swelling or bruising on your neck\n[patient] not that i know about no other mag of my neck i really ca n't see that\n[doctor] yeah okay no just checking okay so if you do n't mind i'm gon na go ahead and do my physical exam so when i press on here on the side of your neck does it hurt\n[patient] yeah a little bit\n[doctor] okay positive pain to palpation of the soft tissues of the neck what about when i press on your back or your shoulders\n[patient] no that's fine\n[doctor] okay so when you flex your neck when you're touching your chin to your chest does that hurt\n[patient] mm-hmm\n[doctor] alright positive pain with flexion what about when you move it back\n[patient] yeah that hurts worse\n[doctor] okay okay severe positive pain to extension okay so can you turn your head from side to side does that hurt\n[patient] yeah a little bit\n[doctor] okay positive pain with rotation and then can you touch your ear to your shoulders\n[patient] no\n[doctor] 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 have is something called neck strain for your neck pain i sorry treatments we are gon na go ahead and treat this a bit conservatively your i'm gon na put you on anti-inflammatories motrin six hundred milligrams and you're gon na take that every six to eight hours i also wan na give you a muscle relaxant called flexeril and it's gon na be ten milligrams and you'll take that every twelve hours as needed i'm gon na want you to try your best to to like relax your neck i'm sorry not to strain your neck anymore like to be conservative with how you move about and everything like that i also wan na order an mri just because you said you did n't go to the hospital or anything like that i just wan na make sure that you you're not suffering from like a concussion but this is something that's commonly referred to as like whiplash right your head just like it it just wiped essentially like back and forth to so severely and and that's probably what's causing your pain i think i wan na refer you to either physical rehab or a chiropractor once we get the results of the mri just to make sure that there is n't any impingement of like the nerves or anything like that do you have any questions\n[patient] i heard the chiropractors will shake they work\n[doctor] i do understand that some people have like reservations about going to the chiropractor but you know we do have some good ones that have like longstanding histories and patients that have had positive results from the experience but if you if you do n't like the idea of that we can consider other options like that rehab and physical therapy\n[patient] okay\n[doctor] alright any other questions\n[patient] no\n[doctor] alright thank you",
            "tgt": "CHIEF COMPLAINT\n\nNeck pain\n\nHISTORY OF PRESENT ILLNESS\n\nJack Torres is a pleasant 40-year-old male who presents to the clinic today for the evaluation of neck pain. The onset of his pain began 1 week ago after he was involved in a motor vehicle accident. He states that he was hit in the back and experienced whiplash. Following the accident he did not present to the emergency room and he does not recall having any swelling or bruising at the neck. He localizes his pain to the posterior aspect of his neck. His pain level is rated at 7 out of 10. When taking ibuprofen he states his pain improves to 5 out of 10. He finds that neck range of motion exacerbates his pain. Initially after the accident he reports that he experienced a couple of headaches, but he states he has not had any recently. He denies any hearing problems or visual disturbances.\n\nSOCIAL HISTORY\n\nPatient reports that he played football years ago without any neck issues.\n\nREVIEW OF SYSTEMS\n\nEyes: Denies visual disturbances.\nHENT: Denies hearing loss.\nMusculoskeletal: Reports neck pain.\nNeurological: Denies headaches.\n\nPHYSICAL EXAM\n\nNECK: No swelling noted\nMSK: Examination of the cervical spine: Positive pain to palpation of the soft tissues of the neck. Shoulders and back are nontender to palpation. Positive pain with flexion, rotation, and lateral bending. Severe pain with extension.\n\nRESULTS\n\n3 views of the cervical spine were taken. These reveal no evidence of any fractures or bony abnormalities.\n\nASSESSMENT\n\nNeck strain.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed his x-rays did not reveal any signs of a fracture or bony abnormalities. Treatment options were discussed and conservative treatment has been recommended. He will begin taking Motrin 600 mg every 6 to 8 hours. A prescription for Flexeril 10 mg every 12 hours as needed was also provided. He was advised to be mindful of how he moves his neck and to be conservative to avoid straining his neck. I have also recommended that we obtain an MRI for further evaluation as the patient did not go to the emergency room following his accident. He will also be referred to either physical rehab or a chiropractor pending his MRI results.\n",
            "file": "D2N115-aci"
        },
        {
            "src": "[doctor] hey hi bobby how are you doing\n[patient] i'm doing good how are you\n[doctor] i'm doing fine so i understand you're here having some left or some right shoulder pain that you've had for a few weeks now\n[patient] yeah it was i was doing some work in my backyard and a lot of different projects going on and you know i was obviously sore all over the next couple of days but my my right shoulder just keeps on bothering me and it keeps it's just really sore and it just has n't been going away\n[doctor] okay so have you had ever had any pain in that shoulder before\n[patient] a little bit i you know i i hurt that same shoulder because it's my my dominant hand my right hand i hurt it playing baseball when i was younger\n[doctor] mm-hmm\n[patient] so i've always had a little bit issues but this is it's does n't feel like it's in the rotator cuff it's it's kinda more on the outside and it's kinda like it's more tender on the outside when i raise my arm up so\n[doctor] okay yeah are you able to move your arm very well or not\n[patient] yeah there is no restriction with my arm it just i definitely feel some pain on the outside of it\n[doctor] okay and are you having pain all the time or just or does it come and go\n[patient] just whenever i move it if i'm sitting still i really do n't notice anything but whenever i move it then i can definitely feel some pain\n[doctor] okay how about at night is it bothering you at night also\n[patient] a little bit because i sleep on that side so\n[doctor] okay\n[patient] of course\n[doctor] okay and i may miss did you say what have you been taking for pain for that\n[patient] i just been taking some advil and then icing as much as i can so that's about it\n[doctor] okay and does that seem to help or\n[patient] a little bit yeah a little bit i mean it's it's still like you know sore to touch but it definitely dulls it a little bit\n[doctor] well sounds like you have quite a few projects going on what all what all are you doing for for your yard and\n[patient] i well let's see i've been putting an outdoor shower in we're extending our patio putting making some flower boxes putting down some you know for stone and all the flower beds so my wife's really put me to work i got a laundry lift\n[doctor] wow it sounds like a variety of projects but if you're putting down stone you're probably lifting those as well and then\n[patient] yeah\n[doctor] yeah i bet that is sore now tell me this have you experienced any numbness in your arm or your hands or\n[patient] no not really no numbness that i can think of\n[doctor] okay alright so see i'm gon na i'd like to do just a quick physical exam and i've reviewed your vitals those look good your no fever so that's good you're ninety seven . eight and your heart rate looks good at sixty two respirations sixteen your blood pressures one sixteen over eighty four that looks fine your oxygen saturation is real good at ninety nine percent so that all looks good so let's take a look at your left at your right shoulder so you have limited active and passive range of motion and there is some tenderness at the great tuberosity of the humerus there is no tenderness at the sternoclavicular or acro acromioclavicular joints you do have a good hand grip okay and on neurovascular exam of your right arm your capillary refill is less than three seconds and your sensation to touch is intact so i've reviewed the results of your shoulder x-ray and there is no fracture so that's good so let me tell you a little bit about my assessment and plan so for your first problem the left shoulder pain your symptoms are most likely due to this rotator cuff rotator cuff tendinopathy that means you that you injured injured the tendons of the muscles that help make your shoulder muscles i think we had to go ahead and order just an mri since you have had some problems before as well to make sure there's nothing else going on with it and i also want to refer you to physical therapy for approximately six to eight weeks and so during that time continue the tylenol and if your symptoms do n't improve we can go ahead and consider a steroid injection of your shoulder which could provide some relief do you have any questions about your plan\n[patient] no that sounds good\n[doctor] okay alright yeah a lot of patients it's very successful with the physical therapy so i really hope that will do it and so we'll just start there okay\n[patient] sounds great\n[doctor] okay thanks\n[patient] thanks\n[doctor] did you have any other any other problems any other injuries that that went along with this or\n[patient] my both my my feet are actually really sore too i obviously have been doing a lot of other yard work so you know it's kinda it's really stiff and stuff and they you know my ankle joints as well my wife seems to think that i do n't drink enough water so it could be something along that lines but i do n't know they're kinda this they just they're really sore and stuff so i've been trying to put them up and kinda put ice on them keep them elevated and it seems to be helping out a little bit but\n[doctor] yeah so if you do n't feel that you did anything to injure it we might start just maybe do some epsom salts have you tried soaking your feet in epsom salts that will tend to kinda pull out what's going on in there and just help your those muscles to relax and the soreness to to go away you might try that\n[patient] okay that sounds like a plan that sounds good",
            "tgt": "CHIEF COMPLAINT\n\nRight shoulder pain.\n\nHISTORY OF PRESENT ILLNESS\n\nBobby Flores is a 56-year-old male, right-hand-dominant, male who presents to the clinic today for the evaluation of right shoulder pain.\n\nThe onset of his pain began a few weeks ago, when he was performing different projects in his backyard. He states that he was sore all over the next couple of days. He locates his pain to the lateral aspect of his right shoulder. His pain is aggravated with movement. The patient denies any restriction with his arm. He also reports pain at night when he sleeps on his right side. The patient denies any numbness in his arm or hands. He has been taking Advil and icing his shoulder, which provides some relief. The patient reports a history of right shoulder pain when he was younger while playing baseball.\n\nThe patient also has complaints of bilateral foot and ankle pain. He attributes this pain to the yard work he has been doing. For treatment, he has iced and elevated them, which provided some relief.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Positive for right shoulder pain.\nNeurological: Negative for numbness in hands.\n\nVITALS\n\nTemperature: 97.8 degrees F.\nHeart Rate: 62 BPM.\nRespirations:16.\nBlood pressure: 116/84 mm Hg.\nOxygen saturation: 99 percent on room air.\n\nPHYSICAL EXAM\n\nCV: >Capillary refill is less than 3 seconds.\nNEURO: Normal sensation. Neurovascularly intact on the right. Sensation to touch is intact on the right shoulder.\nMSK: Examination of the right shoulder: Limited active and passive ROM. Tenderness at the greater tuberosity of the humerus. No tenderness at the sternoclavicular or AC joints. Good hand grip.\n\nRESULTS\n\n3 views of the right shoulder were taken. These reveal no fracture or dislocation. No abnormalities noted.\n\nASSESSMENT\n\n1. Right shoulder rotator cuff tendinopathy.\n2. Bilateral foot pain.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any signs of a fracture. I have recommended that we obtain an MRI of the right shoulder to evaluate for a possible rotator cuff tear. I have also recommended that the patient attend formal physical therapy for 6 to 8 weeks. He can continue taking Tylenol as needed for pain. If his symptoms do not improve with physical therapy, I will recommend a cortisone injection.\n\nIn regards to his bilateral feet pain, I have recommended that we treat the patient conservatively. I am recommending the patient soak his feet in an Epsom salt soak as well as elevate as needed.\n",
            "file": "D2N116-aci"
        },
        {
