{
    "data": [
        {
            "src": "[doctor] hi , carolyn . how are you ?\n[patient] good . how are you ?\n[doctor] i'm good . you're ready to get started ?\n[patient] yes , i am .\n[doctor] so carolyn is a 49-year-old female here for follow-up of her chronic problems . so , how are you doing , carolyn ?\n[patient] i'm doing okay . um , my osteoarthritis has been flaring up a little bit lately , um , so i wan na get- talk about that primarily . so , it's mostly in um , my elbows and it's really been bothering me . i've been sitting at the computer , at the desk more , um , in the office so i do n't know if it's being stagnant in that position all day has um , increased flare-ups for that , but i wanted to talk to you about that .\n[doctor] okay , sure . and , are you right or left-handed ?\n[patient] i'm right-handed .\n[doctor] okay , and does one elbow bother you more than the other ?\n[patient] my right elbow does bother me more than the other , but primarily , i'm typing all day versus writing , so it- it flares up in both .\n[doctor] okay . all right , and um , any other joint pain ?\n[patient] no , just- just really focused on my elbows .\n[doctor] okay , and any numbing or tingling in your hands ?\n[patient] uh , sometimes . when i'm typing for long periods of time , i feel a little bit of numbing , um , i try to shake out my arms a little bit . um , just to kind of relieve that um , sensation .\n[doctor] okay . all right , and i know that you've had this also , had this history of gout . and the last episode you had was about three months ago . you had some inflammation of your toe . have you had any other issues with that ?\n[patient] no , i have n't . um , the medication you gave me really controlled it , and i have n't seen a flare-up since .\n[doctor] okay . all right , and how are you doing with your psoriasis ?\n[patient] that's been under control too . that has n't been a- a major problem for me either .\n[doctor] okay . i- i know that we had given you some clobetasol for your scalp . is that- so that's doing okay ?\n[patient] yeah , that's doing a lot better .\n[doctor] okay , great . um , all right , well , i'd like to go ahead and do a physical exam on you .\n[patient] okay .\n[doctor] let's first look at your vital signs . hey , dragon , show me the vital signs . great , so everything looks good from that perspective . um , so looking at you , i do n't appreciate any cervical lymphadenopathy . your heart is a nice regular rate and rhythm , and your lungs sound really clear . on your right elbow , you do have some edema and inflammation of your right olecranon and there's some tenderness and an effusion right there . so um , does that hurt when i press it ?\n[patient] yeah , that does hurt .\n[doctor] okay , and when i turn your arm , do you have pain ?\n[patient] yeah , that hurts a bit too .\n[doctor] okay , so she has pain- to palpation of the olecranon bursa and pain with pronation and supination . and when you flex- and when you bend it and straighten it , does that hurt ?\n[patient] yeah , it does and it's a bit stiff too .\n[doctor] okay , so pain with flexion and extension of the right arm . uh , your abdomen is nice and soft , and there's no lower extremity edema . uh , let's go ahead and take a look at some of your labs . you know , you have a lot of arthritis for someone so young , so we had sent off that autoimmune panel . hey , dragon . show me the autoimmune labs . hey , dragon . show me the autoimmune profile . hey , dragon . show me the esr . okay , so that's good . hey , dragon . show me the uric acid . okay . all right , well , good . that's great . so , you know , it does n't look like you have any systemic arthritis , or sys- systemic inflammatory in process going on . so , my impression of you at this time is that from a gout standpoint , everything is nice and stable . i think that we should continue you on the colchicine 0.6 milligrams twice a day as needed for flare-ups of your gout . um , and then for your osteoarthritis , i'd like to go ahead and order a right elbow x-ray . hey , dragon . order a right elbow x-ray , and then i'd like to prescribe some meloxicam 15 milligrams once a day for the pain and the swelling .\n[patient] okay .\n[doctor] hey , dragon . order meloxicam 15 milligrams once a day . and then i'd like to um , just see those- how- the x-ray show- shows up and the results of that before we refer you for any type of physical therapy , okay ?\n[patient] okay .\n[doctor] and then from a psoriasis standpoint , i think everything is stable . we'll continue you on the steroid cream for your scalp , okay ?\n[patient] that sounds good .\n[doctor] all right , do you have any questions ?\n[patient] no , that's it .\n[doctor] all right , take care .\n[patient] thank you .\n[doctor] hey , dragon . finalize the note .\n",
            "tgt": "CHIEF COMPLAINT\n\nFollow-up of chronic problem.\n\nHISTORY OF PRESENT ILLNESS\n\nMs. Carolyn Garcia is a 49-year-old female who presents to the clinic today for follow-up of her chronic problem.\n\nThe patient reports her osteoarthritis has been flaring up a little lately, and she would like to talk about that, primarily in her elbows. She states she has been sitting at the computer more in the office, so she is unsure if it is stagnant in that position all day. She notes her right elbow bothers her more than her left elbow, but she is primarily typing all day versus writing. She denies any other joint pain. She notes occasional numbness and tingling in her hands, which she tries to shake out her arms to relieve the numbness.\n\nShe also has a history of gout. Her last episode was about 3 months ago. She had some inflammation of her toe at that time. She denies any other issues with that. She states the medication she was given at that time helped with her gout and she has not seen a flare up since. She reports her psoriasis is under control and has not been a major problem for her either. She is still on colchicine 0.6 mg twice a day as needed for flare-ups of her gout.\n\nREVIEW OF SYSTEMS\n\n\u2022 Musculoskeletal: Endorses joint pain.\n\u2022 Neurological: Endorses numbness and tingling.\n\nPHYSICAL EXAMINATION\n\n\u2022 Neck: Supple without lymphadenopathy.\n\u2022 Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.\n\u2022 Cardiovascular: Regular rate and rhythm.\n\u2022 Gastrointestinal: Abdomen is soft.\n\u2022 Musculoskeletal: No edema to the lower extremity. Examination of\u00a0 the right elbow, there is some edema and inflammation of the right olecranon. Some tenderness to palpation of the olecranon bursa. Pain with pronation and supination. Pain with flexion and extension of the right arm.\n\nASSESSMENT AND PLAN\n\nA 49-year-old female here today for followup of chronic problem.\n\n1. Gout\n\u2022 Medical Treatment: Continue colchicine 0.6 mg twice a day as needed for flare ups.\n\n2. Osteoarthritis\n\u2022 Medical Treatment: We will order a right elbow x-ray. We will prescribe meloxicam 15 mg once a day for pain and swelling.\n\n3. Psoriasis\n\u2022 Medical Treatment: Continue steroid cream.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N128-virtassist"
        },
        {
            "src": "[doctor] good afternoon , beverly . good to see you .\n[patient] nice to see you too .\n[doctor] so , i know my nurse told you a little bit about dax . um , now , if you do n't mind , i'd like to tell dax a little bit about you .\n[patient] go for it .\n[doctor] great . um , beverly's a 24 year old female patient , and i know you have a history of type 2 diabetes and high blood pressure . correct ?\n[patient] yep .\n[doctor] okay . so , you're here today for your yearly exam . have n't seen you in a year . how're you doing ?\n[patient] i've been doing well . i began working in a bakery this summer which has been super fun. i have really been enjoying working there, but i find myself, since i am so close to so many delicious treats, snacking a lot during shifts and eating a lot more desserts than i normally would.\n[doctor] okay , so , that brings me to your diabetes . so , how have your blood sugars been ?\n[patient] uh , not so good .\n[doctor] okay .\n[patient] so , they've been up and down because of my diet , i think , because i've been taking my medication as prescribed . um , so , i have n't missed anything there , but my diet has been pretty bad lately .\n[doctor] pretty bad lately ?\n[patient] yeah .\n[doctor] okay . and , that's really the only thing that's different is your diet , pretty much ?\n[patient] yeah .\n[doctor] and , that's because of the new job and all that ?\n[patient] yeah. it has been really challenging to resist the temptation. \n[doctor] it's hard to ignore those desserts , are n't they ?\n[patient] yeah .\n[doctor] no willpower like me ?\n[patient] no , no willpower .\n[doctor] okay . all right . and , and then , um , i know you've had high blood pressure , hypertension . how is , how have your blood sugars been ? have you been checking them ?\n[patient] so , my blood pressure's been good . um , despite my , um , my diabetes levels being up and down .\n[doctor] okay .\n[patient] so , that's been good .\n[doctor] okay , so , your blood pressures have been normal . you've been sleeping well ?\n[patient] yep , getting a full eight hours .\n[doctor] no concerns about hurting yourself or anything like that ?\n[patient] no .\n\n[doctor] okay , good . okay , and i know my , um , nurse did a review of systems . other than what we've talked about so far , is there anything else that you needed to add ?\n[patient] no .\n[doctor] good . so , pretty much status quo except for those things that we've been working on , right ?\n[patient] yep .\n[doctor] okay , good . all right . well , let me do a quick physical exam , okay ?\n[patient] okay .\n[doctor] okay , squeeze my finger here . good . can you feel me touch out here ?\n[patient] yep .\n[doctor] okay . and , can you feel me touch you down here ?\n[patient] yep .\n[doctor] okay . no swelling . push your leg out . good . pull it back . mm-hmm . go . good . okay . so , on my exam , um , essentially , your exam is normal . your , um , heart is regular . you do have that grade 2 , um , systolic ejection fraction back ejection murmur that you , um , that we've heard in the past . okay ? so , um , we definitely know that's there . that's unchanged , okay ? um , your lungs are clear . um , your grips are equal . neurovascular's intact . you do n't have any carotid bruits in your neck , no thyromegaly . no edema . um , pulses are good , so essentially , your exam is , is essentially normal . let's take a look at some of your lab work , okay ?\n[patient] okay .\n[doctor] hey , dragon , show me the hemoglobin a1c . okay , so , blood sugars have been elevated . your hemoglobin a1c is elevated as well , so that tells me your blood sugars have been a little bit out of control . you're still taking the metformin , correct ?\n[patient] yes , i am .\n[doctor] okay , and you take that twice a day ?\n[patient] yep .\n[doctor] okay . um , uh , hey , dragon ? show me the vital signs . okay , good news here is your blood pressure's good . everything , um , there is fine . so , um , so , my assessment is , is , um , your first problem is diabetes . it's a little out of control . we'd like that hemoglobin a1c to be under seven , um , at least . you know , preferably , under six .\n[patient] mm-hmm .\n[doctor] so , um , uh , i'm not gon na change your medication . i think this is diet related , so i want you to try to cut down on the snacking and additional sweets , okay ?\n[patient] yeah .\n[doctor] and , i want you to check your blood sugars in the morning . i want you to call them in in about two weeks so we know what your first , um , fasting blood sugar was in the morning , and then , we'll come back and see you in about two months and see if everything has straightened out . if it has n't , then we'll talk about adding another medication , okay ?\n[patient] okay .\n[doctor] your second problem is your hypertension . that seems to be relatively stable . i want you to stay on your current medication . you're on li- lisinopril 10 mg once a day . just stay right on that medication . no changes at this point . seems to be doing well , okay ?\n[patient] okay .\n\n[doctor] good . anything else i can do for you today ?\n[patient] no . that's it .\n[doctor] good . come with me , we'll get you checked out .\n[patient] thank you .\n[doctor] hey , dragon ? finalize the note .",
            "tgt": "CHIEF COMPLAINT\n\nAnnual exam.\n\nHISTORY OF PRESENT ILLNESS\n\nBeverly Ortiz is a 24-year-old female patient with a history of type 2 diabetes and high blood pressure. She is here today for her yearly exam.\n\nThe patient states she has been doing well. She has recently began working at a bakery this summer.\n\nThe patient states her diabetes is uncontrolled. Her blood sugars have fluctuated recently, which she attributes to her change in diet due to work. She is trying to improve her diet by removing additional sweets. She has been taking her medication as prescribed and has not missed any doses.\n\nThe patient states her blood pressure has been good despite her blood sugar levels being up and down. She has continued taking metformin twice a day.\n\nShe has been sleeping well and is able to sleep a full 8 hours. She denies thoughts of self-harm or suicidal ideations.\n\nPHYSICAL EXAMINATION\n\n\u2022 Neurological/Psychological: Grip strength equal bilaterally. Neurologically intact.\n\u2022 Neck: Supple without thyromegaly or lymphadenopathy. No carotid bruits appreciable.\nLungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.\n\u2022 Cardiovascular: Regular rate. Grade 2/6 systolic ejection fraction murmur. No gallops or rubs. No extra heart sounds. Good pulses.\n\nRESULTS\n\nHemoglobin A1c is elevated.\n\nASSESSMENT AND PLAN\n\nBeverly Ortiz is a 24-year-old female patient with a history of type 2 diabetes and high blood pressure. She is here today for her yearly exam.\n\nDiabetes mellitus type 2.\n\u2022 Medical Reasoning: Her blood glucose levels have been uncontrolled. She is still taking metformin twice a day, but does admit to dietary indiscretion with an increase in her sweets intake.. Her most recent hemoglobin A1c was elevated.\n\u2022 Medical Treatment: Continue metformin twice a day.\n\u2022 Patient Education and Counseling: I encouraged her to check her fasting blood glucose levels each morning and call them in about 2 weeks. She will follow up in about 2 months, at which time we will discuss further treatment recommendations.\n\nHypertension.\n\u2022 Medical Reasoning: Appears to be relatively stable.\n\u2022 Medical Treatment: Continue lisinopril 10 mg once daily.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.",
            "file": "D2N129-virtassist"
        },
        {
            "src": "[doctor] hi , anna , how are you ?\n[patient] i'm doing okay . how are you ?\n[doctor] i'm doing well . uh , so i know the nurse told you a little bit about dax . i'd like to tell dax a little bit about you .\n[patient] okay .\n[doctor] all right . so , uh , anna is a 26-year-old female with a past medical history , significant for epilepsy , depression , and , uh , peptic ulcer disease , who presents with , uh , some joint pain . so , anna , what's going on with your , uh , what's going on with your joints ?\n[patient] so , um , it's my left elbow that's really been bothering me . uh , i sit at my desk a lot for work , and type , and i stay in this motion specifically all day . and then after , um , work , it's really hard for me to , uh , open and , and close my , my elbow here , my left elbow , and it's been just really stiff and , and hurts .\n[doctor] okay . have you noticed any swelling there on the-\n[patient] yeah , i have .\n[doctor] okay , and is it right here on the , on the tip ?\n[patient] yep , it is .\n[doctor] okay , and are you right or left-handed ?\n[patient] i am right-handed .\n[doctor] okay , so it's your non-dominant hand ?\n[patient] yeah , which is good .\n[doctor] yeah .\n[patient] so , i can still write , which is great , but typing is , is difficult .\n[doctor] okay , and any numbing or tingling in your hands at all ?\n[patient] no , i have n't felt numbing or tingling .\n[doctor] and any weakness in your arm ?\n[patient] a little bit of weakness , uh , but nothing too significant .\n[doctor] okay , and ... and how about ..\n[doctor] and how about , um , any fever or chills ?\n[patient] no fever or chills .\n[doctor] okay . all right , well , let's talk a little bit about your epilepsy , okay ?\n[patient] okay .\n[doctor] um , have you had any recent seizures ?\n[patient] uh , no , i have n't . i think my last seizure was a year ago .\n[doctor] okay , good .\n[patient] yeah .\n[doctor] and you're still taking the keppra ?\n[patient] yes , i am .\n[doctor] okay , great . and then , tell me a little about your depression . how're you doing with that ? i know that you went into therapy last year , and you tried to avoid medication since you're already on the keppra . how's that doing ?\n[patient] uh , therapy , therapy's been good . it , it has definitely helped . uh , i still feel a little down , uh , and , and stressed .\n[doctor] okay . all right , but no , no feelings of wanting to hurt yourself or somebody else ?\n[patient] no , nothing like that .\n[doctor] okay . all right . and then , how are you doing with your , with your ulcer ? i know that you , you know , you had so much stress a year ago and , you know , you were having some issues there . we did the endoscopy-\n[patient] mm-hmm .\n[doctor] . and they showed that . so , how are you doing with that ?\n[patient] i'm doing , i'm doing better . i have n't had any , um , issues with that , um , since we did the procedure , and everything's been good .\n[doctor] okay , well great . let's go ahead and ... i'm gon na go ahead with , um ... and , you know , i know that the nurse did a review of systems sheet on you when you came in , and i know that you were endorsing that left elbow pain .\n[patient] mm-hmm .\n[doctor] any other symptoms , you know , chest pain , shortness of breath , abdominal pain , nausea or vomiting ?\n[patient] no , nothing like that . i have a little bit of nasal , nasal congestion from allergies , uh , but that's it .\n[doctor] okay , so you're endorsing some nasal congestion ?\n[patient] yeah .\n[doctor] okay . all right , well , let's go ahead to a physical exam , okay ?\n[patient] okay .\n[doctor] hey , dragon , show me the vital signs . good , here in the office , everything looks great with your vital signs . i think that's great , so i'm just gon na take a listen to your heart and your lungs , and take a look at your elbow and , and we'll go from there , okay ?\n[patient] okay .\n[doctor] all right , so , so on physical examination of your left elbow , you do have some erythema and edema of your left elbow . does it hurt when i touch ?\n[patient] yeah , it does .\n[doctor] okay , he ... she has some pain to palpation of the olecranon . of the left olecra- olecranon , and it is warm to palpation . um , can you straighten your elbow for me ?\n[patient] yeah , it , it hurts , and it's , uh , it's a bit stiff .\n[doctor] okay , so she has pain with flexion and extension of the left elbow . there's a palpable right ... or s- ... palpable left radial pulse . okay , um , so let's go over ... i just wan na take a look at some of your results , okay ?\n[patient] okay .\n[doctor] hey , dragon , show me the left elbow x-ray . hey , dragon , show me the elbow x-ray . hey , dragon , show me the left arm x-ray . okay , so , in reviewing the results of your left arm x-ray , there's no evidence of any elbow fracture , which is not surprising , okay ?\n[doctor] hey , dragon , show me the endoscopy results . hey , dragon , show me the endoscopy . okay , well , your recent endoscopy showed that you ... hey , dragon , show me the endoscope . all right , so here it looks like , you know ... your endoscopy results look like you had an episode of gastritis . that's for your , your peptic ulcer disease , and so everything , you know ... you took your , your protonix , and i think everything resolved at that point , okay .\n[patient] okay .\n[doctor] so , let's talk a little bit about my assessment and my plan for you . so for your first problem , this left elbow pain , you know , i think you have olecranon bursitis , and we're just gon na , you know , have you , you know , get a little pillow for your elbow there . it's just caused by repetitive trauma .\n[patient] mm-hmm .\n[doctor] so , maybe you're slamming your elbow down a little bit on the desk , so just get a little rest there-\n[patient] yeah .\n[doctor] . and we'll give you some melo- meloxicam , 15 mg , once a day . you can ice the area , okay ? um , for your next problem , the epilepsy , sounds like you're doing really well . i would go ahead and continue with the keppra , 500 mg , twice a day . do you need a refill of that ?\n[patient] yes , i do .\n[doctor] hey , dragon , order a refill of keppra , 500 mg , twice daily . for your third problem , the depression , it sounds like you're doing well with the therapy and , if you want , we can talk about medical treatment options .\n[patient] yeah , i think that would be great .\n[doctor] okay , well , let's go ahead and we'll start you on some lexapro , 10 mg , once a day , and we'll see how you do on that , okay ?\n[patient] okay .\n[doctor] all right , and then , for your last problem , the peptic ulcer disease , um , i want you to continue on the protonix , 40 mg , once a day before meals , okay ?\n[patient] okay .\n[doctor] do you have any questions ?\n[patient] no , i do n't .\n[doctor] okay . all right . well , the nurse will come in soon and see you , okay , and i'll , i'll see you in a couple of weeks .\n[patient] okay .\n[doctor] all right , take care . bye .\n[patient] bye .\n[doctor] hey , dragon , finalize the note .",
            "tgt": "CHIEF COMPLAINT\n\nJoint pain.\n\nHISTORY OF PRESENT ILLNESS\n\nThe patient is a 26-year-old female with a past medical history significant for epilepsy, depression, and peptic ulcer disease who presents with some joint pain.\n\nThe patient reports that her left elbow has really been bothering her. She states that she sits at her desk all day for work with her elbows bent. She reports that after work it is really hard for her to flex and extend her left elbow. She reports that it has been really stiff and painful. She also notes that she has noticed swelling on the olecranon of her elbow. She reports that she is right-handed, therefore, she can still write, which is great, but typing is difficult. She denies any numbness or tingling in her hands. She reports that she has some weakness in her arm but nothing too significant. She denies any fever or chills.\n\nRegarding her epilepsy, she reports that she has not had any recent seizures. She reports that her last seizure was a year ago. She reports that she is still taking Keppra.\n\nRegarding her depression, she reports that she started therapy last year and she is trying to avoid medications for this problem. She reports that therapy has been helpful, but she still feels down and stressed. She denies suicidal and homicidal ideations.\n\nRegarding her peptic ulcer, she reports that she was dealing with a lot of stress last year. She then underwent an endoscopy which showed that she had an episode of gastritis. She was subsequently diagnosed with peptic ulcer disease and started Protonix. She reports that she has not had any issues with her ulcer since the procedure and everything has been good.\n\nThe patient denies chest pain, shortness of breath, abdominal pain, nausea, or vomiting. She reports that she does have a little bit of medial nasal congestion from allergies.\n\nREVIEW OF SYSTEMS\n\n\u2022 Ears, Nose, Mouth and Throat: Endorses medial nasal congestion from allergies.\n\u2022 Cardiovascular: Denies chest pain or dyspnea on exertion.\n\u2022 Respiratory: Denies shortness of breath.\n\u2022 Musculoskeletal: Endorses left elbow joint pain, swelling, and weakness.\n\u2022 Psychiatric: Endorses depression.\n\nPHYSICAL EXAMINATION\n\n\u2022 Musculoskeletal: Examination of the left elbow reveals erythema and edema. Pain to palpation of the left olecranon. Warm to palpation. Pain with flexion and extension. Palpable left radial pulse.\n\nRESULTS\n\nLeft arm x-ray does not reveal any evidence of elbow fracture.\n\nEGD revealed an episode of gastritis.\n\nASSESSMENT\n\nAnna Morris is a 26-year-old female with a past medical history significant for epilepsy, depression, and peptic ulcer disease who presents with some joint pain.\n\nPLAN\n\nLeft elbow pain.\n\u2022 Medical Reasoning: I believe she has left olecranon bursitis caused by repetitive trauma.\n\u2022 Medical Treatment: Initiate meloxicam 15 mg once daily.\n\u2022 Patient Education and Counseling: I encouraged the patient to use a pillow to rest her arm on. She may also ice the area.\n\nEpilepsy.\n\u2022 Medical Reasoning: She has been doing well on Keppra and denies any recent seizures.\n\u2022 Medical Treatment: Continue Keppra 500 mg twice a day. This was refilled today.\n\nDepression.\n\u2022 Medical Reasoning: She reports doing well with therapy.\n\u2022 Medical Treatment: Initiate Lexapro 10 mg once daily.\n\nPeptic ulcer disease.\n\u2022 Medical Reasoning: Her recent endoscopy revealed gastritis\n\u2022 Medical Treatment: Continue Protonix 40 mg once daily before meals.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N130-virtassist"
        },
        {
            "src": "hi , susan , how are you ?\n[patient] good . how are you ?\n[doctor] good . are you ready to get started ?\n[patient] yes , i am .\n[doctor] so , susan is a 26-year-old female here for a high blood pressure check . susan , what's going on with your blood pressure ?\n[patient] so , i've always struggled with , um , high blood pressure , but it's seeming to get really out of control lately . so , i wanted to come in and see if there's any type of new medication i can be on to help it get steady or if there is diet restrictions i should take , um , things like that .\n[doctor] okay . so , i know that we've had you on the norvasc and we had to increase your dose , so you're on 10 milligrams a day now . and what are your blood pressures running at home ? you c- ... like , have they been like over 150 ?\n[patient] yeah , they have been .\n[doctor] okay . all right . and , have you had any headaches ?\n[patient] i have had some headaches . i do n't know if that's just because of more stress at work or , um , because of the high blood pressure .\n[doctor] okay . all right . so , you've had some headaches . have you had any chest pain , shortness of breath , anything like that ?\n[patient] no , nothing like that .\n[doctor] okay . um , and , you know , i know that you've had a kidney transplant a few years ago .\n[patient] yes .\n[doctor] everything is okay with that ?\n[patient] everything's been good and solid there .\n[doctor] and you're taking all of your auto , um , i- um , your immunosuppression medications ?\n[patient] yes , i am .\n[doctor] all right .\nso , let's go ahead and we'll do a quick physical exam . so , looking at you , you do n't appear any distress . your neck is nice and supple . your heart is irregular rate and rhythm . i do hear a slight , uh , two out of six systolic ejection murmur . your lungs are clear . i do see the scar on the left , uh , left plank for your kidney transplant which is healed . and you have no lower extremity edema . so , let's go ahead and look at some of your results , okay ?\n[patient] okay .\n[doctor] hey , dragon , show me the creatinine . so , your kidney function looks really good . so , that's really promising after your transplant . hey , dragon , show me the ekg . and your ekg looks great , uh , perfectly normal , so that's good . um , so , my impression of you at this time ... , let me see your blood pressure .\n[patient] okay .\n[doctor] hey , dragon , show me the blood pressure . yeah , and you're right , it-\n[patient] hm .\n[doctor] . it is high . so , there is something that we can do for that . so , let's go ahead and we'll put you on ... so , my impression of you is that your , your blood pressure is high and the norvasc is n't controlling it . and , you know , we can definitely get it under better control . so , what i would like to do is prescribe you coreg 25 milligrams , twice a day . and that will help bring your blood pressure down , okay ?\n[patient] okay .\n[doctor] hey , dragon , order carvedilol 25 milligrams , twice a day . uh , i'd also like to go ahead and , uh , get a lipid panel and some routine labs on you just to make sure that everything is okay .\n[patient] yeah .\n[doctor] hey , dragon , order a lipid panel . hey , dragon , order a complete metabolic panel . all right . and then , um , from a transplant standpoint , everything looks fine . your kidney function looks great , so we're just gon na continue you on all of those medications .\nso , the nurse will come in soon and she'll help you schedule all of the al- schedule a follow-up appointment with me , and we'll see what your blood pressure looks like in a couple weeks after taking that medication . okay ?\n[patient] okay .\n[doctor] all right . thanks , susan .\n[patient] thank you .\n[doctor] hey , dragon , finalize the note .",
            "tgt": "CHIEF COMPLAINT\n\nHigh blood pressure check.\n\nHISTORY OF PRESENT ILLNESS\n\nMs. Susan Watson is a 26-year-old female who presents to the clinic today for a high blood pressure check.\n\nThe patient reports she has always struggled with high blood pressure, but it is seems out of control recently. She notes that she has interest in new medication or diet changes to help. She is currently on Norvasc 10 mg daily. Her blood pressure at home has been over 150. She notes she has had some headaches, but she is unsure if it is due to stress at work or her high blood pressure. She denies chest pain or shortness of breath.\n\nThe patient underwent a kidney transplant a few years ago, and everything is going well. She is taking all of her immunosuppression medication.\n\nREVIEW OF SYSTEMS\n\n\u2022 Cardiovascular: Denies chest pain or dyspnea on exertion.\n\u2022 Respiratory: Denies shortness of breath\n\u2022 Neurological: Endorses headaches.\n\nPHYSICAL EXAMINATION\n\n\u2022 Constitutional: in no apparent distress.\n\u2022 Neck: Supple without thyromegaly or lymphadenopathy.\n\u2022 Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.\n\u2022 Cardiovascular: 2/6 systolic ejection murmur.\n\u2022 Musculoskeletal: No edema.\n\u2022 Integumentary: Scar on left flank from kidney transplant, healed.\n\nRESULTS\n\nCreatinine: normal.\n\nElectrocardiogram: normal.\n\nASSESSMENT AND PLAN\n\nMs. Susan Watson is a 26-year-old female who is here today for a high blood pressure check.\n\nHypertension.\n\u2022 Medical Reasoning: Her blood pressure is elevated today and based on her recent home monitoring.\n\u2022 Additional Testing: I would like to get a lipid panel and metabolic panel.\n\u2022 Medical Treatment: carvedilol 25 mg twice a day to help bring her blood pressure down.\n\nStatus post kidney transplant.\n\u2022 Medical Reasoning: Doing well.\nKidney function stable.\n\u2022 Medical Treatment: Continue current medications.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N131-virtassist"
        },
        {
            "src": "[doctor] hello mrs. lee , i see you're here for back pain .\n[patient] yes .\n[doctor] hey dragon , i'm seeing mrs. lee today for , uh , back pain . she's a 40-year-old female . so can you tell me what happened to you ?\n[patient] yes . i was at a birthday party and it was surprise party . so we were all like crunched behind and hiding . and when the person came in we all jumped out , and then i fell down the little stair and i rammed my back into the railing of the s- , uh , staircase .\n[doctor] so it was a surprise for you too ?\n[patient] yes it was .\n[doctor] very good . okay . so , um , did it hurt because you hit it , or did you twist ? what happened when you ?\n[patient] i think it was my motion-\n[doctor] okay .\n[patient] . of jumping up , or something .\n[doctor] okay .\n[patient] and maybe a twisting .\n[doctor] okay . any pain shooting down your legs at all ?\n[patient] no .\n[doctor] is it on one side or the other of your back ?\n[patient] um , it's more on the right .\n[doctor] on the right . is there anything that makes it better or worse ?\n[patient] uh , if i'm lying flat it hurts a little more , and any twisting motion for sure .\n[doctor] okay . all right . and do you have any history or any back problems before ?\n[patient] i did . i had a fusion done .\n[doctor] okay , yeah that lumbar fusion . um , let's take an x-ray . hey . or let's look at an x-ray . hey dragon , show me the latest x-ray . okay , we can see where you had your fusion , t4 here on the x-ray . but i do n't see anything that looks , um , significantly abnormal . it does n't appear to have any compression fractures or anything like that . so , it's essentially , except for the fusion , a normal exam . let me do your exam for you here . can i have you stand up please ? does it hurt when i twist you that way ?\n[patient] yes .\n[doctor] okay . you can sit back down . if i lift your leg here , does that bother you ?\n[patient] no .\n[doctor] how 'bout when i lift this leg ?\n[patient] no .\n[doctor] any pain shooting down your legs when i do that ?\n[patient] no .\n[doctor] okay . and can you feel me touching down here .\n[patient] yes .\n[doctor] okay , great . so , you had a injury to your back when you were twisting at the birthday party . you do n't really have any pain or numbness down your legs . you have some stiffness with rotation , um , but you do n't have any evidence of a , um , what we would call a pinched nerved or radiculopathy . so , i think you basically have a strain of your lower back . um , have you been taking any medications ?\n[patient] just some ibuprofen .\n[doctor] okay . and do you have any other , um , medical problems ?\n[patient] um i take medication for anxiety .\n[doctor] okay . and that's all ? okay . um , so what we're gon na do is i'm gon na give you , um , just continue the motrin at 800mg , three times a day , with food . i want you to use some ice and heat , alternating on your back . but i do want you walking .\n[patient] okay .\n[doctor] um , and , uh , this should sort of take care of itself after a few days . if it's not , or it's getting worse , i want you to come back and see me over the next week .\n[patient] okay .\n[doctor] does that sound good ?\n[patient] it does .\n[doctor] okay , dragon . hey dragon , go ahead and order the medications and procedures and close out the note . come on i'll bring you out to check out .\n[patient] thank you .",
            "tgt": "CC:\n\nBack pain.\n\nHPI:\n\nMs. Lee is a 40-year-old female who presents today for an evaluation of back pain. She states she was at a birthday party and she ran her back into the railing of the staircase and twisted her back. She denies any pain radiating down her legs. Lying flat and twisting motions aggravate the pain. She is currently taking ibuprofen.\n\nCURRENT MEDICATIONS:\n\nIbuprofen.\n\nPAST MEDICAL HISTORY:\n\nAnxiety.\n\nPAST SURGICAL HISTORY:\n\nLumbar fusion\n\nEXAM\n\nExamination of the back shows range of motion without pain. Straight leg raise is negative. Sensation is intact.\n\nRESULTS\n\nX-rays of the lumbar spine show no obvious signs of acute fracture. Evidence of a prior lumbar fusion with hardware in good position.\n\nIMPRESSION\n\nLumbar spine strain.\n\nPLAN\n\nAt this point, I discussed the diagnosis and treatment options with the patient. I have recommended ice and heat. She will continue with Motrin 800 mg 3 times a day with food. She will follow up with me as needed.\n",
            "file": "D2N132-virtassist"
        },
        {
            "src": "[doctor] good morning rebecca , nice to see you .\n[patient] nice to see you too .\n[doctor] so , my nurse told you a little bit about dax , now i'm wondering if i can tell dax a little bit about you .\n[patient] go for it .\n[doctor] okay , so rebecca is a 27-year-old female patient . um , you have a history of carpal tunnel , um , uh , release done couple of years ago , you have some chronic back pain , some depression . why am i seeing you today ?\n[patient] so last week , um , and over the course of the month , i have taken up swimming more regularly .\n[doctor] okay .\n[patient] i've been trying to get up and get active . and i've- ... all of a sudden i've been feeling some really bad , um , knee pain-\n[doctor] okay .\n[patient] . in my right knee .\n[doctor] just in your right knee ?\n[patient] yeah .\n[doctor] okay . just when swimming ? are you swimming freestyle with your legs kicking straight or more like breaststroke where your legs kick out ?\n[patient] yeah , it's only while swimming. i use the breaststroke so i guess where the legs are kicking out like a frog ... it kinda starts hurting a little bit after i swim a couple laps , which a month ago when i started i was able to do ten .\n[doctor] okay .\n[patient] but after a couple of laps it starts to hurt .\n[doctor] and no injury ? like you did n't fall or twist it or anything like that that you remember ?\n[patient] no , not that i can remember .\n[doctor] okay . so just swimming a lot and you feeling more and more discomfort ?\n[patient] yeah .\n[doctor] okay , good . so , um ... i know my nurse did a review of systems before you came in . there were really no significant issues . you have a history of chronic back pain , that's been doing well ?\n[patient] yeah , it comes and goes , but right now it's been doing really well .\n[doctor] okay , no pain going down your legs or anything like that ?\n[patient] no .\n[doctor] okay . and i know you have some depression , you've been on medication . how's that been going ?\n[patient] that's been going really well .\n[doctor] okay .\n[patient] with the medication and therapy and then trying to get outside more it's been really helping me .\n[doctor] sleeping well ?\n[patient] yeah .\n[doctor] eating well ? okay . do n't feel any concerns about hurting yourself or others or anything like that ?\n[patient] no .\n[doctor] okay , good . um , and the , you had ca- carpal tunnel done a few years ago . how's that doing ?\n[patient] that's doing-\n[doctor] any flare up with that ?\n[patient] . that's doing really well . i've been getting full range of motion and it's felt a lot better .\n[doctor] okay , great . do you mind if i do a quick exam ?\n[patient] yeah , go for it .\n[doctor] squeeze my fingers for me . good . okay . is it painful if i move your patella like that ?\n[patient] yeah , that hurts .\n[doctor] okay . and i'm gon na hold your leg out , i'm gon na hold , i want you to stiffen your upper ... does that hurt when i do that ?\n[patient] yeah , that hurts too .\n[doctor] okay , good , all right . um , let's take a quick look at your x-ray , okay ?\n[patient] okay .\n[doctor] hey dragon , show me the right knee x-ray . okay , so here's a picture of your right knee . actually normal x-ray , everything looks good , okay ? on my exam , um , you do n't really have any swelling in- in your joints , um , uh , of your knee . you have a little pain with , um , uh , range of motion of the knee . you have real pain when we do what we call patella in- ... patellar inhibition , okay ? so that's what caused most of that pain . so , um , your heart is regular , your lungs are clear , i do n't feel any adenopathy , your thyroid's , um , normal , your grips are equal , the rest of your exam is essentially normal , okay ? so my assessment is , you have what we call chondromalacia of the patella , okay ? it's just from the overuse and all- all the swimming you've been doing , okay ? so , um , to treat that we'll just use some anti-inflammatories , um , go ahead and take some ibuprofen , 600 milligrams four times a day with food . i do want you to do some straight leg raising exercises , that'll strengthen your quadriceps and that'll help with that pain , okay ?\n[patient] okay .\n[doctor] um , basically you want to avoid anything that puts extra pressure on your knees for a little while and it should be fine . if it's not getting any better in a couple weeks i wan na see you again , okay ? so no lunges , avoid the breaststroke . if you're comfortable, you can also do other swimming strokes where your knees are straight instead . or you can take the opportunity to have a little break .\n[patient] all right .\n[doctor] your second problem is your chronic back pain , that's been doing really well . um , keep swimming , that's okay after this gets better .\n[patient] yeah .\n[doctor] um , but i think , um , i think that's been under control . but if it flares up go ahead and , uh , give me a call , okay ?\n[patient] mm-hmm .\n[doctor] um , your third problem is your depression . that's been stable . we're gon na keep you on your current medication , not gon na change anything at this point , okay ? and as far as your carpal tunnel goes , that's relatively stable , so , um , uh , no changes there as well . okay ? so anything else i can do for you ?\n[patient] no , that's it .\n[doctor] okay , well we'll get you checked out .\n[patient] all right .\n[doctor] hey dragon , finalize the report .\n",
            "tgt": "CHIEF COMPLAINT\n\nJoint pain\n\nHISTORY OF PRESENT ILLNESS\n\nMs. Thompson is a 27 y.o. female with a history of carpal tunnel release done a couple years ago, chronic back pain, and depression. She presents today for joint pain.\n\nMs. Thompson reports that over the course of the month she has begun swimming more regularly and trying to be more active. She has experienced bad right knee pain. The patient reports that her knee starts hurting after a couple of laps. She notes previously she could swim 10 laps. She denies injury or trauma to the knee.\n\nThe patient has a history of chronic back pain that has been intermittent, but right now it has been doing well. She denies pain radiating down her legs.\n\nThe patient has a history of depression, which has been going really well with medication and therapy. She is trying to get outside more and it has been helping her with her depression. She notes she is sleeping and eating well. She denies concerns about hurting herself or others.\n\nThe patient's carpal tunnel is doing really well. She has been getting full range of motion and it has felt a lot better.\n\nREVIEW OF SYSTEMS\n\n\u2022 Musculoskeletal: Endorses right knee joint pain. Endorses chronic back pain.\n\u2022 Psychiatric: Endorses depression.\n\nPHYSICAL EXAMINATION\n\n\u2022 Neurological/Psychological: Appropriate mood and affect. Grips are equal bilaterally.\n\u2022 Neck: Supple without thyromegaly or cervical lymphadenopathy.\n\u2022 Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.\n\u2022 Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No extra heart sounds.\n\u2022 Musculoskeletal: No lower extremity edema. Pain with patellar inhibition. Pain with range of motion of the right knee.\n\nRESULTS\n\nX-ray of the right knee is unremarkable.\n\nASSESSMENT AND PLAN\n\nMs. Thompson is a 27 y.o. female who presents today for evaluation of right knee pain.\n\nChondromalacia of right patella.\n\u2022 Medical Reasoning: She has been more active lately but is unaware of any injury to the knee. Her recent x-rays were normal but she did have some discomfort on exam.\n\u2022 Medical Treatment: Prescribed ibuprofen 600 mg 4 times a day with food. I do want her to do some straight leg raising exercises that will strengthen her quadriceps.\n\u2022 Patient Education and Counseling: I encouraged her to participate in physical activity that is less straining on her joints , such as swimming freestyle laps, or to stop activity all together. If her pain does not improve in a couple of weeks, she will follow up.\n\nChronic back pain.\n\u2022 Medical Reasoning: This is stable and well-controlled at this time.\n\u2022 Medical Treatment: She should continue swimming regularly once her knee is feeling better.\n\nDepression.\n\u2022 Medical Reasoning: She is doing well with her current regimen.\n\u2022 Medical Treatment: Continue current medications.\n\nCarpal tunnel syndrome.\n\u2022 Medical Reasoning: Relatively stable status post carpal tunnel release.\n\u2022 Medical Treatment: Continue current regimen with no changes at this time.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N133-virtassist"
        },
        {