            "src": "[doctor] mister jackson is a 45 -year-old male who has a history of diabetes type two and mild intermittent asthma and he is here today with right elbow pain so hey there mark nice to see you again listen sorry you're having some elbow pain let's talk about it but i would like to record this conversation with this cool app that i'm using that's gon na help me focus on you a bit more would that be alright with you\n[patient] yeah that sounds great\n[doctor] okay great so mark tell me about your right elbow pain what's been happening\n[patient] so yeah i've been playing a lot of tennis recently buddy of mine you know you're always telling me to get off the couch and be more active so a buddy of mine asked me if i wanted to go play tennis he just joined a country club i've been hitting hitting the cord a lot more and it's just been killing me for the last three weeks or so\n[doctor] okay alright and where in your elbow is it hurting\n[patient] outside part\n[doctor] hmmm okay does the pain radiate anywhere like down to your arm up to your shoulder or anywhere else\n[patient] no it does n't\n[doctor] okay and what would you say the pain is you know on a scale of zero to ten\n[patient] it's probably an eight when i'm just when i'm using it even if it's to get something out of the cupboard and it's a three when i'm just kinda resting\n[doctor] hmmm okay and do you would you say it's a sharp pain stabbing pain aching throbbing how would you describe it\n[patient] all of the above shooting stabbing very sharp\n[doctor] okay alright and you let's see other than the the tennis you know increase in tennis activity you have n't had any trauma recently falling on it or you know felt a pop anywhere or anything like that have you\n[patient] not that i can recall\n[doctor] okay and and you said it's it's worse with movement better with rest is there anything else that makes it makes it worse or makes it better\n[patient] i've taken some tylenol and ibuprofen but as soon as those wear off it it comes right back so they do n't really help\n[doctor] okay\n[patient] and i did try a little ice i probably should ice it more but i did n't notice it helping much\n[doctor] okay okay alright yeah well i definitely i'm glad you're getting some exercise now that's good for your diabetes and all that and out there playing tennis kinda back back to the back to the old days for you right did do i recall that were n't you a big tennis player back in the day like state champ in high school or something\n[patient] yeah yeah that was a hundred years ago i ca n't i i try to play like that and i ca n't i ca n't do that anymore but yeah a good memory that's a that's a good memory\n[doctor] now\n[patient] kind of a tennis guy too right did you see the the australia open\n[doctor] i did i did yeah that was that was crazy that was a great tournament what a what a finish unbelievable\n[patient] yeah hey did you see the masters i know you're a golfer\n[doctor] yeah yeah yeah i do n't get out as often as i as as i like to but but the masters yeah that was that was amazing that was lot of fun to lot of fun did you catch it too\n[patient] i did\n[doctor] yeah\n[patient] yeah\n[doctor] yeah\n[patient] but that's it was i i could n't believe tiger went out there of course he did\n[doctor] right\n[patient] it was cool to see nothing\n[doctor] yep yep agreed agreed and so well listen we'll we'll hopefully get you feeling better here and get you back out on the court and out on the course and we'll talk about that but let's let me ask you about your diabetes a little bit a little bit here so how have your blood sugars been running mark have they been what in the low one hundreds two hundreds where are they\n[patient] they are like one fifty one sixty you know we just had easter and my kids got a whole bunch of candies so i keep eating that\n[doctor] hmmm okay yeah yeah understood so those cadboy eggs they'll get you every time too right\n[patient] yes\n[doctor] boy my gosh yeah those are the best so those are those are deadly do n't tell my cardiologist so okay so listen you know i see that we have you on metformin five hundred milligrams once a day no actually last visit we increased it so i've got you on metformin five hundred milligrams twice a day correct you're still taking that\n[patient] yes twice a day\n[doctor] okay and but your blood sugars are a bit off you know maybe those the cadberry eggs so how about your asthma how has that been doing you know have you had any asthma attacks you're still taking flovent twice a day and the albuterol as needed\n[patient] yeah knock on wood i my asthma is pretty much under control\n[doctor] okay excellent excellent alright and i recall you know just kinda review a few things i i think you've got an allergy to penicillin is that correct\n[patient] that's correct yes\n[doctor] okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct\n[patient] yes that's right\n[doctor] okay and then let's go ahead and examine you alright so mark your exam is pretty much you know for the most part normal with a few exceptions on your heart exam you still have a grade three out of six systolic ejection murmur and that's unchanged from prior exam we're watching that and so that just means i hear some some heart sounds as your heart is beating there i'm not too concerned about it as as that's not changed otherwise normal cardiovascular exam and your physical exam otherwise on your musculoskeletal exam on your right elbow you do have moderate lateral epicondylar tenderness of the right elbow and how about when i move this when i move your elbow like this does that hurt you\n[patient] kills\n[doctor] okay sorry about that so you've got moderate pain with passive range of motion of the right elbow there is no palpable joint effusion and now what if i press against your wrist like so does that hurt you\n[patient] yeah it hurts a little bit\n[doctor] 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 effusion and otherwise it's a normal right elbow x-ray so that's reassuring okay and hey you know i meant to ask you you know and do you have any history of fever recently you know along with the elbow pain you had noticed a fever\n[patient] no i do n't think so\n[doctor] 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 your tennis activity which normally would be good but maybe we're overdoing it a little bit so i have a few recommendations i'd like you to rest your right arm as much as you can i want you to stop tennis for the next four to six weeks and please avoid repetitive stress in that right arm as well i want you to ice that right elbow for twenty minutes at least three times per day and this should reduce the pain and inflammation and then i'm also going to give you a brace for your right forearm and my nurse will give this to you before you leave that should help with the discomfort okay in that right elbow i will also write you a prescription for ultram and this should help with the pain i'll write you a prescription ultram fifty milligrams once per day that should help with your elbow pain so then i wan na see you in follow-up in four weeks and so we'll reevaluate your elbow at that time and if you we'll consider some additional imaging if needed possibly a physical therapy referral depending on how you're doing mkay now for your second problem of diabetes type two my assessment is is that your blood sugar is a little bit out of control mkay so we need to make some adjustments i'm going to increase your metformin to one thousand milligrams twice per day and i want you to check your blood sugar twice daily for the next two weeks and then let me know how your blood sugar is running and we can make some additional adjustments if needed but i will increase your metformin to one thousand milligrams twice a day now i'm going to also order a hemoglobin a1c level and and a cbc blood test today and and so we'll check those results the hemoglobin a1c and the cbc and then i'm going to also check a chem-12 blood test as well and now for your third problem of the mild acute intermittent asthma you my assessment is that it really remains under good control so let's keep you on that flovent and the albuterol no changes there and you can use those as tolerated it does look like you need a refill on your albuterol so i'm gon na write you a prescription for a refill of the albuterol and you can pick that up at your pharmacy as well so how does that all sound any questions for me\n[patient] it sounds pretty good i ca n't believe it's just tennis elbow feel like a looser coming in here but it's okay i get it\n[doctor] yeah yeah well\n[patient] i'm not i'm not young anymore\n[doctor] yeah well let's let's keep you active but take a break for a bit and let's ease back into it okay so it's great to see you and i'll see you back in four weeks let me know if you have other problems in the meantime\n[patient] okay",
            "tgt": "CHIEF COMPLAINT\n\nRight elbow pain.\n\nMEDICAL HISTORY\n\nPatient reports history of type 2 diabetes and mild intermittent asthma.\n\nSURGICAL HISTORY\n\nPatient reports history of cholecystectomy 10 years ago by Dr. Nelson.\n\nSOCIAL HISTORY\n\nPatient reports he has been playing tennis since high school.\n\nALLERGIES\n\nPatient reports that he has an allergy to PENICILLIN.\n\nMEDICATIONS\n\nPatient reports taking metformin 500 mg twice a day, Flovent twice a day and albuterol as needed.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Denies fever.\nMusculoskeletal: Reports right elbow pain.\n\nPHYSICAL EXAM\n\nCardiovascular\n- Auscultation of Heart: Grade 3 out of 6 systolic ejection murmur, unchanged from prior exam.\n\nMusculoskeletal\n- Examination of the right upper extremity: Moderate lateral epicondylar tenderness. Moderate pain with passive range of motion. No palpable joint effusion. Mild pain with resisted extension of the right wrist.\n\nRESULTS\n\nX-ray of the right elbow taken today is reviewed and shows no acute fracture or other bony abnormality. There is no malalignment or joint effusion. Otherwise normal right elbow x-ray.\n\nASSESSMENT AND PLAN\n\n1. Acute lateral epicondylitis of right elbow.\n- Medical Reasoning: Patient presents today with symptoms consistent with lateral epicondylitis secondary to overuse.\n- Patient Education and Counseling: The nature of the diagnosis was discussed. He was advised that this is like due to increased tennis activity and was encouraged to rest as much as possible. - Medical Treatment: Patient will discontinue playing tennis for the next 4 to 6 weeks, as well as avoid repetitive stress with the right arm. He will apply ice to the elbow for at least 20 minutes 3 times per day to reduce pain and inflammation. Right forearm brace was provided today to help with discomfort. Prescription for Ultram 50 mg once per day was also provided for pain.\n\n2. Diabetes type 2.\n- Medical Reasoning: His blood sugar today is not controlled.\n- Patient Education and Counseling: We discussed that I would like him to take his blood sugars twice a day for the next 2 weeks and to let me know how they are running so we can make additional adjustments if needed.\n- Medical Treatment: He will increase his metformin to 1000 mg twice a day. He will begin home blood sugar monitoring twice a day for the next 2 weeks. Hemoglobin A1c, CBC, and a Chem-12 test were ordered today.\n\n3. Mild acute intermittent asthma.\n- Medical Reasoning: This remains well-controlled.\n- Medical Treatment: The patient will continue his Flovent twice a day. Refill of albuterol provided today to be used as needed.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow-up in 4 weeks to assess his elbow and to determine if additional imaging or physical therapy is needed.",
            "file": "D2N117-aci"
        },
        {
            "src": "[doctor] alright so how're you doing today angela\n[patient] i'm doing pretty well\n[doctor] alright so looking here at your appointment notes it says you're you're here you think you have a kidney stone you had some in the past so we're gon na take a look at that and then you also have a past medical history of hypertension and diabetes we want to take a look at those as well so first thing what's going on with your kidneys you as what how long ago have you been feeling pain and and how's all that\n[patient] pain's been up and down i went to the emergency room last week but now i think i'm doing a little bit better\n[doctor] okay so the case of kidney stones so have you had you said you've had them in the past and how often would you say\n[patient] i do n't know i this is probably like my seventh or eighth kidney stone\n[doctor] seven or eight kidney stones so do you think you passed it yet or is it still in the\n[patient] i think this one passed yeah\n[doctor] this one passed how long would you say it took to\n[patient] well i went last week and then i think it passed about three days ago\n[doctor] okay so are you still noticing any blood in your urine\n[patient] no no more blood\n[doctor] alright are you still having pain\n[patient] nope\n[doctor] yeah\n[patient] the pain's gone\n[doctor] okay that that's that's that's really good did they do anything for you at the hospital giving you any medications\n[patient] they gave me some pain medicine\n[doctor] okay do you remember what it was\n[patient] i think it was percocet\n[doctor] okay well that's good i'm very glad to see that you were able to pass that stone have you seen a urologist before about this\n[patient] i have n't seen one in a while but yes i saw someone maybe a year ago\n[doctor] okay so yeah i know you keep having these recurrent kidney stones so i definitely think we can get you a referral to urology just to check up on that and also wan na do some labs as well\n[patient] okay\n[doctor] so i also see you're here for you have a past medical history of of hypertension and when you came in today your blood pressure was a little bit high it was a one fifty over ninety i'm reading here in your chart you're on two point five of norvasc\n[patient] hmmm\n[doctor] now have you been taking that regularly\n[patient] i have but at home my blood pressure is always great\n[doctor] okay maybe you have a little white coat syndrome some of my patients do have it i have it myself and i'm a provider so i definitely understand yeah i know we we talked about last time you getting a blood pressure cuff and taking those about two to three times a week so what have those readings been i'm usually like one thirty to one forty over sixty to seventy\n[patient] okay\n[doctor] that's that's that's not too bad i think when you first came in you were around like one eighty so it seems to be that that norvasc is is working for you how about your diet i know you were having a little issue eating some fast food and and cakes and cookies and have you been able to get that under control\n[patient] yeah it's hard to give up the fast food altogether because it's a lot of on the go you know\n[doctor] okay so do you think you would be able to get that under control by yourself or would you do you think you would need help with that maybe a dietitian be able to help you out\n[patient] yeah i do n't know i do n't know if i can make another appointment i just add to the extra\n[doctor] okay\n[patient] less time to make food so\n[doctor] yeah yeah definitely understand\n[patient] mm-hmm\n[doctor] alright yeah so i mean that's one thing we just got ta work one is your diet we try to keep you at least just twenty three hundred milligrams or less of sodium per day i know that's hard for a lot of salads and stuff i know it's hard for lot of people especially with all like the the prepackage foods we have around today so that's definitely something we we should work on\n[patient] mm-hmm\n[doctor] so let's also look here you have a history of diabetes and so you're on that five hundred milligrams of metformin daily now have you been taking that as well\n[patient] yeah i take my metformin\n[doctor] okay\n[patient] yeah\n[doctor] so what have your blood sugars been running daily\n[patient] well i do n't check it very often\n[doctor] okay\n[patient] but i think they've been pretty good\n[doctor] okay so i'm looking here i think last after your last visit you got a1c now was six . seven so it's a little bit high it's gone down a little bit since you were first diagnosed with the type two diabetes a year ago so i'm glad we're making progress with that as well alright so i'm just gon na do a quick physical exam on you before i do just wan na make sure are you