            "src": "[doctor] we're gon na go right to the front- . so when you touch that- hi , michelle , how are you ?\n[patient] i'm good . how are you ?\n[doctor] i'm good . so i know the nurse told you about dax . i'd like to dax a little bit about you , okay ?\n[patient] okay .\n[doctor] all right . so , michelle is a 31-year-old female with a past medical history of type 2 diabetes and hypertension who presents with abnormal lab finding . so , michelle , it came back to me that you had had a positive long ... lyme titer .\n[patient] yeah .\n[doctor] and so , uh , can you , you , you know , can you tell me a little bit about it ? i know the last time i saw you , you had had an insect bite , and you know , it came back positive for lyme . so how are you feeling ?\n[patient] i've been feeling ... i could feel better . um ... i've been feeling tired , um , really lacking a lot of energy , and i have swollen joints in my elbows , just really hurts .\n[doctor] okay . all right . and have you had any , any body aches ?\n[patient] yeah , i have .\n[doctor] okay . all right . um , and i know that you were out hiking in the woods and , and that type of thing a couple of weeks ago , and we thought that that's where you got the bite . so , um , how's your , how's your appetite ? have you been okay ? a little nauseous ?\n[patient] yeah , i've been a little nauseous . i have n't been able to eat much . i've been trying just to keep , you know , toast and crackers and that's all about i've been able to stomach , really .\n[doctor] okay , and , and i know that you had had that , that , uh , bite there . have you noticed any other rash anywhere else ?\n[patient] yeah , i have .\n[doctor] okay . all right . sometimes they kind of describe it as looking as like a bull's-eye .\n[patient] yes .\n[doctor] is that what it looked like ?\n[patient] mm-hmm .\n[doctor] okay . all right . well , um , have you had any , any high fevers ?\n[patient] uh , no , not that i've noticed .\n[doctor] all right . um , and how about from a diabetes standpoint ? how ... how's your blood sugar been running ? especially now that you kind of have this , like , acute thing going on ? have your blood sugars been okay ?\n[patient] they've been okay . i've noticed that they sometimes get a little high and a little low . um , but nothing too far out of range .\n[doctor] okay . all right . um , and you're still taking the metformin ?\n[patient] yes .\n[doctor] okay . all right . good . and then in terms of your high blood pressure , are you monitoring the blood pressures at home ?\n[patient] yeah , i , i have a ... i bought a cuff last year , and i've been , um , taking it myself at home . those have looked good . i've been staying away from the salty foods .\n[doctor] mm-hmm .\n[patient] um , so that's been good .\n[doctor] okay . and , um , so you're still taking the lisinopril ?\n[patient] yes .\n[doctor] okay , great . all right , well , you know , i know that you did the review of systems sheet when you checked in , and i know that you're endorsing some nausea and some joint pain and some body aches . any other symptoms ? abdominal pain ? diarrhea ? anything like that ?\n[patient] no , nothing like that .\n[doctor] okay . um , so let's go ahead , and we'll ... i'm gon na do a quick physical exam .\n[patient] okay .\n[doctor] hey , dragon , show me the vital signs . so i'm looking here at your vital signs . they look great . you do n't have a fever at that ... at this time , so that's really encouraging . i'm just gon na check you out , and , uh , i'm gon na listen to your heart and lungs and look for any rashes and let you know what i find , okay ?\n[patient] okay .\n[doctor] okay , so on physical examination , you know , you do have some swelling of your , uh , elbow joints bilaterally . um , does it hurt when i touch them ?\n[patient] yeah , it does .\n[doctor] okay , so she has pain to palpation to both elbow joints . um , and on your skin examination , you do have a bull's-eye rash on your , um , abdomen on the left-hand side . um , it's , it's warm to palpation . any pain with that ?\n[patient] no , no pain for that .\n[doctor] non-tender to palpation , no evidence of cellulitis . um , and the rest of , you know , the rest of your exam is pretty normal , okay ? so let me just go over some of the results with you , okay ?\n[patient] okay .\n[doctor] hey , dragon , show me the lyme titer . so you can see here , you know , in reviewing the results of your lyme titer , it is elevated . so we're gon na go ahead and do some further testing , but we're gon na , you know , we're gon na look into that , okay ?\n[patient] okay .\n[doctor] hey , dragon , show me the labs . and in reviewing the results of your labs , everything else looks good . so again , you know , you do n't have an elevated white blood cell count or anything like that . so i think we got this early enough , and we can go ahead and , and treat it , okay ?\n[patient] okay .\n[doctor] so i wan na talk a little bit about , you know , my assessment and my plan for you . so for your first problem , this newly diagnosed lyme disease , i wan na go ahead and prescribe you doxycycline , 100 milligrams twice a day . you have to take it for three weeks , okay ?\n[patient] okay .\n[doctor] i'm gon na just touch base with an infectious disease doctor to make sure that there's not anything else that we need to do , okay ? and i wan na see you again next week for a follow-up for this , okay ?\n[patient] okay .\nso for your second problem , your type 2 diabetes , i wan na go ahead and order a hemoglobin a1c and just this ... make sure we do n't have to make any changes to the metformin , okay ?\n[patient] okay .\n[doctor] hey , dragon , order a hemoglobin a1c . and for your last problem , your high blood pressure . it looks today like everything is fine . i think you're doing a really good job of managing your hypertension , and i'm going to continue you on the lisinopril , 10 milligrams a day , and i'm gon na go ahead and order a lipid panel , and , um , i want you to continue to record your blood , blood pressure regularly , okay ?\n[patient] okay .\n[doctor] all right . do you need a refill of that ?\n[patient] uh , yes , i do .\n[doctor] okay . hey , dragon , order lisinopril , 10 milligrams daily . do you have any questions ?\n[patient] no , i do n't .\n[doctor] okay , so i'm gon na , you know , the nurse is gon na come in , and she's gon na check you out , and then we'll make a follow-up appointment for you , okay ?\n[patient] okay .\n[doctor] hey , dragon , finalize the note .",
            "tgt": "CHIEF COMPLAINT\n\nAbnormal labs.\n\nHISTORY OF PRESENT ILLNESS\n\nThe patient is a 31-year-old female with a past medical history significant for type 2 diabetes, and hypertension who presents with abnormal labs. She had an insect bite at her last visit after hiking in the woods. We drew a Lyme titer which came back positive.\n\nThe patient reports she has been feeling tired and lacking a lot of energy. She also notes swollen elbow joints, body aches, bullseye rash, and nausea. She states she has not been able to eat much. What she does eat has been bland foods such as crackers. She denies any high fevers.\n\nRegarding her type 2 diabetes, she states her blood sugars have been okay. She notes they are sometimes a little high or low, but nothing too far out of range. She is still taking metformin.\n\nRegarding her hypertension, she is monitoring her blood pressure at home and it has been good. She is avoiding salty foods and is still taking lisinopril.\n\nThe patient denies abdominal pain and diarrhea.\n\nREVIEW OF SYSTEMS\n\n\u2022 Constitutional: Denies fevers. Endorses fatigue.\n\u2022 Gastrointestinal: Denies abdominal pain and diarrhea. Endorses nausea.\n\u2022 Musculoskeletal: Endorses bilateral elbow joint swelling, pain. Endorses body aches.\n\u2022 Integumentary: Endorses a rash.\n\nPHYSICAL EXAMINATION\n\n\u2022 Gastrointestinal: Examination of her abdomen reveals warmth to palpation. Nontender to palpation. No evidence of cellulitis.\n\u2022 Musculoskeletal: Swelling and pain to palpation of elbow joints bilaterally.\n\u2022 Integumentary: Small bullseye rash on the left abdominal quadrant.\n\nRESULTS\n\nLyme titer: elevated.\n\nLabs: WBC is within normal limits. All other labs are normal as well.\n\nASSESSMENT AND PLAN\n\nThe patient is a 31-year-old female with a past medical history significant for type 2 diabetes, and hypertension who presents with abnormal labs.\n\nNewly diagnosed Lyme disease.\n\u2022 Medical Reasoning: This is a new issue for her. She presented with an insect bite at her last visit, and her subsequent lyme titer was elevated.\n\u2022 Medical Treatment: I am going to prescribe doxycycline 100 mg twice a day for 3 weeks. I am going to touch base with an infectious disease doctor to ensure nothing else that needs to be done. I want to see her again next week for follow-up for this.\n\nHypertension.\n\u2022 Medical Reasoning: This has been well-controlled based on home monitoring. She has been compliant with dietary modifications including limiting her sodium intake.\n\u2022 Additional Testing: I am going to order a lipid panel.\n\u2022 Medical Treatment: She will continue lisinopril 10 mg a day. This was refilled today.\n\u2022 Patient Education and Counseling: I advised the patient to continue to regularly monitor her blood pressures at home.\n\nDiabetes type 2.\n\u2022 Medical Reasoning: She has noticed intermittent elevations of her blood glucose levels but has been compliant with the use of metformin. Her diet has been limited due to nausea in the setting of Lyme disease.\n\u2022 Additional Testing: I am going to order a hemoglobin A1c to ensure no medication changes are needed.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N134-virtassist"
        },
        {
            "src": "[patient] um , i have high blood sugar . yeah , osteoarthritis , arterial fibrillation , and reflux .\n[doctor] hi , hannah . how are you ?\n[patient] good , how are you ?\n[doctor] i'm good . you ready to get started ?\n[patient] yes , i am .\n[doctor] so , hannah is a , uh , 52-year-old female here for evaluation of a high blood sugar . so , hannah , what ha- what happened ? i heard you were in the emergency room with a high blood sugar .\n[patient] yes . so , i've been eating a ton of sweets recently . with the holidays it just feels like there is always something sweet available. whether i am at work and there are holiday gift baskets or clients bringing in treats or when i visit my family for the holidays and there is every baked good imaginable, there is always something sweet i can be eating. in the beginning i felt fine, but i have started to feel it after a couple of weeks, and this past week i just felt really light-headed and i could ... was seeing spots , really dizzy . so i went into the emergency room and they said i had a high blood sugar . um , so i wanted to come in and follow up with you to get that , um , get checked out .\n[doctor] okay . all right . and how , how are you feeling now ? did they , did , did they treat you in the emergency room ? did they gi- they give you some iv fluids and things like that ?\n[patient] yeah . they gave me some fluids and they told me just to try to really cut out eating any extra sweets and get back into my normal routine and diet, but i am still staying with my family, and my mom and grandmother are big bakers so i think it will be really hard to get into a routine there so i just want to make sure i am nipping this high blood sugar thing in the bud.\n[doctor] okay . and i saw you went through a review of systems sheet with a nurse . i just want to ask you a few more questions from that standpoint . so you have had any fever or chills ?\n[patient] no .\n[doctor] any chest pain or shortness of breath ?\n[patient] n- uh , no .\n[doctor] abdominal pain ?\n[patient] no .\n[doctor] any burning when you urinate ?\n[patient] no .\n[doctor] any joint pain or muscle aches ?\n[patient] no .\n[doctor] okay .\n[patient] i do have osteoarthritis though , so that , when i say , \" no , \" it's not , like , nothing out of the norm-\n[doctor] okay .\n[patient] . for me .\n[doctor] perfect . um , and then , i know that you have this history of a-fib , atrial fibrillation . have you felt your heart racing at all , recently ?\n[patient] only when i'm really anxious . i , i feel it , um , pumping a little bit . but other than that i have n't .\n[doctor] okay . all right . and how are you doing with your reflux ?\n[patient] i've been doing well . i've been taking the medication that you prescribed to me and that's been helping a lot .\n[doctor] okay , yeah . i see here you're on the protonix , 40 milligrams , once a day .\n[patient] yes .\n[doctor] so that's , you're doing well with that ?\n[patient] yep .\n[doctor] okay . all right . so let's go ahead and do a quick physical exam . so , listening to you , um , look , or looking at you , you appear in no distress . your thyroid is a little enlarged , but non-tender . there's no carotid bruits , your heart is in irregular rate and rhythm , and your lungs are clear . your abdomen is nice and soft , and you have no edema in your lower extremities . let's go ahead and look at some of your test results .\n[patient] okay .\n[doctor] hey , dragon ? show me the blood sugar . hey , dragon ? show me the blood glucose . hey , dragon ? show me the hemoglobin a1c . okay , so i see here that both your blood sugar and your hemoglobin a1c are elevated . so your blood sugars have probably been running high for probably a few months . okay ? um , let's go ahead and look at some of your other results . hey , dragon ? show me the diabetes labs . yeah . okay . yeah , so , um , my impression of you at this time , um , for your high blood sugars , that you do have this diagnosis of diabetes . now , we're not sure if it's type i or type ii . even patients in , you know , in their mid-twenties can develop type i diabetes , so we're gon na go off and , we're gon na go ahead and , and send some labs to work that up . hey , dragon ? order a complete metabolic panel . and i'd like to start you on metformin , 500 milligrams , twice a day . that will help keep your blood sugars down .\n[patient] okay .\n[doctor] hey , dragon ? order metformin , 500 milligrams , twice a day . and then if some of the autoimmune labs that come back show that you have an autoimmune disorder , meaning that you would have type i diabetes , then we would have to go ahead and put you on insulin . but i'm gon na hold off until we have those results , okay ?\n[patient] okay .\n[doctor] but in the meantime , i really want you to avoid , uh , foods high in sugar . um , and the , the nurse will come in and she'll give you a glucometer and teach you how to do blood sugar testing . okay ?\n[patient] okay .\n[doctor] and then , from an atrial fibrillation standpoint , your heart , even though you're in atrial fibrillation right now , is in a good rate . and we'll just continue you on your metoprolol , 25 milligrams , twice a day . do you need a refill on that ?\n[patient] yes , i do .\n[doctor] hey , dragon ? order a refill on metoprolol , 25 milligrams , twice a day . and for your reflux , we'll just continue you on the protonix , okay ?\n[patient] okay .\n[doctor] do you have any questions , hannah ?\n[patient] no , not at this time .\n[doctor] okay , so the nurse will come in and she'll go over all that stuff with you .\n[patient] okay .\n[doctor] take care .\n[patient] thank you .\n[doctor] hey , dragon ? finalize the note .\n",
            "tgt": "CHIEF COMPLAINT\n\nEvaluation of high blood sugar.\n\nHISTORY OF PRESENT ILLNESS\n\nMs. Hannah Phillips is a 52-year-old female who presents for evaluation of high blood sugar. The patient admits to dietary indiscretion. She notes that she has been eating more sweets during the holidays. She reports that this past week, she felt really lightheaded, was seeing spots in her vision, and was really dizzy. She went to the emergency room and was told that she had high blood sugar. Ms. Phillips was given IV fluids. The patient was also instructed to get into a routine and watch her diet. She states that she is staying with family during the holidays and having trouble returning to her routine diet, but wants to make sure that her high blood sugar is not an issue.\n\nThe patient denies any fever or chills. She denies chest pain or shortness of breath. She denies abdominal pain or burning when she urinates. She denies joint pain or muscle aches.\n\nShe notes that she has osteoarthritis, and that nothing seems out of the ordinary for her joint pain.\n\nThe patient has a history of atrial fibrillation. She states that she has felt her heart racing when she is anxious; however, other than that, she has not experienced any issues. She is currently taking metoprolol 25 mg 2 times per day.\n\nRegarding her acid reflux, she states that she has been doing well. She has been taking the medication that was prescribed to her, and it has been very helpful. She is on the Protonix 40 mg once daily, and she is doing well with that\n\nREVIEW OF SYSTEMS\n\n\u2022 Constitutional: Negative for fever, chills\n\u2022 Cardiovascular: Negative for chest pain\n\u2022 Respiratory: Negative for shortness of breath.\n\u2022 Gastrointestinal: Negative for abdominal pain.\n\u2022 Genitourinary: No dysuria.\n\u2022 Musculoskeletal: No Arthralgias, Myalgias.\n\nPHYSICAL EXAMINATION\n\nConstitutional\n\u2022 General Appearance: appear in no distress.\n\nNeck\n\u2022 General Examination: Her thyroid is a little enlarged but nontender. There are no carotid bruits. Respiratory\n\u2022 Auscultation of Lungs: Clear bilaterally. Cardiovascular\n\u2022 Auscultation of Heart: Irregular rate and rhythm. Musculoskeletal\n\u2022 Examination of Abdomen: Nice soft and have no edema in lower extremities.\n\nRESULTS\n\nGlucose: elevated.\nHbA1c: elevated.\n\nASSESSMENT AND PLAN\n\nMs. Hannah Phillips is a 52-year-old female who presents for evaluation of high blood sugar.\n\nDiabetes.\n\u2022 Medical Reasoning: Elevated blood glucose and hemoglobin A1c levels based on recent labs.\n\u2022 Additional Testing: We will order a complete metabolic panel for further evaluation.\n\u2022 Medical Treatment: Initiate metformin 500 mg twice daily. Encouraged dietary modifications. The patient will be given a glucometer to monitor her glucose levels at home.\n\nAtrial Fibrillation.\n\n\u2022 Medical Reasoning: Asymptomatic and well-controlled at this time.\n\u2022 Medical Treatment: Continue metoprolol 25 mg twice daily. Refilled today.\n\nHistory of Reflux.\n\n\u2022 Medical Reasoning: Well-controlled on current regimen.\n\u2022 Medical Treatment: Continue Protonix 40 mg daily.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N135-virtassist"
        },
        {
            "src": "[doctor] hi janet , how are you ?\n[patient] good , how are you ?\n[doctor] i'm good . uh , are you ready to get started ?\n[patient] yes .\n[doctor] okay . so , janet is a 33-year-old female , here for some , some joint paint . what , what joint's been bothering you , janet ?\n[patient] it's been mostly , um , my knees , actually . i've been doing more stair type workouts , which i thought was , you know , building muscle , uh , on my knees and supposed to help .\n[doctor] mm-hmm .\n[patient] but in turn it , it really has n't , so my knees have been really bothering me .\n[doctor] okay . all right . and is it one knee versus the other ? or both equally ?\n[patient] it's both equally .\n[doctor] okay . and have you been having any other joint pain like , elbows or shoulder , or anything like that ?\n[patient] no , but i , i should mention that like , i had a rotator cuff repair about two years ago .\n[doctor] mm-hmm .\n[patient] um , but i have n't had any problems since that point .\n[doctor] okay , and what shoulder was that ?\n[patient] that was my right shoulder .\n[doctor] okay , all right . and , um , any pins and needles in your feet at all ? any swelling in your legs ?\n[patient] uh , no , nothing like that .\n[doctor] okay .\n[patient] um , but it would be something though i look out for often , just because i have diabetes .\n[doctor] okay , and your blood sugars have been under control ?\n[patient] yes , they have been .\n[doctor] okay . and have you had any fever or chills ?\n[patient] no , nothing like that .\n[doctor] okay . any nausea or vomiting , chest pains , shortness of breath ?\n[patient] no , but i do have high blood pressure , um , but i , i monitor that and i've been taking medication for that , and that has n't elevated , um , in any way since the joint pain .\n[doctor] okay . all right . so , yeah , i see on here that you do take norvasc , five mg a day and you've been taking that every day-\n[patient] yes .\n[doctor] okay . um , and , um , so let's go ahead and do a quick physical exam on you . so , hey dragon , show me the blood pressure . your blood pressure's actually pretty high today , so you might be a little nervous here , which is not uncommon .\n[patient] yeah .\n[doctor] um , so , looking at you , your , your neck is nice and soft , there's no enlarged thyroid . your heart has a regular rate and rhythm . your lungs are clear . your abdomen is nice and soft , but looking at your knees , on your left knee you do have a slight erythema and edema . there is a small efusion present over your left knee . um , you have some decrease flexion and extension of your knee , but your strength in your lower extremities is good . uh , so let's go ahead and look at some of your results . i know that we did some x-rays when you came in .\n[patient] yeah .\n[doctor] hey dragon , show me the left knee x-ray . okay , so looking at this , this is an , this is a normal x-ray of your left knee , so you may just have a little bit of a strain going on in your , in your knees there .\n[patient] okay .\n[doctor] uh , let's look at some of your labs , 'cause i know that you have the diabetes . hey dragon , show me the labs . so , here your white blood cell count is not elevated , so i'm not concerned about an infection or anything like that . um , hey dragon , show me the diabetes' labs . okay and , and your a1c is a little elevated , but it's not , it's not terrible , so i think for right now we'll just continue you on the current regimen . um , so my plan from you , for you in terms of the joint pain , um , i'd like to go ahead and , you know , we'll just send some autoimmune labs to work , work up your left knee pain and , uh , we'll work for you to do some physical therapy and i'd like to go ahead and give you anti-inflammatory medication to help with the pain . does that sound okay ?\n[patient] that sounds great .\n[doctor] okay . hey dragon , order meloxicam 15 mg once a day . hey dragon , order a physical therapy referral . hey dragon , order an autoimmune profile . and then from a hypertension standpoint you , because your blood pressure is a little elevated today , i'd like you to continue to monitor it at home and , you know , send me a report in the next couple of weeks sh- , you know , giving me the , the blood pressure reportings . do you have a blood pressure cuff at home ?\n[patient] yes , i do .\n[doctor] okay . and then , um , we'll go ahead and order a lipid profile for you . hey dragon , order a lipid profile . and then for , from a diabetes standpoint let's go ahead and , uh , continue you on your metformin 500 mg twice a day . okay ?\n[patient] okay .\n[doctor] do you have any questions ?\n[patient] no , that's it .\n[doctor] okay . the nurse will be in soon . it was good to see you .\n[patient] nice seeing you too .\n[doctor] hey dragon , finalize the note .\n",
            "tgt": "CHIEF COMPLAINT\n\nJoint pain.\n\nHISTORY OF PRESENT ILLNESS\n\nMs. Janet Sullivan is a 33-year-old female who presents to the clinic today for evaluation of joint pain.\n\nShe localizes the joint pain to her bilateral knees. The patient reports she has been doing stair workouts, which she thought was building muscle on her knees. She denies any pins and needles in her feet or swelling in her legs. The patient notes that she would look out for those symptoms because she has diabetes. She denies any fever or chills. She denies any nausea or vomiting. The patient denies any chest pain or shortness of breath.\n\nShe notes she had a right shoulder rotator cuff repair about 2 years ago, but she has not had any problems since that point.\n\nShe reports that her diabetes are well-controlled.\n\nThe patient does have high blood pressure but she monitors it and takes Norvasc 5 mg a day. She notes her blood pressure has not been elevated since her joint pain started.\n\nREVIEW OF SYSTEMS\n\n\u2022 Constitutional: Negative for fever, chills\n\u2022 Cardiovascular: Negative for chest pain or lower leg swelling.\n\u2022 Respiratory: Negative for shortness of breath.\n\u2022 Gastrointestinal: Negative for nausea, vomiting.\n\u2022 Musculoskeletal: Positive for Arthralgias\n\nPHYSICAL EXAMINATION\n\nNeck\n\u2022 General Examination: Neck is supple without thyromegaly.\n\nRespiratory\n\u2022 Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.\n\nCardiovascular\n\u2022 Auscultation of Heart: Regular rate and rhythm.\n\nMusculoskeletal\n\u2022 Left knee: Slight erythema and edema. Small effusion present. Decreased flexion and extension. Strength in lower extremities is good.\n\nRESULTS\n\nViews: Four views left knee.\nIndication: Knee pain.\nInterpretation: There are no fractures, dislocations, or other abnormalities.\n\nPLAN\n\nMs. Janet Sullivan is a 33-year-old female who presents to the clinic today for evaluation of joint pain.\n\nLeft knee strain.\n\u2022 Medical Treatment: We will order an autoimmune panel for further workup. I am going to refer her to physical therapy and prescribe meloxicam 15 mg once daily to help with pain.\n\u2022 Specialist Referrals: Physical therapy.\n\nHypertension.\n\u2022 Medical Reasoning: Her blood pressure is elevated in office today, but has been well-controlled on Norvasc 5 mg daily based on home monitoring.\n\u2022 Medical Treatment: Continue current regimen and home monitoring. She will send me a report in the next couple of weeks. We will also order a lipid profile.\n\nDiabetes type II.\n\u2022 Medical Reasoning: Her hemoglobin a1C is slightly elevated, but her blood glucose levels have been well-controlled.\n\u2022 Medical Treatment: Continue metformin 500 mg twice a day.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N136-virtassist"
        },
        {
            "src": "[doctor] morning christine , nice to see you .\n[patient] nice to see you too .\n[doctor] so i know my nurse told you a little bit of- ... um , about dax and i'm gon na tell dax a little bit about you , if that's okay ?\n[patient] go for it .\n[doctor] okay , great . um , uh , this is christine . she's a 63-year-old female patient . you're here for your routine , um , yearly exam . um , i know you have a history of high blood pressure and you've had some depression in the past . and i also know you did have a carpal tunnel release done about two years ago . um , how have you been doing ?\n[patient] i've been doing well . um , the depression standpoint is doing great . i've been using , um , the medication you prescribed me last time and going to therapy every week . and that's really helped me manage .\n[doctor] okay . and you're sleeping well at night ? and everything's been going well from that standpoint ?\n[patient] yeah , i've been getting a full eight hours .\n[doctor] okay . and no thoughts of hurting yourself or anything like that ?\n[patient] no .\n[doctor] okay , good . um , and , um , i- i know you've had some high blood pressure in the past . have you been checking your blood pressure ?\n[patient] i have . it's been a little bit up and down-\n[doctor] okay .\n[patient] lately , i have n't had a normal , um , normal reading- reading in a couple of weeks . um , it's either been high or low . um , has n't really stayed put .\n[doctor] has n't really stayed put ?\n[patient] yeah .\n[doctor] okay . and , um , you've been talking your medication though , right ?\n[patient] yes , i have .\n[doctor] okay .\n[patient] my diet's been a little all over the place . i have been really stressed with work and putting in more hours, so you know, it has been hard. i have not had time to go to the grocery store, let alone prepare and cook meals. so, i have been eating a lot of frozen meals.\n[doctor] okay .\n[patient] that type of thing .\n[doctor] and have you had any headaches or swelling or anything like that that's been abnormal ?\n[patient] i have some headaches but i just thought that was looking at a computer screen all day .\n[doctor] okay , well , that's fair .\n[patient] yeah , exactly .\n[doctor] okay good . and , um ... i know my nurse did a review of systems . other than what we've just talked about , has there been anything else that you wanted to add to that ?\n[patient] um , my carpal tunnel release has been doing well . on , uh , we did that , i think it was two years ago now .\n[doctor] okay .\n[patient] uh , on my right , um , wrist , and that's been great .\n[doctor] great , great . no numbness or tingling in your hands ?\n[patient] no .\n[doctor] fingers ? okay , good . all right , well , um , lem me do a quick exam if that's okay ?\n[patient] okay .\n[doctor] deep breath . squeeze my fingers for me . feel me touch you here ?\n[patient] yup .\n[doctor] can you touch down here ?\n[patient] mm-hmm .\n[doctor] can you push your leg out ? push this one up . pull it back . yeah , good . okay . so on my exam , um ... your exam's essentially normal , your lungs are clear , are- ... you do n't have any adenopathy in your neck , you do n't have any , um , uh , hyperthyroidism . um , your heart is regular without any murmurs . um , your grips are equal , neurologically intact , strength is good , pulses are good . so overall , um , your exam is fine . let's take a- a look at some of your labs and vital signs .\n[patient] okay .\n[doctor] hey dragon , show me the blood pressure . okay , so here in the office today it is a little bit elevated , okay ? so your blood pressure is a little bit high . so the results , um , do show that . um , hey dragon , show me the labs . okay , so good news is is your- your labs are all essentially normal , so the results of your labs are essentially normal , okay ? so ... um , my assessment is that your- ... you do have hypertension still . um , and i think we need to increase your blood pressure medicine a little bit , okay ? so i'm gon na increase your lisinopril to 10 milligrams a day , just once a day , um , but i'm gon na increase that a little bit , okay ? and then want you to check it and i'm gon na have you come back in a month and we'll see how you're doing with regards to that , okay ?\n[patient] okay .\n[doctor] um , your second problem is your dep- depression , you're doing great , i do n't wan na change anything at this point . let's just stay- ... we'll change one thing with your high blood pressure-\n[patient] mm-hmm .\n[doctor] so i do n't wan na change any other medications at this point in time , so let's just leave that as it is .\n[patient] okay .\n[doctor] and then your third problem was your carpal tunnel . that seems to be doing well . if you notice any tingling or any changes or you get some of those symptoms back , just let me know . okay ?\n[patient] okay .\n[doctor] all right . anything else i can do for you today ?\n[patient] no , that's it .\n[doctor] okay . great . uh , lem me get you checked out .\n[patient] okay .\n[doctor] hey dragon , finalize the report .\n",
            "tgt": "CHIEF COMPLAINT\n\nAnnual exam.\n\nHISTORY OF PRESENT ILLNESS\n\nChristine Flores is a 63-year-old female presenting for her yearly exam. She has a history of high blood pressure and depression in the past. She also had a right carpal tunnel release done about 2 years ago.\n\nThe patient states that she has been doing well with her depression. She notes that she has been taking her medication as prescribed at her last visit. She states that she has been going to therapy every week, which has helped her manage her symptoms. The patient notes that she is sleeping well at night and has been getting a full 8 hours. She denies any thoughts of self-harm or harming others.\n\nThe patient states that she has been checking her blood pressure at home. She notes that her blood pressure has fluctuated lately. She states that she has not had a normal reading in a couple of weeks. The patient has continued utilizing her medications.\n\nShe states that her diet has been a little all over the place. The patient notes that she has been working more hours. She reports that she has had some headaches, however, she thought that it was related to her increased screen time.\n\nThe patient states that her right carpal tunnel release has been doing well. She denies numbness or tingling in her hands or fingers.\n\nREVIEW OF SYSTEMS\n\n\u2022 Cardiovascular: Endorses blood pressure issues.\n\u2022 Neurological: Endorses headaches.\n\u2022 Psychiatric: Endorses depression.\n\nPHYSICAL EXAMINATION\n\n\u2022 Neurological/Psychological: Appropriate mood and affect. Bilateral grip strength equal. Neurologically intact.\n\u2022 Neck: Supple without thyromegaly or cervical lymphadenopathy.\n\u2022 Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.\n\u2022 Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No extra heart sounds.\n\nVITALS REVIEWED\n\n\u2022 Blood Pressure: Elevated.\n\nRESULTS\n\nLaboratory studies are all within normal limits.\n\nASSESSMENT AND PLAN\n\nChristine Flores is a 63-year-old female presenting for her yearly exam.\n\nDepression.\n\u2022 Medical Reasoning: She is doing well and managing this with medication and weekly therapy.\n\u2022 Medical Treatment: Continue current regimen.\n\nHypertension.\n\u2022 Medical Reasoning: Her blood pressures have been fluctuating lately. She does admit to dietary indiscretion due to her increased workload.\n\u2022 Medical Treatment: Increase lisinopril to 10 mg once daily.\n\u2022 Patient Education and Counseling: She should continue to monitor this at home and follow up in 1 month.\n\nCarpal tunnel release.\n\u2022 Medical Reasoning: She is doing well 2 years postoperatively and is asymptomatic at this time.\n\u2022 Patient Education and Counseling: She will contact us if her symptoms return.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N137-virtassist"
        },
        {
            "src": "[doctor] next patient is emily hernandez . date of birth , march 26 2001 . this is a 20 year old female being seen today for our yearly follow-up for asthma , allergic rhinitis and food allergy . due to insurance changes since our last office appointment in april 2020 , she was switched from symbicort to wixela . she also uses zyrtec in the spring , summer and fall for her seasonal allergy symptoms , which tend to work well . she also has known peanut allergy , she does tolerate almonds and cashews . please put in the asthma section at the very bottom that the act score is 21 . please put under interval history , written consent is obtained today to use dax for documentation .\n[doctor] hi emily , how are you ?\n[patient] i'm pretty good , how are you ?\n[doctor] i'm good , thank you . so gosh , we last talked a little bit over a year ago and it was just a telemedicine visit , but it seems like you've been doing pretty good . i know there was an insurance change . i think you had switched over to wixela , is that right ?\n[patient] yep , that's right , and it's what i'm currently using .\n[doctor] okay , and that's the 250/50 dose , correct ?\n[patient] yes , correct .\n[doctor] perfect . so how does that compare ?\n[patient] i mean , it's working well . i really have n't had any issues with it and i take it once in the morning and once at night .\n[doctor] and that's one puff twice a day ?\n[patient] mm-hmm .\n[doctor] okay . and have you been having to use your albuterol inhaler at all ?\n[patient] rarely , and if i do it's really just before a workout or something out that , if i know i'm really going to be pushing it .\n[doctor] so it sounds like it's around strenuous activity .\n[patient] yes .\n[doctor] okay . so you can do things like go on a walk or going to the grocery store no problem , and just use it for more exertional stuff ?\n[patient] yes . like , if i'm gon na go for a run or something like that i'll really just take it before as a preventative .\n[doctor] okay .\n[patient] and i've been trying to use my daily if i can a little less because i'm trying to go into the military soon .\n[doctor] no kidding , that's great .\n[patient] yeah , so i have to be able to operate basically at a certain fitness level without an inhaler .\n[doctor] really ?\n[patient] yeah , and if i can prove that i'm capable of these activities without an inhaler it makes it easier .\n[doctor] and so by inhaler do they mean both your daily and rescue inhalers ?\n[patient] mm-hmm . so it's like they'll have a fitness test and basically they'll tell me not to take my inhaler that day before the test , and then they'll see how the asthma affects me . and they're looking to see if it's serious enough to hold me back from joining or whatever . so i have been taking it less and less . and really some days i feel like i do n't need it .\n[doctor] and that is the wixela that you're not taking . so on average per week , how many days of the week do you use one puff in the morning and one puff at night ?\n[patient] probably about three or four .\n[doctor] okay , three to four days per week and the other days it's once a day ?\n[patient] yes , that's correct .\n[doctor] okay .\n[patient] and it's either in the morning or at night that i'm taking it .\n[doctor] okay , and do you think that's working okay ?\n[patient] i do .\n[doctor] great . and any urgent care or er visits at all for breathing over the past year ?\n[patient] nope .\n[doctor] okay , so i'm going to assume no one has put you on prednisone for breathing issues then .\n[patient] nope .\n[doctor] okay . and now , military wise , what's the time frame of when you'll be completing some of these exertional tests ? like , what are your next steps ?\n[patient] so , hopefully i'm going to be enlisted early spring of 2022 . so that gives me about six to seven months to get to a point where i'm able to exert my body where i do n't really need the inhaler . or at least show them that i have it under control .\n[doctor] now when you were in the other room you completed a breathing test , correct ?\n[patient] correct .\n[doctor] okay , great . so now let me ask you about the allergies , 'cause i know typically you'll use the zyrtec in the spring , summer and fall , correct ?\n[patient] yeah , i do n't really ... um , or i'm sorry , i use it more during the spring and fall . i do n't really have to use it too much in the summer .\n[doctor] do you use it more just as needed in the summer ?\n[patient] yeah , that's right .\n[doctor] okay . and have you been taking the zyrtec every day recently since you're right in the mix of spring ?\n[patient] not every day , but i do take it on days i know i'm going to be outside a lot . um , i do tend to work outside about three days a week so i'll definitely take it on those days .\n[doctor] and does it seem to work pretty well still ? are you happy with it ?\n[patient] yeah , it does , it works great .\n[doctor] wonderful , good to hear . and then i'm assuming you're staying away from the peanuts . uh , last year you had told me it worked with ... uh , you worked with enterprise rent-a-car and one of the cars had a lot of peanuts in it that you were cleaning out and that gave you hives , uh , when you had touched it , is that correct ?\n[patient] yep , that's correct .\n[doctor] okay . and has there been anything like that since that experience ?\n[patient] no , i do n't think so . i definitely became more cautious after that , so i usually wear , uh , wear long sleeves and change my gloves every time now . so i have n't had a reaction , but i imagine that i probably came into contact with cars that had peanuts in them , but they just d- did n't touch my skin .\n[doctor] super . and it sounds like you're really smart about it .\n[patient] yeah , and the airplanes , they have peanuts . they give everyone too , so .\n[doctor] okay . and you have an epipen that k- that you keep with you , correct ?\n[patient] yes .\n[doctor] okay . and i'm assuming you're going to need refills , um , i can call you in a new set for the year . typically of course , they expire within a year .\n[patient] yeah , okay .\n[doctor] and i remember , um , sometime previously you've had some testing for tree nuts , but you do have almonds and cashews , correct ? and- and you do okay with them , or do you avoid all tree nuts ?\n[patient] i do tend to avoid all of them but i recall eating some almonds at one point , uh , really soon after we discussed i might not be allergic to tree nuts anymore .\n[doctor] okay .\n[patient] and i remember having them and nothing happened , but i usually just tend to stay away from them , um , really if i can help it .\n[doctor] okay . so sometimes when people have a peanut allergy , the nuts in general just are n't very important to them , so it is very common to avoid both . um , so let's do this . i'll have helen come in and i would love to complete a breathing test on you . if your breathing numbers are looking great we can work on getting you , uh , something lower than wixela . if you look at all of our asthma regimens it is a stepwise process , and wixela is a combination of two medications in one . and , well maybe you do n't need both of'em . uh , maybe you just need one of'em . so we can work our way backwards .\n[patient] okay .\n[doctor] and so the breathing test will help give us some- some more guidance , we will look at the results in just a moment .\n[patient] all right , and so this past year i did get into the bad habit of vaping and smoking , but i have been trying to cut that out . so i should be good , and , um , now i only do just a little bit and i am trying to quit . so i am sure that might have an effect .\n[doctor] it can . um , so what we can do today is compare your results with prior results , probably before you started smoking or using the vape .\n[patient] okay .\n[doctor] yeah . and we'll see where you stand at that point .\n[patient] all right , that sounds good .\n[doctor] well let me go ahead and listen , so hop on up here for me .\n[patient] okay .\n[doctor] all right so your ears look good , a little bit of wax on both sides . can i see inside your mouth ? big ahh .\n[patient] ahh .\n[doctor] good . okay let me take a peek in your nose . all right , good . you can put your mask back on .\n[patient] okay .\n[doctor] and go ahead take a big breath in and out . good , your lungs sound terrific . i'll listen to your heart , breathe quietly . okay very good .\n[patient] awesome .\n[doctor] so your breathing test is about the same as it was a couple years ago , and actually looks a little bit better . you may not remember but when we last completed the test in 2019 , uh , do you recall if you were feeling lousy at the time ?\n[patient] i think it was the smoke . there were so many fires at that point and i remember coming in and looking out the window and all you saw was the orange and the smoke .\n[doctor] yes , you're absolutely right , that was a bad year . that was my first fall here and i was really alarmed . well that explains why at that time your numbers were a little bit lower and today they look better . here's what i think , so you'll have kaiser currently , correct ?\n[patient] correct .\n[doctor] okay . most insurances do limit what we can use .\n[patient] yeah i do know that .\n[doctor] okay so option one would be to continue using wixela like you're using it now . we would classify it as off-label and you can use it once a day instead of twice a day , which is fine . some people do that because they just need it once a day , so that's an option . option two would be to actually back up to an inhaler that just has one med .\n[patient] mm-hmm\n[doctor] so the one that kaiser covers is alvesco . the thing about alvesco , though , is that it would be two puffs in the morning and two puffs at night . so it's a bit more work . um , it's not breath activated but we could step down the lowest dose to see how you do . some of the newer guidelines for asthma that were published this year is recommending trying to treat people with inhalers like wixela or alvesco only when you're ill , or say during smoke season . so minimizing their use to those periods of time versus all year . unless you found out that you're getting\n[ inaudible 00:09:25 ] sick having issues every month , then that would indicate would pull back too much .\n[patient] okay .\n[doctor] that we had too much , yeah .\n[patient] okay .\n[doctor] um , so we could step back and possibly get you to the point where you just use those inhalers , uh , when you're ill or it's smoke season , but at the first step to do any of that would be to try to drop down to just alvesco .\n[patient] okay , that actually sounds really good .\n[doctor] okay great . so i will call that in for you , it will be the lower dose , 80 mcg , and you'll have to do two puffs twice a day .\n[patient] all right\n[doctor] okay and that'll be on the box when i call it in . you can put the wixela off to the side , but do n't throw it away just in case the alvesco does n't work well for you .\n[patient] okay , got it .\n[doctor] and then ideally we would repeat your breathing test in four months to see how you're doing , and then be able to document that you're doing well . sometimes , not always , the military will require documentation on breathing tests .\n[patient] okay .\n[doctor] is your pharmacy still the same or did you update it with helen ?\n[patient] yeah i believe she updated it . it should be kaiser permanente broadway .\n[doctor] okay perfect . i'll make sure it's the alvesco and then i'll renew your albuterol and epipen as well .\n[patient] awesome , thank you .\n[doctor] you're welcome . uh , then the zyrtec , do you pick it up over the counter or do get- do you get it as a prescription ?\n[patient] i just get it over the counter .\n[doctor] okay got it . and do you have a nebulizer that you would , uh , need refills on ?\n[patient] i do n't think i need any refills , i have n't used that in such a long time . i think the last time was when i had bronchitis , or there was few select times when i had to use it when i was kid .\n[doctor] okay good . well i think we have our game plan .\n[patient] okay awesome .\n[doctor] and do the alvesco two puffs twice a day and your albuterol if you need it . the zyrtec 10 milligrams as you need it and continue to stay away from peanuts and tree nuts and i'll refill your epipen .\n[patient] okay\n[doctor] all right so we've got it .\n[patient] great .\n[doctor] all right i'll have you take this to the front and i'm gon na say four months re-check for asthma and we'll repeat the spirometer- spirometry at that time .\n[patient] okay sounds good .\n[doctor] all right well thanks so much and you have a great day .\n[patient] you too .\n[doctor] and we'll do a follow-up in four months with act and spirometry , sooner if needed . follow-up 25 minutes .",
            "tgt": "CHIEF COMPLAINT\n\nFollow-up for asthma, allergic rhinitis, and food allergy.\n\nHISTORY OF PRESENT ILLNESS\n\nEmily Hernandez is a 20-year-old female presenting today for an annual follow-up for asthma, allergic rhinitis, and food allergy. Due to insurance changes during the interim of our last office appointment from 04/2020, she was switched from Symbicort to Wixela. She uses Zyrtec in the spring, summer, and fall for her seasonal allergy symptoms, which tends to work well. She has known peanut and tree nut allergies, which she tries to avoid. She does tolerate almonds and cashew.\n\nMrs. Hernandez is trying to join the military, who require a certain fitness level without use of a rescue or maintenance inhaler, so she has been weaning off her inhalers. She uses albuterol prior to a run, but otherwise functions without it. She has been reducing her Wixela dose, using 1 inhalation once daily 3 times per week, with remaining days using it twice per day as prescribed. She feels this is working well. She denies urgent care or emergency room visits for respiratory issues in the past year. She denies requiring prednisone for breathing issues in the past year.\n\nShe hopes to be enlisted in the military in early spring of 2022. She is currently undergoing exertional testing to this purpose. She explains that this gives hers 6 to 7 months to show that she can exert herself without needing any inhalers.\n\nOver the past year, she admits to vaping and smoking, though she is trying to quit and has cut down her use significantly.\n\nShe notes having a nebulizer but denies needing it recently and has only used it in her past for upper respiratory infections and as a child a few times.\n\nMrs. Hernandez uses Zyrtec during the spring and fall but does not typically have to use it consistently during the summer. She confirms she has been taking Zyrtec 3 days per week when she works outside, and it works well to control her symptoms.\n\nShe has been successfully avoiding peanuts. Incident from last year was reviewed where she was exposed to peanuts when she was cleaning an Enterprise rental car that had a lot of peanuts in it. She developed contact hives when the peanuts encountered her skin. Over the past year she denies additional accidental exposures. She wears long sleeves and changes her gloves between each cleaning. She thinks it is likely that she has been in contact with cars that contained peanuts, but due to her protective measures she did not touch them directly. She confirmed she always keeps an EpiPen with her.\n\nThe patient is also avoiding tree nuts. She did ingest almonds without issue following our discussion that she could try them. Despite tolerating them well, she continues to avoid all tree nuts.\n\nPAST HISTORY\n\nMedical\nAsthma.\nAllergy rhinitis.\nFood allergies to peanut and tree nuts.\n\nSOCIAL HISTORY\n\nCurrently smokes tobacco and vapes, trying to reduce and interested in cessation in preparation for joining the army.\n\nCURRENT MEDICATIONS\n\nWixela Inhub 250 mcg-50 mcg/dose powder for inhalation. 1 puff 2 times daily in the morning and evening.\nProair HFA as needed.\nEpiPen as needed.\nAlvesco 80 mcg 2 puff 2 times daily.\n\nALLERGIES\n\nPeanuts cause a severe, anaphylactic reaction.\nMontelukast sodium, \u201cseizure-like\u201d reaction.\n\nRESULTS\n\nAsthma Control Test (ACT) Results: ACT score is 21.\nCurrent food skin test sensitivities include peanuts.\n\nASSESSMENT\n\n\u2022 Moderate persistent asthma, uncomplicated.\n\u2022 Allergic rhinitis.\n\u2022 Anaphylactic reaction due to peanuts.\n\nEmily Hernandez is a 20-year-old female who presented today for her yearly follow-up appointment for asthma, allergic rhinitis, and food allergy.\n\nPLAN\n\nModerate persistent asthma, uncomplicated\nThe patient has been using Wixela inhaler daily and admits to reducing her daily dose to one puff per day, 3-4 days per week as she feels she does not always need it the full dose. Additionally, she aspires to join the military and she must meet certain physical fitness requirements without the use of her inhaler. I counseled the patient on current asthma treatment guidelines which recommend using Wixela and Alvesco only when needed during periods of illness. The patient agreed to reducing her medicine to Alvesco which is a single medication, versus 2 in Welixa. The patient will continue to use her albuterol inhaler as needed. Her ACT score is 21 today and her spirometry test today was better than it was in 2019, though she recalls that it was smoky from wildfires during her last breathing test.\n\nAllergic rhinitis\nShe will continue to use Zyrtec as needed, primarily during spring and fall and sometimes in summer. Her current dose cadence is 3 times per week when she works outside. Symptoms are currently under control.\n\nAnaphylactic reaction due to peanuts\nThe patient has successfully avoided peanuts. Plan is to continue with current methods to avoid exposure. I will refill her EpiPen which expires annually.\n\nINSTRUCTIONS\n\nModerate persistent asthma, uncomplicated\nStart Alvesco, 2 puffs twice daily. Keep Wixela in case Alvesco does not work well. Continue albuterol as needed. Return in 4 months to repeat ACT and spirometry testing.\n\nAllergic rhinitis\nContinue Zyrtec 10 mg daily as needed.\n\nAnaphylactic reaction due to peanuts\nContinue strict avoidance of peanuts. I will refill her EpiPen today.",