having any chest pain today\n[patient] no\n[doctor] alright any any belly pain\n[patient] no\n[doctor] alright so i'm gon na listen to your lungs your lungs are clear bilaterally i do n't hear any crackles listen to your heart so on your heart exam i do hear that grade two out of six systolic ejection murmur and we already knew about that previously so it has n't gotten any worse so that's good so i'm gon na just press here in your abdomen because that you did have those kidney stones does that hurt\n[patient] no\n[doctor] alright i'm gon na press here on your back\n[patient] no pain\n[doctor] 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 the those kidney stones but i i think they are passed this time but i do want to get a couple of labs so we'll get a urinalysis\n[patient] okay\n[doctor] alright we'll get a urine culture just to make sure everything is is cleared up i also want to give you a referral to referral referral to urology\n[patient] okay\n[doctor] because you do keep having these all the time and so maybe there's something else going wrong and so they can help get that under control\n[patient] can i see doctor harris\n[doctor] of course yeah we can we can get you that road to doctor harris and\n[patient] he's not like\n[doctor] he's great he's he's he he he's great i've heard he does really good work so that'll be good so for the hypertension you seem to be doing well on the two . five of norvasc so we are not gon na make any changes to that do you need any refills right now\n[patient] no usually the pharmacy just sends them through when i call\n[doctor] okay great so we we wo n't we gave you refills with that i do wan na give you a consult to nutrition\n[patient] okay\n[doctor] just to help you with that diet\n[patient] okay\n[doctor] because i think that's a major factor of us eventually getting you off of all medications\n[patient] hmmm\n[doctor] and then for your diabetes i'm just keep you on that on that five hundred of metformin okay i think you're doing well with that as well also but i do want you to start taking your blood sugars if you can take them before every meal\n[patient] okay\n[doctor] just to gauge where you are so you can tell how much food you should actually be be eating\n[patient] okay\n[doctor] alright\n[patient] i can try that\n[doctor] so how does that that sound\n[patient] that sounds like a plan when should i come back and see you\n[doctor] 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\n[patient] hmmm\n[doctor] how is that going for you is it still happening\n[patient] i mean sometimes i stay awake just kinda worrying about things but but i've tried some meditation apps and that helps\n[doctor] okay alright and i know we talked a little bit before about practicing proper sleep hygiene you know just making sure that all of your electronics are off you know dark room\n[patient] yeah\n[doctor] cool room have you been doing that\n[patient] well i do like to sleep with the tv on and my phone is right by my bed because i never know if someone's gon na call me you know\n[doctor] yeah i i know i'm like apple i do n't know if you have an iphone or not but i know apple has this the the sleep mode now do that disturbance so you put that on\n[patient] it's a good idea\n[doctor] interrupt you\n[patient] yeah\n[doctor] okay have you tried taking melatonin to sleep\n[patient] i used it a couple times but but it did n't seem to help that much\n[doctor] okay how about i do n't think i've prescribed you anything yet do you think you would need anything\n[patient] hmmm i do n't really wan na take any sleeping pills\n[doctor] okay that's understandable alright so for the last issue for the insomnia i'm just gon na have you take ten milligrams of melatonin as needed\n[patient] okay\n[doctor] and just try i guess the best as possible to practice the proper sleep hygiene so you can get to sleep at night and and feel pretty rested\n[patient] okay\n[doctor] alright\n[patient] mm-hmm\n[doctor] so do you have anything any other questions for me\n[patient] no that's all\n[doctor] alright so we will see you in three months\n[patient] okay sounds good\n[doctor] alright\n[patient] like",
            "tgt": "CHIEF COMPLAINT\n\nKidney stone.\n\nMEDICAL HISTORY\n\nPatient reports history of hypertension, diabetes, and kidney stones.\n\nMEDICATIONS\n\nPatient reports taking Norvasc 2.5 mg and metformin 500 mg.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Reports insomnia.\nCardiovascular: Denies chest pain.\nGastrointestinal: Denies abdominal pain.\nGenitourinary: Denies hematuria.\n\nVITALS\n\nBlood pressure: 150/90 mm Hg\n\nPHYSICAL EXAM\n\nRespiratory\n- Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.\n\nCardiovascular\n- Auscultation of Heart: Grade 2/6 systolic ejection murmur, unchanged.\n\nGastrointestinal\n- Examination of Abdomen: No masses or tenderness. No tenderness of the CVA.\n\nRESULTS\n\nA1c: 6.7\n\nASSESSMENT AND PLAN\n\n1. Kidney stones.\n- Medical Reasoning: Patient recently experience an episode of kidney stones which is her 7th or 8th episode. Based on the patient's symptoms and exam today, I think she has likely passed her kidney stones.\n- Patient Education and Counseling: I advised the patient that we will obtain further testing, however, based on her recurrent episodes a referral to urology is necessary.\n- Medical Treatment: Urine culture and urinalysis were ordered. She will be referred to Dr. Harris in urology.\n\n2. Hypertension.\n- Medical Reasoning: Patient is currently stable and doing well on Norvasc 2.5 mg.\n- Medical Treatment: Continue Norvasc 2.5 mg. Referral to nutrition provided.\n\n3. Diabetes.\n- Medical Reasoning: Patient is currently stable and compliant with her metformin.\n- Patient Education and Counseling: She was advised to start checking her blood sugar prior to every meal.\n- Medical Treatment: Continue metformin 500 mg daily. Start daily blood sugar monitoring before each meal.\n\n4. Insomnia.\n- Medical Reasoning: The patient has a history of insomnia.\n- Patient Education and Counseling: We discussed proper sleep hygiene.\n- Medical Treatment: I have recommended she take 10 mg of melatonin as needed.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nPatient will return for follow-up in 3 months.",
            "file": "D2N118-aci"
        },
        {
            "src": "[doctor] hey betty how are you doing\n[patient] i'm doing okay i just been really frustrated because with my asthma and it just seems like i can never catch a break never get better i'm always it seems like i'm always coughing and wheezing\n[doctor] i'm sorry to hear that what normally triggers your asthma type symptoms\n[patient] i find that it's really really when i get sick if i get sick with a cold i almost always know that my asthma is going to flare i did notice one time though that when i went to my aunt's house i i had a flare afterwards and i think it's because of her cat so i try to avoid going there and i have n't really had an issue since\n[doctor] okay so now you mentioned that that happens somewhat a lot how frequently does this occur that you have these breathing type problems\n[patient] it seems like it happens really every month or every other month for the past six months i usually end up going to the urgent care a lot and get or my primary care doctor and so sometimes they'll give me antibiotics sometimes i'll get steroids one time it was so bad i actually ended up going to the emergency department\n[doctor] wow that that can be a little bit scary so you mentioned that your primary care provider or the urgent care provider gave you medications what medications are you using for your asthma right now\n[patient] i have two inhalers one but i really just use one of them it's a blue one that seems like the only inhaler that helps me the other one when i when i try to use it it does n't work\n[doctor] okay so do you think that's the albuterol inhaler is it do you remember the name like ventolin or\n[patient] yes yes that's the name of it\n[doctor] is that it okay alright and then how often do you feel like you need to use that\n[patient] i would say like almost everyday i feel like i'm using my inhaler because i'm always coughing and wheezing and a couple of times a night i'll wake up as a couple times a week i'll end up waking up needing to use my inhaler as well\n[doctor] okay and then when you use it at that time does it help\n[patient] it does\n[doctor] okay and how many walk me through how you use that you just wake up and you take one puff or is it two puffs\n[patient] yeah i take i usually take two puffs\n[doctor] okay but then you get enough relief that you can go back to sleep\n[patient] yeah for the most part\n[doctor] okay now have you ever needed to be hospitalized due to your asthma symptoms you mentioned you've had to go to the er\n[patient] yeah for only once i can think of when i was young i think like around eight years old i had to be hospitalized but nothing since then\n[doctor] okay i do wan na take a little bit of a a deeper dive here into your er and urgent care visits can you tell me a little bit more about those\n[patient] yeah i feel like i've had several i do n't remember the exact number but i've had several this past year they almost always have to start me on prednisone\n[doctor] okay like a prednisone taper pack that type of thing\n[patient] yeah yeah sometimes they'll just give me like like a like a large dose over five days\n[doctor] okay\n[patient] and then sometimes they make me take less and less and less so the over like nine or ten days\n[doctor] okay so both the dosepak and then also the high dose as well okay\n[patient] yeah\n[doctor] and then when was your last exacerbation\n[patient] probably about a month ago\n[doctor] okay so just out of curiosity you mentioned that you you have trouble when you go over to your aunt's house because of your cat now i see here that you really like to go outside and walk and do those type of things do you have any other type of issues whenever you you go outside any any seasonal allergies or anything like that\n[patient] no not really\n[doctor] okay so you do n't have any history of seasonal allergies which is good so it looks like here that you put down that you enjoyed hiking so you do n't have any trouble getting out and going hiking and and have you tried the new trails there behind behind the wreck center\n[patient] yeah i'm really excited to i mean i have to be careful because i you know with my coughing my wheezing but i'm really i'm looking forward to getting better so i can really start hiking again\n[doctor] okay now i really need you to be truthful when you answer these next questions this is important for taking a good history do you smoke any type of cigarette or tobacco product and have you ever smoked or do you smoke marijuana on a regular basis\n[patient] no i've never smoked and i do n't vape either or yeah i do n't smoke cigarettes or marijuana\n[doctor] okay and then you said you do n't vape so no vaping or e-cigarette use at all\n[patient] hmmm hmmm\n[doctor] okay and then are you routinely in an area where there is a lot of airborne particular like smoking in bars or around any type of of you know like race tracks or anything like that\n[patient] sometimes i go to the bars with some friends and yeah the smoking does irritate me\n[doctor] okay\n[patient] so i do n't try to go there often\n[doctor] okay thank you for sharing that with me so if it's okay with you i'd like to go ahead and do a quick physical exam\n[patient] okay\n[doctor] 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 n't appreciate any ectopic beats or and i do n't hear anything like rubs murmurs or gallops which is good so i'm gon na go take and listen to your lungs here on your lung exam i do appreciate some diminished lung sounds throughout with the occasional slight expiratory wheeze and that's bilaterally so i hear that on both sides i'm gon na go do a quick neck exam here neck is supple trachea is midline i do n't appreciate any lymphadenopathy taking a listen here i do n't appreciate any carotid bruit now i'm also gon na take a look at your hands here i note strong bilateral pulses i do n't appreciate any clubbing on any of your fingertips which is which is important and i also note brisk capillary refill i'm gon na go ahead and review the results of your pulmonary function test that i had you do when you came into the office today and reviewing those results i do see that they are consistent with somebody who would be diagnosed with asthma so lem me go ahead and tell you a little bit about my assessment and plan so now for your first problem of asthma your symptoms are consistent with moderate to intermediate or i'm sorry moderate moderate intermittent asthma and it's gon na be really important for us to be consistent with your inhaled inhaled steroid inhaler so i'm gon na need you to take that as prescribed and that's really gon na help cut down on those daily symptoms and needing to use that rescue inhaler that albuterol inhaler as frequently so the more you take and more consistently you take your inhaled steroid inhaler the less you will use your albuterol now it's not a fast acting inhaler like your albuterol but what is important is as going to be what helps you long term now if you do have an acute exacerbation so if you're having an acute issue with your breathing i do want you to continue to use your albuterol inhaler one to two puffs and then i want you to wait and see how your breathing is before you would take an additional one to two puffs we hope you have less of those acute exacerbations as you continue to use your inhaled steroid i'm also going to put together an asthma action plan for you and that's gon na help us look at your symptoms see where your your pain points can be you know like those being having issues with with cats or dust that type of thing and we'll work on how to handle those symptoms through that asthma action plan so do you have any questions comments or concerns otherwise i will see you in thirty days\n[patient] alright thank you\n[doctor] you're welcome\n[doctor] so let me tell you a little bit about my assessment and plan for your first problem of asthma your symptoms are consistent with moderate intermittent asthma i'm gon na start you on flovent one hundred ten micrograms one puff twice per day that's gon na be important for you to be consistent with your inhaled steroid inhaler this is gon na help prevent those daily symptoms and from needing for you to use your albuterol inhaler or that rescue inhaler less frequently you can continue using your ventolin inhaler and that would be two puffs every four to six hours p.r.n . i'm also gon na put together an asthma action plan for you so we know what to do based on your symptoms i'd like to see you again in a month or sooner if you have any worsening symptoms does that sound okay\n[patient] it does thank you\n[doctor] you're welcome i'll see you in a month\n[patient] alright thanks",