            "file": "D2N138-virtscribe"
        },
        {
            "src": "[doctor] all right , new patient , jordan roberts . date of birth : 3/2/1972 . he's a 49 year old , uh hm , with hypertension and palpitations . please copy forward his thyroid profile from march 1st , 2021 .\n[doctor] hello mr. roberts , how are you doing today ?\n[patient] i'm fine , thank you .\n[doctor] good . good . so , i saw you were recently in the emergency room with high blood pressure and some palpitations .\n[patient] yeah . that was back in march i think , but my girlfriend and i , we talked about it , and on that day i had a few cups of coffee , and no breakfast . so , i think it was probably more of a panic attack than anything else .\n[doctor] yeah . have you , uh , have you felt it again since ?\n[patient] uh , no .\n[doctor] okay . uh , so tell me about the blood pressure then .\n[patient] well , i've had issues with my blood pressure since i was young .\n[doctor] do you have a family history of this ?\n[patient] yeah . a lot of my family does have high blood pressure .\n[doctor] i see .\n[patient] yeah , i thought it was getting better , and , uh , i have a new primary doctor , and she put me on a new medication about a month ago .\n[doctor] uh , can you tell me which medications you're taking ?\n[patient] my new med is , uh , a combo med , something 40-25 .\n[doctor] okay . um . yes , i see that in your chart . the benicar hct . it has hydrochlorothiazide in it .\n[patient] yeah , that's it . my water pill i call it .\n[doctor] okay . are you still taking the amlodipine , 10 milligrams daily ?\n[patient] uh , yes i am .\n[doctor] that's- that's a good start on a regimen . are you checking your blood pressure at home , and if yes , what numbers are you seeing ?\n[patient] um , every day .\n[doctor] awesome .\n[patient] yeah . every morning , i take it when i get up , and it's been running at about , uh , 146 to 155 lately .\n[doctor] so you're not down in the 120s yet ?\n[patient] no , not yet . well , we're trying to get there though .\n[doctor] okay . uh , how are you doing with your salt intake ?\n[patient] i'm trying to back off of it . i think i'm doing good with it , not eating too much .\n[doctor] good , uh , it plays a huge part in lowering your pressure and , uh , staying away from salt is important . um , i'll give you some information on the dash eating plan , which is the only eating plan that has been shown to lower blood pressure .\n[patient] sounds good .\n[doctor] are you doing any exercise ?\n[patient] i do try to walk on the treadmill when i can .\n[doctor] okay , great . um , all right . so , let's take a look .\n[patient] all right .\n[doctor] uh , you're gon na hear me talk throughout your exam , just so i can make sure i get everything documented .\n[patient] okay .\n[doctor] so , use my general physical exam template . let me take a listen to you and make sure everything sounds good .\n[patient] all right .\n[doctor] your heart and lungs sound good , so that's great .\n[patient] good to hear .\n[doctor] all right . go ahead and lie down . uh , and let me know if anywhere i press hurts .\n[patient] nope . nowhere .\n[doctor] all right . so , i'm gon na take a look at your ankles and feet . i'm just gon na look for some swelling .\n[patient] all right .\n[doctor] all right . it all looks good . go ahead and sit up . so , in terms of getting that pressure down , you're on three meds that are maxed out and your blood pressure is still not down . and , the question is what do we need to do to get your- to get it down . uh , your potassium one week ago was 4.0 . uh , has it been redone since in the last week ?\n[patient] uh , no .\n[doctor] okay . uh , four is good for your potassium level , some people have what is called resistant hypertension that is driven by something else in their body , uh , often it is a form , uh , hormonal response . if i were to take 10 people under the age of 50 who have high blood pressure who developed it at a young age , eight out of 10 would respond to reduced salt in their diet with a lower blood pressure . but , for the two out of 10 , there is something else driving it , uh , parathyroid levels or something called your adrenal glands overproduce , um , aldosterone , which we call hyperaldosterone .\n[patient] okay . so , is there something we can do about it ?\n[doctor] um , in these cases , there's medicine called , uh , spironolactone , that is very effective at dropping the ald- aldosterone level , and your blood pressure , and i think we should give that a try .\n[patient] all right . i mean , i'm willing to give it a try .\n[doctor] okay . so , let's discuss the piss- the possible risk of , uh , being on hydrochlorothiazide , which is the fluid med that you're now on . and , the spironolactone . one issue is that they can affect your electrolyte balance . um , they can also cause dehydration . so , when ... so , you got ta make sure that you hydrate . if you do not hydrate , and you get dehydrated , you will know it because you will get dizzy standing up . um , second thing is the spironolactone can raise your potassium too far , it's rare , but it can . uh , you're starting with your potassium at four , so that gives us some room .\n[patient] all right . i guess that makes me feel a little bit better .\n[doctor] yeah . and then the third thing is that spironolactone combined with hydrocholorozide- chlorothiazide can cause your sodium levels to go down . now , this does not mean- mean that you need to be eating more salt , okay ? but , it does mean that you will need to do blood tests in two weeks to make sure that it's okay .\n[patient] all right . no , that i can do . um , are there any other side effects i need to worry about ?\n[doctor] uh , dizziness possibly , as well as , uh , one in 100 guys might develop tenderness in their chest , swollen breasts , or enlarged breasts . this is a rare side effect , um , called gynecomastia , and if it happens , you just cut the medication and you let me know , but it is very uncommon .\n[patient] i'll definitely let you know if that happens .\n[doctor] okay . uh , we'll keep working at it until your blood pressure gets better . um , it can be tricky when your blood pressure starts to go up at a young age though , it is important to get it under control because it can lead to your heart getting bigger or enlarged . um , same thing that happens when you lift weights and your muscles get bigger , uh , and if your heart pumps against high blood pressure , it can eventually lead to heart failure .\n[patient] i understand .\n[doctor] yeah , so getting that under control is really important to help prevent kidney failure , strokes , and- and things like that- that you're at high risk for with high blood pressure .\n[patient] okay .\n[doctor] um , the american heart association has a website called heart.org , it has a lot of really good information about blood pressure to teach- to teach you about it and how to control your diet with exercise . um , if you do your treadmill routinely for 30 minutes or so most days , that could be seven to 10 points off your blood pressure .\n[patient] really ? i did n't realize that .\n[doctor] yeah , yeah . it's very important to be active , lower your salt , and increase your potassium . um , the goal is to keep your salt under 2000 milligrams a day , the actual recommendation is- is 1500 milligrams per day , but most people have a hard time with that . um , so just take a look at the website and the dash diet information . um , that will give you a lot of tips and information to help you start learning about this stuff .\n[patient] okay . i'll definitely check that out .\n[doctor] all right . so , we'll try the spironolactone and schedule a followup in two weeks to check your blood pressure and electrolytes . uh , if the new med does n't work , the next up is going to be the resistant hypertension clinic .\n[patient] all right .\n[doctor] all right . so , there they will look into secondary causes of your hypertension . they have access to newer procedure based technologies that can lower your blood pressure without medication , uh , for example , there is something called a renal , uh , denervation , uh , where they go inside the artery that feeds your kidney with almost like a little coil and heat that artery up . when they do that , they can block the nerve endings that get into your kidneys and lower your blood pressure .\n[patient] that's interesting .\n[doctor] yeah . so , that procedure has been shown to lower blood pressure by 10 points . um , there are of course some risks , so not everyone is a candidate . uh , but we'll cross that road , uh , when we need to , and let's just- let's just see how you do with the addition of the medication .\n[patient] sounds good to me .\n[doctor] all right . so , we will see you in two weeks then .\n[patient] sounds good . thanks doc .\n[doctor] yeah , you're welcome . let me know if you have any questions .\n[patient] will do .\n[doctor] all right . have a great day mr. roberts .\n[patient] you too .\n[doctor] mr. roberts presents with resistant hypertension . he's on three meds and maximum dose . i have added spironolactone to his regiment . we will need to monitor his potassium and sodium . he will have a metabolic panel and blood pressure check in two weeks . uh , next medication would be carvedilol , uh , which i try to avoid giving , it's potential for erectile dysfunction . i have talked to the patient about that , and the potential side effects of spironolactone , including the gynecomastia and electrolyte disturbances . if he is not controlled on spironolactone , the next step would be sending him to resistant hypertension clinic .",
            "tgt": "CHIEF COMPLAINT\n\nHigh blood pressure and palpitations.\n\nHISTORY OF PRESENT ILLNESS\n\nJordan Roberts is a 49-year-old with a long history of hypertension and an acute episode of palpitations.\n\nIn March, Mr. Roberts went to the emergency room for palpitations and hypertension. He attributed this to a panic attack, but also stated he consumed several cups of coffee on an empty stomach the morning of. He denies additional episodes of palpitations.\n\nHe has been monitoring his blood pressure at home daily, obtaining systolic blood pressure readings of 146 to 155. He does report a family history of hypertension. Additionally, he has been monitoring his salt intake and feels he is doing well at reducing it. He also walks on his treadmill as often as he can.\n\nHe has a new primary care physician who started him on a new medication Benicar HCT, which he has been using for the past month.\n\nPAST HISTORY\n\nMedical\nHypertension.\n\nFAMILY HISTORY\n\nSeveral family members positive for hypertension.\n\nCURRENT MEDICATIONS\n\nBenicar HCT 40 mg/25 mg\nAmlodipine 10 mg daily.\n\nPhysical Examination\n\nCardiovascular\nNormal rate, regular rhythm, S2 normal, normal heart sounds, and normal pulses.\n\nPulmonary/Chest\nBreath sounds normal. \n\nAbdominal\nThere is no tenderness.\n\nMusculoskeletal\nThere is no edema.\n\nRESULTS\n\nThyroid profile 03/01/2021.\n\nASSESSMENT\n\n\u2022 Resistant hypertension.\n\nMr. Roberts presents with resistant hypertension, with systolic blood pressure readings between 146-155. He is currently on maximal doses for 3 medications.\n\nPLAN\n\nI have added spironolactone to his regimen which will require monitoring of his potassium and sodium. We will schedule him for a follow up in 2 weeks to complete a basic metabolic panel and check his blood pressure. Next medication to consider adding is carvedilol. I have tried to avoid this, given the potential for issues with erectile dysfunction. I counseled the patient about spironolactone side effects, including gynecomastia and electrolyte disturbances, as well as his increased risk of dehydration, with one sign to watch for being dizziness. If we are not able to improve his blood pressure with spironolactone, the next step would be sending him to the resistant hypertension clinic.\n\nI provided and reviewed with Mr. Roberts the American Heart association website (heart.org) and encouraged him to access for tips on lowering his salt intake and increasing his potassium intake. His maximum salt intake should be 1500 to <2000 mg per day. He was provided materials to follow the DASH diet and encouraged to meet 30-min of walking most days.\n\nINSTRUCTIONS\n\nSchedule follow up appointment in 2 weeks for blood pressure check and basic metabolic panel. Reduce sodium intake to 1500 to <2000 mg per day. Follow DASH diet.\n",
            "file": "D2N139-virtscribe"
        },
        {
            "src": "[doctor] brittany edwards , 07 , 1898 . she is a return visit for ibs with functional abdominal pain , nausea , vomiting . ms. edwards is a pleasant , 32-year-old female who was last seen in august of 2019 with flares of abdominal pain , who was diagnosed with irritable bowl that was treated with bentyl .\n[doctor] she had a previous prescription for reglan that she received from the emergency room that she used as needed for nausea . she was instructed to start a low dose fiber supplement , such as citrucel , daily , probiotics to help with gas and bloating , bentyl up to four times daily for intestinal cramping , and stop reglan and use zofran as needed . neuromodulators such as elavil and buspar were discussed but not started .\n[doctor] hello , how are you ?\n[patient] i'm okay .\n[doctor] good . how have you been feeling ?\n[patient] not so good .\n[doctor] yeah , so my nurse told me you have been going out to eat some on friday nights and saturday nights and that you have had some spicy foods or spicy shrimp .\n[patient] yeah , i have .\n[doctor] okay . well , your gut probably does not always appreciate that .\n[patient] no , it does n't like it at all .\n[doctor] yeah , so ibs is one of those things where you are very sensitive to certain things such as spicy foods or fatty foods and alcohol . and this can cause lower belly stuff like cramps , or you can get upper belly stuff such as nausea .\n[patient] i've been getting both .\n[doctor] okay . um , so how frequently have you been getting or having a bowel movement on normal days ?\n[patient] i'm starting to notice it's between two and three times a day .\n[doctor] okay . and are they soft stools or formed stools ?\n[patient] um , they're formed .\n[doctor] okay . and after you have gone out either drinking with your friends , do you tend to have more diarrhea ?\n[patient] yeah , i do .\n[doctor] okay . do you feel it's the food or the alcohol or both ?\n[patient] uh , well usually we go to friday's restaurant . i always eat pasta , the chicken alfredo .\n[doctor] okay . i can s- i can bet it's the alfredo sauce .\n[patient] but it normally does n't bother me .\n[doctor] okay . well , pasta can make you bloated , uh , but it does n't usually cause diarrhea . grilled chi- uh , grilled chicken is usually all right . alfredo , though , is higher in fat , and it does contain dairy . but you're saying it usually does n't bother you ?\n[patient] no .\n[doctor] okay . what type of alcohol drink do you drink when you are there ? is it a sweet drink ?\n[patient] most of the time it's either tequila or dark liquor . i prefer patron , but if i get brown liquor , i only get two . um , every now and again , i'll drink a martini .\n[doctor] sometimes it's the mixer they tend to put in the drinks , but it can be a variety of things . um , so when you're not eating out or drinking , what we do on a daily basis does help keep us regular , so when it does flare up , it c- it might not be as bad . um , have you had any luck using the fiber like citrucel regularly ?\n[patient] um , no . i guess i need to find a new drink .\n[doctor] okay . and how is it during the week ?\n[patient] like what i eat ?\n[doctor] yeah , and with the diarrhea and abdomal- um , abdominal pain .\n[patient] right now , i'm still having the cramping and sharp pains , so i've been avoiding heavy foods . i did have some fried chicken today , though .\n[doctor] and was everything all right after that ?\n[patient] yeah , for the most part .\n[doctor] okay . remember , it's also the portion sizes . so i mean , if you eat a little and you feel fine , then that's okay . you have to just really watch the portions .\n[patient] okay , good . i ca n't go out- go without some fried chicken at least once in a while .\n[doctor] sounds good . all right , well let's take a look at you today , and we'll do a brief physical exam . you will hear me call out some findings . i will answer any questions , and we will discuss once we have finished the exam .\n[patient] sounds good .\n[doctor] all right . so the patient is alert and cooperative , appears stated age . all right . i'm going to listen to your heart and lungs . and lungs are clear to auscultation bilaterally . heart regular rate and rhythm . all right , so if you could just lay back for me , and i'll examine your abdomen .\n[patient] okay .\n[doctor] all right . do you have any tenderness ?\n[patient] no , not really .\n[doctor] okay . so the abdomen is soft , non-tender . no masses or organomegaly . and let me take a listen . normal active bowel sounds . all right . you can go ahead and sit up now . thank you .\n[doctor] all right , so first i want you to try citrucel . it does come in a tablet . you should use it twice daily for regularity . then i would say , if you know you're going out and will possibly have diarrhea as a result , you can go ahead and use your bentyl 20 milligrams . you can do one tablet before you eat , and then repeat up to four times daily . and then on days when you feel good , you do n't have to use anything . um , and then on friday before you leave the house , you can take a bentyl and put one in your pocket for later , and then you can repeat the same thing on saturday if you want , and that will be totally fine .\n[patient] okay , that sounds good .\n[doctor] okay . and so your bentyl , that's the anti-spasm medication , and i would take the higher dose .\n[patient] can i get a refill of that ?\n[doctor] yes , absolutely . uh , so take one tablet about 30 to 45 minutes before leaving the house and then the second tablet at the restaurant . then with the nausea , um , i think we should try and see if you can recognize a pattern with what you are eating and drinking , um , um , about , like , what makes it worse .\n[patient] yeah , i noticed i've been doing better with drinking water instead of sodas .\n[doctor] okay , good . and then for your zofran , i would n't take that ahead of time . just plan on drinking plenty of water .\n[patient] okay .\n[doctor] okay , and you can take it , but before you do , we want to try to reduce the triggers . uh , so watch out for greasy or fatty foods and sugary drinks .\n[patient] okay , i can do that .\n[doctor] okay . and so , however , if it is not just these isolated inci- incidents and the symptoms are happening all the time , we could put you on a long term medication that would take ... that you would take every night . and so then you do n't have to use so much bentyl or the zofran . how do you feel about that ?\n[patient] i was actually going to ask you about something like that to help avoid flares altogether .\n[doctor] yeah , there is . and it actually works on the chemicals in your brain that are causing your gut to be overly sensitive . one is called elavil , but the only drawback is that it can make you a little sleepy . how does that sound ?\n[patient] that sounds like a much better plan .\n[doctor] okay , great . we can definitely do that . uh , just take it every night before bedtime .\n[patient] okay , that sounds good . thank you so much .\n[doctor] you're welcome . and so i have gone ahead and sent your prescriptions to your pharmacy . just give us a call if you have any questions or need us for anything else . and then let's plan on touching base through mychart email in about a month to just check in to see how you're doing with symptoms . okay ?\n[patient] okay , that sounds good . thank you .\n[doctor] you're welcome , and have a good rest of your day .\n[doctor] so review of symptoms is positive for diarrhea , nausea , and abdominal pain . assessment and plan . brittany edwards is a pleasant female with ibs and functional abdominal pain , aggravated by high stress , poor eating habits , and poor sleeping habits . i've encouraged dietary and lifestyle modifications , as well as starting a neuromodulator such as elavil 25 milligrams at bedtime for ibs .\n[doctor] she can use bentyl 20 milligrams as needed 30 to 45 minutes prior to eating out at a restaurant . she can also use zofran if needed . however , i have encouraged her to reduce greasy and fatty foods and alcohol consumption . i have asked her to follow up in one month by emailing over mychart regarding any side effects and issues , or issues with elavil or if adjustments are needed .",
            "tgt": "CHIEF COMPLAINT\n\nFollow up irritable bowel syndrome (IBS).\n\nHISTORY OF PRESENT ILLNESS\n\nMs. Brittany Edwards is a pleasant 32-year-old female who returns in follow up for irritable bowel syndrome (IBS) with functional abdominal pain, nausea, and vomiting.\n\nMs. Edwards was last seen in August 2019 with flares of abdominal pain and was diagnosed with irritable bowel syndrome that was treated with Bentyl. She had a previous prescription for Reglan that she received from the emergency room that she used as needed for nausea. She was instructed to start a low dose fiber supplement such as Citrucel daily, probiotics to help with gas and bloating, and Bentyl up to 4 times daily for intestinal cramping. She was instructed to discontinue Reglan and to use Zofran as needed for nausea. Neuromodulators such as Elavil and Buspar were discussed but not started.\n\nMs. Edwards continues to have intermittent abdominal symptoms. Monday through Thursday she has less flare ups of her symptoms but states she is currently having cramps and sharp pains. She describes she recently ate shrimp which caused her to have both upper and lower abdominal pain and bloating. However, she notices episodes of diarrhea after eating chicken alfredo and consuming alcohol. She does not believe the alfredo contributes to her symptoms. The patient states she consumes 2 drinks when out of either tequila or brown liquor and occasionally a martini. She does her best to avoid \u201cheavy foods,\u201d but ate fried chicken today without any symptoms. She has stopped drinking sodas which has been helpful.\u202fThe patient reports passing 2-3 formed stools a day.\n\nREVIEW OF SYMPTOMS\n\n\u2022\u202fGastrointestinal:\u202fPositive nausea, diarrhea, and abdominal pain.\n\nPHYSICAL EXAM\n\nAlert and cooperative, appears stated age.\n\nRespiratory\nLungs clear to auscultation bilaterally.\n\nCardiovascular\nHeart regular rate and rhythm.\n\nGastrointestinal\nAbdomen soft, non-tender, no masses or organomegaly. Normoactive bowel sounds.\n\nASSESSMENT\n\n\u2022 Irritable bowel syndrome\n\nBrittany Edwards is a 32-year-old established patient who returned today to discuss management of IBS and functional abdominal pain made worse by high stress, poor eating habits, and poor sleeping habits.\n\nPLAN\n\nI have encouraged dietary and lifestyle modifications as well as starting a neuromodulator, such as Elavil 25 mg at bedtime for IBS. She can use\u202fBentyl\u202f20 mg as needed 30-45 minutes\u202fbefore eating out at a restaurant. She can also use Zofran as needed for nausea. However, I have encouraged her to reduce greasy fatty foods and alcohol consumption.\n\nINSTRUCTIONS\n\nSend MyChart message in 1 month regarding any side effects of issues with Elavil or if dose adjustments are needed.\nReturn to clinic in 1 month or sooner if needed.",
            "file": "D2N140-virtscribe"
        },
        {
            "src": "[doctor] okay , so our next patient is christopher watson . date of birth 04/12/1934 . mr . watson is- is an 86-year-old male who returns in follow-up for adult hydrocephalus . this is his first visit since undergoing sh- shunt surgery , excuse me , on august 1st , 2020 .\n[doctor] i have followed mr . watson since may of 2020 when he first presented with eight to ten years of progressive gait impairment , cognitive impairment , and decreased bladder control . we established a diagnosis of adult hydrocephalus with a spino catheter protocol in june 2020 , and he underwent shunt surgery on august 1st , 2020 . a medtronic strata programmable shunt in the ventricular peritoneal configuration was programmed at a level 2.0 was placed .\n[doctor] good morning , mr . watson , who is the nice lady you have with you today ?\n[patient] hi , doc . this is my daughter , theresa . she is the one who helps me keep things straight .\n[doctor] mr . watson , have you been sick or been hosp -- hospitalized since your shu- shunt surgery three months ago .\n[patient] uh , not that i recall .\n[patient_guest] no , he has n't . he has been doing much better .\n[doctor] good , i'm glad to hear that .\n[doctor] before surgery , you were having some progressive problems that affected your walking , thinking , and bladder control . are these symptoms better , worse , or unchanged ?\n[patient_guest] his walking has improved . he's now able to walk to the dining room just fine . but he could not do that before surgery . he still has times where i have to help him .\n[doctor] that's impressive , mr . watson .\n[patient] yeah , i guess .\n[patient_guest] now his bladder control did improve some after surgery , but now seems to have leveled out . so he is wearing diapers .\n[doctor] no issues with sores from wearing the diaper ? and any decreased or painful urination ?\n[patient_guest] no , not at all .\n[doctor] and how about cognition ?\n[patient] i think i'm better . i do n't feel lost when talking to someone anymore .\n[patient_guest] dad and i both think my sister , hannah , summarized it best . she said \" i feel like i can have a normal conversation with him again , \"\n[doctor] that's so wonderful ! now have you had any headaches or pain where the shunt is ?\n[patient] no . has n't bothered me one bit .\n[doctor] okay . and any pain in your belly at all ?\n[patient] ca n't say that i have .\n[doctor] okay , sounds like you have been improving . alrighty , mr . watson , i'm going to step out of the room while my resident comes in to do a few tests for me . is that all right ?\n[patient] sounds good .\n[doctor] okay , i'm going to go out and review the ct scan you had last month , and then we'll chat about it when i come in .\n[doctor] all righty , mr . watson , so you definitely have made some improvements since the shunt surgery . now on ct scan though i do believe i see a tiny bit of blood fluid collection in the right parietal region . now , i do n't believe that that's causing any symptoms , and i , it actually was n't documented by the radiologist when he read the ct scan .\n[patient] so what does that mean ?\n[doctor] just that i would like to leave the shunt set for another two to three months before we go in changing it . like i said , if you're not having any headaches or pain and you have improved so that's all good for me . so really there's , there's nothing to worry about .\n[patient] all right so i'll come back in three months ?\n[doctor] yep , that's right .\n[patient] i do have a question for you though .\n[doctor] yeah , of course .\n[patient] do you think i will be able to drive again ?\n[doctor] ah man , mr . watson , i knew you were gon na ask me that one . i think at this point it's unlikely that your movement speed will improve to the level that would be needed for you to pass the driver safety evaluation . now , i will say that i do occasionally have patients who surprise me by improving over a nine to 12 month range . and that , that definitely could be you . you could definitely pass it at that point . so if you improve and we can continue to talk about that then , ya know , i think it could be possible , um , and i'd be happy to recommend it .\n[doctor] now , you could definitely also enroll in a driver safety program without my recommendation . so you could kind of do that preemptively , and then we could continue to watch for your improvement as we go .\n[patient] okay . i kinda figured that anyway but i just thought i'd ask . i do n't like to burden anyone when i just need to run to the store but i also know that i need to be safe .\n[doctor] yeah , your safety is our number one priority and , ya know , i'm sure your daughters do n't mind as much , right , they want to keep you here and have you safe . but , i overall am very pleased with how much you have improved . and so , i'm sure when we talk again in three months , we'll continue to be on that upward trajectory or improvement .\n[patient] i sure hope so , doc .\n[patient_guest] we really appreciate all that you've done . do we make the appointment out front ?\n[doctor] yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ?\n[patient] thanks\n[patient_guest] thank you .\n[doctor] all righty , so ros is constitutional significant for impaired ability to carry out daily functions . negative for fever or unintentional weight loss . gu is significant for urinary incontinence and wearing a diaper . negative for genital sores , decreased or painful output . neurological significant for continued walking impairment and cognitive impairment . negative for headaches , recent falls , or hallucinations . psychiatric is negative for depression , excessive worrying , or mood swings .\n[doctor] let's go ahead and use the short pe . vitals , let's see , blood pressure is 124/80 , heart rate 64 , respirations 18 , weight 174 pounds , and pain zero out of 10 .\n[doctor] mr . watson is a pleasant and cooperative man who's able to converse easily through , um , though his daughter does add some details . the shunt sight was clean , dry , and intact with a confirmed setting of two . um he was tested um for recent and remote memory , attention span , and concentration in fund of knowledge . he scored a 26 out of 30 on the mmse when tested with spelling and 25 out of 30 when tested with calculations . of note , he was able to get two of the three memory words with cuing , and the third with multiple choice . this was a slight improvement over his initial score of 23 out of 30 with calculations and 24 out of 30 with spelling . and at the time he was unable um in the previous test , excuse me , he was unable to remember any memory words with cuing without and only one with multiple choice .\n[doctor] gait testing using the tinetti assessment tool . he was tested without an assistive device and received a gait score of six to eight out of 12 and a balance score of 12 out of 16 for a total score of 18 to 20 out of 28 . this is slightly improved from his initial score of 15 to 17 out of 28 .\n[doctor] cranial nerves , pupils are equal . eoms are intact . face symmetric . no disarchria . motor normal for bulk and strength . coordination slow from no- finger to nose . of note , the ct scan from the head of 10/15/2020 shows a frontal horn span at the level of foramen of monro of 4.6 centimeters with a third ventricular contour that is flat with a span of 10 millimeters . by my reading there is a tiny amount of blood in the right front region with a tiny subdermal collection . this was not noticed or noted by the radiologist who stated any extra axial fluid collections . there is also substantial small vessel ischemic change .\n[doctor] diagnosis adult hydrocephalus , gait impairment , urinary incontinence and urgency , and cognitive impairment .",
            "tgt": "CHIEF COMPLAINT\n\nFollow up adult hydrocephalus, 3 months status post shunt surgery.\n\nHISTORY OF PRESENT ILLNESS\n\nMr. Christopher Watson is an 86-year-old male who returns in follow up of adult hydrocephalus. This is his first visit since undergoing shunt surgery 08/01/2020. He is accompanied by his daughter, Theresa, together they give his history.\n\nI have followed Mr. Watson since May 2020. He presented with 8-10 years of progressive gait impairment, cognitive impairment, and decreased bladder control. We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June 2020 and he underwent shunt surgery on 08/01/2020. A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.\n\nMr. Watson has had no hospitalizations or other illnesses since I last saw him. With respect to his walking, his daughter states that he is now able to walk to the dining room just fine but could not before his surgery. His balance has improved though he still has some walking impairment. With respect to his bladder control, initially there was some improvement, but he has leveled off and he wears a diaper. With respect to his cognition, both Theresa and the patient say that his thinking has improved. The other daughter, Hannah summarized it best according to the two of them, she said \u201cI feel like I can have a normal conversation with him again.\u201d Mr. Watson has had no headaches and no pain at the shunt site or in the abdomen.\n\nPAST HISTORY\n\nUrinary incontinence.\nAdult hydrocephalus.\nGait impairment.\nCognitive impairment.\n\nREVIEW OF SYSTEMS\n\n\u2022 Constitutional Symptoms: Significant for impaired ability to carry out daily functions. Negative for fever or unintentional weight loss.\n\u2022 Genitourinary: Significant for urinary incontinence and wearing a diaper. Negative for genital sores, decreased or painful output.\n\u2022 Neurological: Significant for continued walking impairment and cognitive impairment. Negative for headaches, recent falls, or hallucinations.\n\u2022 Psychiatric: Negative for depression, excessive worrying, or mood swings.\n\nVITALS\n\nBlood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.\n\nPHYSICAL EXAM\n\nConstitutional\nMr. Watson is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.\n\nHead and Face\nThe shunt site was clean, dry, and intact and confirmed at a setting of 2.0.\n\nNeurological\nMental status: Tested for recent and remote memory, attention span, concentration, and fund of knowledge. He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations. Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice. This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.\nGait: Tested using the Tinetti assessment tool. He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28. This has slightly improved from his initial score of 15-17/28.\nCranial Nerves: Pupils are equal. Extraocular movements are intact. Face symmetric. No dysarthria.\nMotor: Normal for bulk and strength.\nCoordination: Slow for finger-to-nose.\n\nRESULTS\n\nCT scan of the head from 10/15/2020: It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm. By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection. This was not noticed by the radiologist who stated no extra axial fluid collections. There is also substantial small vessel ischemic change.\n\nASSESSMENT\n\n\u2022 Adult hydrocephalus.\n\u2022 Gait impairment.\n\u2022 Urinary incontinence and urgency.\n\u2022 Cognitive impairment.\n\nMr. Watson has made some improvement with his hydrocephalus since shunt surgery. There is a tiny fluid collection in the right parietal region. I do not believe that this tiny amount of fluid is symptomatic, and it was not documented by the radiologist when he read the CT scan.\n\nMr. Watson asked me about whether he will be able to drive again. Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test. I would certainly be happy to recommend such a test if I believe he is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time. I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.\n\nPLAN\n\nI had a long discussion with the patient and his daughter. We are all pleased that he has started to make some improvement with his hydrocephalus because of the fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.\n\nINSTRUCTIONS\n\nFollow up in 3 months.",
            "file": "D2N141-virtscribe"
        },
        {
            "src": "[doctor] amanda taylor , birth date october 31st 1949 . patient is a 72 year old woman who comes for followup for hypertension . her history includes significant alcohol use disorder and mi- mild hypercholesterolemia . at last visit on april 16th her blood pressure was 130 over 90 . after presenting at 150 over 100 she was prescribed hydrochlorothiazide 12.5 milligrams by mouth once daily , and lisinopril 20 milligrams by mouth once daily . cmp and cbc were essentially unremarkable .\n[doctor] hi miss taylor , how are you today ?\n[patient] hi , i'm- i'm good , thank you .\n[doctor] thanks for coming in today .\n[patient] yeah , no problem .\n[doctor] so how have things been going for you ?\n[patient] uh , they've been all right . i'm struggling with not drinking . i wanted to discuss that , uh , shot that you had mentioned last time , but we did n't get to discuss it too much .\n[doctor] okay , well i'll be happy to provide you with more information . so tell me when did you last have a drink ?\n[patient] on monday .\n[doctor] okay , so you've gone a couple days without it ?\n[patient] yeah , yeah i have .\n[doctor] yeah , and had you been drinking for a while ?\n[patient] yep .\n[doctor] how much had- how much had you been drinking ?\n[patient] um , four or five times a week hard alcohol , so , you know .\n[doctor] okay . well it will certainly help your blood pressure if you're able to stop drinking .\n[patient] yeah , yeah i- i- i agree with you .\n[doctor] okay . are you taking your blood pressure medications ?\n[patient] yeah , but i'm only taking half of the lisinopril .\n[doctor] okay .\n[patient] i- b- well , the first time i took it i felt lethargic and tired , so i only took a half dose the next time . i felt much better and i did n't have the headaches or the swooshing that started in my left ear . so i feel like it's definitely helping but i do n't know ... i know it's not gon na be okay until i stop drinking .\n[doctor] and are you also taking the full dose of the hydrochlorothiazide ? do you have any , um , chest tightness or pressure or any shortness of breath ?\n[patient] yeah i'm taking the full dose of that medicine too , and no none of those symptoms .\n[doctor] okay . anything else i should be aware of or that we should be checking ?\n[patient] mm , no .\n[doctor] okay , good . are you doing the blood pressure checks at home ?\n[patient] yes . yes i am .\n[doctor] okay good . what kind of numbers are you seeing ?\n[patient] well , in the morning i'm seeing lower numbers than in the evening , um , where i run anywhere from like 130 to 145 or 150 over 95 to 100 on the bottom .\n[doctor] okay .\n[patient] but in the evenings if i sit there for a while and then take it , it goes down . kind of like when i come here it's always high but then it goes down . in the mornings it's generally more normal where it's supposed to be .\n[doctor] uh- .\n[patient] mm , also i'm taking my medicine in the morning when i get up instead of in the evening .\n[doctor] yeah , so it sounds like we are not too far out of where we wan na be .\n[patient] right , mm-hmm .\n[doctor] okay . well let me get a listen to your heart , go ahead and hop up here .\n[patient] okay .\n[doctor] use my general exam template . all right , go ahead and take some deep breaths . okay , good . any fever , cough , shortness of breath or sore throat ?\n[patient] no .\n[doctor] any recent travel or contact or exposure to the coronavirus ?\n[patient] nope .\n[doctor] have you received your coronavirus vaccine ?\n[patient] yes , on february 9th .\n[doctor] okay , great . all right well i'm just going to look at your ankles and feet , i'm looking for any signs of swelling .\n[patient] okay .\n[doctor] all right , well everything looks good . you can go ahead and sit up miss taylor . all right , so the good news is everything is looking okay . i think we both agree if you were able to stop drinking your blood pressure would cease to be an issue for you .\n[patient] yeah i agree with that .\n[doctor] so let us discuss the potential medicine to help you with that . what it does is it blocks some of the brain receptors that alcohol stimulates and it tricks the brain into thinking it does not need alcohol , thereby cutting down the urges .\n[patient] the urge to drink or the constant thinking about it ?\n[doctor] it actually will help with both .\n[patient] okay . so is it like a one-time thing ?\n[doctor] generally the shot is given about once a month , it can also be given as a daily pill , but the shot does tend to work a bit better .\n[patient] yeah i've taken things like this in the past and if it is a pill , i know i wo n't take it . with a shot , it's not like you can un-take it .\n[doctor] yeah that's true . and the shot has been shown to work , it is more just a matter of getting you in to get your shot a month later with the nurse .\n[patient] yeah , sure , sure .\n[doctor] okay , so it's called naltrexone . i think the other name might be vivitrol . like i've said , the research on it is pretty good .\n[patient] i think i may have taken the naltrexone before .\n[doctor] okay , yeah , maybe you have .\n[patient] yeah , if it was available in a pill form then i'm almost certain i've tried it b- before .\n[doctor] okay . if this sounds good though , we can go ahead get you started with the shot . i am looking and it looks like we have you coming back in on may 17th for your first shot , does that sound good ?\n[patient] yeah , yeah , that sounds great . are there any possible side effects ?\n[doctor] yeah , some people will experience some nausea , headache , dizziness , anxi- anxiety , tiredness and trouble sleeping , but generally the side effects are mild and should go away within a few days .\n[patient] okay .\n[doctor] then we can schedule you for a follow-up in june to see how you are doing .\n[patient] all right that sounds good .\n[doctor] all right great . well otherwise stay with your current medicines , keep checking your blood pressure , and let's see if we can stop the alcohol for good . let us know if you have any questions or any issues come up after you receive the first dose .\n[patient] all right , sounds good , thank you .\n[doctor] you are welcome , have a good rest of your day .\n[patient] you too .\n[doctor] miss taylor is drinking alcohol four to five days per week to excess . no tobacco , no substance abuse , skin is moist , good trigger . on exam she is alert , pleasant , in no acute distress . she is not diabetic , there is no tremor , no cva tenderness , chest clear to percussion and auscultation , unlabored breathing , cardiac rhythm regular , no murmur , no gallop , jvp flat , with a head at 90 degrees . she does not appear anxious , agitated or depressed . my impression , alcohol use disorder . she would like to start naltrexone which we have previously discussed . she will take the injectable form and start on may 17th . we reviewed side effects and risks . the potential benefit of alcohol cessation would be highly beneficial to her for many reasons . hypertension , she is taking lisinopril 10 milligrams daily and hydrochlorothiazide 12.5 milligrams daily . quite possibly her blood pressure will improve completely with cessation of alcohol . her target bp is 130 to 140 over 70 to 80 . i will see her back week of june 14th , which is likely around the time of her second naltrexone injection . i recommend upgrading influenza vaccination and shingrix . number two , she did defer this .\n",
            "tgt": "CHIEF COMPLAINT\n\nHypertension.\nAlcohol use disorder.\n\nHISTORY OF PRESENT ILLNESS\n\nAmanda Taylor is an 72-year-old woman who presents for a follow-up for hypertension. History includes significant alcohol use disorder and mild hypercholesterolemia. At last visit on April 16, BP was 130/90. After presenting at 150/100 she was prescribed hydrochlorothiazide 12.5 mg by mouth once daily and lisinopril 20 mg by mouth once daily. CMP and CBC were essentially unremarkable.\n\nMrs. Taylor admits to consuming alcohol 4-5 times a week and is interested in Naltrexone injections. She acknowledges that her blood pressure would likely improve if she stopped alcohol consumption. She is checking her blood pressure in the morning and evening, stating it is higher at night but will improve after sitting for a few minutes. She is averaged 135-145 or 150 over 95-110.\n\nShe experienced side effects from lisinopril, such as headaches, \u201cswooshing\u201d in her left ear, and lethargy. She took half a dose and did not experience the side effects.\n\nPAST HISTORY\n\nMedical\nHypertension.\nHypercholesterolemia.\nAlcohol use disorder.\n\nCURRENT MEDICATIONS\n\nLisinopril 20 mg tablet once daily.\nHydrochlorothiazide 12.5 mg once daily.\n\nPHYSICAL EXAM\n\nConstitutional\nNo distress. No fever. No tobacco or other substance use.\n\nNeurological\nAlert.\n\nPsychological\nShe does not appear anxious, agitated or depressed.\n\nNeck\nJVP flat with a head at 90 degrees.\n\nRespiratory\nNo cough or shortness of breath. Chest clear to percussion and auscultation. Unlabored breathing.\n\nCardiovascular\nNo CVA tenderness. Cardiac rhythm regular. No murmur. No gallop.\n\nMusculoskeletal\nNo ankle edema.\n\nIntegumentary\nSkin is moist. Good trigger.\n\nASSESSMENT\n\n\u2022 Alcohol use disorder.\n\u2022 Hypertension.\n\nMrs. Taylor presents for a follow-up for hypertension. History includes significant alcohol use disorder and mild hypercholesterolemia. At last visit on April 16, BP was 130/90. After presenting at 150/100 she was prescribed hydrochlorothiazide 12.5 mg by mouth once daily and lisinopril 20 mg by mouth once daily. CMP and CBC were essentially unremarkable.\n\nPLAN\n\nAlcohol use disorder\nI will start her on naltrexone which we have previously discussed. She will take the injectable form and start on May 17. We reviewed side effects and risks. The potential benefit of alcohol cessation would be highly beneficial to the patient.\n\nHypertension\nShe will continue taking lisinopril 10 mg/day and hydrochlorothiazide 12.5 mg daily. Quite possibly her blood pressure will improve significantly if she is able to completely stop consuming alcohol. Target BP is 130-140/70-80. I will see her back week of June 14 which likely will be the time of her second naltrexone injection.\n\nRecommend upgrading influenza vaccination and Shingrix #2, she defers this.\n\nINSTRUCTIONS\n\nCall the clinic with any questions. Make follow up appointment week of June 14th.\n",
            "file": "D2N142-virtscribe"
        },
        {
            "src": "[doctor] next patient is grace ross . date of birth 8-23-97 . ms. ross is a new patient . she's here today for a full spectrum std testing . the patient states that she's having symptoms of discomfort , a change in discharge , and odor in her vaginal region . she says that the right side of her vagina is starting to become painful . she denies any fevers or chills . she reports , that she recently learned , her partner has been in sexual encounters with other people , and she wants to be evaluated for all stds .\n[doctor] hello , ms. ross . i'm dr. diaz . it's good to meet you .\n[patient] hi . yes . nice to meet you , too .\n[doctor] so , how are you doing today ? i hear that you're here for std testing . is that correct ?\n[patient] yeah . actually , i found out earlier this week , that my boyfriend has been cheating on me , for some time . i'm really worried , that i could have caught something , you know ?\n[doctor] mm-hmm .\n[patient] i wanted to make sure i do n't have anything .\n[doctor] yeah . i'm sorry to hear that . of course , we can do that today . um . well , let's see . how do you feel ? do you have any symptoms ?\n[patient] well , um , i started noticing some weird discharge last week .\n[doctor] mm-hmm .\n[patient] uh , it smells different . it's not the same color , or consistency , as usually , it is .\n[doctor] right .\n[patient] um . that part did n't even phase me , until i noticed that the right side of my vagina was hurting . just sore , you know , but that has n't gone away .\n[doctor] yep . nah , that does sound like a cause for concern . how long have you been with him ?\n[patient] hmm , we've been dating for three years .\n[doctor] mm-hmm .\n[patient] as far as , i can figure , he started cheating on me , i think , about three months ago .\n[doctor] uh- . um , okay . do you ... have you ever had an irregular pap smear ?\n[patient] well , yeah , i did , but it was back whenever i was 20 or so . it has n't ... and i have n't had one since .\n[doctor] okay . and when was your last pap smear ?\n[patient] uh , about six months ago . it came back normal , though .\n[doctor] okay . good , okay . well , let's see ... let's take a look at you , and then , we'll get some samples for std testing . okay ?\n[patient] all right .\n[doctor] you'll hear me talk through your exam , so that i can get it all documented . uh- ?\n[doctor] use my general physical exam template . pelvic exam demonstrates no external lesions . normal labia majora and labia minora . normal physiological discharge , with normal color and smell .\n[doctor] ms. ross , i'm going to touch you , now . you'll feel my fingers , and the speculum in your vagina . you'll feel some pressure , now .\n[doctor] cervix is normal . vaginal wall is normal . no cervical motion tenderness and no adnexal tenderness or masses noted . swabs were done for std testing .\n[doctor] okay , ms. ross . everything looks good from a visual standpoint . i'm going to send off std testing for , uh , gonorrhea , chlamydia , trichomoniasis , and i'll have you give some blood for syphilis , hiv and hepatitis c. some of these tests will take longer than others . we will call you , if we see anything , but if you have n't heard anything , you can call us in three days for results .\n[patient] okay . sounds good . thank you , so much .\n[doctor] of course , my pleasure . and , if everything is normal , i'll see you again , at your next annual checkup .\n[doctor] assessment : is screen for std .\n[doctor] plan : discussed with patient , and please add that she is high risk due to an abnormal pap smear in the past , and the recent discovery of her sexual partner having multiple partners , for some period of time .\n[doctor] end of recording .",
            "tgt": "CHIEF COMPLAINT\n\nFull-spectrum sexually transmitted disease testing.\n\nHISTORY OF PRESENT ILLNESS\n\nMs. Ross is a 23-year-old female who presents today as a new patient for full-spectrum STD testing.\n\nThe patient states that she is having symptoms of discomfort, a change in discharge, and an odor in her vaginal region. She says that the right side of her vagina is starting to become painful but denies any fever or chills. She states that she recently learned her partner of 3 years has been engaging in sexual encounters with other people for quite some time, and she wants to be evaluated for all sexually transmitted diseases.\n\nMs. Ross reports noticing a change in the odor, color, and consistency of her vaginal discharge last week. She notes that this did not alarm her until the right side of her vagina became painful and sore, which has not subsided. She states that she had an abnormal Pap Smear around the age of 20, but all her Pap Smears since then, including her most recent one approximately 6 months ago, have all been normal.\n\nPHYSICAL EXAM\n\nGenitourinary\nPelvic exam: No external lesions, normal labia majora and labia minora. Normal physiological discharge with normal color and odor. Cervix is normal, vaginal wall is normal, no cervical motion tenderness or masses noted. Swabs were obtained for sexual transmitted disease testing.\n\nASSESSMENT\n\n\u2022 Screening for sexually transmitted disease.\n\nPLAN\n\nMs. Ross is a 23-year-old female who presents today as a new patient for full-spectrum STD testing. We will screen her today for gonorrhea, chlamydia, trichomoniasis, syphilis, HIV, and hepatitis C. Patient is high risk due to an abnormal pap smear in the past and the recent discovery of her sexual partner having multiple partners for some period of time. We will call the patient with the results of the laboratory testing.",
            "file": "D2N143-virtscribe"
        },
        {
            "src": "[doctor] tyler nelson , date of birth : 3 , 6 , 1949 , mrn , 385729 . he is here today for ongoing management of rheumatoid arthritis . last time he was here , he received a steroid injection in his right knee . hello mr. nelson , how are you ?\n[patient] um , about the same as last time . my knee is still swollen .\n[doctor] that was your right knee , correct ? i take it the injection did n't help ?\n[patient] it did , maybe for a couple of weeks .\n[doctor] that's it ? and is it still painful ?\n[patient] yeah , it's pretty painful , and now the whole leg is getting swollen .\n[doctor] okay , what would you say your pain level is ?\n[patient] i mean , right now it's about a 3 or so , but , typically on a normal day it's around 6 .\n[doctor] okay , and its been swollen like that for how long now ?\n[patient] since i was last here a couple weeks after that . so about , maybe two months now .\n[doctor] okay , but before it was just the knee ?\n[patient] yeah , the whole thing was n't swollen like this , but i tried to wear compression socks a lot of the time , but it has n't been helping .\n[doctor] okay , okay , so that has n't been working for you ?\n[patient] i mean , it helps to some degree , but it's still swollen , especially around the knee .\n[doctor] hmm . has it been keeping you from doing things during the day ?\n[patient] well , i slowed down a little bit , and i found a few things too fast . but when it really hurts , is when i've been sitting for a while , and then i have to try and get up . i'm so stiff getting up i have to use a cane to get my bearings . i mean , after a little bit , it loosens up , but that first getting up is real difficult .\n[doctor] yeah , i can see , that makes sense . have you been taking your medication regularly ? your on xeljanz right ?\n[patient] yeah , the xr , i think its , uhm , 11 milligrams a day ? yeah , but i'm taking it everyday , and i'm also taking celebrex which i started maybe 2 months ago .\n[doctor] yes , the 200mgs daily . how's that working for you ?\n[patient] pretty good , up until it started swelling again .\n[doctor] okay , well come sit over here , and if you could take of your socks and shoes , and we'll take a look at your knee . and just to let you know , i have a service now that writes my note about the visit , so you'll hear me call things out and describe what i see fully .\n[patient] okay , gotcha .\n[doctor] right , so let's check your leg . can you straighten it , and does it hurt ?\n[patient] yeah , when i try to straighten it all the way it does .\n[doctor] okay , range of motion slightly diminished . i'm going to press here , okay ? and how about here , hmm , i see some pitting around the knee and ankle . normal capillary refill in the toes . does any of this area hurt ?\n[patient] um , just kinda sore , like an old bruise ?\n[doctor] so , i can feel that the knee is hot , and that means there's something going on , like some inflammation . so we can give you another steroid injection for that . i also want to get an x-ray of that knee , so we can see where all the swelling is coming from .\n[patient] yeah . let's do it . sounds go to me .\n[doctor] okay , and did we set up physical therapy for you last time you were here ?\n[patient] yeah , that was some years ago , but that was the other knee .\n[doctor] okay . so i think we'll set that up for you now . we'll also do an x-ray on that knee . i can send you for a physical therapy , and if nothing is helping , then we really might need to get a surgery consult to see what we can do with that knee .\n[patient] okay , sounds like a plan .\n[doctor] all right , so for today we'll go ahead and we'll give you the steroid shot . i'll try to see if i can get a little bit of fluid out before i do give you the injection . there might be no fluid , but i'll see if i can get anything out regardless .\n[patient] okay . and that's a procedure you're going to do right now ?\n[doctor] yep . once we're done talking here , and as far as the edema in your legs , uh , we'll take an x-ray to look for the cause , but there is a lot you can do as well . the compression socks are a good start . um , and also , do you eat a lot of salt ?\n[patient] i mean , um , i mean i love my salty snacks .\n[doctor] okay . well , salt does have a tendency to make your body hold on to water , reducing your salt intake could help with some of the swelling . you can also prop your feet up any time you get a chance , especially at night . and have you talked to your private care doctor about this at all ?\n[patient] no , i figured i would just come here first .\n[doctor] okay . so i think , try some of those things out first , and if it does n't help , definitely make an appointment with them , also , as you know , xeljanz is a high-risk medication , so we need to check your cmp levels every couple of months . so this time your levels are good , but do make sure to make an appointment for the blood work for next time .\n[patient] all right . i can do that . thank you so much doc .\n[doctor] yes , of course . well let me go ahead and get supplies and we'll get to work on your knee .\n[doctor] fluid aspiration and steroid injection procedure . the risks , benefits , and alternatives were explained . the risks of steroid injection were explained , including , but not limited to : hypopigmentation , soft tissue atrophy , tendon ruptures , and transient hypoglycemia among others . verbal consent was attained . the right knee was , uh , um , accessed through the lateral approach with 3 milliliters of initially clear fluid , then bloo- blood tinged fluid . then the right knee was prepped in a standard-fashion . the right knee was injected with 80 milligrams of triamcinolone , and one milliliter of lidocaine . the procedure was tolerated well , with no complications . post-procedure instructions were given . patient will follow up with his pcp . thank you .",
            "tgt": "CHIEF COMPLAINT\n\nRheumatoid arthritis management.\n\nHISTORY OF PRESENT ILLNESS\n\nMr. Nelson is a 72-year-old male who presents today for ongoing management of rheumatoid arthritis. He was last seen by me on 03/04/2021, where he received a steroid injection to his right knee. He continues to experience right knee pain and swelling. The pain level is 6/10. He notes when he stands after he has been sitting for a while, he has to use a cane to \"get his bearings.\" The injection he received to the right knee at the last visit was only beneficial for a few weeks. The patient notes whole right leg swelling since the last visit. He usually wears support hose, which helps to some degree. He has not attended physical therapy.\n\nPHYSICAL EXAM\n\nMusculoskeletal\nLower right extremity: Swollen right knee, slightly reduced range of motion. Skin warm to touch. Lower right leg pits with pressure.\n\nPROCEDURE\n\nFluid aspiration and Steroid injection.\nRisks, benefits, and alternatives were explained. The risks of steroid injection were explained, including but not limited to, hypopigmentation, soft tissue atrophy, tendon ruptures, and transient hyperglycemia among others. Verbal consent was obtained. The right knee was accessed through the lateral approach with 3 mL of initially clear fluid then blood-tinged fluid. Then the right knee was prepped in a standard fashion. The right knee was injected with 80 mg triamcinolone and 1 mL lidocaine. The procedure was tolerated well with no complications. Post procedure instructions were given.\n\nASSESSMENT\n\n\u2022 Rheumatoid arthritis management.\n\u2022 High risk medication use.\n\u2022 Right knee pain.\n\u2022 Lower extremity pitting edema.\n\nPLAN\n\nRheumatoid arthritis management.\nThe patient will continue Xeljanz XR 11 mg daily. He will also continue Celebrex 200 mg daily.\n\nHigh-risk medication use.\nThe patient is currently on the high-risk medication Xeljanz. We will check his CMP levels and monitor periodically every couple of months.\n\nRight knee pain.\nHe has right knee pain and swelling, with pain level 6/10. On exam today, the right knee continues to be hot, which is ongoing inflammation. We performed a fluid aspiration of the right knee today, see procedure note above. A steroid injection to the right knee was given today, see procedure note above. We will arrange for x-ray of the right knee and refer his to physical therapy.\n\nLower extremity pitting edema.\nThe patient notes whole right leg swelling since the last visit. He usually wears support hose, which helps to some degree. He has not seen his PCP. We discussed compression stockings, elevate feet, and a low salt diet. He will check with his PCP for further instructions.",
            "file": "D2N144-virtscribe"
        },
        {
            "src": "[doctor] uh , mrn49282721 . patient's name is jacqueline miller . use last visit exam where appropriate .\n[doctor] hi , how are you doing , jacqueline ?\n[patient] i'm pretty . good . how are you ?\n[doctor] good as well . so it sounds like we're , um , under good control right now .\n[patient] yes . it's doing much better .\n[doctor] good , good . do you have any rash leftover ?\n[patient] yeah , i have a- a small bit leftover . i started using , uh , doxycycline only one a day because i think the pharmacist said if it's getting better , to just limit it to once a day .\n[doctor] okay , that sounds good .\n[patient] but i was taking it twice a day and i did notice a lotta improvement .\n[doctor] okay .\n[patient] and then when i started doing it only once a day , it seems the same and it's not continuing to get better . so it's kinda plateaued a little bit .\n[doctor] i see . um , are you breastfeeding at this time ?\n[patient] no , i'm not right now .\n[doctor] okay , good . so you- you should not be breastfeeding while you're on that medication .\n[patient] yeah , actually i stopped breastfeeding and then asked for the doxycycline at that time .\n[doctor] okay . even with the doxycycline , you can keep using the elidel .\n[patient] okay . and i did n't take the elidel because when i read about it i got worried . so i wanted to just try the doxycycline and see .\n[doctor] okay . so we can talk about the elidel . a lot of the things you read about is not actually relevant to the cream or ointment form , but it's about the oral form that's used in really high doses , longterm , after people have a heart transplant or a kidney transplant or something like that .\n[patient] okay . i did n't realize that .\n[doctor] yeah , and when you suppress the immune system that hard for that long , it can predispose you for developing cancers like hematologic type cancers . it does n't apply to as-needed use of the medicine , a cream or an ointment , okay ?\n[patient] okay . then i can resume taking - taking the doxycycline twice a day again ?\n[doctor] so let me clarify . what exactly are you using ? and then we'll look at you and figure out , okay ? so you're using the sulfacetamide wash ? uh , how frequently are you using that one ?\n[patient] twice a day .\n[doctor] okay , and that's not drying you out too much ?\n[patient] no , that's fine .\n[doctor] okay . and you're using the metro cream ?\n[patient] yes .\n[doctor] how often are you using that one ?\n[patient] after my face wash , i immediately apply the cream .\n[doctor] okay . and then , are you using any other kind of lotions or anything ?\n[patient] no .\n[doctor] so you're not using the cetaphil cleanser ?\n[patient] i'm not .\n[doctor] okay . and no neutrogena wipes ?\n[patient] no wipes .\n[doctor] okay . um , and then what about , um , any lotions that you're using ?\n[patient] i'm not using any lotion right now , just those two .\n[doctor] no lotion , okay . so that may be something else we should add in , a lotion to just help moisturize . but we'll see .\n[patient] okay .\n[doctor] um , and then again , when did you go down to just taking the doxycycline once a day ?\n[patient] that was last week . so the first two weeks , i did twice a day .\n[doctor] okay .\n[patient] and then i started seeing improvement , and then i changed to just once a day .\n[doctor] okay . let me take a look at your face here . i'm gon na describe for the transcriptionist what i'm seeing . you're fitzpatrick skin type iv , meaning you're not going to burn , you're going to sun tan , um , essentially , iv to v. and then on bilateral medial cheeks , there are a few really faint erythematous papules and just maybe a little bit of redness around and underneath your nostrils . so you're right , it's not totally gone .\n[patient] yeah .\n[doctor] i think i would go ahead and go back to twice a day , every day , with the doxycycline .\n[patient] okay .\n[doctor] uh , but i would pickup the elidel too .\n[patient] okay , i can do that .\n[doctor] i mean , out of known risks associated with medications , topicals are usually safer and preferable to oral medications . with that being said , doxycycline is low risk .\n[patient] it is ? okay .\n[doctor] um , and doxycycline can give you bad upset stomach or heartburn . um , it will make you sunburn , even if you never sunburn , so you have to protect yourself .\n[patient] yeah , i mean , i feel sun sensitive whenever i go out , so i am taking all the precautions , with wearing a hat and all of that .\n[doctor] great . i just wanted to make sure you knew about that .\n[patient] yes , i did . thank you .\n[doctor] all right . but i think to help get rid of it sooner rather than later , if insurance will cover the elidel , pick it up and start using it .\n[patient] yeah , i did check . the insurance is not covering it .\n[doctor] it's not ? okay . well , let's look around really quick because if you use a goodrx coupon , it will be around 30 to $ 40 or something .\n[patient] okay .\n[doctor] let's see .\n[patient] so with your coupon , it was around $ 850 or something .\n[doctor] ugh , yeah . that's way too much .\n[patient] i agree . and- and because i also looked at the eucrisa that you recommended in my notes , and if it's still ex- if it's still expensive , i could try that instead .\n[doctor] yeah , so it ... actually ... it is actually more expensive . i think the prices fluctuate .\n[patient] okay .\n[doctor] because now it's showing the cheapest of $ 70 , and when i looked before , it was around 30 to $ 40 .\n[patient] yeah . if it was around $ 200 , i would've picked it up . but it was coming to around $ 850 after insurance .\n[doctor] okay . so i've found the cream form . we could try ointment form .\n[patient] you mean the tacrolimus ?\n[doctor] yeah , mm-hmm .\n[patient] okay .\n[doctor] so if we send it to pick'n save or metro market ... let's see where else .\n[patient] can you do the metro market ?\n[doctor] yeah . let me put in the prescription and we'll see what we can find .\n[patient] sure .\n[doctor] pharmacy is what i'm trying to say .\n[patient] okay . but it's not a steroid , right ?\n[doctor] correct , it's not a steroid .\n[patient] okay , good .\n[doctor] it's called a calcineurin inhibitor . it's kinda like a steroid in that it calms inflammation .\n[patient] okay .\n[doctor] but it's not a steroid , so do n't use steroids on your face , for sure , as they'll make this kind of rash worse . but also , steroids carry the risk of causing thinning of the skin .\n[patient] all right .\n[doctor] these medications do n't cause thinning of the skin and they're not going to cause some other kind of rash . um , the thing to know is that sometimes five to 10 minutes after you put it on , it can cause this weird kind of tingly or needle-like sensation or make it redder or flush . but it should only last a few seconds and then go away . it's not an allergy or anything bad .\n[patient] okay . got it .\n[doctor] so it only lasts a couple seconds . it does n't mean it's going to happen again . it's nothing bad . it will still work , so keep using it as long as you know you can stand it , okay ?\n[patient] okay , thank you for explaining .\n[doctor] so i will say , \" apply to rash on face twice daily , until resolved . \"\n[patient] okay . so only apply to the rash area ?\n[doctor] yes , and keep using the face wash.\n[patient] okay .\n[doctor] i think you could just do it once a day . i do n't think you need to do it twice a day , just because i do n't wan na dry your sky out too much , okay ?\n[patient] i never noticed that my face is dry or got thin . i feel so good after using it .\n[doctor] i understand , but it could get dry and i do n't wan na create other problems for you .\n[patient] all right . i'll just wash once a day with it . but it was feeling very good , like there's this little bit of moisture getting back in . with the other wash , when i would use it twice a day , i was drying out . but not with this one .\n[doctor] i see . okay . well then do what feels good . if you do notice that you're starting to get dry , then reduce to once per day .\n[patient] that sounds good .\n[doctor] so to review , um , continue using the same face wash , continue with metro cream , and increase the use of doxycycline to twice a day .\n[patient] okay .\n[doctor] and then just do it until it's gone , and then do it for once a day for another week before stopping .\n[patient] okay , sounds good .\n[doctor] all right . and i'll rewrite your instructions here .\n[patient] thank you so much .\n[doctor] if there are any other questions or you're getting different instructions , feel free to reach out to me and we'll clarify , okay ?\n[patient] okay .\n[doctor] but in general , doxycycline is such a low risk . we're not gon na have you on this forever . but especially since we're adding the tacrolimus , i expect it will clear quickly .\n[patient] sounds good .\n[doctor] all right . and i just wan na really help knock it out as fast as possible , since you've been dealing with it for so long now . i would take it twice a day until it's gone , and then once a day for a week before you stop . i'll write it out like that . so twice a day until rash is gone , and then once a day for another week before stopping .\n[patient] okay .\n[doctor] once the rash stops , you can stop the tacrolimus ointment . um , continue doxycycline another week and then stop . but you can keep using the wash and the metro cream .\n[patient] okay , that sounds good . i can do that .\n[doctor] and then hold off until i see you again before you start back any of your old products . um , if it's starting to flair again , um , if it's just a little bit , you can try just doing the tacrolimus for a couple days , to see if that's enough . if it's not , then restart the dy- doxycycline as well .\n[patient] all right .\n[doctor] i do n't expect that to happen , but , you know , if it does , you have the tools . um , then you'll be seeing me for a followup . we can figure out what to do next . i would say if it's getting worse rather than better , just give me a call or send me a mychart message , okay ?\n[patient] yeah , sounds good .\n[doctor] do you have enough refills ?\n[patient] yeah , i think so .\n[doctor] okay . so it looks like you have another refill of the doxycycline , so you're good there . metro cream , you probably still have enough of that one .\n[patient] yes , i do .\n[doctor] all right . and i'll cancel the elidel cream , just so we do n't complicate your list . uh , you have plenty of the face wash still .\n[patient] yes .\n[doctor] okay . uh , and we'll get rid of the clindamycin from your list as well .\n[patient] and what would you suggest for a moisturizer ?\n[doctor] yeah , so for that i would do something really basic like vanicream . or even , if it's just really dry , you could use a little bit of petroleum jelly . um , i'll give you a couple samples , okay ? let's make sure we have a followup in about four weeks .\n[patient] okay , thank you .\n[doctor] okay . and i would stay away from any kind of anti-aging thing , any kind of plant thing . um , really let's just be sure we talk about any new products , or reach out to me if you're gon na try something else . um , let's go get those samples .\n[patient] okay , that sounds good .\n[doctor] for assessment and plan , perioral dermatitis , rosacea , including ocular rosacea , and copy and paste her patient instructions . i recommend that she gently wash her eyelids once a day with gentle cleanser such as vanicream , also use bruder mask as needed .",
            "tgt": "CHIEF COMPLAINT\n\nFollow-up for perioral dermatitis.\n\nHISTORY OF PRESENT ILLNESS\n\nJacqueline Miller is a 40-year-old female who is being seen today for a follow-up skin exam for perioral dermatitis. She also has a history of rosacea, including ocular rosacea. Today, she states that her perioral dermatitis is well-controlled, although it has not fully resolved. The patient was applying doxycycline twice a day with improvement, but her pharmacist advised her to reduce to once daily since it had started to improve; therefore, for approximately the past week, she has been using the doxycycline only once per day. She has not seen continued improvement but it has not worsened. She is using the sulfacetamide wash twice daily, denies drying of the skin, and reports that her skin is much improved moisturization. She also applies MetroCream immediately after using the sulfacetamide wash. She denies using other lotions and products, Cetaphil lotion or soap, or Neutrogena wipes. The patient did not begin Elidel because it is not covered by her insurance, and she was concerned about possible side effects from the medication.\n\nPAST HISTORY\n\nMedical\nPerioral dermatitis.\n\nCURRENT MEDICATIONS\n\nDoxycycline cream. Apply twice daily.\nMetroCream. \nSulfacetamide wash. Apply topically twice daily.\n\nPHYSICAL EXAM\n\nIntegumentary\nSkin inspection of the face was performed today. On bilateral medial cheeks, there are a few, very faint, erythematous papules with mild redness around and underneath the nostrils. Fitzpatrick skin type is 4 to 5.\n\nASSESSMENT\n\n\u2022 Perioral dermatitis\n\u2022 Rosacea, including ocular rosacea\n\nJacqueline Miller is a 40-year-old female who presented today for follow-up for her perioral dermatitis, which has improved but not resolved. She decreased her doxycycline per her pharmacist\u2019s recommendation, which possibly stagnated the resolution of symptoms.\n\nPLAN\n\nPerioral dermatitis.\nI counseled the patient about the risks and benefits of doxycycline and recommended she resume twice daily application until she reaches full resolution, and at that point she should reduce application to once a day for an additional week. The patient will not be using Elidel as I reviewed the cost of the medication and without insurance, it was too expensive. I provided a prescription for Tacrolimus and counseled her on possible side effects of using the medication. She will continue with Sulfacetamide face wash once a day. Also, use Bruder mask as needed.\n\nRosacea, including ocular rosacea.\nContinue using MetroCream twice daily. I recommended to gently wash her eyelids once daily with a gentle cleanser and try a gentle cream such as Vanicream.\n\nINSTRUCTIONS\n\nCall the clinic if symptoms worsen. The patient will have a follow-up appointment in 4 weeks.",
            "file": "D2N145-virtscribe"
        },
        {
            "src": "[doctor] hey good morning bobby how are you\n[patient] i'm doing okay i as you're aware doctor miller sent me over for this pain in my belly that i've had for several weeks they did he did an ultrasound and and said i had gallstones and they recommended i stay several way from some high fat food but i'm just still having a lot of pain and he referred me to you\n[doctor] alright well i'm i'm sorry to hear that you're having pain but i i'm glad that he sent you over to see me i wan na talk a little bit more about that pain can you describe the kind of pain that you feel\n[patient] well it's it's on the right hand side of my belly it's it's right underneath my ribs and it feels like a a squeezing severe pain it comes and goes but when it comes it's really severe and i get kind of nauseated and sick in my stomach\n[doctor] okay and then when you get that pain can you rate that pain for me on a scale like zero being none ten being the worst pain you've ever been in your life\n[patient] when it's severe it's it's probably an eight\n[doctor] okay alright and then time wise are we looking at can it just come and go anytime or is it specifically around mealtimes how how does that pain kinda wax and wane for you\n[patient] most of the time it comes right after i eat\n[doctor] okay\n[patient] but it also can come on a couple of hours after i eat also so it's either immediately after i eat or a couple hours later but it's related to eating\n[doctor] okay\n[patient] you know i like to eat right\n[doctor] do n't weigh all so speaking of eating let's talk a little bit about your diet i see here on your chart that you're a type two diabetic and it looked like that you were gon na handle that with diet and exercise let's talk about that a little bit\n[patient] well you know i my my diet was worse when i before i was diagnosed with the the type two diabetes\n[doctor] okay\n[patient] and since then i've cut back on sugar and i started a little bit of a keto diet and i've lost about twenty five pounds over the last three months\n[doctor] okay so other than the weight loss how how is your diet is that has that been working out for you i mean do you does does that does that fit your lifestyle pretty well\n[patient] yeah it does it does it it i was surprised it was n't as hard as i thought to go back and cut back and go more of a keto diet\n[doctor] okay\n[patient] but you know trying to cut out all those carbs my symptoms got better\n[doctor] yeah\n[patient] with the diabetes and my my blood sugars are improving but i still get that pain underneath the ribs\n[doctor] yeah and that can happen and one of those things that causes that is that those intake of that fatty foods which is you know kind of the the keystone or the hallmark of the keto diet and have you noticed any improvement when you do cut out that fatty food and has that been difficult since you are watching your carb intake\n[patient] the fatty food it is a little bit difficult you know i like those pork grinds and you know i i've had to kind of cut those out they were a nice staple for me when i was on the keto diet but i have cut out the those pork rinses because those were just so delicious and you know i would say it's a little bit better but i still get that pain\n[doctor] okay and then do you have any family history of gallbladder disease\n[patient] yeah but you know you know i knew that was coming both my dad and my mother both had gallbladder disease and had to have their gallbladders off\n[doctor] okay so both both your parents your mom and your dad had your had their gallbladders taken out\n[patient] yeah\n[doctor] okay and then i wan na talk a little bit about your activity level and your and and if you're exercising has this affected your ability to to get out and exercise\n[patient] not really i mean i usually i got ta watch it around meals you know but i've never been a big exerciser right after eating anyhow but you know i'm i'm so glad springs here because it gives me that opportunity to get back out and you know i love photography i i love nature of photography and with the with the the woods going from you know that dark barron look to coming alive with that green and and butting i i love to get out and take foot photographs there\n[doctor] that's awesome to hear yeah i my wife and i like to go over and take nature hikes through the new park behind the rex center that just opened up have you ever been over there to do any any picture taken we've got a bunch of beautiful nature pictures that we took about a week ago\n[patient] no i have n't been there i might have to try that out yeah\n[doctor] yeah it's awesome\n[patient] i like to get down near the river that's where i i like to catch especially around spring time\n[doctor] that's great yeah next time you come in maybe you can bring in some of your pictures that'd be awesome to see\n[patient] okay cool\n[doctor] so i'm just curious talking about your symptoms here have you had any fevers you mentioned something about nausea but have you actually vomited from those symptoms\n[patient] there's times when the pain is really bad for a couple of days i've had some what i i would describe as low grade fevers and yes you're right i have feel nauseated but i have n't thrown up\n[doctor] okay so if it's okay with you i'm gon na go ahead and do a quick physical exam your vital signs look good today blood pressure was one twenty eight over eighty eight respiratory rate was sixteen your pulse rate was sixty eight you were afebrile today which is a good thing and your oxygen saturation on room air was ninety nine percent taking a listen to your heart here your heart is regular of rate and rhythm no i do n't hear any ectopic beats no clicks rubs or murmurs noted listening to your lungs here they are clear and equal bilaterally to auscultation now i'm gon na go ahead and do an an abdominal exam i do note positive bowel sounds soft nondistended abdomen however you are positive for some slight guarding there to the right upper quadrant but i do n't note any rebound tenderness now i'm gon na press slightly here beneath your ribs on the right hand side now take a breath in does that hurt when i press\n[doctor] so i i see that you're guarded there so i'm gon na say that that it did hurt when i it did hurt when i\n[patient] absolutely that hurts so much when you push right there\n[doctor] okay\n[patient] sorry i was just trying to capture capture my breath\n[doctor] okay that's that's no problem so you are positive for murphy's signs but i do n't appreciate any peritoneal signs so let's talk a little bit about your results that i reviewed before you came in today so your abdominal ultrasound shows multiple gallstones present in the gallbladder and i do appreciate some mild thickening now the common bile duct size is within normal limits at four . one millimeters now let's talk a little bit about my assessment and plan for you okay i do believe you have some mild cholecystitis with gallstones i do n't appreciate any frank obstruction but it looks like your gallbladder is inflamed and it looks like that's happened maybe over the last few weeks since you've been having those symptoms now since you have n't had any improvement with dietary modifications i am going to make the recommendation that we do remove your gallbladder and i would like to perform a laparoscopic cholecystectomy now what that means is i'll make a few small incisions and insert a scope with some of those instruments that's gon na remove that gallbladder through one of those little bitty incisions now the surgery is gon na take about an hour to an hour and a half and you'll probably spend the night in the hospital because we just wan na monitor you post procedure to make sure everything is okay you're still gon na wan na avoid those high fat foods after surgery and eat foods that are gon na be high in fiber now do you have any questions about what our assessment and plan is for for this\n[patient] no no questions today\n[doctor] okay now the other thing\n[patient] how soon can i how soon will i be able to get up and get moving back outside after the surgery\n[doctor] so the good news is since it's a laparoscopic procedure you're gon na be back on your feet pretty quick now for the first twenty four hours i'm gon na want you to take it pretty easy but after a couple of days if you feel like moving around on some solid ground you know we do n't want you hiking or anything like that but if you feel like moving around on some solid ground you can get up and walk around within a day or two and then in about a week or so i'll see you again and then we'll release you to go get back out there in nature\n[patient] okay thank you very much\n[doctor] you're very welcome the other thing i wan na talk briefly about is now your not your type two diabetes i want you to follow up with your physician just to make sure that you're handling your diabetes especially the fact that you're gon na have surgery and those type of things and we will just continue to monitor your diabetes as has been outlined by your your additional either your endocrinologist or your primary care provider i'm gon na have the nurse come in and get some paperwork signed and if you do n't have any questions for me i will see you next week and we will get this gallbladder out\n[patient] well thank you very much i'm looking forward to i i do n't want anymore of that pain so\n[doctor] alright that sounds good we'll see you next week then\n[patient] okay take care\n[doctor] yeah",
            "tgt": "CHIEF COMPLAINT\n\nAbdominal pain.\n\nMEDICAL HISTORY\n\nPatient reports history of type 2 diabetes.\n\nSOCIAL HISTORY\n\nPatient reports enjoying nature photography.\n\nFAMILY HISTORY\n\nPatient reports family history of cholelithiasis. Both of his parents have had cholecystectomies.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Reports low-grade fevers.\nGastrointestinal: Reports right-sided abdominal pain and nausea. Denies vomiting.\n\nVITALS\n\nBlood Pressure: 128/88 mmHg.\nRespiratory Rate: 16 breaths per minute.\nHeart Rate: 68 beats per minute.\nOxygen Saturation: 99% 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 ectopic beats. No murmurs, clicks, or rubs.\n\nGastrointestinal\n- Examination of Abdomen: Soft, nondistended abdomen. Positive slight guarding to the right upper quadrant, but without rebound tenderness. Positive for Murphy signs. Peritoneal signs not appreciated.\n- Auscultation: Bowel sounds normal in all 4 quadrants.\n\nRESULTS\n\nAbdominal ultrasound obtained at an outside facility is reviewed today. This demonstrates multiple gallstones present in the gallbladder. I do appreciate some mild thickening. The common bile duct size is within normal limits at 4.1 mm.\n\nASSESSMENT AND PLAN\n\n1. Mild cholecystitis with gallstones.\n- Medical Reasoning: Based on the patient's symptoms, exam findings, and ultrasound, I do believe he has some mild cholecystitis with gallstones. I do not appreciate any frank obstruction, but it looks like his gallbladder is inflamed. This appears to have happened maybe over the last few weeks or since he has been symptomatic.\n- Patient Education and Counseling: I had a thorough discussion with the patient concerning surgical treatment. The preoperative, intraoperative, and postoperative courses of care were described and discussed. I explained the surgery will take approximately 1 to 1.5 hours, and he will probably spend the night in the hospital for post-procedure monitoring. We also discussed that he should avoid high fat foods after surgery and eat foods that are high in fiber. All questions were answered.\n- Medical Treatment: Since he has not had any improvement with dietary modifications, I recommend a laparoscopic cholecystectomy. A mutually agreed upon surgical date has been scheduled for 1 week.\n\n2. Type 2 diabetes.\n- Medical Reasoning: The patient is currently managing his diabetes with diet and exercise.\n- Patient Education and Counseling: I advised the patient he should refrain from hiking in the immediate postoperative period; however, he may return to walking outdoors on solid ground 1 week status post-surgery.\nMedical Treatment: I recommended he follow up with his physician regarding his impending surgery. We will continue to monitor his diabetes as has been outlined by either his endocrinologist or his primary care provider.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow up with me 1 week status post-surgery.",
            "file": "D2N146-aci"
        },
        {
            "src": "[doctor] hi matthew how are you the medical assistant told me that you injured your shoulder\n[patient] hey yeah i'm i'm hanging in there\n[doctor] what happened\n[patient] yeah so well when i was younger i used to be a little bit more active with my friends with the playing\n[doctor] pick up football and so you know me being a little bit older now i thought i'll take back up with no problem well i did i tried and all the other guys were a little bit bigger than me so i got i got tackled a couple of times and it just\n[patient] i kinda landed on my shoulder a little bit weird one time and so like i got back into the game i was okay but yeah ever since then the past couple of days it's just been it's been really bothering me\n[doctor] okay alright and so when exactly did this happen\n[patient] yeah i'd say maybe it was probably about last weekends so i'd say about like four days ago\n[doctor] okay well i'm happy at age 67 you're out there playing tackle football so good good for you and was it your right shoulder or your left shoulder that you injured\n[patient] it was my right\n[doctor] okay and are you right or left handed\n[patient] i'm right handed\n[doctor] okay and have you had any numbing or tingling in your fingers at all\n[patient] no fingers have been okay\n[doctor] okay and any problems with the strength of the arm at all are you able to grab a cup of coffee\n[patient] yeah i hand's doing okay i can grab yeah i'm just trying to avoid lifting anything yeah anything anything anything a little bit too heavy like i had a chipment command so i had a box in the driveway the other day and reaching down and picking up the box was a little tough\n[doctor] okay and where exactly on your shoulder does it hurt\n[patient] yeah it's kinda on the on the back side right right around here\n[doctor] mm-hmm okay alright and are you able to lift up your shoulder so that your shoulder touches your ear at all\n[patient] yeah no that's that's that's hurting a little bit\n[doctor] okay alright and what have you taken for the pain\n[patient] just a little bit of tylenol trying to take it easy\n[doctor] did that help at all\n[patient] it it kinda like kept it at the same spot that has been but it really did n't make it go down\n[doctor] okay so are your symptoms any better since it happened or they about the same\n[patient] no they are about the same\n[doctor] okay and any neck problems did you injure your neck when this happened\n[patient] no neck has been okay\n[doctor] okay and any other joint problems like does your elbow hurt on that side or your wrist or is it just your shoulder\n[patient] nope the the rest of it's doing okay it's just the just the shoulder\n[doctor] okay and any other orthopedic injuries in the past have you ever injured that shoulder before as far as you know\n[patient] nope nope that one that one's been fine\n[doctor] okay and any any other surgeries or any other medical problems\n[patient] i mean i had a appendicitis so i had an appendectomy\n[doctor] okay\n[patient] maybe like three four years ago but that's about it\n[doctor] okay alright well i'm just gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so and last thing have you had any fever or chills since this happened at all\n[patient] a slight headache but no no no fever\n[doctor] okay did you hit your head when you when this happened\n[patient] a little bit\n[doctor] okay alright did you pass out\n[patient] nope nope stayed conscious throughout\n[doctor] okay alright well looking at your vital signs here in the office you do n't have any fever your blood pressure looks quite good it's about one twenty two over seventy six your heart rate is appropriate at eighty two beats per minute and your oxygenation is ninety five percent on room air on your cervical spine exam there is no tenderness to palpation of the cervical spine there is full range of motion on head exam there does not appear to be any trauma there is no ecchymosis or bruising on the right shoulder exam on your musculoskeletal exam there is pain to palpation of the posterior shoulder at the acromioclavicular joint there is decreased abduction and adduction to about ninety degrees only there is there is a he has pain with supination and pronation of the right arm and there is a palpable radial radial artery pulse okay so what does that mean that just means that you have some you know evidence of the injury there and we'll we're gon na talk about that so i had the nurse do a shoulder x-ray on you before i came in the room and the results of your right shoulder x-ray showed that you have an acute acromioclavicular joint fracture so you just have a a a small fracture of the acromion i do n't think that it it's gon na be anything that we need to do surgery for so let's just talk a little bit about my assessment and plan so for your right shoulder injury for your acute acromioclavicular joint fracture i wan na go ahead and just put you in a sling for now i wan na go ahead and prescribe meloxicam fifteen milligrams once a day i wan na go ahead and just order a cat scan of your right shoulder just to kinda get a better look of how the joint looks and we're gon na go ahead and refer you to physical therapy to strengthen your shoulder in hopes of avoiding surgery in the future how does that sound\n[patient] yeah that that sounds great just being able to take a little bit of something for the pain would would would be really appreciated\n[doctor] okay do you think you need something stronger than meloxicam\n[patient] no i'll give that a shot\n[doctor] okay\n[patient] and see how that goes\n[doctor] okay any questions\n[patient] when can i get back out on the field\n[doctor] well you ca n't play taggle football for a while you have to have this fracture healed\n[patient] okay\n[doctor] and i would avoid doing it you know as we get older you know our bones get a little bit weaker so i would avoid the tackle football maybe flag football in the future okay\n[patient] yeah yeah that sounds good\n[doctor] okay anything else\n[patient] no i think that's that's been great thank you so much\n[doctor] okay you're welcome have a good day bye\n[patient] thanks",