            "tgt": "CHIEF COMPLAINT\n\nAsthma.\n\nMEDICAL HISTORY\n\nPatient reports history of asthma.\n\nSOCIAL HISTORY\n\nThe patient denies the use of any type of cigarette or tobacco product, as well as marijuana. Occasionally, she will be at a bar that allows smoking inside, which does bother the patient. She enjoys being outside and hiking.\n\nALLERGIES\n\nDenies seasonal allergies.\n\nMEDICATIONS\n\nPatient reports using an albuterol inhaler, 2 puffs.\n\nREVIEW OF SYSTEMS\n\nRespiratory: Reports coughing and wheezing.\n\nVITALS\n\nBlood pressure: 128/82 mm Hg.\nRespiratory rate: 16\nO2 saturation: 99% on room air.\n\nPHYSICAL EXAM\n\nNeck\n- General Examination: Neck is supple without lymphadenopathy. Trachea is midline. No carotid bruit.\n\nRespiratory\n- Auscultation of Lungs: Diminished lung sounds throughout with the occasional slight expiratory wheeze, bilaterally.\nCardiovascular\n- Auscultation of Heart: Regular rate and rhythm. No ectopic beats. No rubs, murmurs, or gallops.\n\nMusculoskeletal\n- Examination: Strong bilateral radial pulses. No clubbing. Brisk capillary refill.\n\nHematology/Lymphatic/Immunology\n- Palpation: No enlarged lymph nodes.\n\nRESULTS\n\nPulmonary function test obtained today is reviewed and findings are consistent with asthma.\n\nASSESSMENT AND PLAN\n\n1. Moderate intermittent asthma.\n- Medical Reasoning: The patient's symptoms and results of her PFT are consistent with moderate intermittent asthma.\n- Patient Education and Counseling: I explained the importance of consistency with her daily inhaler as this will help prevent daily symptoms and the need to use the albuterol inhaler as frequently. My hope is that she has less acute exacerbations as she continues to use her inhaled steroid.\n- Medical Treatment: Prescribed provided for Flovent 110 mcg 1 puff twice per day. She can continue using her Ventolin inhaler 2 puffs every 4 to 6 hours as needed. I have recommended using her albuterol inhaler 1 to 2 puffs and then monitor her breathing prior to taking an additional 1 to 2 puffs. I am also going to put together an asthma action plan for her so we know what to do based on her symptoms.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow up in 1 month for reevaluation or sooner for worsening symptoms.\n",
            "file": "D2N119-aci"
        },
        {
            "src": "[doctor] hello larry how are you doing today\n[patient] i've been better my primary care doctor wanted me to see you for this back pain that i've been having for a couple of years now\n[doctor] okay\n[patient] and i have tried so many things and just nothing seems to work\n[doctor] i'm sorry to hear that now do you remember what caused the pain initially\n[patient] you know i never fell or was in an accident but i do remember it all happened like i started having back pain after i was moving furniture one weekend\n[doctor] okay and now can you describe the pain for me\n[patient] yeah it feels like a sharp stabbing pain in my back and it does go down even down to my right leg sometimes all the way down to my toe it feels like my big toe\n[doctor] okay\n[patient] and i also feel like i just ca n't get comfortable which is worse when i sit down okay yeah\n[doctor] okay now with that do you have any numbness or tingling associated with your back pain\n[patient] yeah i do get some numbness and tingling especially to my right leg that goes down to my foot\n[doctor] okay\n[patient] let me separate these\n[doctor] and how about a loss of sensation in the genital or the rectal area\n[patient] no nothing like that\n[doctor] okay now do you have any weakness\n[patient] i would n't say i have any weakness no\n[doctor] okay do you experience like any loss of control of your bladder or your bowels\n[patient] no\n[doctor] okay now you mentioned earlier that you you have some tried tried some things in the past so tell me what were they\n[patient] so i've tried some physical therapy before and so when it gets really bad they've even had to prescribe some strong pain medications for me but that was only temporary and they even mentioned surgery to me in the past but i really would like to avoid surgery\n[doctor] okay sure so tell me what is your day like\n[patient] my day so i try to be as active as i can but of course it's been difficult with my back pain and so because of that i have gained some weight over the past years\n[doctor] okay alright well i'm sorry to hear that i know that you used to like playing golf\n[patient] yeah i and you know golf is relatively new for me i've been trying to get into it but this has definitely set me back\n[doctor] yeah i'm sorry yep probably now at the peak of you know just learning it and being able to do more with it this comes and this happens right\n[patient] exactly\n[doctor] well let's see what we can do for you here so you can go out into the you know the golf course again now do you tell me do you have any family members with spine conditions\n[patient] no i ca n't recall any family members\n[doctor] okay alright and do you smoke\n[patient] not now i i quit about twenty years ago\n[doctor] okay alright well alright well i like to do a quick physical exam on you here\n[patient] okay\n[doctor] i'm gon na go ahead here i reviewed your vitals and they overall look pretty good so that's a good sign now on your musculoskeletal back exam there is no overlying erythema and that just means redness or ecchymosis and that just means bruising of the skin now there is midline tenderness at l4 l5 disk space with right-sided lumbar paravertebral tenderness so do me a favor and i'm gon na just have you you know bend forward and straighten up a bit\n[patient] okay that's painful\n[doctor] 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 and achilles reflexes are symmetrical so good now i reviewed the results of your mri and it shows disk herniation with nerve impingement so let me tell you about my assessment and plan here larry so for your problem of chronic lumbar back pain so based on your symptoms your exam and reviewing your mri results your symptoms are consistent with an l4 l5 herniated disk with radicul radiculopathy so this means that one of your disks that sits between your spinal vertebrae is bulging out and this bulge is pinching on some nerves and that's why you feel that tingling in your leg so yeah yeah so i am recommending a spinal injection with a strong inflammatory medication called a corticosteroid and what i do is i will inject the corticosteroid into that lumbar spine under fluoroscopy which you can think of you know an x-ray to help localize to the exact area of your pain now this should this should help the inflammation that is causing the pain so what do you think about that\n[patient] is there something i'm gon na have to do all the time\n[doctor] well you know patients are different so what we do is we will monitor you and we see how you respond to the injection and the patient's intervals can be different as well but we usually do not do more than four times a year\n[patient] okay okay\n[doctor] alright and it's not a long procedure it's it's relatively quick and common and you should be out of the office within an hour\n[patient] okay\n[doctor] okay\n[patient] alright sounds good\n[doctor] alright well let's go ahead and get you started on the first one today if that works for you if not we'll get you scheduled to start your first injection\n[patient] alright thank you\n[doctor] alright thank you\n[patient] bye",
            "tgt": "HISTORY OF PRESENT ILLNESS\n\nLarry Garcia is a pleasant 41-year-old male who presents to the clinic today for the evaluation of back pain.\n\nThe onset of his pain began 2 years ago, after moving furniture. He denies any specific injury. The patient describes his pain as sharp and stabbing. He locates his pain to his lower back, which radiates distally into his right leg and occasionally into his great toe. Sitting will increase his pain and he notes he is unable to get comfortable. The patient also reports numbness and tingling, especially in his right leg that radiates distally to his foot. He adds that he tries to be as active as he can, however it has been difficult with his back pain. The patient adds that he has gained weight over the past year. He denies any loss of sensation in his genital or rectal area, weakness, or loss of bladder or bowel control.\n\nIn the past, he has attended physical therapy. The patient has also been prescribed pain medications, however they only provided temporary relief. He would like to avoid any surgical procedure at this time.\n\nSOCIAL HISTORY\n\nHe quit smoking 20 years ago.\n\nFAMILY HISTORY\n\nThe patient denies any family history of spine conditions.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Reports weight gain.\nMusculoskeletal: Reports lower back pain.\nNeurological: Positive for numbness and tingling in the right leg and foot. Denies loss of bowl or bladder control, or loss of sensation in the genital or rectal area.\n\nVITALS\n\nVitals are within normal limits.\n\nPHYSICAL EXAM\n\nNEURO: Decreased sensation to light touch at the right lateral thigh at the L4 dermatome. Patellar and Achilles reflexes are symmetrical.\nMSK: Examination of the lumbar spine: No overlying erythema or ecchymosis. Midline tenderness at L4-5 disc space with right-sided lumbar paravertebral tenderness. Pain with lumbar flexion. Supine straight leg test is positive.\n\nRESULTS\n\nThe MRI of the lumbar spine was reviewed today. This revealed a disc herniation with nerve impingement.\n\nASSESSMENT\n\nL4-5 herniated disc with radiculopathy.\n\nPLAN\n\nAfter reviewing the patient's examination and MRI findings today, I have discussed with the patient that his symptoms are consistent with an L4-5 herniated disc with radiculopathy. I have recommended that we treat the patient conservatively with a corticosteroid injection under fluoroscopy. With the patient's consent, we will proceed with a cortisone injection into the lumbar spine today.",
            "file": "D2N120-aci"
        },
        {
            "src": "[patient] hi kenneth how are you the medical assistant told me that you had some knee pain yeah i was getting ready for the holiday weekend and i was out on my boat skiing and i i did a jump and kinda twisted when i landed and my knee has been hurting me ever since\n[doctor] okay so that was about five days ago then\n[patient] yeah yeah that was last weekend\n[doctor] last weekend okay now which knee is it\n[patient] it's my right knee\n[doctor] your right knee okay and i know that it sounds like you were on a motor boat as you were you know water skiing but did you hear anything pop or feel anything pop when it happened\n[patient] no it just felt like something stretched and then it swelled up some afterwards\n[doctor] okay and were you i assume that you were were you able to get out of the water by yourself or did you need some assistance\n[patient] i was able to get out but it was very sore to climb up and you know any kind of squatting or bending is really pretty sore\n[doctor] yeah okay and have you ever injured this knee before\n[patient] no that was the first time\n[doctor] that was the first time okay where do you have a boat what lake do you have it on lake\n[patient] lake martin\n[doctor] okay nice and so you're a frequent water skier\n[patient] yeah i try to go every weekend when we can\n[doctor] that's nice very very good are you looking forward to spring are you a baseball fan are you excited by opening day\n[patient] no i'm not a baseball fan but i love spring and chicken time of year launds of outdoor activities nice nice i'm i'm not really a baseball fan either but my husband makes me watch the the meds all the time and they lose all the time so he is always upset so so anyway\n[doctor] yeah right so how about your high blood pressure how are you doing with that are you taking your blood pressure medication like i asked\n[patient] i'm taking it everyday and i check my blood pressure at home and it's been about one twenty five over eighty most of the days\n[doctor] nice okay so i believe we have you on lisinopril about twenty milligrams a day any side effects from that that you're noticing\n[patient] not that i know of it's been a good medicine for me and i do n't have any trouble with it\n[doctor] okay great alright and since you had this knee pain any numbing or tingling in your foot at all\n[patient] no just the swelling and the pain\n[doctor] okay and what have you taken for the pain\n[patient] i i took some aleve twice a day some over the counter aleve twice a day\n[doctor] okay and\n[patient] putting a cold pack on it\n[doctor] okay and has that helped at all\n[patient] yeah that's helped a fair amount it's still pretty sore though\n[doctor] okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here\n[patient] i had my tonsils out\n[doctor] okay you had your tonsils out okay alright well let me go ahead i wan na do a just a quick physical exam i'm gon na go ahead and be calling out some of my clinical exam findings and i'll let you know what that means when i'm done okay so looking at your vital signs here in the office it does look like you're doing a really good job managing your blood pressure your blood pressure is up is about one twenty over seventy seven today here in the office and that's with you probably in a little bit of pain so that's good and on your neck exam i do n't appreciate any lymphadenopathy on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are clear to auscultation bilaterally on your musculoskeletal exam on your right knee i do appreciate some ecchymosis some edema there is an effusion present does it hurt when i press\n[patient] yeah that's sore\n[doctor] okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt\n[patient] yeah do n't do that anymore\n[doctor] 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 i agree with you you had quite quite an injury to your knee and you do have a little bit of fluid in your knee there and just some inflammation which i think we need to talk about okay so i wan na go ahead and just talk a little bit about you know my assessment and my plan for you so for your first problem of your right knee pain i do believe you have what we call a a medial collateral ligament strain you know i wan na go ahead and just order an x-ray of your right knee just to make sure that we're not missing any broken bones which i do n't think we are but what's good about this particular injury is that people typically heal quite well from this and they typically do n't need surgery we can just go ahead and refer you to physical therapy to to strengthen those muscles around your knee so that you do n't have another injury and i wan na go ahead and just prescribe meloxicam fifteen milligrams once a day and that will help take down the swelling and help with some of the pain and you only have to take it once a day and it wo n't really cause any upset stomach or anything like that do you have any questions about that\n[patient] yeah if i start that medicine today am i going to be able to ski tomorrow because we got a a big weekend plan\n[doctor] i would say i would like you to rest your knee i i think that my concern is that if you go skiing again and you fall that you might injure your knee even more so i think you'll recover from this injury right now but i do n't want you to injure it anymore so i would rest it for a little while at least until we have the results of the x-ray and that type of thing okay for your second problem of your hypertension i wan na just go ahead and continue on lisinopril twenty milligrams a day i wan na just go ahead and order an a lipid panel just to make sure everything is okay from that standpoint and then i'm just looking through your health record and it looks like you're due for a tetanus shot so we'll go ahead and just give you a a tetanus shot for a from a health maintenance perspective any other questions\n[patient] i think so sounds like a good plan to me\n[doctor] okay sounds good alright so i'll see you later we'll get those ordered and i'll be in touch okay take care bye\n[patient] thank you",
            "tgt": "CHIEF COMPLAINT\n\nRight knee pain.\n\nMEDICAL HISTORY\n\nPatient reports history of hypertension.\n\nSURGICAL HISTORY\n\nPatient reports history of tonsillectomy.\n\nSOCIAL HISTORY\n\nPatient reports that he has a boat on Lake Martin. He is frequent water skier.\n\nMEDICATIONS\n\nPatient reports taking lisinopril 20 mg once a day.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports right knee pain and swelling.\nNeurological: Denies numbness or tingling in the right foot.\n\nVITALS\n\nBlood pressure: 120/77\n\nPHYSICAL EXAM\n\nNeck\n- General Examination: Neck is supple without lymphadenopathy.\n\nRespiratory\n- Auscultation of Lungs: Clear bilaterally.\n\nCardiovascular\n- Auscultation of Heart: Regular rate and rhythm. No murmurs.\n\nMusculoskeletal\n- Examination of the right knee: Ecchymosis noted. Effusion present. Pain to palpation medially. Decreased range of motion. Negative varus and valgus test. Negative Lachman sign. Palpable dorsalis pedis and posterior tibial pulse. There is otherwise no lower extremity edema.\n\nHematology/Lymphatic/Immunology\n- Palpation: No enlarged lymph nodes.\n\nASSESSMENT AND PLAN\n\n1. Right knee pain.\n- Medical Reasoning: Based on the patient's symptoms and exam, I believe he has a medial collateral ligament strain.\n- Patient Education and Counseling: We discussed the nature of this injury as well as the expected recovery outcome. He was advised surgery is typically not needed and that physical therapy will be beneficial for strengthening to prevent future injuries. He was also counseled to rest his knee until we at least receive his x-ray results in order to prevent further injury and to allow for a quicker recovery.\n- Medical Treatment: X-ray of the right knee was ordered for further evaluation. Referral to physical therapy was provided for strengthening. A prescription for meloxicam 15 mg once a day for pain and swelling was also provided.\n\n2. Hypertension.\n- Medical Reasoning: The patient is doing well on his current medication regimen. He is monitoring his blood pressure at home and has not had any elevated readings.\n- Medical Treatment: He will continue taking lisinopril 20 mg a day. Lipid panel was ordered today.\n\n3. Health Maintenance.\n- Patient Education and Counseling: I advised the patient that his records indicate that he is due for a tetanus vaccine.\n- Medical Treatment: The patient will receive his tetanus vaccine in office today.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow-up for his x-ray results.",
            "file": "D2N121-aci"
        },
        {
            "src": "[doctor] hey kyle it's nice to see you today can you tell me a little bit about what brought you in\n[patient] yeah i went to see my pcp for a cough which they diagnosed as bronchitis but then they did that chest x-ray to make sure i did n't have pneumonia and they found this lung nodule i went for a cat scan that confirmed it and they referred me here to you i'm really nervous document\n[doctor] okay well first of all i'm i'm sorry that you're nervous and what we're gon na do is we're gon na partner together okay and i'm gon na be right by your side the whole time to hopefully make you a little less nervous and and recognize the fact that we're you're gon na have a big support team around you okay\n[patient] okay\n[doctor] so let's talk a little bit about how long you've had that cough before you went to see your doctor\n[patient] i you know off and on i've had it for about three months i first noticed it when i was loading some pay i have horses and i i bought you know four hundred bills a day and when i spent a day loading it and then it's i just started coughing a lot more i think around that time and after that i i i just got a cold so that's what sent me to my pcp now i i i do exercise i i do a lot of biking and i typically do n't get sick and my cough has gone away\n[doctor] okay that's good to hear you mentioned exercise and biking i love to bike myself i've got a track seventy one hundred hybrid have you been on the the new trails they opened it was the old the old rail the old rail road right away they've opened that up it's like sixty miles of trails\n[patient] i love that that road i just i i do n't like riding on the road so i prefer to do those rails the trails type\n[doctor] yeah\n[patient] and it's just so phenomenal i do that a lot\n[doctor] yeah i love riding over there way we will we will get you all fixed up we will have to go for a bike ride\n[patient] absolutely i'd love it\n[doctor] that'd be great so i see here on your medical history that you also have a history of rheumatoid arthritis is that under control at this time and and and what do you do to to take care of your ra\n[patient] yeah it's it's it's fair you know arthritis never really goes away but i take methotrexate\n[doctor] okay\n[patient] i think it's seven and a half milligrams every week and as long as i'm keeping active my joints feel okay and if i do have any problems it's it's mostly with my hands but i have n't had any recent flares so i'm okay right now\n[doctor] okay that's good i also see here that you marked down that you were a previous smoker and and when when did you when did you stop smoking\n[patient] i stopped smoking probably about seven years ago\n[doctor] okay\n[patient] and i was young and should have stopped the way before that my kids were on me all the time but you know i i got a new start and finally was able to stop and i felt better after stopping\n[doctor] okay that's good and i'm glad to hear that you were able to to to stop and and stay tobacco free that that's great to hear do you have any pain or any shortness of breath or anything like that\n[patient] no not at all\n[doctor] okay and i would like to talk about your familial history here for just a second do you have any family history of lung cancer or any other type of malignancies\n[patient] no lung cancer my mom did have breast cancer but she is doing well now\n[doctor] okay alright and then things like lung infections or pneumonia do you have any previous history of that\n[patient] no no not not anything that i'm aware of\n[doctor] 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 listen to your lungs here your lungs are clear and equal bilateral when i listen to them or when i auscultate your lungs now listening to your heart regular rate and rhythm no clicks rubs or murmurs and i do n't appreciate any extra beats doing a quick extremity exam your skin is pink warm and dry i do n't appreciate any edema to your lower extremities it looks like you do have a little bit of swelling to to your knuckles there on your third digit on each hand which can be normal for somebody who has ra however pulses are intact in all extremities and capillary refill is brisk so a quick review of your results now you had a chest ct before you came in to see me and the results of that chest ct do show a solitary two centimeter nodule in the lateral aspect of the right upper lobe now it appears the nodule is smooth in appearance and no evidence of any type of emphysematous disease is present which is good now for my assessment and plan for you so you do have an incidentally found right upper lobe lung nodule i'm going to order some pft which is pulmonary function test i just wan na get a check and and a baseline for your lung function i'm also going to schedule a pet ct this is gon na help to determine if that nodule is metabolically active meaning if it lights up it it can suggest that it's cancer or inflammatory i'm going to go ahead and suggest that we do remove this during or via video assisted thoracoscopy which means it's just gon na be three small incisions made on the side of your right chest i'm gon na go in with a camera and a scope and we'll remove that along with a very small portion of your lung you're gon na be under general anesthesia and it'll take about an hour and a half or so post procedure you're gon na be admitted and you will have a chest tube in until the following day and i'm gon na go ahead and take that out then at bedside most likely you're gon na be in the hospital for one night and go home the next day it could be a benign nodule but because your smoking history i really do think it's gon na be best that you have that removed now for your secondary concern of your rheumatoid arthritis i want you to continue to follow up with your rheumatologist and continue your medication therapy as has been previously outlined for you now do you have any questions comments or concerns before before we get the paperwork signed to start the the treatment process\n[patient] no i do n't think so i think i'll be okay i'm scared\n[doctor] i i know you're scared but we'll be right here with you the whole way\n[patient] okay\n[doctor] alright we'll get some paperwork and i'll see you again in a few minutes\n[patient] okay thank you",
            "tgt": "CHIEF COMPLAINT\n\nCough.\n\nMEDICAL HISTORY\n\nPatient reports a history of rheumatoid arthritis. He denies any previous history of lung infections or pneumonia.\n\nSOCIAL HISTORY\n\nPatient reports he stopped smoking tobacco 7 years ago and has felt better since doing so. He notes that he enjoys biking.\n\nFAMILY HISTORY\n\nPatient reports his mother has a history of breast cancer, but is doing well. He denies any family history of lung cancer.\n\nMEDICATIONS\n\nPatient reports taking methotrexate 7.5 mg every week.\n\nREVIEW OF SYSTEMS\n\nRespiratory: Denies cough or shortness of breath.\n\nVITALS\n\nBlood Pressure: 124/76 mmHg.\nHeart Rate: 70 beats per minute.\nRespiratory Rate: 16 breaths per minute.\nOxygen Saturation: 98% on room air.\nBody Temperature: Afebrile.\n\nPHYSICAL EXAM\n\nRespiratory\n- Auscultation of Lungs: Clear and equal bilaterally.\n\nCardiovascular\n- Auscultation of Heart: Regular rate and rhythm. No clicks, rubs, or murmurs. Pulses are intact in all extremities.\n\nMusculoskeletal\n- Examination: No lower extremity edema. Mild swelling to the 3rd digit knuckles on the bilateral hands, consistent with RA.\n\nIntegumentary\n- Examination: Skin is pink, warm, and dry. Capillary refill is brisk.\n\nRESULTS\n\nCT scan of chest, obtained at an outside facility, is reviewed today and demonstrates a solitary 2 cm nodule in the lateral aspect of the right upper lobe. It appears the nodule is smooth in appearance. No evidence of any type of emphysematous disease is present.\n\nASSESSMENT AND PLAN\n\n1. Right upper lobe lung nodule.\n- Medical Reasoning: The patient has incidentally found right upper lobe lung nodule visible on his chest CT. It could be a benign nodule, but because of his smoking history, I think it is best that he has it surgically removed.\n- Patient Education and Counseling: I had a thorough discussion with the patient concerning surgical treatment. Surgery will require general anesthesia and will take approximately 1.5 hours. I explained to the patient that his procedure will consist of 3 small incisions being made on the side of his right chest. I will then insert a camera and scope to assist in removing the nodule along with a very small portion of his lung. He was advised that he will be admitted for most likely an overnight stay. He will have a chest tube in until the following day when I remove it at his bedside. All questions were answered.\n- Medical Treatment: Pulmonary function test ordered today to obtain patient's baseline. PET CT will also be scheduled to determine if the nodule is metabolically active, which can suggest if it is cancerous or inflammatory. Nodule will be removed via video assisted thoracoscopy.\n\n2. Rheumatoid arthritis.\n- Medical Reasoning: Stable.\n- Patient Education and Counseling: I encouraged the patient to continue to follow up with his rheumatologist.\n- Medical Treatment: Continue medication therapy and routine follow up with rheumatologist as previously outlined.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N122-aci"
        },
        {