            "tgt": "CHIEF COMPLAINT\n\nRight shoulder injury.\n\nHISTORY OF PRESENT ILLNESS\n\nMatthew Allen is a 67-year-old male, right-hand-dominant, male who presents to the clinic today for the evaluation of a right shoulder injury. The patient sustained this injury 4 days ago, when he was tackled a couple of times playing pick up football and landed on his right shoulder. He states that he was able to return to the game, however he has had pain since that time. The patient locates his pain to the posterior aspect of his shoulder. He denies any numbness or tingling in his fingers. He states that the strength in his hand is okay; however, he has been trying to avoid lifting anything too heavy. Mr. Allen denies being able to touch his shoulder to his ear because of pain. The patient has been taking Tylenol for pain, which does not provide relief. He denies any neck problems or other joint problems. The patient denies any previous orthopedic injuries to his right shoulder. He denies any fever or chills since the injury, but does note a headache. The patient states that he hit his head at the time of the injury but did not pass out.\n\nSURGICAL HISTORY\n\nThe patient has a history of an appendectomy 3 to 4 years ago.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Denies fever or chills.\nMusculoskeletal: Reports right shoulder pain. Denies neck pain.\nNeurological: Reports headache. Denies numbness or tingling.\n\nVITALS\n\nBP: 122/76.\nHR: 82 bpm.\nSpO2: 95% on room air.\n\nPHYSICAL EXAM\n\nNECK: Examination of the cervical spine reveals no tenderness to palpation. Full ROM.\nHEAD: There does not appear to be any trauma. No ecchymosis or bruising.\nMSK: Examination of the right shoulder reveals pain to palpation of the posterior shoulder at the acromioclavicular joint. There is decreased abduction and adduction to about 90 degrees only. Pain with supination and pronation of the right arm. Palpable radial artery pulse.\n\nRESULTS\n\nX-ray of the right shoulder reveals an acute acromioclavicular joint fracture.\n\nASSESSMENT\n\nRight shoulder acute acromioclavicular joint fracture.\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 revealed an acute acromioclavicular joint fracture. The plan is to place the patient in a sling and prescribe meloxicam 15 mg once a day to treat his pain. I also recommend that we obtain a CT scan of the right shoulder to evaluate further. I recommend that the patient attend formal physical therapy to strengthen his right shoulder in hopes of avoiding surgery in the future. In the meantime, I have advised him to avoid tackle football.",
            "file": "D2N147-aci"
        },
        {
            "src": "[doctor] hi jeremy how are you the medical assistant told me that you injured your back\n[patient] yeah i was moving some boxes when my son was moving out of his college dorm and i really hurt my lower back\n[doctor] okay how long ago did that happen\n[patient] this was about four months ago\n[doctor] about four months ago okay that's quite a long time and you're just seeing me now for it\n[patient] yeah the appointments were backed up and i tried some pt at my gym but it it really did n't seem to help and i was really concerned\n[doctor] okay and what exactly are your symptoms are you having pain when you're just sitting there or when you're moving around for a very short period of time it felt like i was gon na tapple over i like i could n't support my my upper body weight and then my right toe or the the toes on my right foot tingled a little bit but that went away after about an hour okay are you still getting that numbing and tingling periodically in your feet or is that completely gone\n[patient] that's completely gone it it just happened when i first felt the the tweak in my lower back i felt that sensation but i have n't since\n[doctor] okay and how about any difficulty or weakness in your legs\n[patient] only if i'm carrying something heavy otherwise it seems relatively normal but i i feel the sensation so i'm a little nervous about carrying something heavy\n[doctor] okay and are and do you still have pain down there in your lower back if i turn a certain way or if i roll over in my sleep i'll wake up from it from a like a sharp pain but then that that goes away if i if i position myself the right way okay and what have you been taking for the pain\n[patient] i took some tylenol i took some ibuprofen i've tried heat i've tried ice and nothing really seems to help\n[doctor] okay is the ibuprofen any better than the tylenol\n[patient] a little bit but for sure a shorter period of time\n[doctor] okay and did you get any stomach upset from the ibuprofen\n[patient] no i try not to take too much so i i do n't have an upset stomach from it\n[doctor] okay and did you go to like an urgent care centing or an emergency room have you had any imaging on this at all\n[patient] i went to an urgent care and they wanted me to do an mri but i was a little concerned because i think we maxed out our insurance so i i did n't do it because it started to feel better but because it's been going on so long i'm i'm a little bit concerned now i i do wan na actually move forward with that\n[doctor] okay alright and any other symptoms any problems with like your bladder or your bowels any incontinence or you know you feel like you ca n't go to the bathroom\n[patient] no i have n't had any of those issues\n[doctor] okay alright and any other any other past medical history do you that you have any\n[patient] i had knee surgery about two years ago on my right knee\n[doctor] okay\n[patient] that went fine i rehabbed it pt has been fine it it feels about ninety five percent ever since\n[doctor] okay and what did you have done to your right knee\n[patient] it was a total knee replacement\n[doctor] okay a total knee replacement in twenty eighteen is that what you said\n[patient] no it was actually about two years ago so it's the spring of twenty twenty\n[doctor] okay alright alright well i wan na go ahead and just move on to a physical exam i'm gon na be calling out some of my exam findings\n[patient] mm-hmm\n[doctor] now you have you had any fever or chills with this\n[patient] no\n[doctor] okay alright alright so looking at your vital signs here in the office you know they look really good your you you do n't have any temperature your blood pressure is good it's about one seventeen over fifty six\n[patient] mm-hmm\n[doctor] your heart rate is nice and slow at sixty eight and your oxygenation is fine at ninety five percent on room air so that means everything looks good\n[patient] good\n[doctor] on your neck exam i i do appreciate some bony protuberance of the c5 c6 do you have any pain when i touch here\n[patient] no\n[doctor] no okay on your lumbar spine exam i do appreciate do you have pain when i touch here\n[patient] no\n[doctor] okay so there is no pain to palpation of the lumbar spine there is decreased flexion and extension of the lower back the patient does have a positive straight leg raise and there is some spasm of the paraspinal muscles of the lumbar spine on musculoskeletal exam the lower extremities strength is equal bilaterally so what does that mean jeremy that means that you have some you know maybe a some arthritis in your neck here and or maybe just a a little bit of some injury from from that from that back that back thing that you told me about\n[patient] mm-hmm\n[doctor] okay but i think overall things look really good so you know i had them do an lumbar spine x-ray on you before i saw you and i looked at the results of your lumbar spine x-ray which showed no acute bony abnormality you know there was no fracture of your back or anything which is not surprising based on your history so let's just talk a little bit about my assessment and plan so i do believe it sounds like you have an acute disk herniation now this did happen a few months ago but it sounds like that's what you had based on the fact that you're still having symptoms\n[patient] mm-hmm\n[doctor] i do wan na go ahead and order a a lumbar spine mri to get a a a better look at what's going on you know x-rays really just look at the bones they do n't show us any of the soft tissue so let's go ahead and order the lumbar spine mri i wan na continue with physical therapy so i'm going to refer you to a a physical therapist through our health system\n[patient] mm-hmm\n[doctor] and then i also wan na go ahead and prescribe meloxicam fifteen milligrams once a day\n[patient] mm-hmm\n[doctor] to help with that do you have any questions about that\n[patient] no questions\n[doctor] now if you do have a herniated disk we can go ahead and talk about some other treatment options maybe like an epidural steroid injection to help take down some of that inflammation\n[patient] mm-hmm\n[doctor] it might make you feel better but we'll we'll deal with that when we get get there okay\n[patient] sure\n[doctor] any questions\n[patient] not at this point\n[doctor] okay great thank you\n[patient] thank you",
            "tgt": "HISTORY OF PRESENT ILLNESS\n\nJeremy Adams is a pleasant 57-year-old male who presents to the clinic today for the evaluation of low back pain. The onset of his pain began 4 months ago, when he was moving boxes out of his son\u2019s college dorm. At that time, he noted tingling in his right toes, which resolved after approximately 1 hour. After his injury, he felt as though he was unable to support his upper body weight. The patient reports weakness in his legs when carrying heavy objects. He reports a sharp pain in his lower back when he turns a certain way or rolls over in his sleep. The pain will resolve with repositioning. The patient was seen at urgent care and was referred to obtain an MRI, however he did not undergo this secondary to insurance issues. He has been utilizing Tylenol, ibuprofen, heat, and ice for pain, which does not provide relief. The patient notes the ibuprofen is slightly more beneficial than the Tylenol, however it does not relieve his symptoms. He denies upset stomach with the use of ibuprofen. Additionally, he attempted physical therapy at his gym without any relief. He denies any bladder or bowels issues, fevers, and chills.\n\nSURGICAL HISTORY\n\nThe patient has a history of a right total knee arthroplasty 2 years ago, in spring of 2020. He states that his right knee feels 95% improved since the surgery.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Denies fevers or chills.\nGastrointestinal: Denies bowel issues.\nGenitourinary: Denies bladder issues.\nMusculoskeletal: Reports lower back pain.\n\nVITALS\n\nTemperature: Normal.\nBlood pressure: 117/56 mm Hg.\nHeart rate: 68 BPM.\nOxygenation: 95% on room air.\n\nPHYSICAL EXAM\n\nNECK: Bony protuberance of the C5-C6. No pain to palpation of the C5-C6\nMSK: Examination of the Lumbar spine: No pain to palpation of the lumbar spine. Decreased flexion and extension of the lower back. Positive straight leg raise. Spasm of the paraspinal muscles of the lumbar spine. Strength is equal bilaterally.\n\nRESULTS\n\nX-rays of the lumbar spine were reviewed. These reveal no acute bony abnormalities.\n\nASSESSMENT\n\nLow back pain, possible acute disc herniation.\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. His x-rays did not reveal any signs of a fracture. I would like to obtain an MRI of the lumbar spine to evaluate for a possible acute disc herniation. I have prescribed the patient meloxicam 15 mg to treat his pain. He will continue with physical therapy and a referral was provided for this today.",
            "file": "D2N148-aci"
        },
        {
            "src": "[doctor] so dennis is a 57 -year-old male today complaining of shortness of breath he has also got a history of diabetes high blood pressure and history of asthma so dennis tell me what's going on how're you doing\n[patient] not too good\n[doctor] okay how long have you been feeling not too well\n[patient] about a couple of weeks\n[doctor] couple of weeks tell me what's going on\n[patient] i wake up with shortness of breath\n[doctor] okay\n[patient] i go to when i'm short of breath there i get back home and i'm again short of breath so i had a tough time dealing with this\n[doctor] have you noticed any are you coughing up anything any swelling in your legs or what's going on\n[patient] yeah i've been i've been coughing up i've been coughing up blood\n[doctor] okay how long has that been going on for\n[patient] probably three weeks or so\n[doctor] okay and are you coughing a lot of blood or just a little bit of blood\n[patient] i shave three to four cups a day\n[doctor] wow that's a lot of blood okay are you throwing up any blood are you having bleeding in any place else or just when you cough\n[patient] only when i cough\n[doctor] okay have you noticed any bruising or bleeding from your teeth or anything like that or from your gums or anything like that\n[patient] no\n[doctor] okay any leg swelling or calf swelling or any any anything like that any recent travel history you've been on a plane or trip recently\n[patient] i had some knee problem but there is no swelling but it hurts that's been going on for quite some time\n[doctor] okay so that's not near the knee problem okay and have you had any have you been to the hospital or been to the emergency room or anything like that for your coughing and coughing up blood\n[patient] no i tried to get an appointment in the office but they were kinda booked up\n[doctor] okay\n[patient] they just numb\n[doctor] alright and alright no but no fevers with this so since you're here your oxygen level looks pretty good in the clinic it's about ninety four percent on pulse your pulse oxygenation so that's good are you short of breath so when you walk or you or you exert yourself you're short of breath you said right okay and have you and how how is your blood sugar been doing since this has been going on i know you're on metformin how's your diabetes been doing\n[patient] not so good you know it kinda going up and down i wear this dexcom\n[doctor] okay\n[patient] you know after meal they spike up well over two hundred\n[doctor] okay and\n[patient] and morning when i get up they are around one fifty\n[doctor] okay alright so it's been running a little bit high i know we checked your hemoglobin a1c last time and it was about seven . seven . i think and we had talked about you know improving your diet and improving some exercise but is this blood sugar been high and low or high and normal when you're especially in the last three weeks or has it been going on for longer than that\n[patient] i would say about a month\n[doctor] okay alright and how is your blood pressure been at home since you've been taking since these episodes that you've been sick are you taking norvasc\n[patient] yes i am but i keep them on some days because my blood pressure has been running somewhat on the low side\n[doctor] okay alright and right now it's about a hundred and twenty over seventy what how low does it go in the more when you check it\n[patient] well there are sometimes in the lower nineties\n[doctor] okay alright well let me let me examine you here in a second and we'll think about you know what we need to do especially with your coughing and your shortness of breath okay so nita i'm i'm examining you now let's pretend i did my exam i'm just gon na verbalize some of my findings so i can put it into my chart okay and i'll explain what those things mean so on my exam you've got no jvd there is no swelling in your neck no carotid bruits your lung exam you've got some rails and some rhonchi on on more on the right side i do n't hear any wheezing right now there is some diminished breath sounds in the right side as well on your heart exam you've got two over successolic ejection murmur you've had that in the past that's unchanged from before the rest regular rate and rhythm otherwise your belly exam is nice and soft on your extremity exam you've got one plus nonpitting edema on both of your lower extremities on your on your ankles no calf tenderness no negative homan sign so what does all this mean so basically you've got you know you've got some sort of infection or something going on in your lungs that i can hear right now the rest of your exam is pretty much stable it's unchanged from before so let's talk about what we what we should do about this so for the for the first problem with the shortness of breath the first thing i wan na do is go ahead and get a chest x-ray for you okay you've been coughing up blood i also wan na send you to the emergency department to get some blood testing done i'm worried about a blood clot or something else going on so i wan na get a cat scan of your chest as well so i'm gon na go ahead and refer you to the emergency department i'll call them and and have you head over that way they can get a chest x-ray and a cat scan and some blood work as well and then we'll evaluate why you're having the shortness of breath and why you're coughing up this blood okay and then depending on what they find you may need you know it could be as simple as a pneumonia or it could be something a little bit more serious we may have to get you know start you know depending on what you find we will get the right treatment started any questions about that or can you drive to the emergency department from here or is that okay\n[patient] yeah i can bike no problem i have no question\n[doctor] alright for the second problem for the diabetes since your blood sugar is running a little bit high once you get over this i'm blood sugars running a little bit high once we get you over this hump of the shortness of breath and get this diagnosed i'm gon na go ahead and order another hemoglobin a1c today we will probably increase your dose of metformin from five hundred twice a day to seven fifty twice a day so why do n't we do that and then why do n't we have we'll have the hemoglobin a1c back and then we can once you get over this illness that you're undergoing we'll we'll we'll discuss that more i'll have you come back in about three weeks to just discuss your diabetes and what our treatment plan will be for that okay\n[patient] okay\n[doctor] for the high blood pressure definitely hold off on the norvasc for right now let's figure out what's going what's causing this episode of shortness of breath i want some blood testing done and and once we have that under better control we can reassess your blood pressure so right now hold the norvasc and then we'll have you come back once everything is done okay\n[patient] no\n[doctor] any other questions or anything we know if we need to talk about today\n[patient] no i'm good\n[doctor] sounds good we'll get you signed out here in a second",
            "tgt": "CHIEF COMPLAINT\n\nShortness of breath with hemoptysis.\n\nMEDICAL HISTORY\n\nPatient reports history of diabetes, hypertension, and asthma. He also has a long history of knee pain.\n\nMEDICATIONS\n\nPatient reports taking metformin and Norvasc.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Denies fever.\nHENT: Denies bleeding gums.\nRespiratory: Reports shortness of breath, hemoptysis.\nMusculoskeletal: Reports knee pain. Denies lower extremity edema.\nHematologic/Lymphatic: Denies bruising.\n\nVITALS\n\nPulse oxygenation: 94 percent. Blood pressure: 120/70 mm Hg.\n\nPHYSICAL EXAM\n\nNeck\n- General Examination: Neck is supple. No JVD. No carotid bruits.\n\nRespiratory\n- Auscultation of Lungs: Some rales and rhonchi, more on the right. No wheezing right now. There is some diminished breath sounds in the right as well.\n\nCardiovascular\n- Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur, unchanged from before.\n\nGastrointestinal\n- Examination of Abdomen: Soft.\n\nMusculoskeletal\n- Examination: 1+ nonpitting edema on bilateral lower extremities. No calf tenderness. Negative Homan's sign.\n\nHematology/Lymphatic/Immunology\n- Examination: No bruising.\n\nASSESSMENT AND PLAN\n\n1. Shortness of breath.\n- Medical Reasoning: The patient has been coughing up blood.\n- Patient Education and Counseling: We discussed the importance of further testing as his symptoms could be as simple as a pneumonia or something more serious.\n- Medical Treatment: I have ordered a chest x-ray, CT scan, and blood work to be done in the ER. I have instructed the patient to go into the ER immediately after this appointment and I will call ahead.\n\n2. Diabetes.\n- Medical Reasoning: The patient's blood sugar has not been well controlled.\n- Medical Treatment: I have ordered an updated A1c today. He will increase his metformin to 750 mg twice daily.\n\n3. Hypertension.\n- Medical Reasoning: His blood pressure has been running low for approximately 3 weeks. I believe this could be caused by his shortness of breath. I would like to get a better understanding of the cause of his shortness of breath prior to pursuing further treatment for his hypertension.\n- Medical Treatment: At this time, he will discontinue the use of Norvasc.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nWe will have him follow up in about 3 weeks to just discuss his diabetes and further treatment recommendations.\n",
            "file": "D2N149-aci"
        },
        {
            "src": "[doctor] alright scott so so i understand that you you had some right knee injury can you tell me a little bit about what happened\n[patient] yeah i was trying to go out and play some pickup soccer games over the weekend and went to go plank kick the ball and and just felt a pop in my right knee\n[doctor] okay and and how long ago did that happen\n[patient] about three days ago\n[doctor] three days okay and when did you notice any swelling anything like that\n[patient] it it's swollen some some of that swelling has gone down\n[doctor] okay\n[patient] but it it mainly just it it feels like that i just i ca n't my knee is just not as functionally it's not moving as well as what it used to be it seems to be a little limited\n[doctor] okay alright and then so how's the pain with your knee on a scale of one to ten one being the least pain ten being the worst pain how's how's it been ranging\n[patient] it's somewhere between six and seven right now it's about four or five with some of the swelling going down\n[doctor] okay alright and did you take anything at all to relieve the pain\n[patient] anti-inflammatories\n[doctor] okay alrighty and did that help\n[patient] yeah the ibuprofen helped a little bit but i'm on it pretty on a pretty regular basis right now\n[doctor] gotcha okay now tell me are you able to bend or straighten your leg ever since then\n[patient] i can bend it but it hurts towards the end of the motion and i can straighten it but it does n't it feels like i have to help get it straightened\n[doctor] okay alright and then how about you able to bear any weight on it or walk on it at all\n[patient] i can still bear weight on it but it feels just really loose it it does n't feel normal\n[doctor] gotcha okay alright well let's go ahead and take a look at your knee here real quick before i take a look at your knee here i'm gon na do a physical exam and in terms of your gait here i did notice that you do have a marked limp on your looks like it's your right leg upon ambulation so let me go ahead and take a look at that right knee real quick i do appreciate some significant effusion in the right knee just a slight bit of ecchymosis let me just feel around here scott how does that feel does that hurt when i kinda press on that there\n[patient] a little bit of pain there not not really bad it's it feels like it's just more on the inside of my knee\n[doctor] yep okay so you definitely feeling some a little bit of pain to palpation at the medial joint line now i'm gon na have you lie on your back and also i'm gon na do some maneuvering here of your leg i'm gon na do a real quick test on you here okay alright how does that feel\n[patient] just feels just feels loose it hurts when you pull it at the very end\n[doctor] okay sorry about that alright so you're definitely having some difficulty with some passive range of motion here and you're lacking a few degrees of terminal extension to about a hundred and fifteen degrees as well as lacking about maybe twenty to thirty degrees of terminal flexion on the secondary secondary to the pain here and you do have a positive lachman exam so one more thing i wan na take a look at real quick i'm gon na take a look at your toes here real quick very good so neurovascularly your bilateral lower extremities are intact and it looks like you have a muscle strength of a five out of five so scott you know based on my examination here your right knee injury is really suggestive of anterior cruciate ligament tear and you've heard of it probably even heard as acl tear sometimes especially when a lot of people do sports and they injure their knee that that can happen so my plan for you though is i wan na i wan na go ahead and order an mri because i wan na evaluate the integrity of that acl now you may need surgery but we'll we'll first take a look at that mri result and reevaluate and reevaluate that first but in the meantime i wan na go ahead and order some anti-inflammatory medication meloxicam fifty milligrams a day it's gon na help reduce that swelling and the pain and then i want you to go ahead and ice the knee if you need to if you're still seeing some swelling and some pain you can go ahead and use ice as well but i definitely would like for you to moderate your activities so i would like for you to wear a knee immobilizer and then also use crutches when you walk around just to help you a little bit so not to put too much stress and strain on that knee does that sound like a plan\n[patient] it it does now well i need to limit my work activities i i typically sit behind a desk but it's not been very comfortable sitting here lately\n[doctor] yeah definitely so yeah so you you can limit the activities for sure in terms of your work activities i know if you sit too long sometimes it can be painful because you do need to move that leg a little bit so it does n't lock up so i i would like for you to you know do do some slight activities not enough to stress your legs but definitely move move them a little bit every now and then so it does n't lock up on you okay\n[patient] okay\n[doctor] alright i do want you to i know you are i know you actually jog often so i want you to just slow that down for a bit no jogging for a while until we get you know results of your mri till we figure out what we what we are gon na be doing okay\n[patient] okay\n[doctor] alright and how's your dog you has it been jogging with you before this incident\n[patient] how's just how's my dog or how is my job\n[doctor] your your dog\n[patient] my my my dog is okay\n[doctor] good\n[patient] is doing really well and and he enjoys still playing around outside but looks like wo n't be able to do that for a little bit\n[doctor] very good alright well i'm gon na go ahead and have the nurse take you to the scheduler to get your mri and i'll get back with you as soon as we get the results of that\n[patient] okay sounds good thank you\n[doctor] thank you",
            "tgt": "CHIEF COMPLAINT\n\nRight knee injury.\n\nHISTORY OF PRESENT ILLNESS\n\nScott Miller is a pleasant 36-year-old male who presents to the clinic today for the evaluation of a right knee injury. The injury occurred 3 days ago, when he was playing pickup soccer games and felt a pop in his right knee. He reports swelling at the time of the injury, which has improved. The patient states that his knee is not as functional or moving as well as it used to be. He rates his pain level as a 6 to 7 out of 10 currently and a 4 to 5 out of 10 when the swelling decreases. The patient has been taking ibuprofen on a regular basis, which provides some relief. He states that he is able to bend his knee with pain towards the end of this motion; however, when he goes to straighten his knee, he feels like he has to help it straight. The patient adds that he is able to bear weight on his right knee, however it feels loose and does not feel normal.\n\nSOCIAL HISTORY\n\nThe patient works at a desk.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports right knee pain.\n\nPHYSICAL EXAM\n\nGAIT: Marked limp in the right leg upon ambulation.\nMSK: Examination of the right knee: Significant effusion. Slight ecchymosis. Pain with palpation at the medial joint line. Difficulty with passive ROM. Lacking a few degrees of terminal extension to 115 degrees. Lacking 20-30 degrees of terminal flexion secondary to pain. Positive Lachman's test. Muscle strength is 5/5. Neurovascular intact distally.\n\nASSESSMENT\n\nRight knee pain, possible anterior cruciate ligament tear.\n\nPLAN\n\nAfter reviewing the patient's examination findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have recommended that we obtain an MRI of the right knee to evaluate the integrity of the ACL. I have prescribed the patient meloxicam 15 mg a day to reduce swelling and pain. We discussed that the patient should utilize ice and activity modification to reduce swelling and pain. I recommended that he wears a knee immobilizer and use crutches when he is ambulating. He will avoid jogging until we have the results of his MRI.\n\nINSTRUCTIONS\n\nThe patient will follow up with me once the MRI results are available for review and further discussion.",
            "file": "D2N150-aci"
        },
        {
            "src": "[doctor] alright teresa i see here in your chart that you seem to be experiencing some elbow pain could you tell me where it hurts\n[patient] yeah so it's hurting on the inside of my elbow\n[doctor] mm-hmm\n[patient] and when i i i've been doing some pottery i've been creating you know i have a pottery wheel and i've been i love my pottery and for my son's birthday i've been making a a ceramic bowl and i'm gon na paint it and i have to do some real full decorations but i've really been working on it a lot and my gosh this is hurting and i ca n't work on it right now because it's hurting so much\n[doctor] i am so sorry so i mean that's really cool that you do parttery it's something that i've wanted to pick up you know but i do n't know that i have those skills yet does the pain radiate down your arm or up your shoulder or anything\n[patient] yeah it does down my arm and along that inside of my arm\n[doctor] okay so the medial aspect okay have you did you hit it on anything\n[patient] no not that i recall\n[doctor] okay and have you ever injured your elbow before\n[patient] no i have n't\n[doctor] okay alright so on a on a scale of one to ten with ten being your arm is actively being sought off by a chainsaw how bad is the pain\n[patient] well i'd say it's about a seven\n[doctor] wow that's pretty bad does it keep you up at night\n[patient] yes it really does it's you know if i roll over and it it it just wakes me up\n[doctor] okay have you done anything to relieve the pain\n[patient] well i have been taking some ibuprofen but that is n't really helping\n[doctor] okay and have you tried anything like ice or heat or anything else\n[patient] i tried a little bit of ice at first\n[doctor] mm-hmm\n[patient] but and it's just it's been hurting for about four days now\n[doctor] okay\n[patient] did n't getting better\n[doctor] okay okay so it's probably it do you think it's getting worse\n[patient] well it's just not getting better\n[doctor] okay no i understand okay so i know that you also have like a history of hypertension and that we have you on ten milligrams of lisinopril have you been checking your blood pressures regularly\n[patient] yeah you know what i remember too i mean they they have been pretty good one teens to one thirties\n[doctor] okay alright and okay do you think that you've been good about taking your medications do you usually take them everyday\n[patient] yeah pretty much i i i you know set an alarm for that lisinopril\n[doctor] awesome that's great alright and so i see that you also we are treating you for diabetes as well and that we have you on five hundred milligrams of metformin twice a day how about that have you been taking that regularly\n[patient] well sometimes i forget i mean having a medication twice a day you know sometimes i'm out doing stuff and i just forget to take it\n[doctor] okay\n[patient] and plus i kinda have a sweet tooth so you know sometimes they're a little bit higher you know like one fifty to one seventy so\n[doctor] okay alright so when you say a sweet tooth what are we talking about there\n[patient] i love to bak also besides my ceramics i'm really big and baking and i like to make cakes and and take them to you know parties and get togethers you know family get togethers and i like to make senna rules too i've been doing that since i was very young so i kinda noticed that\n[doctor] okay cinnamon rolls can be kind of hard like do you for your cakes do you do you use fondant you know to like do any of the decorations\n[patient] no i i mine are just pretty basic they're not overly fancy\n[doctor] okay\n[patient] simpon rolls i got that recipe out of a southern living magazine\n[doctor] oof\n[patient] a long time ago and\n[doctor] so you know it's good\n[patient] yeah\n[doctor] alright well so i totally understand like baking and like the excitement of being able to give those to your family but we maybe wan na start cutting down on eating and taste testing ourselves is do you think that's something we could manage\n[patient] yeah i know i need to get better on it i probably could use maybe a refresher on just managing what i should and should n't eat how like if i need to combine a protein you know if i do eat something a little bit sweet maybe pling a protein or something with it\n[doctor] mm-hmm yeah that sounds like a\n[patient] had some friends tell me something about that\n[doctor] yeah that sounds like a great idea and i think if that's something that we can maybe discuss to get you in contact with someone who can offer you someone with a degree that can offer you some really good advice you know i do n't wan na as much as it's really helpful to have friends i do wan na be able to give you like a source of truth right\n[patient] yeah i i had a diabetic consult a long time ago but yeah it it would be nice to see a dietitian again and go over those and maybe there is some new stuff too\n[doctor] a hundred percent yeah you know like i one of the things that i struggle with is like are eggs good for you or bad for you you know like with cholesterol i feel like it changes every other year or something like that so you're right there may be some pieces of information that we do need to update and and you know over a fresh of course would n't hurt but if you do n't mind i'm gon na go ahead and start my physical exam i'm gon na call out my findings and just go let me know if you have any questions or if anything sounds anything that you you want me to expand on further but this is just for the recording sake so we can get everything documented okay\n[patient] yeah and can i ask you what word what were my vital signs can you show me what my vital signs were\n[doctor] yeah that's uh uh that's a really good question so our big and favorite one is gon na be your blood pressure right so you're right like we are seeing some some definite improvement today it was one twenty over seventy and honestly that's a great place to be so that tells me that your medication is working and that maybe we can start to evaluate a bit more your respiratory rate is completely normal so i see it here as eighteen that's wonderful you are not running a fever so ninety seven . nine and you're honestly that's within like a good enough range for me you're satting pretty well your oxygen saturation is a hundred percent again so that means that you're not experiencing any kind of difficulty getting in that oxygen to the rest of your body i do wan na say that you know pain is one of the vitals that we worry about and you're saying that at it's worst your the pain in your elbow is a seven out of ten so that's something that i'm gon na evaluate and then your pulse rate seems to be appropriate as well so those are all great do you have any questions about that so far\n[patient] no that sounds good yeah i was just curious\n[doctor] yeah\n[patient] checked it in a while so\n[doctor] mm-hmm i do wan na say that like looking at your the weight we do see like maybe a five pound increase from the last time that you were here but that's completely normal right to be able like to fluctuate you know give or take five pounds so i'm not i'm not i'm not like seriously worried about it but if we do come back and notice an additional five pounds then we might have to start talking about like actually you know what let's do that right now what kind of exercise regimen are you on\n[patient] well i do go for some walks in the evening i try to get one in on the morning too\n[doctor] mm-hmm\n[patient] so not a whole lot other than that because i'm busy with my pottery or baking so but i do try to get out and walk daily\n[doctor] okay that's awesome so like how about about how long are your walks\n[patient] well i just walk around the neighborhood there is you know the sidewalks and there is kind of a little bit more of a nature type area that goes across the bridge and so it's probably you know maybe one to two miles a day\n[doctor] wow that's intense i was not expecting that number that's awesome okay alright so maybe this five pounds is muscle we're gon na go for it okay but thank you but that's some really important information but i'm gon na start your physical exam now okay\n[patient] okay\n[doctor] alright so i know that you said that you are experiencing elbow pain could you tell me is it your left or your right elbow\n[patient] it's my right\n[doctor] okay alright right elbow when i touch it does it hurt on the inside\n[patient] yes it does\n[doctor] okay so moderate tenderness at the medial epicondyle when you turn like when you turn your wrist is if you're trying to open a door knob do you experience pain\n[patient] no not really\n[doctor] alright so turning out no pain but when you turn your wrist inwards do you have any pain\n[patient] yeah\n[doctor] okay so pain with resisted pronation of right forearm when you rest your arm on a table with the palm side up alright i want you to raise your hand by bending the wrist do you experiencing any pain\n[patient] yeah that hurts\n[doctor] alright alright so when you are when i'm pressing here and like flexing your wrist are you experiencing any pain\n[patient] yes\n[doctor] alright pain with flexion and when bending the wrist alright when i listen to you you know i'm just gon na check your heart and lungs everything sounds sounds good no murmur no rub no gallop your lungs are clear bilaterally to bilaterally to auscultation i'm not noticing any rash for your at your elbow i do n't notice any bruising any swelling we do wan na note that tenderness but otherwise there is no discoloration no lesions so that's good your pulses and are equal bilaterally and i think i think we have an idea of what we are dealing with here okay so i'm gon na go ahead and give you my impression and plan for your your first problem like your primary problem that you are here for is right elbow pain it's consistent with medial epicondylitis and that it just means it's pain caused from overuse and damage to the tendons in your arm what we are gon na do is rest it i'm gon na order a sling for your right arm and you can wear this while you're awake well i want you to apply ice to your elbow for twenty minutes three times a day i'm going to i'm gon na ask you to take six hundred milligrams of ibuprofen that's three pills every six hours with food and you can take that for one week i know it's really important that you said that you have something that a gift that you wan na make for your son but we're gon na hold off on pottery for the next couple of weeks just to give your arm a chance to heal you know like it's awesome that you wan na be able to do these things for your family but sometimes you know your body is not where your where your where your heart is like where your heart and your head are right and then so\n[patient] i'll i'll just let him know that that i maybe i'll take a picture of what i have so far\n[doctor] absolutely that's awesome and so it'll be like a a movie like coming soon to a shelf near you that's great for your second problem right we have this longstanding diabetes i want to increase your metformin to a thousand milligrams twice a day i know that you're saying you're having a hard time keeping up with that so i want you to do a good job of like checking and recording your blood sugars every day i do need you to follow up with me in a couple weeks i also wan na order something called an a1c since you are having a hard time with like the blood like the blood sugars everyday an a1c will give me a more accurate picture of like a longer period of time and then we might need to evaluate like what are what other options that we have if your sugars if we ca n't get them a bit more under control i do want you to follow up with me in a couple of weeks about the about your diabetes and for your third problem of hypertension we're just gon na continue you on your lisinopril at ten milligrams that's it seems to be doing it's job i'm really i'm really glad about that and it's probably due to the walking that you're doing i forgot to mention for your diabetes we are gon na i'm gon na recommend a a referral to diabetic counseling that way you can get like a bit more information on like the steps that you can take to help you with that\n[patient] i was gon na ask you how about my x-ray the x-ray of my elbow how did that look\n[doctor] your x-ray honestly looks great in that i do n't see any kind of fracture or bony abnormality so that's what makes me think that this is like a tendon related thing right so in reviewing your x-ray like it it does support the the the assessment and plan that i have given you i\n[patient] okay\n[doctor] do you\n[patient] just true\n[doctor] yeah absolutely i do think for your your primary problem the elbow that we might wan na get put you in some physical rehab if the problem is taking a little longer to heal but we'll discuss that at your next visit here okay\n[patient] okay\n[doctor] alright no problem any other questions\n[patient] nope\n[doctor] alright thank you for keeping me accountable",
            "tgt": "CHIEF COMPLAINT\n\nRight elbow pain.\n\nHISTORY OF PRESENT ILLNESS\n\nTeresa Sullivan is a pleasant 33-year-old female who presents to the clinic today for the evaluation of right elbow pain. Her pain began 4 days ago, without any improvement. She denies any specific injury; however, she has recently increased her usage of a pottery wheel in creating a bowl for her son. She is currently unable to work with the pottery wheel secondary to pain. Her pain is in the medial aspect of her elbow. She notes it radiates medially down her arm as well. The patient rates her pain level as 7 out of 10 at its worst. She reports the pain wakes her at night if she rolls over. She denies ibuprofen or ice provide pain relief. The patient denies any previous elbow injuries.\n\nThe patient has a history of hypertension. She states she has been checking her blood pressures regularly. She adds that her blood pressures have been in the 110s to 130s range. She affirms she is taking lisinopril 10 mg daily and denies missing doses.\n\nRegarding her diabetes type 2, she reports she sometimes forgets to take metformin 500 mg twice daily. At times, her blood sugar levels range from 150 to 170 mg/dL. She states that she has a sweet tooth and indulges in home baked goods. For exercise, she walks in the evening and in the morning. She walks 1 to 2 miles per day around her neighborhood.\n\nThe patient enjoys working with ceramics as well as baking cakes and cinnamon rolls for family gatherings.\n\nMEDICAL HISTORY\n\nPatient reports history of hypertension and diabetes type 2.\n\nMEDICATIONS\n\nPatient reports taking lisinopril 10 mg and metformin 500 mg twice daily.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports right elbow pain.\n\nVITALS\n\nBlood Pressure: 120/70 mmHg.\nPulse Rate: Appropriate.\nRespiratory Rate: 18 breaths per minute.\nOxygen Saturation: 100% on room air.\nBody Temperature: 97.9 degrees F.\nPain Level: 7/10 at its worst.\nWeight: 5 lb increase since last visit.\n\nPHYSICAL EXAM\n\nCV: No murmurs, gallops or rubs. Pulses are equal bilaterally.\nRESPIRATORY: Normal respiratory effort, no respiratory distress. Lungs are clear bilaterally to auscultation.\nSKIN: No rash or lesions.\nMSK: Examination of the right elbow: Moderate tenderness at the medial epicondyle. Pain with resisted pronation of the right forearm. Pain with flexion and bending the right wrist. No bruising or swelling. No discoloration or lesions.\n\nRESULTS\n\nAn x-ray of the right elbow was reviewed today. It demonstrated no evidence of any fractures. No other abnormalities are noted.\n\nASSESSMENT\n\n1. Right elbow pain, consistent with medial epicondylitis.\n2. Diabetes type 2.\n3. Hypertension.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with her regarding her current symptoms. I have explained to her that her elbow pain is consistent with medial epicondylitis and was most likely caused by overuse and damage to the tendons in her arm. I have recommended that we treat the patient conservatively. The patient will wear a sling on her right arm while she is awake to provide increased support. I advised her to ice her right elbow for 20 minutes 3 times per day. She will take ibuprofen 600 mg every 6 hours with food for 1 week. I have also advised her to hold off on creating pottery for the next 2 weeks to allow her arm to heal. If the patient continues to experience persistent elbow pain, we may consider formal physical therapy at her next visit.\n\nI have encouraged the patient to check and record her blood sugars every day. I will increase her metformin to 1000 mg twice a day. The patient and I discussed the importance of her taking her medication on a regular basis twice a day. I have also recommended that she be referred to diabetic counseling for more information on the steps she can take to manage her diabetes. I will also order a hemoglobin A1c test for a more accurate assessment of her long-term blood sugar levels.\n\nThe patient\u2019s hypertension is currently controlled with medication and exercise. I have instructed her to continue taking lisinopril 10 mg. I also encouraged her to continue with her walking routine.\n\nAll questions were answered.\n\nINSTRUCTIONS\n\nThe patient will follow up with me in 2 weeks to review the results of the hemoglobin A1c test and discuss her progress.",
            "file": "D2N151-aci"
        },
        {