            "src": "[doctor] so tyler is a 56 -year-old male who presents today complaining of difficulty swallowing and has a past medical history of diabetes and high blood pressure so tyler tell me what's going on with your swallowing problem\n[patient] well it's just been something that i have noticed over the last you know four to five weeks it seems like something is always stuck in my throat and you know just i kinda go about my day and it kinda bothers me you know a little bit sometimes a little painful and when i try to eat it just seems like i have to i do n't know when it's something solid i kinda have to wash it down on occasion i i've never really fully choked but i have to admit that i've thought about potentially choking\n[doctor] okay and is it seem to be stuck in your throat or does it seem to go in your lungs area or are you coughing with this at all or just mostly when you're swallowing\n[patient] no coughing just kinda when i swallow it's all okay with liquids but when i kinda swallow you know like a bite of a sandwich sometimes it just feels like like i just need a little help pushing it down\n[doctor] okay and is it more kind of a like heart like steaks or heart like larger solid like things that are that you have to chew more or is it even soft stuff like you know to eat yogurt and stuff like that\n[patient] i'm not a hundred percent sure but i think it's probably more with solids\n[doctor] okay how about have you noticed anything different with when you're swallowing cold or or or hot liquids is there is there a temperature change any modification to that\n[patient] it's really just about solids\n[doctor] okay alright so have you noticed any blood in any place or blood in your stools or are you vomiting anything up at all\n[patient] no\n[doctor] okay that so no vomiting blood no coughing up blood or anything like that any weight loss or changes in your weight at all\n[patient] not that i want\n[doctor] okay yeah i mean i think we all like to lose a little bit of weight but yeah it's a it says it's a struggle so no no chest pain or shortness of breath with this\n[patient] no\n[doctor] okay so i i'm gon na you know we'll talk about that in a second i'll look at your throat as well and see what we need to do but it sounds like we may have to send you to a specialist to take a look at that and see if there is something causing this how about how are you doing with your diabetes by the way since i have n't seen you in a while i know we have you on metformin five hundred milligrams twice a day we checked your hemoglobin a1c last time was seven . four we talked about improving your diet and exercise how are things going\n[patient] i think they're going great i mean i'm taking my meds i'm sticking to them and i feel pretty good otherwise\n[doctor] okay are you checking your blood sugars in the morning or are you checking those at all\n[patient] yeah i do i mean once in a while i i'm in a hurry and i skip it but i have to say i probably do so about eighty percent of the time\n[doctor] and how are the numbers looking\n[patient] they're looking you know okay they are all within you know the range that we are targeting\n[doctor] okay alright and any any no nausea vomiting or diarrhea or any other side effects from the metformin or anything like that\n[patient] no\n[doctor] 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 your blood pressure i know we have you on norvasc we asked that you check it like you know once a week or more than that if you have time blood pressure looks good today in the office it's about one fifty i'm sorry one twenty over fifty right now so no nothing here in the office how are things at home\n[patient] i get there now every once in a while you know the lower numbers a little bit you know higher but it's not you know usually it's either close or or on on range\n[doctor] 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 no masses or any swelling that i can see there is no redness yeah there is no carotid bruit your lung exam is clear your heart exam is normal no murmurs on your belly exam you have some epigastric tenderness right here in the right here where i'm pressing but i do n't feel any masses or any significant swelling back there no normal back exam your extremity exam looks normal your neurological exam's fine so for this difficulty swallowing i'm concerned that you may have a narrowing in your throat that's causing this and sometimes it can be from a stricture where some narrowing of the esophagus and sometimes i need to go in and dilate that so i'm gon na go ahead and send you give you a referral for gastroenterology and have them do a scope and take a look down there i'm gon na recommend we put you on some prilosec sometimes also reflux medicine can if you have reflux sometimes that can also exacerbate this sometimes so i'm gon na put you on some prilosec twenty milligrams once a day again i'm gon na recommend that you chew your foods frequently and make sure you have a you know especially if you're eating something hard like steak or meat chew them really well so they do n't get tend to get stuck some people have sometimes things get stuck and they do n't go down and if that happens as an emergency you do have to go to the emergency department but seems like you know things are going down they just seem to sometimes slow down or get stuck temporarily so why do n't i get you a referral for gi we will start you on the prilosec and then we will have you you know if you you know if you have any other symptoms or worsenings give my office a call we will get you in or get you referred to the er if needed any questions about that\n[patient] no that sounds great\n[doctor] okay and for the diabetes i'm gon na order another hemoglobin a1c i'm gon na order some more blood work today we'll check a kidney function and i notice that you have not had an eye referral so i'm gon na also give you an eye referral to ophthalmology to check your eyes for your diabetic for your for any retinopathy continue the metformin i'll have you come back in about a month and that way we'll have the results back for the blood test if we need to make any adjustments we can but i i wan na see you back in about a month and i think that's it for that any questions about that\n[patient] no\n[doctor] okay and the high blood pressure i think you're doing great continue with the norvasc if you have any issues certainly call me but otherwise there is really nothing else to add for that did we forget anything or do you need refills for anything\n[patient] you know i think i'm low on the norvasc so if you could send something to my pharmacy that would be great\n[doctor] okay sure i'll get you a refill for norvasc we'll get that sent over to the pharmacy okay\n[patient] thank you\n[doctor] alright thanks good seeing you thanks for coming in to them",
            "tgt": "SUBJECTIVE\n\nDifficulty swallowing. Tyler Green is a 56-year-old male who presents today complaining of difficulty swallowing.\n\nThe patient noticed the difficulty swallowing approximately 4 to 5 weeks ago. He describes it as something stuck in his throat. He states that it bothers him a little bit throughout the day as sometimes it becomes painful. The patient states that occasionally when he tries to eat something relatively solid it seems to get stuck and he will have to wash it down with a drink. He states that he has never fully choked before, but has recently thought about potentially choking. He denies having to cough. Denies having this issue with liquids, hot or cold. Denies hematochezia, vomiting blood, coughing up blood, any weight changes, chest pain, or shortness of breath.\n\nRegarding his diabetes, the patient states he is doing well. He states that he checks his blood sugars most of the time, but sometimes he is in a hurry and will forget. However, he does note that when he checks his blood sugar, they are within range. He is compliant with his metformin 500 mg twice a day. He denies any side effects of the metformin such as nausea, vomiting, or diarrhea. His last hemoglobin A1c was 7.4.\n\nIn regards to his blood pressure, the patient states that he is doing okay. He notes that occasionally he will have a lower blood pressure and then other days it will be elevated. However, he states they usually close in range. He is still taking Norvasc.\n\nMEDICAL HISTORY\n\nPatient reports a history of diabetes and hypertension.\n\nMEDICATIONS\n\nPatient reports that he take metformin 500 mg twice a day and Norvasc.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Denies weight changes.\nHENT: Reports dysphagia.\nCardiovascular: Denies chest pain.\nRespiratory: Denies cough, shortness of breath, or hemoptysis.\nGastrointestinal: Denies hematochezia, hematemesis, vomiting, nausea, or diarrhea.\n\nVITALS\n\nBlood pressure in office today is 120/50.\n\nPHYSICAL EXAM\n\nNeck\n- General Examination: Neck is supple without thyromegaly or lymphadenopathy. No swelling. No masses noted. No carotid bruits. No redness noted.\n\nRespiratory\n- Assessment of Respiratory Effort: Normal respiratory effort.\n- Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.\n\nCardiovascular\n- Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs.\n\nGastrointestinal\n- Examination of Abdomen: No masses or swelling. Epigastric tenderness noted.\n\nMusculoskeletal\n- Normal back examination.\n- Normal capillary refill and perfusion.\n\nHematology/Lymphatic/Immunology\n- Palpation: No enlarged lymph nodes.\n\nASSESSMENT AND PLAN\n\n1. Difficulty swallowing.\n- Medical Reasoning: The patient describes difficulty swallowing when he eats solid foods.\n- Patient Education and Counseling: We discussed that I am concerned he has a narrowing in his throat that is causing this. I advised the patient the gastroenterology will do a scope. I recommended Prilosec as he might be experiencing reflux. We discussed that he should eat his food slowly and chew his food frequently. I advised the patient to call our office if his symptoms worsen.\n- Medical Treatment: I referred the patient to gastroenterology. I prescribed Prilosec 20 mg once a day.\n\n2. Diabetes.\n- Medical Reasoning: This seems well-controlled.\n- Patient Education and Counseling: The patient will continue with his metformin as he seems to be doing well. I advised the patient to follow up in 1 month for results and any adjustments that may be needed.\n- Medical Treatment: Continue metformin 500 mg twice a day. I ordered another hemoglobin A1c, as well as a kidney function test. I referred the patient to ophthalmology for retinopathy.\n\n3. High blood pressure.\n- Medical Reasoning: This seems well-controlled.\n- Patient Education and Counseling: I advised the patient to continue his current medication, Norvasc.\n- Medical Treatment: I refilled the Norvasc.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow-up in 1 month for his diabetic lab results and any modifications needed.\n",
            "file": "D2N123-aci"
        },
        {
            "src": "[doctor] so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened\n[patient] hey doctor michael yeah so my son sean i think you met in the past he he started playing basketball and there we do multiple seasons and so we're kinda getting ready for the next season that starts in in april and we were at the courts plan and i went up for a shot and he's far more aggressive than with me than he is with you know his peers i guess he could say and so he he found me while i was going for a lap and then when i came down i kind of landed awkwardly and i kind of like rolled and twisted my my ankle so now it's it's hurting a bit like kind of on the outside you can you can even see it's it's bruised up and a bit swollen\n[doctor] yeah\n[patient] and yeah i've been having trouble walking and it just does n't feel solid really stable which is a problem i i recently got back into working out and i had been in a really good rhythm going to the gym\n[doctor] okay\n[patient] and i do n't want to disrupt that moments on because it took a lot for me to get back to a good place so\n[doctor] absolutely okay totally understand that glad to hear that you're back out on the court playing with your son how is he doing by the way\n[patient] he is doing great he is doing great i mean you know he is a big step kurry fan so he likes to keep up shots from from way out past the three point line and he is only ten and tiny so it's it's not a good idea for him to do that but he is doing really well and i'm just happy he's tried every sport and basketball's really what took so i'm just really happy that he has a sport and loves and couple of his buddies playing to lead with him so it's just makes me happy that he's found something he really enjoys\n[doctor] good good to hear alright well let's take a look at that ankle it looks like it's pretty swollen so let me just do a quick exam on that right now alright so looks like the outside of your ankle if i push on that does that hurt pretty bad\n[patient] yeah yes\n[doctor] okay so exquisite tenderness tenderness laterally and then if i push here does that hurt too\n[patient] yeah a little bit\n[doctor] okay so some tenderness over the medial deltoid region so swelling on the lateral side of the ankle no epidermolysis skin is intact looks like you have brisk capillary refill no horrible malalignment so alright can you can you stand on it did you say that you're having trouble walking at all\n[patient] yeah i mean i can stand on it and i ca n't walk on it it just it hurts and it feels like i'm going to possibly injure it more just because it does n't feel particularly solid\n[doctor] sure so it does n't quite feel stable\n[patient] yeah\n[doctor] 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 there's no evidence of medial or posterior malleolar fractures but this is a fracture on the lateral side of your ankle now based on the position it's a bit unstable that's why you're feeling some of that that instability when you're walking so for your diagnosis what i'm gon na put down is a lateral malleolar fracture and what i would recommend for that since it is in the location that it is is you're probably unfortunately gon na need surgery we're gon na wan na get that healed what that includes is putting some plate and some screws in and you're gon na be out for a little bit so i know you've been trying to work out and and you wan na get back on the court but but you may have to have to sit out for a little bit we'll get you some crutches\n[patient] how long it's a little bit because i'm also i i forgot to say i'm also i did volunteer to coach\n[doctor] great\n[patient] starting in april so\n[doctor] alright well\n[patient] how long\n[doctor] yeah you you're probably gon na be out for about three months but continue the coaching go ahead and and let's get you back out there we'll get you some crutches and and hopefully you can kinda you know get back on the court start coaching and then within that three months we'll we'll get you back out doing some exercise again\n[patient] okay\n[doctor] alright in the meantime i'm gon na prescribe some medication for now let's try meloxicam and try to get some of the swelling down i want you to ice it and also keep that that ankle elevated do you have a job where you can elevate your ankle regularly\n[patient] yeah i i work from home so that that should n't be a problem it's just everything else i do n't know who is gon na walk my dogs and and do all this stuff that's rest of my family refuses to walk my dog so we'll figure it out\n[doctor] yeah i i'm a dog walker as well so alright sorry for the bad news but let's get you healed up so that we can get you back out doing everything you need to do\n[patient] alright thank you doctor\n[doctor] alright thanks",