            "src": "[doctor] good morning noah tell me a little bit about why you are here today\n[patient] hi document i'm i'm just had you know the back pain you know and i've i've had it for you know about a week and\n[doctor] oh\n[patient] you know i mean i tried some you know i mean medications but you know some over the counter stuff but it does n't go away\n[doctor] okay can you tell me a little bit more about it how did it start or how did it do you remember injuring yourself\n[patient] no not really i mean i was just like you know i guess i one day i mean i just twisted you know on my left and maybe i mean i might have picked something up\n[doctor] okay\n[patient] so i mean at that time i mean there was this pain but i you know it went away you know and i thought that was you know that was you know the end of it but you know i mean after you know a few hours you know it's it kinda it came back\n[doctor] okay\n[patient] it's been there since then you know\n[doctor] okay and is it anywhere in specific is it in the middle of the back across the whole low back or on one side or the other\n[patient] i think it's more towards you know right in the middle maybe on the lower side and nothing on the you know i mean it sometimes it goes back you know maybe having troubles with the left eye i suppose but i mean it's aggravated you know when i you know when i do some you know maybe i'm a sudden movement to the left\n[doctor] okay and that's when you get the pain more maybe located in the center but it goes across to the little back and i on the left side and i also heard you say you know if you twist suddenly that makes it worse is that correct\n[patient] it makes it worse it makes it worse i mean yeah\n[doctor] now you know i was looking at your records and i know you have that history of diabetes and i have n't seen you a while for a follow-up for that how you've been feeling\n[patient] i mean been okay i mean i take my meds\n[doctor] okay\n[patient] and i try to still have sugar but you know i mean i you know you know i mean whenever i get the chance i mean i you know i exercise but you know i mean that's about it\n[doctor] okay so you're on\n[patient] mm-hmm\n[doctor] yeah i think i think you're on that metformin twice a day\n[patient] yeah\n[doctor] yeah okay\n[patient] yes\n[doctor] do you test your blood sugar at home in the mornings\n[patient] yeah i mean i try to\n[doctor] okay\n[patient] most of the morning but sometimes i mean i go skiing yeah\n[doctor] and how have those numbers been\n[patient] they bumped towards i mean bit towards the higher side i mean i must have been\n[doctor] okay\n[patient] you know but\n[doctor] well if\n[patient] yeah\n[doctor] yeah if i remember right your family do n't they own that that bakery down on the corner of main street and did n't they own that\n[patient] yeah thank you\n[doctor] and how do you do you stay away from those i i got ta be honest i love i love the cakes and donuts they make those are delicious\n[patient] yeah i try to\n[doctor] okay\n[patient] but i mean you know they they you know i have to visit them and you know i end up you know i mean getting some stuff but it's not that much\n[doctor] okay\n[patient] but it's been i try to contain it you know\n[doctor] well let me so we're gon na have to watch that and i'll come back and we'll talk a little bit about the diabetes but let's go ahead and do that i do n't wan na do a a a quick physical exam on you i'm gon na look in your eyes here and so let me quickly look in your ears\n[patient] i see\n[doctor] okay that looks good and any let me let me listen to your lungs okay your lungs are clear and your heart it's a regular rate and rhythm that's all good as we go through that now i want you to sit up here i'm gon na press down your back starting at the top and any pain up top no\n[patient] no\n[doctor] okay and then once i get down here and around that low back i wan na press in the center first does that cause you a lot of pain\n[patient] yeah\n[doctor] yeah okay\n[patient] yeah that that's the spot\n[doctor] okay and if i come over here to the right no\n[patient] not that much you know\n[doctor] okay so and then on the left hand side if i push down here kind of into your butt\n[patient] yeah\n[doctor] yeah okay\n[patient] yeah\n[doctor] lay back on the stretcher for me for a second i'm gon na go ahead and and lift your legs for me or i'm gon na go ahead and lift your legs for you just relax i'm gon na start here on the right side when i lift that right leg up does that cause you significant pain or any pain at all\n[patient] a little a little bit\n[doctor] okay let me come around let me lift up the left side if i lift that up does that cause\n[patient] yeah yeah yeah that's that's\n[doctor] yeah\n[patient] still get tender yeah\n[doctor] i can see that gritts on your face so okay that's good and you know as i look at your lower extremities there is no pain or numbness or tingling in your feet or anything like that\n[patient] hmmm no\n[doctor] okay okay so lem me talk a little bit about my impression and plan so for that low back pain i believe you have a musculoskeletal low back strain i'm going to order a low back x-ray so we'll order that and get that done as an outpatient i do n't expect to see anything significant but it's gon na tell me how those joint spaces look and if you know if we're dealing with any disk issue but that will be the start of it and i'm also gon na order some physical therapy two for two reasons to help with a little bit with the pain but also strengthen some of the muscles there in the back so those are the two things that we are gon na do now i want you to take take four hundred milligrams of ibuprofen you can take that occasionally with some tylenol when the pain gets more severe up to about three times a day i'm gon na also give you a prescription for some flexeril that's a muscle relaxant and i want you to take one of those once a day every evening but be careful if you're doing any strenuous or hazardous activities such as driving after you take those now for your diabetes my impression is that your diabetes is is under control i noticed that we do n't have n't had a a1c for almost five months so i'm also gon na order an a1c so we can find out where we are with that continue with your diet and exercise we know that's really important and then continue with your metformin i'm not gon na make any changes today but we'll go ahead and look at that once i get that results of that a1c do you have any questions for me\n[patient] yeah can i still go to the bakery\n[doctor] i would yes it's nice for you to go to the bakery but you ca n't have any donuts i'm no i you just really need to watch that intake of of anything that you might get at the at the bakery so just just be careful with those carbohydrates those sweets that you're taking as we go through your day it's occasional occasional one perfectly fine but on a routine basis we need to watch that\n[patient] right and how soon should i you know check my blood sugars i mean what's a good you know\n[doctor] yeah i that's a great question i'm really glad you asked that i would prefer that you're taking your blood pressure every morning the first thing you get up when you get up in the morning that's gon na give me a good idea and so if you can do that the first thing in the morning and keep a record of it you know i know your glucometer keeps a record of it but if you can write them down and once we get that a1c that's gon na give me a little more guidance on how to deal with your blood your diabetes\n[patient] right do you think would i need to see you know a pain doctor or you know\n[doctor] not yet let's let's get the that's a great question i may end up referring you to a a pain doctor for that low back pain but i really would like to start with some of the diagnostics first let's get an x-ray and if there is you know any question of that x-ray and the pain continues i'm gon na go ahead and maybe order a cat scan and then at that point in time we can refer you to a pain doctor if we're still having significant pain\n[patient] sounds good\n[doctor] okay thank you i'm gon na send my nursing to see you and we'll get you out the door\n[patient] thank you\n[doctor] take care\n[patient] that one is a follow-up mm-hmm",
            "tgt": "CHIEF COMPLAINT\n\nBack pain.\n\nMEDICAL HISTORY\n\nPatient reports history of diabetes.\n\nSOCIAL HISTORY\n\nThe patient's family owns and runs a bakery.\n\nMEDICATIONS\n\nPatient reports taking metformin twice daily.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports back pain.\nNeurological: Denies numbness or tingling in feet.\n\nPHYSICAL EXAM\n\nEyes\n- Examination: No redness, discharge, or icterus.\n\nEars, Nose, Mouth, and Throat\n- Examination of Ears: Auditory canal and tympanic membranes are clear.\n\nRespiratory\n- Auscultation of Lungs: Clear bilaterally.\n\nCardiovascular\n- Auscultation of Heart: Regular rate and rhythm.\nMusculoskeletal\n- Examination: No pain to palpation of the upper back. Pain to palpation of the midline of the lower back, especially on the left. No pain to palpation on the right lower back. Mildly positive straight leg rise on the right Positive straight leg rise on the left.\n\nASSESSMENT AND PLAN\n\n1. Low back pain.\n- Medical Reasoning: I believe he has a musculoskeletal low back strain. I do not expect to see anything significant on x-ray, but we will obtain one for further evaluation of any possible disc issues.\n- Patient Education and Counseling: We discussed his diagnosis at length today. I explained that physical therapy can help with the pain, but also strengthen some of the muscles in the back. I explained that he needs to be careful while taking medications, such as an overuse of muscle relaxers if he is doing any strenuous or hazardous activities such as driving.\n- Medical Treatment: Low back x-ray ordered. Referral to physical therapy provided. He will take 400 mg of ibuprofen up to 3 times per day. Tylenol can be used for severe pain. Prescription for Flexeril also provided.\n\n2. Diabetes.\n- Medical Reasoning: His diabetes is currently under control.\n- Patient Education and Counseling: We discussed the importance of maintaining a healthy lifestyle. I encouraged him to try an avoid foods high in sugar. He asked many questions and I feel he is confident in the plan at this point.\n- Medical Treatment: Hemoglobin A1c ordered as he has not had an updated one in almost 5 months. He will continue with his diet and exercise. Continue current dose of metformin for the time being. The patient will be checking his blood sugar in the morning and will log this information for me.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N152-aci"
        },
        {
            "src": "[patient] i hope i did n't hurt it again\n[doctor] hi gregory how are you i the medical assistant told me that you injured your knee\n[patient] yeah yeah i heard it stepping off a curb\n[doctor] how long ago did that happen\n[patient] about two and a half weeks ago\n[doctor] two and a half weeks ago and what what knee is bothering you\n[patient] the right knee the outside of my right knee\n[doctor] the outside of your right knee\n[patient] yeah\n[doctor] okay and did you actually fall down when this happened or\n[patient] no i just sorta turned over my ankle\n[doctor] okay\n[patient] to the outside and i thought my ankle was the thing that was gon na hurt most but after the ankle soreness went away the only my knee hurt and it sort of clicks when i walk\n[doctor] and no okay so now it clicks when you walk okay does it hurt when you walk\n[patient] no unless i stand on one foot for an extended period of time like leaning my foot up against the wall\n[doctor] okay\n[patient] then i feel like it's locked and then i sort of have to ease into walking again\n[doctor] okay and what have you taken for the pain\n[patient] really nothing\n[doctor] okay\n[patient] ibuprofen but i'm not a big pill taker so i sort of sucked it up and\n[doctor] does the ibuprofen work\n[patient] at night you know during the day i'm more active so it it really does n't impact it because i just work through it but at night it does help me to settle down and sleep better\n[doctor] does your knee hurt when you're just resting and sitting there\n[patient] no when it's up it's fine when it's down on the floor with my foot flat it's fine it does hurt when i rest it on my heel\n[doctor] okay and are you able to do things like bending or things like that\n[patient] a full squat that's when i feel the most clicking like if i go all the way down to a full squat like a catcher that's when i feel the most clicking but otherwise no there is no pain it's just the clicking and i'm fearful that that's an injury of some type\n[doctor] okay alright now you said squats are you are you active are you doing like burpees going to\n[patient] no i ride the bike\n[doctor] okay\n[patient] i ride the bike i ride the bike which i'm not doing now peloton inside for the winter i do have a winter bike though\n[doctor] okay alright well i have a peloton who is your favorite instructor\n[patient] i i actually do n't have a favorite instructor i have more favorite rides\n[doctor] okay what kind of rides do you like\n[patient] i like rock music and regain music rides so whoever is doing those in a began or a medium content i'm cool with\n[doctor] i ca n't picture you as a regade person so that's interesting to know okay alright and any numbing or tingling in your foot at all\n[patient] yes but not from the knee injury i broke my foot my second toe on my right foot and i have numbness depending upon the shoe i wear\n[doctor] okay when did you break your toe\n[patient] i've broken it three times over the last ten years so it's just something that's a an annoyance but it was n't caused by this injury\n[doctor] okay so you do have some numbing and tingling but it's not new\n[patient] right correct\n[doctor] alright alright well let's just go ahead and i'm gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so on your musculoskeletal exam on your right knee i do appreciate some slight edema you do have a slight effusion does it hurt when i press on the outside of your knee\n[patient] no not physically\n[doctor] okay there is no pain to palpation of the right lateral knee i'm gon na be bending your knee in all sorts of positions does that hurt\n[patient] only when you pull it to the outside\n[doctor] okay\n[patient] from my my foot when you pull it to the outside that's the only time it hurts\n[doctor] okay the patient has a positive varus test there is full range of motion there is a negative lachman sign the patient does on cardiovascular exam the patient does have a palpable dorsalis pedis and posterior tibialis pulse okay well let's just i wan na talk a little bit about i had the nurse do an x-ray on you and i looked at the results of your knee x-ray and it does n't show any acute fracture or bony abnormality which is not surprising based on your injury so let's just talk a little bit about you know my assessment and my plan for you so i think you do have a a lateral a lateral collateral ligament strain based on your exam findings and this this type of injury essentially can be healed by itself you know i do n't think we're gon na need to refer you to surgery or anything like that i want you to go ahead and i'm gon na prescribe meloxicam fifteen milligrams once a day i do wan na go ahead and refer you to physical therapy because if we strengthen up those muscles and areas around that injury then that will make your knee stronger it help prevent future injuries are you able to ice it at all during the day now you said you working you work in sales so you said you're home\n[patient] yeah i actually i'm at home so i can ice it and i have been icing it\n[doctor] okay\n[patient] i mean twenty on twenty off at least four times a day\n[doctor] okay and so does that help at all\n[patient] it's it it makes it feel better in the morning when i first go to my desk and at the end of the day before bed you know i take ibuprofen so i do n't have swelling overnight but honestly i have a pretty decent threshold for pain so it's not good it's not changing it by much\n[doctor] okay do you feel like your symptoms are getting worse or better i think i think pretty much for the last two weeks they've remained about the same the the only time i feel like they get worse is when i exert myself doing up and down like gardening in the yard or moving pots\n[patient] and stuff outside that's the only time i felt like it got any worse but nothing to the point where it stayed worse\n[doctor] okay alright well let's go ahead and refer you to physical therapy if you're still having pain then we might have to consider an mri\n[patient] okay\n[doctor] any questions about that\n[patient] no\n[doctor] okay alright well it was very nice seeing you today call me if you need anything\n[patient] i will\n[doctor] okay bye\n[patient] bye",
            "tgt": "HISTORY OF PRESENT ILLNESS\n\nGregory Price is a pleasant 68-year-old male who presents to the clinic today for the evaluation of a right knee injury. The onset of his pain began 2.5 weeks ago, when he stepped off of a curb and turned over his ankle. He locates his pain to the lateral aspect of his right knee. The patient also reports clicking with ambulation. He denies any pain with ambulation unless he stands on one foot for an extended period of time. The patient also reports locking of his knee with prolonged standing. He notices pain when he is resting his foot on his heel. He denies any pain at rest and elevated, or when his foot is flat on the ground. The patient states that he is more active during the day, which does not impact his knee pain. He adds that he is able to perform a full squat without pain. The patient reports numbness and tingling in his right foot, however this is not new. The patient has been taking ibuprofen, which provides him with relief at night. He has also been icing his knee 4 times per day, which provides him with relief in the morning and at the end of the day.\n\nMEDICAL HISTORY\n\nHe states that he has fractured his 2nd toe 3 times over the last 10 years.\n\nSOCIAL HISTORY\n\nThe patient works in sales. He rides a bike for exercise.\n\nREVIEW OF SYSTEMS\n\nNeurological: Positive for numbness and tingling in his toes on his right foot from prior injury.\n\nPHYSICAL EXAM\n\nCV: >Palpable dorsalis pedis and posterior tibialis pulse.\nMSK: Examination of the right knee: Slight edema. Slight effusion. No pain with palpation of the right lateral knee. Positive varus test. Full ROM. Negative Lachman's.\n\nRESULTS\n\n4 views of the right knee were taken. These reveal no evidence of any fractures, dislocations, or bony abnormality. No other abnormalities are noted.\n\nASSESSMENT\n\nRight knee lateral collateral ligament 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. I have explained to him that his x-rays did not reveal any acute fractures or bony abnormality. I have recommended that we treat the patient conservatively with formal physical therapy to strengthen his right knee. I have also prescribed the patient meloxicam 15 mg to treat his pain. If his pain does not improve with physical therapy, I will recommend obtaining an MRI.\n",
            "file": "D2N153-aci"
        },
        {
            "src": "[doctor] hi dennis how are you today\n[patient] good\n[doctor] so what what brings you into the office i do n't believe i have ever seen you before here\n[patient] the i'm training for a triathlon and the back of my heel hurts typically after a workout or when i first get up in the morning it will really hurt in the back of my heel all the way up into my calf\n[doctor] okay now tell me a little bit about this triathlon training what do you are you are you running far are you tell me kind of how you work out for that today\n[patient] i i will run about ten klometers\n[doctor] okay\n[patient] in the morning at lunchtime i try to get on the bike for about forty five minutes to an hour\n[doctor] okay\n[patient] and then in the evening i go to the aquatic center and i jump in the pool and swim for about another thirty minutes to an hour\n[doctor] wow that's that's a that's an aggressive campaign to get there so really hope you get that triathlon in so you're how many days a week does this occur that you're training\n[patient] i i do that five days a week on the weekends i kinda alternate between you know a long run and a long bike do n't really do a long swim but\n[doctor] okay\n[patient] i i just swimming on those other five days and i take one day off\n[doctor] okay on your running days or when you do the running tell me a little bit about your stretching routine do you are you aggressive stretchers you do not stretch at all i know people that do both\n[patient] yeah i do n't i do n't stretch at all i do n't have time for that\n[doctor] okay and i'm assuming that with the bicycle either you do n't really work the lower legs to get them stretched out you just jump on and go correct\n[patient] yeah\n[doctor] okay\n[patient] yeah you know i you know when i first start off i go slow until i'm warmed up and then i\n[doctor] okay tell me a little bit about the pain is you said it it's after the activity but it you when you first wake up in the morning it it's it's there also\n[patient] yeah when i first get out of bed it's just it just feels really tight and almost like it's tearing and i after i been walking around for about ten or fifteen minutes it eases up a little bit but if if i ever sit down for any extended period of time and then try to get back up it's really sore again\n[doctor] okay\n[patient] or\n[doctor] no go ahead go ahead\n[patient] or after a lot of activity it'll get sore too\n[doctor] okay okay i'm sure this is impacting that ability to to really focus on your training uh as you're going with that with that type of a pain so lem me go ahead and let's let's take a look at your your and your lower extremities here and yeah okay so roll up your pants yeah okay good now does your left leg hurt at all do you get that severe pain or is it mainly on the right\n[patient] no it's mainly just on the right\n[doctor] okay okay so i'm gon na just hold your leg here and i want you to take your your foot and ankle and i want you to go ahead and just pull your your toes up towards you does that create some pain when you do that\n[patient] yeah a little bit\n[doctor] a little bit okay now i'm just gon na hold your foot up and i want you to push against me and does that hurt\n[patient] yeah that hurts a little bit too\n[doctor] yeah okay okay roll over here on my my stretcher for me and i want you to dangle your your feet over the edge and what i wan na do is i just wan na i'm gon na squeeze your left calf first and when i do that does that hurt on your left side\n[patient] no\n[doctor] okay\n[patient] no\n[doctor] and i'm gon na squeeze on the right side anything there\n[patient] no\n[doctor] okay okay well that's good your your thompson test is negative that's a really good finding and i just wan na continue pressing here on your right from your heel when i squeeze your heel does that cause significant pain at all\n[patient] yeah\n[doctor] yeah okay and if i come up a little bit further as i i run up that achilles tendon does that hurt\n[patient] that's real tender\n[doctor] yeah okay okay great not great so yeah go ahead and sit up for me so dennis my diagnosis is achilles tendinitis and it's really from overuse when we see this frequently when somebody starts to you know get in and train aggressively for an event i'm unfortunately i'm gon na have to ask you to stop training for a a week or two i know that's concerning but i really want this to heal before we move into that next phase i did n't ask you about medication but i'm assuming whatever you were doing was n't working significantly so what i'd like you to do is take some ibuprofen or advil that's the same medication and i want you to take three tablets every six hours and that's really an anti-inflammatory see if we can eliminate some of that tendinitis type pain that you're getting that inflammation around that achilles tendon i'm gon na also order a couple physical therapy visits and the reason for that is i'd like you to get some strength and stretching understanding i think it's important for you especially here at the beginning is to get some of that real stretching knowledge in and learn how to stretch those muscles before you start these activities and they are gon na help strengthen your your lower extremities also and i want you to come back to me within you know a week to ten days following your first couple physical therapy appointments so i can monitor how you're doing i see no reason for an x-ray at this point but if this continues we're gon na you know if you're still having pain ten days in significant pain without change modification of your activity then we may have to look at more aggressive treatment plans how does that sound for you\n[patient] sounds good\n[doctor] okay hey did you happen to catch that pittsburgh pang one hockey game last night\n[patient] no i i was watching the track meet\n[doctor] my gosh the the pang ones are on fire you know they beat up on new york seven to two i mean the hockey's just an amazing sport i i just do you guy do you do a lot of hockey down there in town here\n[patient] used to when i lived in detroit\n[doctor] oh\n[patient] hockey town but not so much anymore\n[doctor] no yeah detroit is a hockey town yeah the red wings okay well i'm gon na go ahead and i'll send my nurse in and go ahead and get you discharged and like i said i'd like to see you back here in seven to ten days after that first physical therapy appointment i've got a great phenomenal office staff you just call in once that gets scheduled they will get you in to that next available appointment so take care and i will talk to you later\n[patient] thanks",
            "tgt": "HISTORY OF PRESENT ILLNESS\n\nDennis Martin is a pleasant 46-year-old male who presents to the clinic today for the evaluation of right heel pain. The onset of his pain began 10 days ago while training for a triathlon. He locates his pain to the posterior aspect of his heel, which radiates proximally into his calf. His pain is aggravated by working out and when he first gets up in the morning. If he sits for a long period, his pain will return upon standing. The patient states that he runs 10 kilometers in the morning. At lunchtime, he tries to get on a bike for about 45 minutes to an hour. In the evening, he goes to the aquatic center and swims for 30 minutes to 1 hour. The patient states that he runs 5 days per week. He adds that he alternates between a long run and a long bike ride on weekends. He currently takes one day off from his exercises. The patient states that he does not stretch at all. He denies any left leg pain.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports right heel pain. Denies left leg pain.\n\nPHYSICAL EXAM\n\nMSK: Examination of the right heel: Pain with resisted extension. Mild pain with flexion. Positive calcaneal squeeze test. Severe tenderness to the Achilles tendon. Thompson test is negative, bilaterally.\n\nRESULTS\n\nNo new imaging was obtained today\n\nASSESSMENT\n\nRight Achilles tendinitis.\n\nPLAN\n\nAfter reviewing the patient's examination today, I had a lengthy discussion with the patient regarding his current symptoms. I have explained to him that his symptoms are likely secondary to overuse. I have recommended that we treat the patient conservatively. The patient was instructed to take at least 1 week off from his training to recover from this. I will provide him with a referral for formal physical therapy to strengthen his right lower extremities. I have advised him to take 3 tablets of ibuprofen every 6 hours for pain. If his pain does not improve with physical therapy, I will recommend obtaining an x-ray.\n\nINSTRUCTIONS\n\nThe patient will follow up with me in 7 to 10 days to check on his progress.",
            "file": "D2N154-aci"
        },
        {
            "src": "[doctor] so hey christina good to see you today i see you're here you have a nonhealing foot ulcer well also looks like in my notes that you got some you've got type two diabetes and that probably the reason for your ear but ulcer not healing so how you doing today what's going on\n[patient] doing pretty good except i ca n't get this ulcer to heal\n[doctor] okay how long has that wound been present\n[patient] maybe about a year\n[doctor] a year well that that's a that's a a long time so when it started i guess did you have any trauma to the foot or did was it just all of a sudden\n[patient] no trauma it just it seemed like a little blister and then i picked at it and it did get a little bit red and infected so i talked to my primary about it\n[doctor] okay\n[patient] i went on some antibiotics it seemed to get better but nothing is really making it go away\n[doctor] okay when was the last time you were on antibiotics\n[patient] it's probably been five months\n[doctor] five months alright do you remember which antibiotics you were on\n[patient] keflex\n[doctor] keflex alright so kinda does your foot hurt or is it just just the\n[patient] no pain but i do n't have much feeling in my foot\n[doctor] alright so you've got neuropathy yeah that that that makes sense with the the diabetes so have you had any other symptoms like a fever chills any drainage coming from it\n[patient] lately there has been a lot more drainage and i just feel a little more tired\n[doctor] okay alright well that that sounds good so today is thursday so what do you have for the weekend\n[patient] not too much i'll probably be walking around at the zoo on this ulcer all weekend and eating out and not doing anything my doctor wants me to do\n[doctor] no yeah i yeah i know you do have that diabetes i know your pcp probably would n't be excited about you you eating out and all that but you know hopefully we can we i can at least get your your foot a little bit better so your diabetes i know we talked a little bit earlier how is that going for you is it controlled you know what's your your blood sugars running\n[patient] yeah they are running better than they were but they are still in the two hundreds so my doctor does n't like that my last a1c was about ten\n[doctor] okay alright yeah i i you probably definitely need to get back with your pcp about that because the a1c is is pretty high and i know he probably had you on some medication and insulin and metformin and insulin just to try to to get that lower but\n[patient] yes\n[doctor] you know we are here for your foot so let's let me take a look at that so we will do a quick exam of your foot so you do n't have any fever your vitals look good so on your your right foot exam i can see here you do have a one by two centimeter two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint i do see some yellow slough that's present with minimal granulation tissue you have no surrounding erythema or cellulitis and there is n't any evidence of fluid collection i do n't see necrosis so there is no dead tissue around it there's no odor and i i do n't appreciate any bony exposure and does it hurt when i touch it here\n[patient] no\n[doctor] okay so we did a x-ray of your right foot before you came in and it showed no evidence of osteomyelitis that means that there is no bone infection which is really good so let me just talk a little about my assessment and plan of your your foot so you do have that diabetic foot ulcer so what i'm gon na do is i'm going to order a abi or ankle brachial index and that's just to determine your blood supply just to see if we can actually heal that wound i know it's been there for about a year which is a pretty long time and so we just need to see if we can if you do have that blood flow just in case we need to to make other goals for that foot just to depend upon that i'm also gon na do a debridement here have you had that done before of the\n[patient] yes i think so\n[doctor] okay so you know you know pretty much about that so i'm just gon na try to take off some of that dead tissue we'll do that here in the office afterwards and then i'm going to prescribe you some colaganase ointment and you could just add that to your wound once a day and cover it with a sterile dressing and we're gon na try to continue that until we see it start to shrink and hopefully you know that will work between the debridement and then the ointment did they give you at your pcp they give you a surgical shoe or have you been wearing your regular shoes\n[patient] i've just been wearing my regular shoes\n[doctor] okay so we're gon na get you a surgical shoe and i want you to to wear that and that can help you take pressure off the area because i know you said you're gon na walk around with this zoo this this weekend so i definitely do n't want you to put much pressure on it from now on and hopefully that can help it heal and so after all that i'm just gon na see you back in two weeks and we could take another look and possible do another debridement of the ulcer so do you have any questions for me\n[patient] i do n't think so\n[doctor] alright so i'll see you back in two weeks and i hope you have fun at the zoo this weekend\n[patient] thank you\n[doctor] alright thanks",
            "tgt": "CHIEF COMPLAINT\n\nNon-healing right foot ulcer.\n\nHISTORY OF PRESENT ILLNESS\n\nChristina Cooper is a pleasant 77-year-old female who presents to the clinic today for the evaluation of a non-healing right foot ulcer. The onset of her wound began 1 year ago with no specific injury. The patient states that it seemed like a blister and she picked at it where it then turned red. The patient was seen by her primary care physician and was prescribed Keflex. She states that the antibiotics improved her symptoms, however they did not resolve them. The patient adds that she was last on Keflex 5 months ago. She denies any pain, however she reports decreased sensation in her foot. The patient also reports increased drainage and fatigue. She states that she has been wearing her regular shoes.\n\nThe patient has type 2 diabetes with neuropathy. She states that her blood sugars are running better than they were; however, they are still in the 200's. Her last hemoglobin A1C was 10.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Reports fatigue.\nSkin: Reports right foot ulcer and drainage.\n\nVITALS\n\nNo fever noted. Vitals look good today.\n\nPHYSICAL EXAM\n\nMSK: Examination of the right foot: There is a 1.0 cm x 2.0 cm wound on the dorsal aspect of the lateral right foot, just proximal to the 5th MTP joint. I do see some yellow slough that is present with minimal granulation tissue. No surrounding erythema or cellulitis. There is no evidence of fluid collection. I do not see necrosis. No odor. I do not appreciate any bony exposure. No pain to palpation.\n\nRESULTS\n\nX-ray of the right foot today reveals no evidence of osteomyelitis.\n\nASSESSMENT\n\nRight diabetic foot ulcer.\n\nPLAN\n\nI have recommended that we obtain an ankle brachial index to determine her blood supply to see if we can heal the wound. We discussed doing a debridement in office today, which she agreed to. I have also recommended that the patient be placed in a surgical shoe to provide increased support. I have also prescribed the patient collagenase ointment to apply to her wound 1 time per day and cover it with a sterile dressing. I advised the patient that this should be continued until we see the ulcer decrease in size.\n\nINSTRUCTIONS\n\nThe patient will follow up with me in 2 weeks to check on her progress.",
            "file": "D2N155-aci"
        },
        {
            "src": "[doctor] alright julia so you've been coming to see me for a while now ever since you had an rca stent placed back in twenty eighteen but i see you're here for follow-up after an interior stemi where we had to put in another stent right so like how are you doing\n[patient] well i mean it was a real shock for me i thought everything was fine after my last heart attack and then i just started having this horrible chest pain and it would n't go away so i went to the emergency room and yeah they told me i needed another stent\n[doctor] wow so you were experiencing similar symptoms similar to what you had the first time\n[patient] yeah yeah it was yeah it was bad it was just like the last time\n[doctor] okay have you had any chest pain or shortness of breath\n[patient] no i think i saw you about six months ago and and i was doing fine\n[doctor] okay have you been able to like exercise at all since since you last saw me\n[patient] yeah you know i walk my dog everyday and you know we go like a mile and a half or two miles\n[doctor] awesome okay yeah you know because like fall is setting in like are you excited\n[patient] yeah yeah i'm excited\n[doctor] do you have any like plans for the holiday\n[patient] no mm-hmm no i'm just you know looking forward to seeing family and having some nice weather and yeah\n[doctor] okay so i do wan na ask i know that you have a history of coronary artery disease hypertension and diabetes so i wan na get an idea of like where you stand with those have you been experiencing any kind of leg swelling\n[patient] i have noticed that my legs are a little swollen since they sent me home from the hospital\n[doctor] okay are you able to lie flat at night when you sleep\n[patient] yeah i mean i always use a couple of pillows you know i maybe i've had to sit up a little bit more but i mean for the most part i think it's pretty normal\n[doctor] okay and then have you been able to afford your medications and are you taking them like your like you were prescribed\n[patient] yeah i'm able to afford afford them i have good insurance i am taking them they told me it's really important to take them so so yeah\n[doctor] yeah that's very accurate you know like there are huge consequences to not taking them so if you are noticing any problems please please please please let us know how about your diet are you watching your salt intake\n[patient] i mean i'm not i i i have n't really adjusted i mean i tried to watch it after the last heart attack and now you know i i've kind of been less strict with my diet but i'll have to go back to watching the salt intake\n[doctor] mm-hmm\n[patient] i love pizza it's my favorite food\n[doctor] yeah\n[patient] my tries are probably my second favorite food\n[doctor] what are you for her toppings on pizza\n[patient] pepperoni occasionally vegetables\n[doctor] mm-hmm alright but you know that pepperoni is pretty high in salt on top of a cheesy pizza right\n[patient] i know i know i'm gon na work on it\n[doctor] okay so we are we are gon na have to negotiate some of these diet things and then especially since you have diabetes like have you been managing that well\n[patient] my i've been watching my sugars yep because i do n't wan na go on insulin so i'm taking that metformin that's why i've been walking my dog i'm trying to stay active\n[doctor] okay okay so you know maybe this is just a situation of like where we are on the right path but probably need to step up a few things okay\n[patient] okay\n[doctor] alright so i do want to do a quick physical exam so you are aware i'm going to be calling out my findings as i run through it alright\n[patient] okay\n[doctor] alright so your vital signs look good you know so i'm glad that it looks like you're tolerating your medication pretty well on your neck exam i do n't appreciate any jugular venous distention so and then on top of that i'm not i do n't appreciate any carotid bruits so i'm not feeling anything like too concerning on your heart exam though there is a three over six systolic ejection murmur heard at the that i'm hearing at the left base that's not like a huge deal especially considering like what you've been through already in terms of the hospital but it is something that i wan na know in your chart when i listen to you your lungs your lungs are clear over here with your extremities i do notice you know some lower lower edema swelling sorry some lower swelling edema lower limb edema and it it is pitting one plus on your right radial artery the cath site is clean dry and intact without hematoma and i also your right radial artery pulses are palpable so i did review the results of your ekg and they show a normal sinus rhythm and a good r wave progression and a a evolutionary changes that are anticipated after a stemi one of the reasons though that we had you come in is that we noticed on your echo there is a reduced ejection fraction of thirty five percent we are a little bit concerned about that so let's talk about my assessment and plan for you your primary and like first diagnosis is gon na be coronary artery disease right you already have a history of that but you know we're gon na do some things to make we're gon na continue to evaluate that over time i want you to continue your aspirin eighty one milligrams daily and your brilinta ninety milligrams twice daily i wan na continue you on a high dose statin called lipitor and you're gon na be taking that eighty milligrams a day and we're gon na continue you on your toprol and that's gon na be fifty milligrams daily i am gon na refer you to cardiac rehab so we can get you some education and give you some confidence to get back to exercising regularly i know it was kinda scary to have such an episode but i promise like most of the patients i have love cardiac rehab and i think you'll do pretty well for your second diagnosis we have newly you have newly reduced left ventricular dysfunction and moderate mitral regurgitation what i think is like what that means is that you're you're pumping like the way that your heart is pumping is a bit concerning but i think like given your history that it will improve over time they got you into the cath lab pretty quickly so i think that the muscle is just kinda like stunned like surprised and since you're compliant with your meds i think you will recover we are gon na continue you on your lisinopril twenty milligrams daily however considering that you are retaining fluid i think that your third diagnosis is like we are crossing into acute heart failure i'm gon na prescribe something called a diuretic it's called lasix and i do want to we need to take that forty milligrams once a day i wan na add aldactone twelve . five milligrams daily and i need you to get labs finally we will repeat another echo in about two months last but not least there is the hypertension your blood pressure seems fine i think with the aldactone that you'll tolerate that pretty well but we do want to maybe get you into some nutrition counseling to consider like what other diet options might be available to you maybe suggestions of things that you have n't thought about like cutting out meat especially any kind of preserved meat like pepperoni but maybe finding you some alternatives how does that sound\n[patient] that sounds good yeah so i'm yeah as long as you tell me i'm gon na get better i believe you\n[doctor] yes yeah i i strongly believe this is our best course of action and that you will get better given enough time i i see that you are making efforts i'm really glad that you are out there walking and that you're cognizant of your diet and willing to make changes we will just you know monitor it over time okay\n[patient] okay\n[doctor] alright thank you",
            "tgt": "CHIEF COMPLAINT\n\nFollow up status post inferior STEMI.\n\nSURGICAL HISTORY\n\nRCA stent 2018\n\nMEDICATIONS\n\naspirin 81 mg daily\nBrilinta 90 mg twice daily\nLipitor 80 mg daily\nToprol 50 mg daily\nlisinopril 20 mg daily\nmetformin\n\nREVIEW OF SYSTEMS\n\nCardiovascular: Denies chest pain.\nRespiratory: Denies shortness of breath.\nMusculoskeletal: Reports bilateral leg swelling.\n\nVITALS\n\nWithin normal limits\n\nPHYSICAL EXAM\n\nNeck\n- General Examination: No jugular venous distention.\n\nRespiratory\n- Auscultation of Lungs: Clear bilaterally.\n\nCardiovascular\n- Auscultation of Heart: No carotid bruits. A 3/6 systolic ejection murmur is heard at the left base.\n- Examination: Right radial artery cath site is clean, dry, and intact without hematoma. Radial artery pulses are palpable.\n\nMusculoskeletal\n- Examination: Bilateral lower limb edema. Pitting 1+.\n\nRESULTS\n\nEKG is reviewed and demonstrates a normal sinus rhythm. Good R wave progression. Evolutionary changes that are anticipated after a STEMI.\n\nEchocardiogram is reviewed and demonstrates a reduced ejection fraction of 35%.\n\nASSESSMENT AND PLAN\n\n1. Coronary artery disease.\n- Medical Reasoning: The patient has a history of coronary artery disease that we will continue to monitor.\n- Medical Treatment: She will continue aspirin 81 mg daily and Brilinta 90 mg twice daily. She will continue Lipitor 80 mg a day and Toprol 50 mg daily. I am going to refer her to cardiac rehab for education and to gain confidence to resume exercising regularly.\n\n2. Newly reduced left ventricular dysfunction and moderate mitral regurgitation.\n- Medical Reasoning: A recent echocardiogram revealed a reduced ejection fraction of 35%. She was able to be treated in the cath lab in a timely manner, so I think that the muscle is just stunned. Given her history. it will improve over time.\n- Patient Education and Counseling: I advised the patient that she will recover since she is compliant with her medications.\n- Medical Treatment: Continue lisinopril 20 mg daily.\n\n3. Acute heart failure.\n- Medical Reasoning: The patient is retaining fluid.\n- Medical Treatment: I am going to prescribe Lasix 40 mg once a day. I want to add Aldactone 12.5 mg daily. I will order lab work. We will obtain a repeat echo in approximately 2 months.\n\n4. Hypertension.\n- Medical Reasoning: Blood pressure is well controlled. She will tolerate the Aldactone well.\n- Patient Education and Counseling: I encouraged the patient to continue exercising and to be cognizant of her diet. I explained that there are healthier alternatives available to reduce the amount of preserved meats she consumes.\n- Medical Treatment: Continue lisinopril 20 mg daily. The patient received a referral to nutrition counseling to consider what other diet options might be available to her.\n\n5. Type 2 diabetes.\n- Medical Reasoning: Stable.\n- Patient Education and Counseling: I encouraged the patient to continue monitoring her blood glucose levels.\n- Medical Treatment: Continue metformin as prescribed.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow up as instructed.",
            "file": "D2N156-aci"
        },
        {
            "src": "[doctor] hey jose how are you doing it's been about you know three or four months since i last saw you what's going on\n[patient] i'm doing okay i i guess the medications are helping i'm concerned about all the medications i'm taking but i think i'm doing okay\n[doctor] yeah yeah you are on a fair amount of medications you know we do have you on those medications because you did have a heart attack about six months ago they put that that stent into your left anterior descending artery and so that's a major artery on the left side of your heart and so we need to keep those stents open and and kinda help your heart heal so it is gon na be very important for you to continue on those medications so you're still taking your aspirin and are you still taking the brilinta\n[patient] yes and and fish oil\n[doctor] and fish oil okay good now how are you doing with the crestor i know that that's you know that's the statin that's the cholesterol medication you were concerned that it might cause you to have some muscle aches are you taking that\n[patient] i i think i'm doing good but i i am i feel like i i when i i guess the only complaint that i have is ever since i i do n't know if this is the heart attack or if this this is the the medication but when i stand up real fast i get really dizzy\n[doctor] you get you get dizzy okay yeah you know we do have you on a what we call a beta-blocker metoprolol i think your dose is fifty milligrams once a day and you know sometimes it takes a little bit for your body to adjust to that but yes if you stand up too quickly it can cause you to be a little dizzy so\n[patient] okay okay that makes sense okay that's good to know because i did n't know what what what the problem was so can i ask you a question regarding the stents\n[doctor] yep\n[patient] how long do i have to have that in there\n[doctor] so the stents are permanent we do n't we do n't remove them so yep so that's why it's gon na be super important for you you know you're gon na be on aspirin for the rest of your life and then i'm gon na keep you on that brilinta for another six months that's gon na help prevent the that stent from clogging\n[patient] okay okay do i need to ever replace the stents then\n[doctor] no i mean every so often the stents can become narrowed again but you know that's why you're seeing me your cardiologist so that i can follow you for that now if you start to have symptoms again of any chest pain like you had before or any shortness of breath when you start to exert yourself i want you to tell me and we might have to go ahead and send you for further testing to make sure that those stents are okay but typically if you continue to take the medication watch your diet that type of thing your stents will will stay open for a long time\n[patient] okay alright that sounds good you know i have n't i had a i had i know you asked me to follow up with the dietitian because i had diabetes as well which probably contributed to my heart attack\n[doctor] yeah\n[patient] i may need a new order i do n't i i forgot who i was supposed to talk to\n[doctor] okay that's okay yeah i certainly can help you with that now managing your diabetes is also going to play an important role in your coronary artery disease which it sounds like you already know that which is really good so i will put in another referral for diabetic education for you how are you doing watching your sweets i know that you know you do have an afinity for those chocolate chip cookies\n[patient] it's okay my a1c was n't where i wanted but my glucose is coming in in about one thirty\n[doctor] okay\n[patient] fasting\n[doctor] okay what was the what was the a1c the hemoglobin a1c if you do n't mind me asking\n[patient] i thought it was close to sixty\n[doctor] okay yeah that's really high so we want it to be about six so you you do have some work to do with your diet\n[patient] yeah yeah so okay so i know you asked me to do a blood test so i did that i was wondering if you got the results\n[doctor] i did you know i looked at the results of your kidney function that's what we call your creatinine just because you had some contrast dye and sometimes contrast dye can impact the kidneys and your kidney function is stable which is great when was the last time you saw your nephrologist\n[patient] oh\n[doctor] that's your kidney doctor\n[patient] i'm a bad i'm a bad patient so probably a year ago\n[doctor] okay you know you do have the stage three ckd so that's the the stage three kidney disease so it is gon na be important for you to follow up with your nephrologist just to make sure that everything is okay now i did check your kidney function and and it was fine but are you staying away from things like motrin and advil\n[patient] right yeah that's i threw all of those out\n[doctor] okay good okay perfect now i know that you're from the west coast are you super excited that la one the super bowl or are you more of a san francisco forty nine or span\n[patient] i'm a more of a san francisco fan\n[doctor] so do you like jimmy g do you think he can beat erin rogers again\n[patient] okay we'll see we'll see what happens but i'm pretty flexible when he comes to you know that is but one thing that since i ca n't take motrin what pain killer can i take for headaches\n[doctor] you can take tylenol\n[patient] okay\n[doctor] yeah\n[patient] alright that sounds good\n[doctor] yeah\n[patient] okay\n[doctor] okay\n[patient] this is i i do n't think i have any other question the only thing i'm gon na need is a i need some refills on my medications\n[doctor] yeah i can do that but i do wan na just do a physical exam on you okay so and looking here at your vital signs here you know your your vital signs look quite good you know your blood pressure is what right where it should be it's about one twenty seven over eighty which is great so you're doing a good job taking your metoprolol now in terms of on your neck exam i do n't appreciate any jugular venous distention or carotid bruits on your heart exam i do appreciate a slight three out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do appreciate some one plus nonpitting edema now what does that mean what does that mean jose so all of that means is that i do hear a little heart murmur on your heart which i've heard before in the past and it does n't it does n't look like you're retaining any fluid which is good but you do have a little puffiness in your legs which sometimes some of the medications can cause\n[patient] yeah i do have that\n[doctor] so let's just go over a little bit about my assessment and and plan for you going forward so for your first problem of your coronary artery disease i think you're doing really well i wan na go ahead and refer you for cardiac rehab just so that you can be more active and have some confidence in in exercising again okay and i am gon na go ahead and refill your metoprolol your crestor forty milligrams once a day as well as the aspirin okay i do n't think we need to proceed with a a stress test or anything at this time but you know to let me know if you have any symptoms okay\n[patient] okay\n[doctor] okay for your\n[patient] sounds really good\n[doctor] good for your second problem of your stage three chronic kidney disease i am gon na reach out to doctor miller and make an appointment for you to be seen just because again i think it's important for you to follow up with your nephrologist okay\n[patient] okay\n[doctor] and then for your third problem of your diabetes i am gon na go ahead and order another hemoglobin a1c and i'm gon na put that referral in for the dietitian to give you some dietary education and i'm gon na go ahead and talk with your primary care physician about your your insulin regimen okay\n[patient] okay\n[doctor] any questions\n[patient] yeah you know i've been kinda down ever since i had my heart attack is there any medication that i could take to make me feel a little bit less sad\n[doctor] yeah i mean are you having any thoughts of of harming yourself or harming others\n[patient] no no i just feel kinda down\n[doctor] you feel kinda down what's your\n[patient] life sucks\n[doctor] what well i do n't think so what what's your support system like\n[patient] you know i i live with my dog and that's it so it's kind of you know lonely\n[doctor] okay alright well would you be interested in in like a referral to psychiatry or something like that so that you have someone to talk to about some of of issues because medication can help but i do i think it's important to have you know talk some of these things out\n[patient] okay yeah you know i'll give that a try i mean i'm retiring i got plenty of time\n[doctor] okay so why do n't we go ahead and i'm gon na place a referral to psychiatry for you know you know difficulty adjusting after having a heart attack maybe some some mild depression okay does that sound okay okay\n[patient] yeah that sounds really good thank you\n[doctor] okay you're welcome anything else\n[patient] so you will do the medication refill do i so that's automatic\n[doctor] yep i'm gon na put them into the computer and and whatever pharmacy you want yep mm-hmm\n[patient] okay alright sounds great thank you\n[doctor] okay you're welcome i'll be in touch bye\n[patient] okay alright bye-bye",
            "tgt": "CHIEF COMPLAINT\n\nFollow-up.\n\nMEDICAL HISTORY\n\nPatient reports having a heart attack 6 months ago, coronary artery disease, diabetes.\n\nSURGICAL HISTORY\n\nPatient reports history of stent placement at the left anterior descending artery.\n\nSOCIAL HISTORY\n\nPatient reports that he is from the west coast and is a San Francisco 49ers fan. He lives with his dog.\n\nMEDICATIONS\n\nPatient reports taking aspirin, Brilinta, fish oil, Crestor, metoprolol 50 mg once a day,\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports non-pitting lower extremity edema. Denies muscle aches.\nNeurological: Reports dizziness and headaches.\nPsychiatric: Reports depression. Denies suicidal ideation or homicidal ideation.\n\nVITALS\n\nVital signs look good with blood pressure of 127/80.\n\nPHYSICAL EXAM\n\nNeck\n- General Examination: No jugular venous distention or carotid bruits.\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: Slight, 3/6 systolic ejection murmur heard at the left base.\n\nMusculoskeletal\n- Examination: 1+ non-pitting lower extremity edema.\n\nRESULTS\n\nLab results are reviewed and show stable a creatinine level.\n\nASSESSMENT AND PLAN\n\n1. Coronary artery disease.\n- Medical Reasoning: The patient is doing very well and has been compliant with all medications. A slight 3/6 ejection murmur was heard on exam, however, this is stable and has been present in the past. He is experiencing 1+ non-pitting edema, but this seems to be medication related.\n\n- Patient Education and Counseling: Patient was advised that his stents will remain in place permanently and that they typically do not require replacement. We discussed it is common to experience dizziness when standing quickly and that this should resolve once he is adjusted to his medications. We also discussed that cardiac rehab will be beneficial in helping him become more active and confident with exercising. He was advised to watch for symptoms such as chest pain or shortness of breath on exertion as this would need further testing such as a stress test.\n- Medical Treatment: Referral to cardiac rehab was provided. A refill for metoprolol 50 mg once a day and Crestor 40 mg once a day was also provided. He is also advised to continue aspirin daily long term as well as Brilinta for the next 6 months.\n\n2. Stage 3 chronic kidney disease.\n- Medical Reasoning: Patient's most recent creatinine levels are stable.\n- Patient Education and Counseling: We discussed the importance of following up with nephrology.\n- Medical Treatment: He will follow up with his nephrologist, Dr. Miller.\n\n3. Diabetes.\n- Medical Reasoning: Patient reports most recent hemoglobin A1c was 16.\n- Patient Education and Counseling: We discussed the importance of diabetes management and how plays an important role in his coronary artery disease. He was advised that his hemoglobin A1c goal will be 6.\n- Medical Treatment: Repeat hemoglobin A1c was ordered today. A dietitian referral for diabetes education was also provided. We will contact his primary care physician regarding his insulin regimen.\n\n4. Mild depression:\n- Medical Reasoning: Patient reports feeling depressed and having a hard time adjusting since having his heart attack. He mentions he is also lonely and does not have a support system.\n- Medical Treatment: Referral to psychiatry was provided today.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n",
            "file": "D2N157-aci"
        },
        {
            "src": "[doctor] yeah so sorry so barbara is a 31 -year-old female and she has history of diabetes type two and asthma and she is here today with abdominal pain so barbara tell me a little more about your abdominal pain what's been going on\n[patient] so i've been having this pain for the past one week and as you know i have a longstanding history of diabetes and i guess i've been drinking too much coffee lately i do n't know if that triggered my gastritis so\n[doctor] yeah\n[patient] i think it's been but lately\n[doctor] okay alright and so is it increasing in severity would you say or staying about the same or what\n[patient] it's gradually increasing for sure\n[doctor] okay alright and along with the pain have you had any nausea or vomiting or diarrhea\n[patient] nausea and vomiting is on and off\n[doctor] hmmm\n[patient] so i would say i've experienced nausea for about like three times in the past week\n[doctor] okay okay and and so and you vomited how many times\n[patient] a couple of times\n[doctor] okay alright been drinking a lot of coffee you said too uh is that is that starbucks i love those nitrocolbrus and starbucks we ever had those those are incredible\n[patient] yeah\n[doctor] that's\n[patient] and the venti\n[doctor] yeah the for sure you got ta go venti on that you really have to coax them into it though they wo n't even give you it's it's like you need a license to get a venti on that that nitro it's so strong so that's my achilles heel i tell you but okay so you think that might have you think maybe coffee contributed to your abdominal pain uh you you you you've been drinking more coffee and maybe that's related as you're thinking\n[patient] yeah i think so because i started last week and towards the end of last week my coffee intake was pretty bad so i've been controlling myself this week and you know i i probably just had one cup\n[doctor] okay yeah okay and so is the pain in your upper abdomen or where in your abdomen is it\n[patient] it's on both the sides of my upper abdomen\n[doctor] hmmm okay\n[patient] so i it also increases when i work out like if i wan na jog or like go for a run my abdominal pain just like spikes you know so i have to take it easy\n[doctor] okay alright understood you've not had any fever with that pain have you\n[patient] no i have n't\n[doctor] okay alright and so how about your diabetes how's your diabetes been doing how your blood sugars been what low one hundreds two hundreds where where is it\n[patient] i think it's been under control it's eight hundred so\n[doctor] okay good and you're still taking the metformin five hundred milligrams once a day right no actually it looks like last visit we increased that to five hundred milligrams twice per day is that correct\n[patient] yes that's probably helping me keeping it under control so\n[doctor] okay good good and then for your asthma have you had any recent asthma attacks and are you still taking the flovent twice a day and albuterol as needed for wheezing\n[patient] yes but sometimes i forget you know i have n't had any asthma attacks lately so i just figured i could decrease\n[doctor] yep okay\n[patient] i think that's a good decision though\n[doctor] yeah well better to stay on the flovent daily and then just use the albuterol if you need it but if you stay on the flovent daily it will decrease the frequency of those attacks so yeah alright well let's go ahead and examine you okay so on your physical exam it's pretty normal for the most part unremarkable but i i'll i'll say on your on your heart exam you do still have a grade three out of six systolic ejection murmur that's unchanged from your prior exam and and i'm not worried about that we're kinda watching that but it just means i hear some heart sounds when your valves are moving and otherwise normal heart exam for your abdominal exam you do have mild tenderness in the epigastrium of your abdomen your abdomen's otherwise soft there's no tenderness in the right lower quadrant whatsoever and there is no significant tenderness in the right upper quadrant so i think you know that's right where your stomach is in the upper abdomen so i think that you know that may be you may be right this could be some gastritis so so then otherwise on your exam on your lung exam you do have some mild end expiratory wheezes very faint and otherwise normal lung exam with excellent air movement and otherwise pretty normal physical exam so let's talk about your my assessment and your plan here so first of all for the first problem of the abdominal pain i do think that you have acute gastritis and i think this is probably related to the caffeine intake and i i know that you've had a a moderately heavy history of alcohol use too so i want you to cut back on the alcohol as well you know keep that down to a dull roller like maybe keep that less than two or three drinks a week would be great and then also cut back on the caffeine and that should help and i'm going to write you a prescription for zantac as well as we need and so i'll write you a prescription you can take that twice a day that should help with the acid in your stomach and the pain and then i'm going to check a urinalysis a urine pregnancy test a cbc a comprehensive metabolic panel as well and we'll see what those results show just to be sure it's nothing else going on and then for your second problem of diabetes type two let's continue you on the metformin but i wan na adjust the dose slightly i'm gon na increase the morning dose to one thousand milligrams and the evening dose we can keep at five hundred so we'll go metformin one thousand milligrams in the morning and five hundred milligrams in the evening please continue to check your blood sugars let me know what they are when you come back you know we just keep track of those and then we'll see you back in four weeks by the way i wan na have you follow up with me in four weeks and for your third problem of asthma let's continue you on the flovent that seems to be doing pretty well continue to take that daily and then also albuterol as needed so how does that sound for a plan any other questions comments suggestions\n[patient] that sounds good and i also feel like i'm eating been eating a lot of spicy food\n[doctor] hmmm\n[patient] lately that could be contributing towards my gastritis so i'm gon na cut back on that as well\n[doctor] okay yeah i'd also recommend while this is hurting you definitely cut back on the spices the spicy food easier said than done sometimes i know but yep yep alright sounds good well listen i'll see you back in four weeks give me a holler if if you have any questions or anything else in the meantime\n[patient] i will\n[doctor] alright you take care sure you got",
            "tgt": "CHIEF COMPLAINT\n\nAbdominal pain.\n\nMEDICAL HISTORY\n\nPatient reports history of diabetes type 2, asthma, and gastritis.\n\nSOCIAL HISTORY\n\nPatient reports history of moderately heavy alcohol use. She also enjoys coffee.\n\nMEDICATIONS\n\nPatient reports taking metformin 500 mg twice daily, Flovent twice daily, and albuterol as-needed.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Denies fever.\nGastrointestinal: Reports abdominal pain, nausea, and vomiting. Denies diarrhea.\n\nPHYSICAL EXAM\n\nRespiratory\n- Auscultation of Lungs: Mild end expiratory wheezes, very faint.\n\nCardiovascular\n- Auscultation of Heart: Grade 3/6 systolic ejection murmur, unchanged from prior exam.\n\nGastrointestinal\n- Examination of Abdomen: Mild tenderness in the epigastrium. Abdomen is soft. No tenderness in the right lower quadrant. No significant tenderness in the right upper quadrant.\n\nASSESSMENT AND PLAN\n\n1. Abdominal pain.\n- Medical Reasoning: This appears to be acute gastritis, likely related to her increased caffeine intake. She has a history of moderately heavy alcohol use as well.\n- Patient Education and Counseling: We discussed appropriate limitations for alcohol intake as well as spicy foods.\n- Medical Treatment: Reduce caffeine intake. Reduce alcohol intake. Prescription for Zantac twice daily provided. I'm going to order a urinalysis, urine pregnancy test, CBC, and a comprehensive metabolic panel.\n\n2. Diabetes type 2.\n- Medical Reasoning: She is doing well, but I want to make a slight adjustment to her dosage.\n- Patient Education and Counseling: I advised her to continue with home monitoring and bring those readings to her next appointment.\n- Medical Treatment: Metformin 1000 mg in the morning and 500 mg at night.\nContinue home blood sugar monitoring.\n\n3. Asthma.\n- Medical Reasoning: She seems to be doing well on her current regimen and has not had any asthma attacks lately.\n- Patient Education and Counseling: She was advised to take Flovent daily despite no recent asthma attacks as this will decrease the frequency of her attacks.\n- Medical Treatment: Continue on daily Flovent. Continue albuterol 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.",
            "file": "D2N158-aci"
        },
        {
            "src": "[doctor] good afternoon alexis i understand you're having some issues with your hand\n[patient] yes i sit at the keyboard all day long and recently i've been having some numbness and tingling in my right hand\n[doctor] okay how long has that been going on\n[patient] i do n't know probably on and off for six months but over the last month or so it's been a little more persistent\n[doctor] okay okay and when does that numbness and tingling do you get a lot of pain with it first let me ask that question\n[patient] some pain\n[doctor] some pain\n[patient] mostly when i'm actually typing on the keyboard is when i experience the pain\n[doctor] okay\n[patient] but the numbness and tingling is all the time now\n[doctor] okay and when you get this pain what makes it better is it stopping and just resting for a while or do you take medications or try other\n[patient] i've been taking ibuprofen so ibuprofen and seem like not typing on the keyboard helps the most\n[doctor] okay\n[patient] the other thing that makes it hurt is my mouse\n[doctor] your mouth okay\n[patient] wow\n[doctor] yeah when you're moving that around okay\n[patient] yeah\n[doctor] does this pain ever wake you up in the middle of the night or the pain or the tingling\n[patient] no\n[doctor] no okay\n[patient] not affecting my sleep hmmm\n[doctor] okay so and you're using motrin for for ibuprofen for for the pain well let me go ahead and take a take a look here at your is it both hands or just your right hand\n[patient] mostly my right hand\n[doctor] mostly your right hand okay so let's go ahead and take a look at that right hand when i bend your wrist does that cause any pain\n[patient] yes\n[doctor] it does okay and so you do have some pain on extension and if you pull your your hand wrist up towards you does that cause the pain also\n[patient] yes\n[doctor] yeah okay so you do have pain on flexion and extension and when i touch the fingertips here now you said you had some numbness in your thumb and your index finger and a little bit in your your middle finger the other two fingers they feel okay or do you think that there is different than the other hand\n[patient] yeah for some reason it really is just that the thumb the pointer in the middle finger that i experience the most symptoms with\n[doctor] okay\n[patient] not why that is\n[doctor] okay so i i want you to grip my hands here and just squeeze tight okay so you do have a a little bit of a less grip strength on the right and that's typical that we would see with this type of pain and and numbness that you have going on now i want you to turn your arm over for me and i'm gon na touch on or tap on the inside of your wrist or or forearm and when i do that i can see your face you're grimacing so that that that must cause that shooting pain yeah okay so you do have a positive tinel's sign so in alexis what i think is going on is that you have a a carpal tunnel syndrome and we see that frequent\n[patient] i was afraid of\n[doctor] yeah you see this frequently but people who are doing data entry spend a lot of time on keyboards or you know some a lotta manufacturing people who do a repetitive procedure again and again will get that type of pain so here is my plan i'd like to put you in a splint and it's it's it's kind of a wrist splint i would like you to wear that at night that will help with that i want you to continue with the ibuprofens but i would like you to go up to six hundred milligrams four times a day and\n[patient] okay\n[doctor] we're gon na do that now i am going to order some a a outpatient test called an emg where we look at that nerve conduction study in that wrist and that's really what's happening here is you've got some thickening in the the in the wrist and the the the membranes of the wrist that are just pressing down and just compressing some of those nerves any other questions for me for now if that test comes back positive and we'll talk about that later on your next visit if it comes back positive we may have to do we're gon na stick with conservative treatment first but we may consider some surgery where i can go in and release that impingement on your nerves through your wrist it's a simple outpatient procedure and then i think you would feel better how does that sound\n[patient] that sounds like a good plan i was hoping maybe i could get some relief with some therapy rather than having to go to surgery so i like that plan very much\n[doctor] yeah we'll start with the the wrist splint and once i get the nerve conduction studies that will give me another idea whether or not i need to send you some physical therapy in addition or if we need to go directly to surgery but that will all hinge on that nerve conduction test do you so do you have any further questions\n[patient] no that's great thank you so much\n[doctor] thank you very much",
            "tgt": "CHIEF COMPLAINT\n\nRight hand pain.\n\nHISTORY OF PRESENT ILLNESS\n\nAlexis Gutierrez is a pleasant 33-year-old female who presents to the clinic today for the evaluation of right hand pain.\n\nApproximately 6 months ago, the patient began experiencing intermittent episodes of numbness and tingling in the 1st, 2nd, and 3rd digits on her right hand. The numbness and tingling has become constant over the past month or so and is accompanied by pain with typing and using a mouse, which she does all day while working on a keyboard. She denies any sleep disturbance associated with her symptoms. Rest and ibuprofen have been the most helpful at providing symptomatic relief.\n\nSOCIAL HISTORY\n\nThe patient reports that she works on a keyboard all day.\n\nMEDICATIONS\n\nThe patient reports that she has been taking ibuprofen.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Denies sleep disturbance.\nMusculoskeletal: Reports pain in the 1st, 2nd, and 3rd digits on the right hand.\nNeurological: Reports numbness and tingling in the 1st, 2nd, and 3rd digits on the right hand.\n\nPHYSICAL EXAM\n\nMSK: Examination of the right hand: Pain with flexion and extension of the wrist.. Decreased grip strength on the right compared to the left. Positive Tinel's sign.\n\nASSESSMENT\n\nRight carpal tunnel syndrome.\n\nPLAN\n\nAfter reviewing her symptoms and exam findings, I believe her symptoms are secondary to carpal tunnel syndrome. We discussed the nature of this condition, as well as her treatment options, in detail. I recommend we treat this conservatively with nighttime wrist splinting and ibuprofen, but I want to increase her dose to 600 mg 4 times daily. I'm also going to order an EMG/Nerve conduction study for further evaluation. If this is positive, we can consider additional treatment with physical therapy or surgical intervention with carpal tunnel release.",
            "file": "D2N159-aci"
        },
        {
            "src": "[doctor] hey good to see you philip so i see here you're coming in you had some right elbow pain also you have a past medical history of hypertension diabetes we are gon na check up on those as well so can you tell me what happened to your elbow\n[patient] sure i hurt it about a week ago playing lacrosse with my kids just suddenly started hurting me when i was throwing the ball\n[doctor] okay okay so how old are your kids\n[patient] my oldest is thirteen and the other one is ten i was playing with a thirteen -year-old\n[doctor] okay yeah i know i i play with my kids sometimes and i think i'm getting too old to do all that so i just i've hurt myself before as well alright so with your your elbow what part of your elbow would you say hurts\n[patient] it's really like right at the point of the elbow right at right at like the tip of it\n[doctor] okay\n[patient] and it just it hurt hurts anytime i move it\n[doctor] anytime i move it do you remember falling\n[patient] no i do n't think so but my kid got pretty rough with me and was checking me several times with a sick\n[doctor] okay\n[patient] so i could have got hit there\n[doctor] okay alright yeah that that that definitely makes sense so how would you describe the pain is it like a dull pain is it stabbing what what would you say\n[patient] it it's a pretty sharp pain\n[doctor] okay\n[patient] anytime i move\n[doctor] okay and does it radiate down your arm or does it stay in that one spot\n[patient] it radiates down the forearm\n[doctor] radiates down the forearm alright so have you taken any medications for it to make it better\n[patient] i tried taking advil couple of days but i usually just forget about it\n[doctor] okay when you took it did it did it help at all did it change your your pain score\n[patient] yeah i i think it helped some\n[doctor] okay that's good alright so we'll we'll do a physical exam on that elbow we'll take a look at it in a second but i do wan na talk to you about your your hypertension you came in today i know you have past medical history of hypertension came in today your blood pressure's a little bit high it was a one fifty over seven over ninety which is pretty high today i see you're on twenty of lisinopril have you been taking that daily\n[patient] yes\n[doctor] okay so maybe you just have a little little white coat syndrome i know i have that myself and even though i'm a physician i i still do n't like to go to the doctor so i definitely understand how about your diet i know we talked a little bit about that before and you said kinda during the pandemic you fell off a little bit how you been doing that have you been lowering your salt intake\n[patient] yeah but i only eat low salt items avoid adding salt to food kind of the whole whole family follows like a you know like a mediterranean diet\n[doctor] okay\n[patient] we try to be pretty good about it\n[doctor] okay yeah that's good that that's that's definitely good yeah i know a lot of people during the pandemic it was you know sitting at home and and eating more than we should but that's i'm very happy that you've been compliant and you have that low salt diet so let's talk about your diabetes i think you see here on on five hundred of metformin are you taking that as well daily\n[patient] yes\n[doctor] okay and your blood sugars how have they been\n[patient] since i do n't take insulin i do n't check it everyday when i have checked it it's usually running somewhere between eighty to a hundred\n[doctor] okay yeah that's that's really good yeah so i that's that's pretty good so what we're gon na do we're gon na get a a1c just to see you know that range and it's possibility we can we can you know lower that metformin dosage but we will do that after your visit then we will take a look at that so lem me go ahead and will do that quick exam of your elbow but first i want to make sure you're not having any chest pain or anything like that\n[patient] no\n[doctor] no belly pain\n[patient] no\n[doctor] alright so listen to your lungs so your lungs are clear bilaterally listen to your heart so your heart exam you do still have that grade two out of six systolic ejection murmur but we know it about that before so let me take a look at your elbow so when i press right here on the back of your elbow is that painful\n[patient] yes\n[doctor] alright so when i have you you you flex and extend it it's painful does that does that hurt\n[patient] yes it does\n[doctor] alright so your right elbow exam shows you have pain to palpation of the olecranon area of the posterior elbow you do have mild pain with flexion and extension but you do have also normal range of motion at that elbow so we we did do an x-ray before you came in and luckily nothing's broken no fracture no bony abnormality so it's a normal x-ray which is really good so let me just talk to you a little bit about my assessment and plan for you so you have a elbow contusion i believe your son did hit you with the lacrosse stick and it caused that that pain i see some swelling little inflammation there as well you have a little bit of a bruise i think that's that's what happened so for that i know you're having some pain i'm gon na prescribe you eight hundred milligrams of ibuprofen you can take that twice a day and that should help with some of that swelling and pain i also want you to ice it three times a day for twenty minutes at a time that should also help with the swelling and pain and just for the time being for the next couple of weeks just you know maybe you know not play lacrosse with your son just to help that heal then you can get back on on the field so for your your high blood pressure we're just gon na keep you on the hypertension we'll just keep you on that twenty milligrams of lisinopril looks like you're doing great with that and your diet and then for your diabetes we will keep you on the five hundred milligrams of metformin and we will also get a a1c just to check your levels and see if we do need to adjust the medication in the future alright so do you have any questions for me\n[patient] no sounds good\n[doctor] alright so we will see you next time and my nurse will be in with those prescriptions\n[patient] alright thank you",
            "tgt": "CHIEF COMPLAINT\n\nRight elbow pain.\n\nREVIEW OF SYSTEMS\n\nCardiovascular: Denies chest pain.\nGastrointestinal: Denies abdominal pain.\nMusculoskeletal: Reports right elbow pain.\n\nVITALS\n\nBlood pressure: 150/90 mmHg\n\nPHYSICAL EXAM\n\nRespiratory\n- Auscultation of Lungs: Clear bilaterally.\n\nCardiovascular\nGrade 2/6 systolic ejection murmur.\n\nMusculoskeletal\n- Examination: Pain to palpation of the olecranon area of the posterior elbow. Mild pain with flexion and extension but otherwise normal range of motion. There is swelling about the elbow, as well as mild ecchymosis.\n\nHematology/Lymphatic/Immunology\n- Examination: Bruising noted over the right elbow.\n\nRESULTS\n\nX-ray of the right elbow was reviewed and demonstrates no evidence of fracture or bony abnormalities.\n\nASSESSMENT AND PLAN\n\n1. Right elbow contusion.\n- Medical Reasoning: The patient sustained an injury to his elbow when his son struck him with a lacrosse stick. His x-ray and exam findings are consistent with an elbow contusion.\n- Patient Education and Counseling: I encouraged the patient to avoid playing lacrosse for the next couple of weeks, just until his elbow heals. After that, he should be fine to continue playing normally.\n- Medical Treatment: I'm going to prescribe him ibuprofen 800 mg twice daily to help with some of the pain and swelling. He should also ice the area in 20-minute intervals 3 times per day to further reduce his symptoms.\n\n2. Hypertension.\n- Medical Reasoning: This appears to be well-controlled with dietary modifications and lisinopril.\n- Patient Education and Counseling: I encouraged him to keep up with his dietary modifications.\n- Medical Treatment: We will keep him on lisinopril 20 mg daily.\n\n3. Diabetes.\n- Medical Reasoning: This appears to be well controlled at this time.\n- Medical Treatment: We will keep him on metformin 500 mg and order a hemoglobin A1c to evaluate any need for medication adjustments.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.",
            "file": "D2N160-aci"
        },
        {
            "src": "[doctor] patient is an 82 -year-old male with past medical history significant for hypertension and stage three chronic kidney disease who presents for hospital follow-up after an acute on chronic chf exacerbation alright hey hey kevin how are you doing today\n[patient] hi document well i mean i thought i was doing good but then i've been trying to watch my diet like you said and i really noticed that my ankles were swelling and then one day i got really super short of breath and i even had to call nine one one now when the paramedics got there they put me on the special mask to breathe when i got to the er the doctor in the er said my blood pressure was super high\n[doctor] yeah okay so yeah so i saw that and i was notified that you were in the hospital for heart failure now i do see here that your blood pressure was two hundred over ninety are you have you been taking your medications\n[patient] well i take them most times but i do n't know sometimes i miss a dose or two but i really do try to take it for the most part\n[doctor] okay well good i'm i'm glad you're trying there you do need to take them though okay consistently now you said you were watching your diet did you have some slips you said your ankles were swelling\n[patient] well be honest with you you know i'm a big cheese man i love me some football and and we go to parties on the weekends and i mean i i ca n't help it i really like pizza and i love chicken wings and i know i should n't have them but they are good and i want to eat them when i'm with my friends\n[doctor] man i know i i totally understand i mean i do love pizza too and i love chicken minks but i do love them with dallas cowboys not so much the cheese but everybody's got your preference but but you do have to you know you have to watch those right you can you can you can have a little pizza maybe a little chicken wings every now and then but you know when you go to a lot of parties on weekends we we have to really watch that okay\n[patient] yeah i mean you're wrong about the cowboys but yeah i guess you're right about everything else\n[doctor] okay thank you so tell me how are you feeling now though\n[patient] man doc i feel good i was in the hospital a couple of days and they gave me this medicine made me go to the bathroom like nobody's business and then they gave me this water pill through my iv and i think i'm on different medications for my blood pressure now too but and i feel so much better now\n[doctor] okay well that's good to hear so have you been watching your diet too and taking taking your pills since you've been home\n[patient] yeah i've been doing just what they told me to do because i do n't wan na go back to the hospital\n[doctor] okay alright and we do n't want you to go back to the hospital it's never a good experience so you know being in a hospital it's better to be well and be at home and watching your chiefs play now have you bought a blood pressure cuff at home i know we talked about that\n[patient] yes ma'am i finally did what you told me to do and i ordered one and it came last week i've been checking it about every other day and my blood pressure has been really good\n[doctor] good very good how about have you been having any shortness of breath or problems sleeping since you've been home\n[patient] nope no shortness of breath i can get up and move around i do n't have any trouble and no problem sleeping i do have a good afternoon nap\n[doctor] good that's good you need to rest every now and then as well and now tell me have you had any chest pain\n[patient] no chest pain at all since i've been home\n[doctor] okay alright very good alright well i'm gon na go ahead and do a quick physical exam on you here kevin and so i'm looking at your vital signs here and your blood pressure today is actually pretty good at one twenty eight over seventy two your vital signs also look good in general your heart rate's been nice at like seventy nine so that's very nice and normal your respiratory rate is twenty six that's probably because you're talking to me here but that's that's alright and then your o2 sat is ninety nine percent so that's good and now on your neck exam there is no jugular venous distention so that's good on your heart exam i appreciate a two out of six systolic ejection murmur which i have heard this before and it's stable so we will just keep on monitoring that okay now your lungs here lem me listen okay they're clear bilaterally and let me take a look at your legs real quick here kevin okay so your lower extremities they do show a trace of edema so that that's gon na be that we're gon na be able to help that with the water pills that you're taking okay\n[patient] okay\n[doctor] now i did review the results of your echocardiogram which shows a preserved ef of fifty five percent abnormal diastolic filling and also mild to moderate mitral regurgitation so what all that means let me go ahead and tell you about my assessment and plan so for your first problem of your you know congestive heart failure it sounds like this was caused by you know dietary indiscretion in an uncontrolled hypertension so what i wan na do is i want you to continue on bumex two milligrams one daily that's that water pill that you're talking about and then i want you to continue to watch your diet and also avoid salty foods i know you love your pizza and chicken wings but we are gon na have to cut back on those okay kevin\n[patient] alright\n[doctor] alright now i want you to weigh yourself though everyday and then call me if you gain like three pounds in two days okay\n[patient] okay\n[doctor] okay now i do want you to see a nutritionist too and give you some education about what foods you can eat\n[patient] alright sounds good\n[doctor] alright now for your second problem of hypertension i do want you to continue on that cozaar a hundred milligrams daily and then also continue on that norvasc five milligrams once daily and i'm gon na go ahead and order a renal artery ultrasound just to be sure that we are n't missing anything we wan na make sure there's no other causes like secondary causes that that's gon na cause some problems with your with your kidney okay\n[patient] okay\n[doctor] alright now for your third problem your kidney disease i do want to get some more labs some more blood work to make sure that you tolerate this regimen\n[patient] alright that sounds good\n[doctor] okay and if do you have any other questions for me\n[patient] i do n't think right now\n[doctor] okay well then i'll see you again in three months then kevin okay take care of yourself\n[patient] alright thanks document\n[doctor] alrighty bye",
            "tgt": "CHIEF COMPLAINT\n\nHospital follow-up after acute on chronic CHF exacerbation.\n\nMEDICAL HISTORY\n\nPatient reports history of hypertension and stage 3 chronic kidney disease.\n\nSOCIAL HISTORY\n\nPatient reports being a football fan.\n\nMEDICATIONS\n\nPatient reports taking Bumex 2 mg once daily, Cozaar 100 mg daily, and Norvasc 5 mg once daily.\n\nREVIEW OF SYSTEMS\n\nCardiovascular: Denies chest pain.\nRespiratory: Denies shortness of breath.\nMusculoskeletal: Reports bilateral ankle swelling.\nNeurological: Denies any sleep disturbance.\n\nVITALS\n\nBP: 128/72.\nHR: 79 bpm.\nRR: 26.\nSpO2: 99%.\n\nPHYSICAL EXAM\n\nNeck\n- General Examination: No jugular venous distension noted.\n\nRespiratory\n- Auscultation of Lungs: Clear bilaterally.\n\nCardiovascular\n- Auscultation of Heart: Regular rate. There is a 2/6 systolic ejection murmur, stable.\n\nMusculoskeletal\n- Examination: There is trace edema to the bilateral lower extremities.\n\nRESULTS\n\nPrevious echocardiogram is reviewed and revealed a preserved EF of 55% abnormal diastolic filling and mild to moderate mitral regurgitation.\n\nASSESSMENT AND PLAN\n\n1. Congestive heart failure.\n- Medical Reasoning: This appears to be cause by dietary indiscretion and uncontrolled hypertension.\n- Patient Education and Counseling: We discussed that he should continue to monitor his diet and avoid salty foods. I advised him to weigh himself every day and call me if he gains 3 pounds in 2 days.\n- Medical Treatment: Continue Bumex 2 mg once daily. Referral to nutrition provided for dietary education.\n\n2. Hypertension.\n- Medical Reasoning: This was uncontrolled prior to his hospital visit.\n- Patient Education and Counseling: We discussed the importance of diet and home blood pressure monitoring.\n- Medical Treatment: Continue Cozaar 100 mg daily. Continue Norvasc 5 mg once daily. Renal artery ultrasound ordered for further evaluation.\n\n3. Kidney disease.\n- Medical Reasoning: Due to patient's acute CHF exacerbation, this is to be monitored.\n- Medical Treatment: Lab work ordered.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow up in 3 months. He is advised to call should he experience weight gain of 3 pounds in 2 days.",
            "file": "D2N161-aci"
        },
        {
            "src": "[patient] okay\n[doctor] hi gregory hi how are you doing today\n[patient] good how are you\n[doctor] i'm alright so i understand that you were having some you know right ankle pain and some swelling after you fell can you can you tell me a little bit about what happened\n[patient] yeah so i was going out to take off the trash and i you know i was icy and i i was being very careful and then i noticed that there must have been a little patch of ice or something because all i know is that i slipped and i was on the ground and i was being really really careful\n[doctor] okay yeah i know especially this this winter has been rough so you got ta watch for those little ice patches sometimes well okay so this occurred yesterday after falling on the ice so have you been able to walk on it at all\n[patient] when it first happened i could n't and i actually had a friend who was with me he was she was actually coming to visit and so she had to help me up and so last night i was you know keeping it elevated i was resting it icing it so today it feels a little better like i could put a little bit more weight on it but i'm definitely still limping it it's not my normal\n[doctor] okay alright and tell me what have you been doing for that foot pain since then\n[patient] you know other than the icing i have taken some ibuprofen and i do feel like it's it it is helping\n[doctor] okay okay very good alright and tell me have you ever injured this ankle before\n[patient] you know considering i do a lot of sports my favorite right now is soccer or my favorite always is soccer and i've had a lot of injury but i ca n't remember if i actually injured this ankle i do n't think i ever have\n[doctor] okay alright well good i mean considering how long you've been playing soccer i know you're actually playing for the community league now so that is really great representing the community\n[patient] yes it's so much fun\n[doctor] yeah and and do your kids come and watch you play\n[patient] yeah they come and watch and then now the oldest one is old enough to play himself so they have a leak for four and five -year-olds so he should be starting that soon too so i know he's really gon na enjoy that\n[doctor] that's gon na be exciting for him\n[patient] so much fun\n[doctor] that's a great you had a great soccer league of your own here in your family\n[patient] yeah my husband's really into soccer too\n[doctor] yeah\n[patient] play a lot so\n[doctor] oh\n[patient] yeah\n[doctor] well you i guess you'll be watching it for a while instead of playing it though\n[patient] i well i hope not not for too long\n[doctor] yeah we'll we'll see what we can do just to get you back out there again okay so tell me have you experienced any kind of numbness in your foot at all\n[patient] no not that no i have n't had any numbness\n[doctor] okay alright very good well let me go ahead and do a physical exam on you real quick here let me take a look at your vital signs good good everything here looks good lem me go ahead and take a look at your right ankle real quick i'm just gon na pull your pant leg up here and then look look at it now on the skin here there is ecchymosis and that's bruising this bruising gregory and over the lateral malleolus associated swelling now lem me go ahead and just feel around here how does that feel\n[patient] that hurts\n[doctor] i'm sorry so you definitely there is some tenderness to palpation and anterolaterally in the soft tissue there is no laxity on anterior drawer and inversion stress and there is no bony tenderness on palpation of the foot now i'm just gon na take a look at your right foot here just to make sure it's still intact here so okay good on the neurovascular exam of your right foot your capillary refill is less than three seconds with strong dorsalis pedis pulse and your sensation is intact to light touch so that's good sign now so gregory i did review the results of your right ankle x-ray and it showed no fracture so that's good so let's go ahead and talk about my assessment and plan so for your problem of right ankle pain what i'm seeing is that your symptoms are consistent with right ankle sprain so what i would like to do is i would like you to keep your leg elevated and especially when you're seated and to continue to ice it okay\n[patient] okay\n[doctor] alright and then you're going to also be given an aircast which is really gon na help stabilize the ankle and then you also be given some crutches for the next one to two days and then you may start walking on it as tolerated\n[patient] okay\n[doctor] okay\n[patient] okay\n[doctor] do you have any questions any other questions for me\n[patient] so when will i will i be able to play\n[doctor] well let's see now your symptoms should significantly improve in the next two weeks and what i'll do is i'm gon na follow up with you then and then see how you're doing okay and then just please continue to take the nsaids as needed to help with any of that pain that you may have okay\n[patient] okay\n[doctor] and then we will see in in a few weeks how how if you're ready to go play soccer again okay alright\n[patient] alrighty\n[doctor] well do you have any other questions for me or is there anything else i can do for you\n[patient] no i think that's it thank you\n[doctor] okay well i will have the nurse check you out and then if you experience any kind of symptoms in the next you know before your next visit with me go ahead and feel free to call the clinic okay\n[patient] okay\n[doctor] alright alright take care gregory\n[patient] alright thank you\n[doctor] bye\n[patient] bye",