            "tgt": "CHIEF COMPLAINT\n\nRight ankle injury.\n\nHISTORY OF PRESENT ILLNESS\n\nJerry Cook is a 45-year-old male who presents today with a right ankle injury.\n\nThe patient sustained an injury to the right ankle while playing basketball with his son. He reports he landed awkwardly and twisted his right ankle after jumping to make a layup. His pain is primarily located along the lateral aspect of the right ankle. He notes bruising and swelling. The patient is able to weight-bear while standing. He experiences pain and feelings of instability within the ankle while ambulating and is concerned for further injury.\n\nSOCIAL HISTORY\n\nThe patient works from home and plans to coach his son\u2019s basketball team in 04/2022. He enjoys working out and reports he recently resumed engaging in a consistent gym routine.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports right ankle pain and instability.\nSkin: Reports right ankle bruising and swelling.\n\nPHYSICAL EXAM\n\nCV: Brisk capillary refill.\nSKIN: No epidermolysis. Intact.\nMSK: Examination of the right ankle: Exquisite tenderness laterally. Mild tenderness over the medial deltoid region. Swelling on the lateral side of the ankle. No horrible malalignment.\n\nRESULTS\n\nX-rays, including AP, lateral, and oblique views of the right ankle, were obtained in the office and reviewed today. These demonstrate a displaced lateral malleolus at the Weber C level. There is no evidence of medial or posterior malleolar fractures.\n\nASSESSMENT\n\nRight lateral malleolar fracture.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding treatment options. Recommendation was made for an open reduction internal fixation of the right ankle. We discussed the risks and benefits of the procedure as well as the postoperative recovery period following surgery. I advised that it will be 3 months before he can resume his exercise routine. In the meantime, I will prescribe meloxicam to reduce swelling. I recommended he ice and elevate the ankle as well. He will be given crutches to assist with ambulation.\n\nThe patient understands and agrees with the recommended medical treatment plan.",
            "file": "D2N124-aci"
        },
        {
            "src": "[patient] miss edwards is here for evaluation of facial pain this is a 54 -year-old male\n[doctor] how're you doing doctor cruz nice to see you today\n[patient] good to see you mister edwards i'm doctor\n[doctor] tell me what's been going on yeah so i've got this stabbing shooting pain i've had for a while you know and it it especially right here in my right face right in that cheek bone area it's sometimes it gets super hot i've had it for i think a couple of months now and i went to my family doctor and they said i should come see you\n[patient] okay great i would like to ask you a little bit more about that\n[doctor] had in your face do you remember how long that you had it probably for about two or three months just just came on slowly i started noticing it but now it's i have episodes where just shooting stabbing kind of a pain in my right cheek bone right face area\n[patient] mm-hmm do you have any sensory loss meaning like numbness or tingling in that part of your face\n[doctor] not that i've noticed no okay do you have any symptoms like this anywhere else on your face including the other side of your face\n[patient] no it's just on the right side mostly not on the left side just on the right side of my face\n[doctor] have you noticed any weakness on that side of the face like when you smile or while you're doing other things any weakness there not really i mean i've i've i've tried to you know when i smile my smile seems equal on both sides my eyes i do n't have any weakness there my vision seems to be unchanged but just this stabbing severe pain it's just like excruciating pain that i get sometimes does it happen on its own or there are certain things that trigger it\n[patient] sometimes if i'm if certain temperatures seem to trigger it sometimes or if it's super where it's cold i get a trigger sometimes\n[doctor] sometimes certain kind of sensory outside of the wind sometimes that seems to trigger it but that's about it\n[patient] okay and anything that you've done to to that helps for a little bit when you\n[doctor] pain excess\n[patient] you know i've tried ibuprofen and motrin that had really has n't helped it just comes on suddenly and then it's kinda stabbing excruciating pain i've tried rubbing some you know some tiger balm on it that did n't work\n[doctor] but that's you know so i i went to my family doctor and he said you know i really need to see a neurosurgeon\n[patient] got it how long do these episodes last these pain\n[doctor] you know it can last for anywhere from a few minutes to sometimes about an hour but generally generally a few minutes\n[patient] any history of something like multiple sclerosis or any brain tumors that you know\n[doctor] no nothing like that alright any other kinda headache symptoms that have anything like you had migraines or anything related to the headaches i mean i get occasional headaches but not really i do n't have a history of migraines but i occasionally get headaches like everybody else i take some tylenol that usually goes away but this is different\n[patient] how severe is the pain on a scale of one to ten\n[doctor] when it comes on it's like a ten it's like somebody is stabbing you with an ice pick and but usually you know after a few minutes usually it goes away but sometimes it can last up to an hour great so mister i would like to do a physical exam if that's okay with you\n[patient] sure\n[doctor] i would like you to follow my finger here and i see that you're following my finger in in both directions can you show me your teeth\n[patient] that looks nice and symmetric i'm gon na rub my fingers next to your ear can you hear that\n[doctor] yep\n[patient] you can hear it on the other side as well\n[doctor] yep\n[patient] okay\n[doctor] i'm gon na take this cotton tape and run it along the side of your face can you feel that okay\n[patient] yeah it's a little bit numb on my right side not so much on my left side\n[doctor] okay alright i'm gon na use this little needle here and i'm gon na poke here and i wan na see if you feel like it's being sharp or dull on that part of your face does that feel different or normal\n[patient] it feels a little bit dull on my left on my right side my left side it feels sharp\n[doctor] alright good well i had a chance to look at your mri\n[patient] okay\n[doctor] and i looked at your mri and it appears to have small blood vessel that is abutting and perhaps even pinching the trigeminal nerve the trigeminal nerve is nerve that comes from the brainstem that goes out to the face and provides the sensory inflammation from the face and you may have a condition called trigeminal neuralgia\n[patient] okay\n[doctor] where the nerve compression causes this kind of shooting electrical pain in the face how do we treat it\n[patient] well the first line would be to try some medications usually we start with medications that are called gabapentin\n[doctor] or tegretol these are medications that really help reduce the excitability of the nerve\n[patient] okay\n[doctor] most people can get the pain control with that but there are some people where the medications are n't gon na be enough and in that situation we would consider surgery i would n't i would n't recommend that now we usually try the medications first\n[patient] for considering a surgery to decompress the nerve the root cause of the problem is the compression of the blood vessel against the nerve\n[doctor] okay so we should be tried which one would you recommend the tegretol or yeah i think we could start with the tegretol to start with i just want to make sure that you understand some of the potential side effects that you can have with this\n[patient] sure\n[doctor] it's always a little bit of trial and error to figure out what the right dosing that would work for you but some common side effects can include you know memory loss tingling imbalance some people can actually have like dermatologic\n[patient] skin reaction to this medication and particularly people who have eustachian descent so that we may do some genetic testing just to make sure that it will be safe for you\n[doctor] okay sounds good let's do it\n[patient] okay so i will prescribe that for you and then we will see how that goes and if your pain continues we can talk about different surgical options to treat the pain\n[doctor] yeah i think i would like to try the tegretol first and if that does n't work then i can come back and so once should i come back and just to kinda check back with you and see if you know if it's had enough time for a fact or not\n[patient] i think one month would be a great time to follow up\n[doctor] okay sounds good so if you want to send that prescription over to my pharmacy that would be fine and then why do n't i come back in about a month and we'll go from there\n[patient] great i'll see you then\n[doctor] alright",
            "tgt": "CHIEF COMPLAINT\n\nRight-sided facial pain.\n\nREVIEW OF SYSTEMS\n\nEyes: Denies vision changes or weakness in right eye.\nHENT: Reports right sided facial pain. Denies left sided facial pain. Neurological: Reports headaches. Denies sensory loss, numbness, or tingling in the right cheek. Denies right sided facial weakness.\n\nPHYSICAL EXAM\n\nNeurological\n- Orientation: Light touch testing of the right side of the face reveals numbness when compared to the contralateral side. Pinprick testing is sharp on the left side of the face; dull on the right side of the face.\n\nEars, Nose, Mouth, and Throat\nBilateral finger rub test is negative.\n- Examination of Mouth: Teeth are symmetric.\n\nRESULTS\n\nMRI of the head is reviewed today. This demonstrates a small blood vessel that is abutting, and perhaps even pinching, the right trigeminal nerve.\n\nASSESSMENT AND PLAN\n\n1. Trigeminal neuralgia.\n- Medical Reasoning: The patient has been experiencing facial pain for 2 to 3 months. A recent MRI revealed a small blood vessel abutting, or perhaps even pinching, the right trigeminal nerve. The root cause of his facial pain is the compression of the blood vessel against this nerve.\n- Patient Education and Counseling: The patient and I discussed treatment options including medicating with gabapentin or Tegretol. I explained the common side effects associated with these medications can include memory loss, tingling, and imbalance. We discussed the need for genetic testing due to the possible side effect of dermatologic reactions in people of East Asian descent. We also briefly discussed surgical treatment to decompress the nerve, but this is not recommended at this time.\n- Medical Treatment: A prescription for Tegretol will be sent to the patient\u2019s pharmacy.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow up with me in 1 month. If at that time his facial pain persists, we may further discuss surgical options.",
            "file": "D2N125-aci"
        },
        {
            "src": "[doctor] hi michelle what's been going on the medical assistant told me that you injured your knee\n[patient] yeah i'm gon na have to keep this my favorite story is that i had a sandra who injured her knee cold dancing so that would immediately came up to mine but let's try skiing so i was skiing in vermont last weekend and i caught my ski when i was coming off the lift and i fell and my knee popped and it's hurt ever since\n[doctor] okay and were you able to ski down the hill or did you have to be taken down by the ski patrol\n[patient] i had to be taken down by the ski patrol i was unable to bear weight\n[doctor] okay is n't that slightly terrifying they had to do the same thing for me and you're just kind of sitting there watching all of the trees go by so anyway so what part of your knee is bothering you the most is it the inside the outside\n[patient] it hurts on the outside but it also feels like it wo n't hold my weight\n[doctor] okay so it feels like it's gon na buckle\n[patient] hmmm yes\n[doctor] okay alright and are you able to bend it\n[patient] i was immediately after the injury but not really now\n[doctor] okay and how about straightening it are you able to straighten it at all\n[patient] somewhat but it really hurts when i try to straighten all the way\n[doctor] okay alright now do you have any numbing or tingling in your toes\n[patient] no\n[doctor] okay and can you feel your toes okay\n[patient] i think so\n[doctor] okay alright now are you a pretty active person you said you were skiing do you do what kind of other activities do you do\n[patient] i chase my two four -year-old\n[doctor] okay do you have twins\n[patient] i do\n[doctor] nice that's great\n[patient] yeah\n[doctor] so okay and what's your support like at home who is who is able to help out are you still doing that kind of hobbling around on crutches or\n[patient] yeah now my husband is home with me but he also works a job where he is gone quite a bit so it's just me and the kids\n[doctor] okay alright and did the ski patrol give you crutches i i see you have them here with you okay alright great and are you otherwise generally healthy\n[patient] yes\n[doctor] okay and no high blood pressure diabetes anything like that\n[patient] mm-hmm\n[doctor] no okay alright and well i i wan na go ahead let me just do a quick physical exam i'm gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay alright so on your heart exam your heart sounds in a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are nice and clear to auscultation and remind me what knee did you injure again\n[patient] my right knee\n[doctor] your right knee okay so on your right knee examination i do appreciate some edema and an effusion over the right knee does it hurt when i press\n[patient] yes\n[doctor] 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 my plan for you so you know i know that you had the x-ray done of your of your right knee that did n't show any bony abnormality but i i'm concerned that you have ruptured your your acl or your anterior cruciate ligament that's like a major ligament that helps connect and helps your knee move back and forth so i wan na go ahead and order a knee mri just so that we can get a a a good look and just you know confirm that physical exam okay now some people can have a normal physical exam and their acl can still be torn but you do have a lot of pain on the lateral aspect of your knee so i wan na make sure if there make sure that there is not any other structures that have been damaged by this accident okay i wan na go ahead and you know are you what are you taking for the pain\n[patient] ibuprofen\n[doctor] is that helping\n[patient] somewhat yes\n[doctor] okay alright do you want something stronger\n[patient] no i'm okay\n[doctor] alright so let's just continue with ibuprofen you can take you know six hundred to eight hundred milligrams every eight hours as needed i wan na go ahead and put you in a brace that's gon na help your knee feel a bit more supported okay and let's go ahead and i'm hoping that we can get this mri done in you know the next couple days and then we can have a conversation about what needs to be done now you said that you are are are you know obviously a very active active mom any other exercise or anything else that that i should be aware of that you do just wondering in terms of which kind of graft we would use to fix this with your with your acl being injured\n[patient] hmmm no i not i i would like to get back to the running but currently not that active\n[doctor] okay alright alright do you have any questions about anything\n[patient] i think you've explained it well\n[doctor] okay alright so i'll see you again soon okay\n[patient] okay thank you\n[doctor] alright take care bye",
            "tgt": "CHIEF COMPLAINT\n\nRight knee injury\n\nHISTORY OF PRESENT ILLNESS\n\nMichelle King is a pleasant 44-year-old male who presents to the clinic today for the evaluation of a right knee injury. Her injury was sustained while skiing in Vermont last weekend after she caught her ski when coming off of the lift and fell. She reports a pop in her knee at the time of injury and has been experiencing pain since that time. Due to her fall she was unable to weight bear and had to be taken down by the ski patrol. She locates her pain to the lateral aspect of her knee and also describes the feeling of instability as well as buckling. At this time she is experiencing difficulty with knee flexion; however, she states this was not a problem immediately after the injury. Full knee extension is also quite painful for her. The patient denies any numbness or tingling in her toes. She is currently utilizing crutches for ambulation which were provided to her by the ski patrol. In terms of pain control, she is taking ibuprofen which is providing some relief.\n\nMEDICAL HISTORY\n\nPatient reports she is otherwise healthy and denies a history of high blood pressure or diabetes.\n\nSOCIAL HISTORY\n\nPatient reports she is very active with skiing and taking care of her 4-year-old twins. She mentions that she would like to get back into running at some point. She states that her husband is home with her, but he also works a job where he has gone quite a bit.\n\nMEDICATIONS\n\nPatient reports she is taking ibuprofen.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports right knee pain and limited range of motion.\nNeurological: Denies numbness or tingling in toes.\n\nPHYSICAL EXAM\n\nGAIT: The patient is ambulating with crutches.\nCV: Regular rate and rhythm. No murmur.\nRESPIRATORY: Lungs are clear to auscultation.\nMSK: Examination of the right knee: Edema and effusion noted. Pain with palpation of the lateral knee. Decreased flexion and extension. Positive Lachman's. Palpable dorsalis pedis and posterior tibial pulse. No ankle edema.\n\nRESULTS\n\n4 views of the right knee were taken today. These reveal no bony abnormalities.\n\nASSESSMENT\n\nRight knee pain, possible ACL tear.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have recommended that we obtain an MRI of the right knee to evaluate for a possible ACL tear. In the meantime, I have advised her to continue taking ibuprofen 600 to 800 mg every 8 hours as needed for pain. She will also be placed into a brace for increased knee support.\n\nINSTRUCTIONS\n\nThe patient will follow up with me once the MRI results are available for review and further discussion.",
            "file": "D2N126-aci"
        },
        {
            "src": "[doctor] hey brandon you know glad to see you in here today i see on your chart that you're experiencing some neck pain could you tell me a bit about what happened\n[patient] yeah i was in a car crash\n[doctor] wow okay when was that\n[patient] well which car crash\n[doctor] okay so multiple car crashes alright so let's see if we can how many let's start\n[patient] my therapist said well my well actually my mother said i should go see the therapist and the therapist said i should see the lawyer but my neck's hurting\n[doctor] okay so i'm glad that you know you're getting some advice and so let's let's talk about this neck pain how many car crashes have we had recently\n[patient] well the ones that are my fault or all of them\n[doctor] all of them\n[patient] i was fine after the second crash although i was in therapy for a few months and then after the third crash i had surgery but i was fine until this crash\n[doctor] okay the most recent crash when was that\n[patient] that's when i was coming home from the pain clinic because my neck hurt and my back hurt but that was in february\n[doctor] okay alright so we had a car crash in february\n[patient] what year it was which february it was\n[doctor] okay so let's let's try with this one see what happens hopefully you remember i need you to start writing down these car crashes that this is becoming a thing but you know it's okay so let's let's say maybe you had a\n[patient] you're not judging me are you\n[doctor] no there's no judgment here whatsoever i want to make sure that i'm giving you the best advise possible and in order to do that i need the most information that you can provide me makes sense\n[patient] yes\n[doctor] alright so we're gon na say hope maybe that you had a car crash and we can verify this in february of this year and you've been experiencing some neck pain since then right\n[patient] yes\n[doctor] okay alright on a scale of one to ten what ten is your arm is being cut off by a chainsaw severe how bad is your pain\n[patient] twelve\n[doctor] okay terrible pain now i know you mentioned you had previous car crashes and you've been to therapy has anyone prescribed you any medication it's you said you went to a pain clinic yes\n[patient] well they had prescribed it recently i was i was on fentanyl\n[doctor] oh\n[patient] i have n't gotten a prescription for several weeks\n[doctor] okay alright and so we will be able to check on that when you take your medication so before you take your medication rather like are you able to move like are you experiencing any stiffness\n[patient] yes but it hurts\n[doctor] okay it hurts what kind of pain is it sharp is it dull is it throbbing\n[patient] it's the sharp incapacitating pain i ca n't work\n[doctor] wow okay are you having any headaches\n[patient] of course\n[doctor] any dizziness\n[patient] just sometimes\n[doctor] any visual disturbances is it hard to like are you\n[patient] not recently no\n[doctor] okay alright any numbness\n[patient] yes\n[doctor] where\n[patient] my left arm and my right leg\n[doctor] okay any spasms\n[patient] of course\n[doctor] okay where\n[patient] my body hurts i told you my neck hurts\n[doctor] okay so i no i'm absolutely i wan na make sure that we are gon na give you the medication that works like the best for you so i'm sorry if these questions seem like frustrating i would just wan na make sure that i understand what the problem is so\n[patient] i saw pamela and doctor collins's office she's much nicer than you know\n[doctor] i mean okay so you know what like maybe maybe pamela would be better like we could maybe talk talk about a referral if that would make you more comfortable\n[patient] my lawyer told me to come here\n[doctor] then you're stuck with me okay i'm so sorry but here it's we're gon na try and make it as good as possible alright so last thing i do wan na do my physical exam alright and i need you to let me know as as much as you as much as you can verbalize right so when i push here in the middle of your neck on top of the bone does it hurt\n[patient] yes yes\n[doctor] okay alright sorry what about on the side does that hurt\n[patient] yes\n[doctor] okay so pain on palpation both on the bony process and on the muscle can you move your neck from side to side can you move your neck can you swive it side to side no no alright so i'm i'm seeing i'm seeing some range of movement moderate range of movement that's fine okay i so when can you bend your neck forward that that's your whole body just just the neck are you capable of bending up\n[patient] really hurts it really hurts\n[doctor] okay it really hurts to bend forward and backwards okay alright so i'm just gon na make a little note here i do n't i do n't see any bruising i'm not noticing any swelling there is i i do n't see any laceration what\n[patient] just sometimes it bruises\n[doctor] okay sometimes alright that's fine i i just i'm not seeing one here today so that's okay alright so with that being said i do wan na ask have you been experiencing any fatigue are you tired\n[patient] well since the accident yes\n[doctor] okay alright just making sure okay so this is what this is my assessment and plan this is what we are gon na do i want to be able to like we had you do an x-ray before you came in here and looking at it i'm not noticing any fracture that's a really good sign considering how many car accidents we've been in lately\n[patient] it hurts it hurts\n[doctor] absolutely no i we're gon na address the pain so for my first so looking at your imaging results though i'm not seeing a fracture that's a great sign so for your first diagnosis i'm gon na say that you have what is called a neck sprain that\n[patient] thinking are are you saying i'm thinking\n[doctor] no not by any means i am saying\n[patient] pain i have a lot of pain\n[doctor] yes and your pain can be explained by multiple things but thankfully it's not a broken neck is that okay\n[patient] yes\n[doctor] alright so what we are gon na do when we are gon na like try and treat this as conservatively as possible\n[patient] said it might be broken\n[doctor] what\n[patient] pamela said it might be broken\n[doctor] if pamela said it's broken then you know what this is what we're gon na do we're gon na order something called a ct that's gon na give us even nope you know what let's upgrade to an mri it's gon na give us the most thorough image of everything that's going on the heart and the soft tissues is that gon na is that so that way we can really get a good image of what's happening inside right\n[patient] okay because what the lawyer said i needed was an mri\n[doctor] not a problem we're we're gon na make your lawyer happy next step we are going to try working like from the outside in so i do need you to work on getting like you're you're saying you've seen some bruising and some swelling yourself so i want you to put ice on that whenever you're experiencing that in the moment when you wake up i want you to do your best to just like i'm gon na give you some exercises on the sheet and i want you to roll through these exercises every morning right to just get some like movement and like free frenosive movement back into your neck i also wan na put you on a couple medications now i know that you said you were on fentanyl before that's a bit extreme and i i want i i i wan na like monitor this a little more conservatively so what we're gon na start with is something called robaxin\n[patient] hurts a lot if i do n't get more fentanyl\n[doctor] you know we can refer you to pain medicine if it really is getting that complicated but for this current period we're gon na put you on some robaxin it's gon na be fifteen hundred milligrams and you're gon na take that six to eight hours every six to eight hours and that really should help kinda relax the muscles in the area take off some of that tension and really help with that pain if you're noticing that the robaxin still is n't helping maybe then we can start we can like start using like a heat pad or maybe some icyhot the biofreeze is a really good one to kinda help with that and then we will refer you to physical therapy i think with the mri we can start evaluating maybe some additional steps so rather than you having to like take that fentanyl because i do n't want you to be in danger right like people i do n't want you to get rubbed so what we could explore are local injections right and we can refer you to pain medication and see about like locally injecting the area and that should be able to help you out hopefully with this\n[patient] i ca n't go to work like this\n[doctor] okay so if it's if it's that bad let's wait for the mri result we're gon na give you off for work because you know you ca n't move and we'll see what the mri says about what whether or not we can get you like true local injections in the moment is that alright for now\n[patient] yeah\n[doctor] okay okay any other questions\n[patient] not right now\n[doctor] alright",
            "tgt": "CHIEF COMPLAINT\n\nNeck pain.\n\nHISTORY OF PRESENT ILLNESS\n\nBrandon Green is a pleasant 46-year-old male who presents to the clinic today for the evaluation of neck pain. His pain began when he was involved in a motor vehicle accident in 02/2022 when he was on his way home from a pain clinic. The patient notes that he has been in 4 motor vehicle accidents; however, he notes that he was fine after the first two accidents, but the third motor vehicle accident is when his neck and back pain began. He states that he was in therapy following the second accident and had surgery after his third accident. The patient was seen at a pain clinic secondary to neck and back pain. He was prescribed fentanyl; however, he has not received a prescription for several weeks. Today, he reports that his pain is a 12 out of 10. He describes his pain as sharp and incapacitating with stiffness and pain. The patient also reports headaches, occasional dizziness. He denies any recent visual disturbances. He also reports numbness in his left arm and right leg. The patient also reports spasms throughout his body. He states that he has been experiencing fatigue since the accident. He notes that he is unable to work with this much pain.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Reports fatigue.\nEyes: Denies any recent visual disturbances.\nMusculoskeletal: Reports neck and back pain, and occasional swelling and bruising of the neck.\nNeurological: Reports headaches, dizziness, spasms, and numbness.\n\nPHYSICAL EXAM\n\nSKIN: No lacerations.\nMSK: Examination of the cervical spine: Pain on palpation on the bony process and muscle. Moderate ROM. No bruising or edema noted.\n\nRESULTS\n\nX-rays of the neck reveal no fractures.\n\nASSESSMENT\n\nNeck sprain.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any signs of a fracture. I recommended an MRI for further evaluation. I have also prescribed the patient Robaxin 1500 mg every 6 to 8 hours to treat his pain. I have also advised him to utilize ice, a heating pad, IcyHot, or Biofreeze on his neck as needed. I have also provided him with a home exercise program to work on his range of motion. I advised the patient that he will not be able to work until we have the MRI results.\n\nINSTRUCTIONS\n\nThe patient will follow up with me after his MRI for results.",
            "file": "D2N127-aci"
        }
    ]
}