            "tgt": "CHIEF COMPLAINT\n\nRight ankle pain and swelling.\n\nHISTORY OF PRESENT ILLNESS\n\nGregory Hernandez is a pleasant 42-year-old male who presents to the clinic today for evaluation of right ankle pain and swelling. The onset of his pain began yesterday after he slipped and fell on the ice while taking out the trash. He states that he was unable to ambulate at the time of injury and that a friend had to help him up. He then proceeded to ice and elevate his ankle throughout the night. His pain has since improved and he is able to bear more weight on his right ankle, however he is still limping. He denies experiencing any numbness to his right foot. In addition to ice and elevation he has been taking ibuprofen for his pain, which has provided some relief. He does not recall any other previous injury to his right ankle.\n\nSOCIAL HISTORY\n\nPatient reports that he is very active and enjoys playing soccer. He currently plays for the community soccer league.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports right ankle pain.\n\nVITALS\n\nVitals signs look good today.\n\nPHYSICAL EXAM\n\nCV: Mild edema\nNEURO: Normal sensation.\nMSK: Examination of the right ankle: Ecchymosis is present. There is swelling over the lateral malleolus. Tenderness to palpation anterolaterally in the soft tissue. No laxity on anterior drawer and inversion stress. No bony tenderness on palpation of the foot. Neurovascular intact. Capillary refill is less than 3 seconds with a strong dorsalis pedis pulse. Sensation is intact to light touch.\n\nRESULTS\n\n3 views of the right ankle were taken today. These reveal no evidence of fracture.\n\nASSESSMENT\n\nRight ankle 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. We discussed that his x-rays did not reveal any signs of a fracture and that he sustained a right ankle sprain. Treatment options were discussed. He was advised to keep his right lower extremity elevated, especially when seated. He will also continue to ice his right ankle. An Aircast was provided today to help stabilize his ankle. He is to also utilize crutches for the next 1 to 2 days followed by weight-bearing as tolerated. For pain control he can continue to take NSAIDs as needed. We discussed that he should see significant improvement in his symptoms over the next 2 weeks.\n\nINSTRUCTIONS\n\nThe patient will follow up with me in 2 weeks to assess his progress and to determine his return to play date. He is advised to call the office should his symptoms change or worsen prior to his next appointment.\n",
            "file": "D2N162-aci"
        },
        {
            "src": "[doctor] julie cruz is a 17 -year-old non- binary immensipated minor with no significant past medical history presents for evaluation of newly diagnosed hypercholesterolemia patient is here at the clinic hi julie how're you doing\n[patient] i'm okay\n[doctor] so i now i know you're worried about you know what's been happening with your with your you know with your blood cholesterol so can you tell me a little bit more about what's going on\n[patient] yeah i mean i'm worried about this finding i went for my annual checkup and they checked my cholesterol one of those finger prick tests and it came back elevated and they told me i should come and see you\n[doctor] okay alright well i think it's a good thing that you know we're aware of this elevated cholesterol at a young age and that we can do something about it so lem me ask you julie a couple of questions here okay so what kind of activities do you like to do\n[patient] well i really like to go outside i ride my bicycle a lot\n[doctor] okay\n[patient] which is it's a lot of fun i ride the trails\n[doctor] that's fun very nice so you stay pretty active it sounds like\n[patient] well i keep pretty active during the week yeah\n[doctor] okay very good good for you now tell me what what kind of foods do you like to eat\n[patient] well i mean i really like chocolate chip cookies\n[doctor] yeah\n[patient] i mean i i try to cook pretty much everything is fresh but i i really do like like cookies and i i mean but even after that i mean i i try to eat pretty clean diet most days\n[doctor] yeah\n[patient] that's why i was really surprised my cholesterol was high\n[doctor] yeah okay well we will we will try to look check and see what's going on there okay so so what kind of so have you you've done any fun activities that now that you know it's getting warm out\n[patient] yeah i went for a bike ride over the weekend and some friends have morning we we went for a bike ride and then we had a pick\n[doctor] that's fun\n[patient] it was pretty nice it was a little chilly but it's nice now that it's springtime\n[doctor] yeah but yeah that sounds like fun\n[patient] it was fun\n[doctor] techniques are fun so tell me do you do you have any history at all of you know hypercholesterol serol anemia on the like at a early age any other you know family members that that you remember that may have that problem\n[patient] well i do n't really think so i do n't really talk to my parents too much\n[doctor] i know\n[patient] but i i have a pretty good relationship with my grandparents\n[doctor] okay\n[patient] you know and i remember talking to my grandmother and my grandfather both and they do n't they said that when they were young they did n't have anything like that so i had mine checked last year and the doctor said it was a little borderline\n[doctor] okay\n[patient] but it was n't anything to be worried about that time it kinda just blew it off just told me to watch what i was eating and now they say it's really hot and i do n't understand what's going on\n[doctor] okay alright okay we'll we'll we'll we'll take a look at that okay now tell me have you had any issues you know with growing growing up bones are feeling okay you feel like you're growing okay\n[patient] i i guess so i mean when i met with my doctor i they talked about making health goals and making sure that that i i feel okay and i i decided about two years ago that i i do n't feel much like a girl i it's it's more of just kind of a nongender and that's how i've been living\n[doctor] yeah\n[patient] and but i mean i thought i was healthy\n[doctor] yeah okay well you know we can get you there too you know we can work on that so we we'll take we'll talk more about some tips to help achieve those goals okay\n[patient] okay\n[doctor] okay and tell me does anyone at home smoke\n[patient] well when i used to live with my parents they did but i live on my own now\n[doctor] right\n[patient] nobody smokes my apartment\n[doctor] okay you know if your friends come over if they smoke too or what okay\n[patient] nope\n[doctor] okay\n[patient] no nobody that i spend time with smoke\n[doctor] okay now tell me is there any history at all of like maybe heart disease or sudden death you know like early early in those your family's years\n[patient] well come to think of it i did have my my grandparents told me that that i had a cousin that died and and he was only like forty four or forty five\n[doctor] okay\n[patient] they they think that he had a heart attack\n[doctor] okay well i'm sorry to hear that okay so that's that's helpful information though okay let's go ahead and do physical exam on you there julie i'm gon na go ahead and take a look at your vital signs looks like your blood pressure looks good so that's good now on your heart exam i do n't appreciate any murmur rubs or gallops on your lung exam your lungs are clear on your eye exam i do n't appreciate any zenthomas and also on your neck exam here there is no thyroid megaly so now on your abdominal exam i do n't appreciate any hepatomegaly or splenomegaly why can i see these today so i reviewed the results of your cholesterol level and it was elevated at two ten so that's high so let me go ahead and tell you about my plan so for your problem of elevated cholesterol what we wan na do is you know the american academy of pediatrics actually recommends that all children be screened screened once you know they become between ages and nine and eleven and then again between ages seventeen and twenty so that's why you were screened okay so we do we yeah so we do this because studies have shown a link between high cholesterol and premature heart attacks so i wan na go ahead and order a full cholesterol panel there could be other reasons that could be causing the the high cholesterol but i'll go ahead also and check some glucose a complete metabolic panel some thyroid studies and liver panels and i wan na perform a genetic testing to see if this problem is familial or this is a secondary cause so we are also gon na go ahead i wan na follow up in a follow-up with a well balanced diet so including a variety of foods that are lower in saturated fat and sugars so i want you to follow that and i want you to meet a nutritionist and so who can give you information about what kind of foods to eat okay\n[patient] okay\n[doctor] alright now i do want you to continue to be active and exercise so that's great especially that you know your bike riding so you keep that up that's a great thing and you're doing well with that so keep that up for you okay and then i wan na follow up with another cholesterol level in three to six months after you've met with the nutritionist and then and they've you know instituted those dietary changes\n[patient] okay it sounds good\n[doctor] okay good well take care julie i'll talk to you soon\n[patient] alright thanks document\n[doctor] thank you bye",
            "tgt": "CHIEF COMPLAINT\n\nHypercholesterolemia.\n\nSOCIAL HISTORY\n\nPatient denies any history of smoking; however, they note that their parents smoked when they lived with them. They enjoy being outside and riding their bike on trails.\n\nFAMILY HISTORY\n\nPatient reports a cousin who died of a heart attack in their 40's. but denies any family history of hypercholesterolemia.\n\nVITALS\n\nBlood pressure looks good.\n\nPHYSICAL EXAM\n\nEyes\n- Examination: No xanthomas noted.\n\nNeck\n- General Examination: Neck is supple without thyromegaly.\n\nRespiratory\n- Auscultation of Lungs: Clear bilaterally.\n\nCardiovascular\n- Auscultation of Heart: No murmurs, gallops or rubs.\n\nGastrointestinal\n- Examination of Abdomen: No hepatomegaly or splenomegaly.\n\nRESULTS\n\nRecent cholesterol level is reviewed and shows patient is elevated at 210.\n\nASSESSMENT AND PLAN\n\n1. Elevated cholesterol.\n- Medical Reasoning: The patient's previous tests are consistent with hypercholesterolemia.\n- Patient Education and Counseling: We discussed that the American Academy of Pediatrics recommends children between the ages of 9 to 11 years old and again between 17 to 20 years old be screened for their cholesterol. We also discussed that studies link high cholesterol to pre-mature heart attacks. I advised the patient that genetic testing can be done to see if the problem is genetic or a secondary cause. They were also advised to follow a balanced diet with a variety of foods that are low in saturated fat and sugars, as well as remain active.\n- Medical Treatment: Full cholesterol panel ordered. Hemoglobin A1c, CMP, thyroid study, and liver panel were also ordered. Genetic testing ordered. Referral to nutritionist provided.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow-up in 3 to 6 months after meeting the nutritionist for another cholesterol level.\n",
            "file": "D2N163-aci"
        },
        {
            "src": "[doctor] so elizabeth is a 53 -year-old female today complaining of chest pain and she has a past medical history of diabetes and high blood pressure so elizabeth tell me what's going on with your with your chest pain\n[patient] i do n't know every time i start walking i'm just having this kind of pressure and chest pain in my chest\n[doctor] okay are you having it now or is it gone right now\n[patient] right now it's not there\n[doctor] okay and how long have you been having this\n[patient] probably maybe three months\n[doctor] okay and what seemed to bring it on anything exacerbated or relieve it\n[patient] it mainly happens when i'm walking i like to try and walk but lately i just have n't been able to keep up with it because i'm having this pain\n[doctor] alright and well how would you describe this pain it's like a dull pain sharp pain stabbing pain how would you describe it\n[patient] i would say it's dull it's kinda like a pressure\n[doctor] okay and does it go anywhere or radiate any place\n[patient] no\n[doctor] okay alright but no chest pain right now no shortness of breath no sweats or clamminess or anything like that right now\n[patient] nothing right now\n[doctor] okay alright well certainly you know i looked at your ekg that did we did in the office when you came in the ekg i do n't see any signs of a heart attack or anything like that so i'm you know we should definitely talk about the plan for this chest pain in a few minutes but right now the good news is i do n't see any signs of a heart attack or anything like that so let's talk a little bit about your other conditions since you are here today how are you doing with your diabetes i know we have you on metformin and we talked about last time about you know improving your diet and exercise i'm glad you're exercising but i'm so sorry to hear about the chest pain so tell me about how is that going\n[patient] yeah i mean i think my blood sugars have been a little higher because i have n't been able to be active and i'm trying with the diet you know i do love sodas so i'm really trying strength dose\n[doctor] yeah i i am addicted to diet coke myself so i i hear you on that one and we had checked your hemoglobin a1c last time it was you know seven . which is pretty good it's not you know it could be better but it's not it's not bad and we talked about sending you to ophthalmology also for an eye exam have you seen ophthalmology in the last few months or last before i saw you\n[patient] i have an appointment in two weeks it was a long waiting\n[doctor] okay got it and any nausea vomiting or diarrhea or anything like that with your diabetes or any side effects from your medications the metformin\n[patient] no\n[doctor] okay alright good and i saw also there was a record in your i was looking at your record before previously before i walked in you also had we've been checking your blood pressure but but i think you've been into several other clinicians and they had documented high blood pressure have you noticed any findings with that or have you know have anybody talked about high blood pressure with you or mentioned that because we do n't have it in our system here yet but i did add it in today but we do n't have you on any medications yet for that\n[patient] no i mean i do n't know doc no one told me about high blood pressure do i have high blood pressure\n[doctor] well i think the last time you were in the clinic and one of the clinics said the referrals the your blood pressure was elevated so they had mentioned that i noticed a trend in your blood pressure it's been running on a little bit on the high side we have n't really diagnosed you with that yet but i think we are something that we should definitely consider looking at your trend of your blood pressure readings over the last you know a few years\n[patient] okay do you think that could be causing me my my chest pain\n[doctor] it certainly could be contributing to that it certainly could be a factor that we need to look at so\n[patient] someone had told me before\n[doctor] yeah me too but we we can we can definitely you know get you started on some monitoring devices for that and also maybe start you on some some diet control things that we can do to help with the blood pressure and maybe start you on some blood pressure medications if we need to okay\n[patient] okay sounds good\n[doctor] so let me examine you elizabeth for a second for the because we're running out of time here for a second so i'm gon na go ahead and do my exam we got ta just did my magical exam and i'm gon na go ahead and verbalize some of my findings just so i can get it documented in my note okay and i'll explain things as we go along so there is no jvd there is no swelling in your neck there's no carotid bruits your lung exam is clear i do n't hear any crackles or rhonchi your heart exam you do have a two over six systolic ejection murmur you had that in the past otherwise it's regular rate and rhythm your pulses are equal your belly exam is nice and soft your no tenderness no guarding no masses that i can feel on your belly and your back exam is fine your extremity exam you have a little bit of swelling in your lower legs one plus nonpitting edema or swelling in the in your in your ankle area here no calf tenderness so what does all this mean i'll explain that in a second so basically your exam is pretty normal except for you have a little bit of swelling in your legs so you know with this chest pain i'm a little bit so the first diagnosis that we talk about is this chest pain i'm worried about my suspicion is you have something called unstable angina especially considering your history of diabetes and the suspected history of high blood pressure and your family history of of heart disease in the past as well i'm i'm gon na go ahead and refer you to cardiology i reviewed your ekg today so that looks normal so that's good no other signs of a heart attack but i am worried that you may have some sort of a blockage going on that's causing this chest pain i'm gon na go ahead and start you on some aspirin daily i'm also gon na give you a prescription just a baby aspirin you can take eighty one milligrams once a day and also i'm gon na give you a prescription for nitroglycerin it's a it's a little pill you split underneath your tongue if you have this chest pain if it does n't go away after one or two pills i want you to go to the hospital call nine one one and go to the hospital but we will try to get you into cardiology the next week and get you set up for some sort of a stress test to look at your heart okay any questions about that\n[patient] so anytime i have a chest pain even if i'm just like walking i have to take that pill\n[doctor] yeah if you if you stop walking the chest pain goes away you do n't have to take the pill but if you are walking or you stop and the chest pain does not go away i would take the pill and see if it goes away if it does not\n[patient] how long like how long do i wait to see if it goes away\n[doctor] about five minutes so you can take it up to three pills every five minutes and if it does n't go away then i would you know go to the hospital and get this checked out because i worry about with this chest pain that you're having making sure it does n't lead to a heart attack those chest pain could be a you know a a a sign that you may be having some less blood flow to your heart and we need to get that checked out pretty quickly\n[patient] okay\n[doctor] alright\n[patient] mm-hmm\n[doctor] and for the second problem the diabetes you know i think you're doing fairly well continue with your eye ophthalmology appointment you have for your eye exam for the diabetic retinopathy continue the metformin five hundred milligrams twice a day i'm gon na order another hemoglobin a1c today and i'm gon na have you come back in about two weeks and we can see if we need to make any adjustments continue to try to stay away from you know the the pop and the sweet things and once we have your heart taken care of or make sure your heart is okay you can and we can hopefully resolve this chest pain that you're having get back to your exercise regimen okay any questions about that\n[patient] no\n[doctor] okay and for the third diagnosis the high blood pressure you you do have a trend i've noticed in your chart that your blood pressure's been running a little bit high several other people have documented as well i'm gon na go ahead and start you on some hydrochlorothiazide it's a pretty low dose medication to help you with your blood pressure plus it'll also help with you some of the swelling you have in your in your feet i'm gon na have you use a blood pressure cuff at home and enter your findings at epic mychart and i'll get a reading of those as well and then what when you come back in two weeks we'll keep a log of your blood pressure daily in the morning when you wake up and see how things are going and then if we need to make any adjustments to the medications we can but especially considering your history and the chest pain and the diabetes and the swelling i think starting this hydrochlorothiazide is a probably a good idea\n[patient] okay are there any side effects with this medication\n[doctor] yeah it can cause sometimes it can cause a little bit of make you go to the bathroom a little bit more often in the evening but generally most people do n't have a whole lot of side effects i'll give you a handout of the side effects but sometimes you can have a cross reaction with some other medications like sulfa medications but generally most people tolerate this pretty well\n[patient] okay\n[doctor] alright any other questions we got\n[patient] that's it\n[doctor] alright well great seeing you thanks for coming in today\n[patient] thank you appreciate it",
            "tgt": "CHIEF COMPLAINT\n\nChest pain on exertion.\n\nMEDICAL HISTORY\n\nThe patient has a medical history of diabetes type 2. She has not been formally diagnosed with hypertension, but her blood pressures have been trending high.\n\nFAMILY HISTORY\n\nPatient reports family history of heart disease.\n\nMEDICATIONS\n\nPatient reports taking metformin 500 mg twice daily.\n\nREVIEW OF SYSTEMS\n\nConstitutional: Denies diaphoresis or clamminess.\nCardiovascular: Reports chest pain.\nRespiratory: Denies dyspnea.\nGastrointestinal: Denies nausea, vomiting, or diarrhea.\n\nPHYSICAL EXAM\n\nNeck\n- General Examination: No JVD, swelling, or carotid bruits.\n\nRespiratory\n- Assessment of Respiratory Effort:\n- Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.\n\nCardiovascular\n- Auscultation of Heart: 2/6 systolic ejection murmur, otherwise normal rate and rhythm. No murmurs, gallops or rubs. Pulses are equal.\n\nGastrointestinal\n- Examination of Abdomen: No masses or tenderness. Soft, no guarding.\n\nMusculoskeletal\n- Examination: 1+ nonpitting edema in the ankles. No calf tenderness.\n\nRESULTS\n\nEKG was obtained and reviewed in office today and is unremarkable. Hemoglobin A1c: 7.0\n\nASSESSMENT AND PLAN\n\n1. Chest pain.\n- Medical Reasoning: Considering her history of diabetes, possible history of hypertension, and family history of heart disease, I suspect her chest pain is likely unstable angina. Her recent EKG was unremarkable and there are no other signs of heart attack, but I am worried she may have some sort of a blockage causing her pain.\n- Patient Education and Counseling: We discussed proper protocol for sublingual nitroglycerin for chest pain. I advised her to go to the emergency department if the medication is not effective after approximately 5 minutes.\n- Medical Treatment: We will have her start a regimen of baby aspirin at 81 mg daily, for which I have sent in a prescription today. I also sent a prescription for nitroglycerin up to 3 tablets every 5 minutes as needed. Finally, I am going to have her follow up with cardiology for further evaluation.\n\n2. Type 2 diabetes.\n- Medical Reasoning: She appears to be doing well on her current regimen.\n- Patient Education and Counseling: I encouraged the patient to keep her appointment with ophthalmology for evaluation of diabetic retinopathy.\n- Medical Treatment: I'm going to put in an order for a repeat hemoglobin A1c to check for any needed medication adjustments and have her follow up in 2 weeks. In the meantime, I want her to continue with metformin 500 mg twice daily and dietary modifications.\n\n3. Hypertension.\n- Medical Reasoning: Several providers, including myself, have noted a trend of elevated blood pressures in the patient's chart.\n- Patient Education and Counseling: I advised the patient to monitor her blood pressures at home over the next 2 weeks and report her readings to me via MyChart. This should help us determine if any adjustments need to be made to her new medications. We discussed the possible side effects of hydrochlorothiazide how this will hopefully reduce some of her swelling seen on physical exam. All of her questions were answered.\n- Medical Treatment: I'm going to have her start hydrochlorothiazide at a low dose.\n\nPatient Agreements: The patient understands and agrees with the recommended medical treatment plan.\n\nINSTRUCTIONS\n\nThe patient will follow up in 2 weeks.",
            "file": "D2N164-aci"
        },
        {
            "src": "[doctor] hey sophia how are you doing today\n[patient] i've been better my primary care doctor wanted me to see you because of this knee pain that i've been having for about six months now\n[doctor] okay do you remember what caused the pain initially\n[patient] you know i really ca n't recall any specific event that caused the pain\n[doctor] alright well can can you describe the pain for me\n[patient] yeah so it's it's like a deep achy pain that it i feel like it's behind my kneecaps and sometimes i can even hear like what seems like like some creaking in my knees\n[doctor] hmmm alright now tell me what what type of activities makes that pain worse\n[patient] so i feel like the pain gets worse anytime i'm like getting from like a seated position to standing so i i work from home so i'm at my desk a lot so anytime i get up i have some pain or after watching tv or even like going up and down stairs it's really painful\n[doctor] hmmm okay and does anything make the pain feel better\n[patient] usually after i rest it for some time it does help with the pain\n[doctor] okay now you did mention earlier that you have tried some things in the past can you tell me what they were\n[patient] yeah so when it first started hurting i was putting ice on it and i even got like some ace bandage like wrapping from the pharmacy i do take ibuprofen or aleve sometimes but i try to avoid really taking any medications\n[doctor] okay and and tell me what is your day like\n[patient] well i try to be as active as i can i actually love to run and i would run like five to six miles a day but now i i mean honestly i ca n't even get to half a mile and my leg will start hurting my knee will start hurting\n[doctor] okay that's definitely a decrease in your mileage there where have you been running lately like do you run outside or on a treadmill or\n[patient] yeah i i you know i will do the treadmill during the winter but i just love being outdoors and running\n[doctor] yeah yeah there are some really nice senior routes here in boston is n't there like\n[patient] there are\n[doctor] so many knee places there's some right by the harbor that i've i've done some runs there before too it's pretty nice well i mean the boston marathon what can you say right\n[patient] right exactly exactly no it's very nice\n[doctor] well okay well hopefully that we get you feeling better so you can start running again more than . five miles but tell me though have you noticed any swelling or redness in your knees\n[patient] no not really\n[doctor] okay and have you ever injured your knees before\n[patient] no i've been pretty good i actually have never broken a bone actually no i'm gon na change that actually i did break my arm when i was in sixth grade but nothing since then\n[doctor] okay\n[patient] i\n[doctor] okay and it's just your arm right not not your knee\n[patient] right\n[doctor] okay well alright well let's go ahead and do a quick physical exam on you here let me look at your vital signs okay i reviewed your vitals they they overall they look good take a listen to your heart real quick alright and your heart exam i hear regular rate and rhythm with no murmurs and on your musculoskeletal exam i have seen you and walk around here and you do have normal gait alright now i'm gon na have you do some movements on your legs here okay\n[patient] okay\n[doctor] alright good your strength is three out of five for abduction of legs bilaterally and the remainder of muscle strength for your lower extremities are five out of five so that's good let me take a look at your knee now on your knee exam there is no overlying erythema that's redness or ecchymosis and that's bruising or any warmth of the skin appreciated there is no effusion let me go ahead and feel around here does that hurt right here how does that feel\n[patient] it does\n[doctor] sorry so there is tenderness to palpation of the bilateral retinacular retinaculum and there is positive patellar grind test alright and can you are you able to squat for me\n[patient] i can but that hurts\n[doctor] okay alright so you're definitely having some knee pain with squatting and i'm just gon na maneuver your leg just a little bit here real quick okay so lachman anterior and posterior drawer and mcmurray tests are all negative bilaterally so that's good there okay now your neuro exam patella and achilles reflexes are symmetrical alright so now i did review the results of your x-ray and both of your knees which shows no fractures or osteoarthritis so let me go ahead and tell you about my assessment and plan so for your problem of bilateral knee pain based on what you told me your exam and reviewing your mri your symptoms are consistent with patellofemoral pain syndrome and this is a very common condition that we see that causes knee pain especially in active young people so this condition has to do with the way your kneecap which is your patella how that moves along the groove of your thigh your thigh bone which is the femur now for the pain you may continue taking ibuprofen or anti-inflammatory as needed to help with the pain but i'm also going to recommend physical therapy where where they will show you a number of lower extremity exercises and this will help increase your lower extremity strength your mobility and correct any incorrect running mechanics that you may have so do you have any questions for me about that\n[patient] will i be able to run anytime soon\n[doctor] well that is a goal of treatment and to get you back in running again now you will have to take an take it easy from running for now but we will continue to assess your progress with each visit okay\n[patient] okay\n[doctor] alright anything else\n[patient] no i think that's it\n[doctor] okay well very good well i will be following up with you soon and again just take it easy for now from the running okay\n[patient] okay thank you\n[doctor] bye\n[patient] bye",
            "tgt": "CHIEF COMPLAINT\n\nBilateral knee pain.\n\nHISTORY OF PRESENT ILLNESS\n\nSophia Jackson is a pleasant 30-year-old female who presents to the clinic today for the evaluation of bilateral knee pain. She was referred by her primary care provider. The onset of her pain began 6 months ago. She denies any specific injury. The patient describes her pain as a deep, achy pain. She locates her pain to the posterior aspect of her patellae. The patient also reports \u201ccreaking\u201d in her knees. She denies any swelling or redness in her knees. Her pain is aggravated by transitioning from a seated position to standing as well as ascending and descending stairs. Her pain is alleviated by rest. The patient has been icing her knees and wrapping her knees with an ACE bandage. She also takes ibuprofen or Aleve occasionally for pain. She states she tries to be as active as she can. She enjoys running outdoors. The patient adds that she would run 5 to 6 miles per day; however, she is unable to go 0.5 miles secondary to the pain. She denies any previous injuries to her knees.\n\nShe works from home.\n\nMEDICAL HISTORY\n\nPatient reports history of an upper extremity fracture when she was in 6th grade.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports bilateral knee pain and crepitus. Denies swelling or redness in the bilateral knees.\n\nVITALS\n\nAll vital signs are within the normal limits.\n\nPHYSICAL EXAM\n\nGAIT: Normal, no deformity present.\nCV: Auscultation of Heart: Regular rate and rhythm. No murmurs.\nNo edema\nNEURO: Patella and Achilles reflexes are symmetrical.\nMSK: Examination of the bilateral lower extremities: Abduction strength is 3/5. Remainder of muscle strength is 5/5. Examination of the bilateral knees: No overlying erythema, ecchymosis, or warmth of the skin appreciated. No effusion. Tenderness to palpation of the bilateral retinaculum. Positive patellar grind test. Knee pain with squatting. Negative Lachman test bilaterally. Negative anterior and posterior drawer tests bilaterally. Negative McMurray test bilaterally.\n\nRESULTS\n\nX-rays of the bilateral knees were reviewed today. These demonstrate no evidence of any fractures or osteoarthritis.\n\nASSESSMENT\n\nBilateral knee patellofemoral pain syndrome.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient regarding her current symptoms. I have explained to her that her symptoms are consistent with patellofemoral pain syndrome. We discussed treatment options and I have recommended that we begin with conservative treatment in the form of formal physical therapy to increase her lower extremity strength, mobility, and correct any incorrect running mechanics. I encouraged her to take running easy for now. She can continue taking ibuprofen or anti-inflammatories as needed for pain. All questions were answered.\n\nINSTRUCTIONS\n\nThe patient will follow up with me soon.",
            "file": "D2N165-aci"
        },
        {
            "src": "[doctor] hey kyle so i see here on your chart that you've been having some back pain could you tell me like how you've been doing what's going on\n[patient] yeah i have this real bad low back pain it started a couple of weeks ago i was lifting something and i just felt a pop and i i do n't know what's going on\n[doctor] okay and so you were like moving what what were you moving exactly when you say lifting\n[patient] i was lifting a box of books\n[doctor] okay\n[patient] yeah\n[doctor] alright did we use proper lifting technique do you wonder\n[patient] you know probably not\n[doctor] okay alright i'm sorry about that alright can you describe the pain for me\n[patient] yeah i i feel like kind of it's like achy and sharp\n[doctor] oh\n[patient] in in my low back\n[doctor] uh uh and does the pain like radiate anywhere\n[patient] you know it did n't at first but now i'm feeling it's kinda starting to shoot down my left leg\n[doctor] okay alright and how is positioning for you does any sitting in any particular position hurt more or hurt less\n[patient] no sitting is usually okay for me\n[doctor] mm-hmm okay and then do you have any numbness or tingling associated with the pain\n[patient] no\n[doctor] okay alright any loss of sensation\n[patient] no\n[doctor] okay how yes sir okay how about any weakness\n[patient] no i do n't feel any weakness\n[doctor] okay and i know this sounds like a weird question but i do need to know do you experience any loss of control of your bladder or bowels\n[patient] no\n[doctor] alright this this is a no judgment zone i there i'm working through some things in my head to make sure that i give you the best care that we need right i'm making a plan as we move along you mentioned that the pain has been getting worse have you done anything or tried anything that's worked in the past\n[patient] i tried to take some ibuprofen and tylenol\n[doctor] mm-hmm\n[patient] that that sometimes helps\n[doctor] okay alright and has anyone discussed the option of like just no has anyone discussed surgery with you\n[patient] no this is the first time i'm talking about it\n[doctor] okay alright that's good so what is your like how what is your activity level right now that i know that you're you know an olympic weightlifter with books what else do you do to like exercise\n[patient] you know i try to exercise a few times a week but i'm pretty inconsistent i have a sedentary job\n[doctor] okay alright and has this like pain started to like affect you like in your job or anything like that\n[patient] not my job but i feel like i do n't want to be as active as i was previously\n[doctor] alright so do you have any family members that have spine conditions\n[patient] yeah my dad has back pain\n[doctor] okay alright and then do you smoke\n[patient] i do n't smoke\n[doctor] okay awesome alright so sorry one question did you do you have a history of playing sports\n[patient] yes\n[doctor] okay what did you play\n[patient] soccer\n[doctor] okay what position\n[patient] i played midfield\n[doctor] okay the people who hide in the back that's fine i was centered forward fine no baby do you have a team that you wrote for\n[patient] you know i am a tatnham hotsper fan\n[doctor] they have the best colors not going to lie but i i grew up manu so sorry\n[patient] well i wo n't fault you for that\n[doctor] thanks okay so if you do n't mind i'm gon na go ahead and do my physical exam i'm gon na call out my findings just to have them recorded and if you have any questions please feel free to stop me and let me know okay\n[patient] okay\n[doctor] alright so looking at your vitals your blood pressure seems alright we are in like the one thirty over seventy range that's perfectly fine your respiratory rate i have you at an eighteen again pretty normal when i listen here to your heart you have a regular rate and rhythm i do n't appreciate any murmurs rubs or gallops that means your heart sounds great on your respiratory exam your lungs sound clear to auscultation bilaterally on your musculoskeletal back exam as i'm looking here i do n't notice any overlying redness or bruising on the skin when i push here on the midline of your back does it hurt\n[patient] yes\n[doctor] okay so there is midline tenderness at the l4 l5 disk space with right sided lumbar paravertebral tenderness alright so are you able to bend forward\n[patient] yes\n[doctor] alright and are you able to bend backward\n[patient] yes\n[doctor] alright do either of those actions cause you pain\n[patient] bending forward\n[doctor] okay so pain with lumbar flexion and so i'm gon na have you lie down and we're gon na do i'm sorry okay and then i see that a supine straight leg test is positive alright so for your neurological exam you said that you are experiencing pain radiating down radiating down your left leg correct\n[patient] yes\n[doctor] alright when i touch are there any like decreased sensation\n[patient] no\n[doctor] okay alright so patella and achilles reflexes are symmetrical alright so i received before you came in here we got an mri and so in reviewing your results it does show a disk desiccation a disk bulge with paracentral disk herniation resulting in moderate right neuroforaminal i do n't like this word neural foraminal stenosis what those complicated words is that i just said is that it seems that you have a a a herniated disk with nerve impingement so let's talk about my assessment and plan alright your symptoms are in line with a i'm sorry you have lumbar back pain at the l4 l5 disk space due to a herniated disk with radiculopathy this means that one of your disks that sits between your vertebrae like the bones in your spine is bulging out and the bulge is pinching on some nerves so that's why you are feeling that pain like radiating down your leg i'm gon na recommend something a spinal injection with a strong nsaid and called the i'm sorry and a corticosteroid i'm just gon na inject it into the lumbar spine under fluoroscopy which you can think of like an x-ray to localize the exact area of your pain this should help with the inflammation that's causing your pain i know that sounds a bit scary it this is a typical procedure that i do all the time it's in office and we can get you scheduled today if you would like so what questions do you have right now\n[patient] is that something that we can do today\n[doctor] yeah i think i have time in my schedule to get it done today just you know i'm here for you right now\n[patient] alright\n[doctor] okay\n[patient] are there are there any complications with this\n[doctor] there are sorry yeah you're right there are risks associated with this kind of injection just like any procedure but we aim to minimize them and my ma when she comes in we will give you some paperwork with explanations and any and hopefully answer most of the questions that you have if after reading that you have any more questions please feel free to stop us we want to make sure that you feel as comfortable as possible during this time\n[patient] okay\n[doctor] alright\n[patient] great\n[doctor] anything else\n[patient] i think that's it\n[doctor] alright",
            "tgt": "HISTORY OF PRESENT ILLNESS\n\nKyle Morales is a pleasant 58-year-old male who presents to the clinic today for the evaluation of low back pain.\n\nOnset of his pain began 2 weeks ago, when he was lifting a box of books and felt a pop. The pain is described as aching and sharp. His pain has been increasing since the time of onset and is beginning to radiate down his left leg. The patient denies any pain with sitting. He adds that he has a sedentary job. The patient states that his pain does not affect his job, however he feels that he does not want to be as active as he was previously. He tries to exercise a few times per week, however he is inconsistent. He denies any numbness, tingling, loss of sensation, weakness, and loss of control of his bladder or bowels.\n\nThe patient has been taking ibuprofen and Tylenol for pain, which provides some relief. He has not been evaluated for surgery.\n\nSOCIAL HISTORY\n\nHe denies smoking. The patient has a history of playing soccer in the midfield position.\n\nFAMILY HISTORY\n\nThe patient states that his father has back pain.\n\nREVIEW OF SYSTEMS\n\nMusculoskeletal: Reports low back pain.\nNeurological: Denies bowl or bladder control issues, numbness, tingling, decreased sensations, or weakness.\n\nVITALS\n\nBlood pressure: 130/70 mm Hg.\nRespiratory rate: 18.\n\nPHYSICAL EXAM\n\nCV: I do not appreciate any murmurs, rubs, or gallops.\nRESPIRATORY: Normal respiratory effort no respiratory distress. Clear to auscultation, bilaterally.\nBACK: No evidence of trauma or deformity\nNEURO: Normal sensation. Patellar and Achilles reflexes are symmetrical.\nMSK: Examination of the lumbar spine: No ecchymosis noted. Midline tenderness at the L4-5 disc space with right-sided lumbar paravertebral tenderness. Pain with lumbar flexion. Positive supine straight leg test.\n\nRESULTS\n\nThe MRI of the lumbar spine was reviewed today. It revealed disc desiccation and a disc bulge with a paracentral disc herniation resulting in moderate right neural foraminal stenosis.\n\nASSESSMENT\n\nLumbar back pain at the L4-5 disc space due to a 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 MRI revealed a herniated disc with radiculopathy. We discussed treatment options for this and I have recommended that we begin with conservative treatment in the form of a corticosteroid injection. With the patient's consent, we will proceed with a corticosteroid injection into the lumbar spine today. The patient was made aware of the risks of bleeding, infection, nerve damage, blood vessel damage, reaction to the medication, including skin changes, swelling, and also, the risk of elevated glucose levels if the patient were diabetic.",
            "file": "D2N166-aci"
        },
        {
            "src": "[doctor] angela good to see you today so i'm writing here in my notes that you're you're coming in you had some left knee pain so how did you hurt your knee\n[patient] yeah so i hurt my knee the other day when i was running around with my niece she she is learning how to take off the training wheels for her bike\n[doctor] mm-hmm\n[patient] and i fell and i think i twisted my knee in some kind of funky way\n[doctor] okay that that that that's not good how old are your niece\n[patient] she is five and perfect\n[doctor] well that's good that you're trying to help her with the learning how to ride a bike\n[patient] yeah\n[doctor] that sounds fun but i'm i'm sad as you hurt your knee doing it so for your knee pain are you are you able to bear weight on that leg the left leg\n[patient] well i've been limping ever since and it really has n't gotten better so i thought it was maybe time to come see you because it happened about a week ago\n[doctor] yeah yeah it's a definitely a good time to come see me so what part of your knee would you say it hurts\n[patient] honestly it's been hurting on both sides more so on the inside than the the outside\n[doctor] so okay so more in the medial aspect less on the lateral okay that makes sense and you said did you hear a pop when you when you twisted it\n[patient] yeah i did\n[doctor] okay alright so how would you rate your pain with your knee out of out of one to ten\n[patient] it started off as like a four but i think it's getting worse and it's starting like it's it's like a like a throbbing kind of pain yeah\n[doctor] alright and have you taken anything for the pain\n[patient] yeah so i i had like a ulcer not too long ago so my doctor told me that i could n't take any like kind of advil or ibuprofen\n[doctor] mm-hmm\n[patient] so i've been taking some tylenol and i wrapped it with kinesiology tape are you familiar with that\n[doctor] yep yeah i'm i'm familiar\n[patient] okay\n[doctor] alright and has the has the ibuprofen been helping you at all\n[patient] i ca n't take ibuprofen\n[doctor] i mean i'm sorry the tylenol\n[patient] no it's okay but the tylenol it helps like a little bit but you know like it's it's got like a time limit right so by the time and i'm not supposed to take it like more than like every like four hours or something like that but by hour or two like it it hurts again\n[doctor] okay yeah that yeah you ca n't take too much of that tylenol because it'll it'll mess up your liver definitely\n[patient] right\n[doctor] alright so go ahead and do a quick exam on your knee here so when i press here does that hurt\n[patient] yeah like when you press on the inside that hurts a lot\n[doctor] okay alright i'm gon na do a couple of other other maneuvers here for your knee so on your left knee exam i do appreciate some edema you also have some effusion some fluid in the knee you have moderate range of motion so you're able to move it a little bit but not all the way i also see you have some pain on flexion and extension of the knee even negative lachman's test and a negative valgus and varus test as well so all that to say is i do n't think anything is is torn in your knee based on the your physical exam so we did do a x-ray of your left knee and luckily it was normal so there is no fractures no bony abnormalities so everything is good there so let me talk to you little bit about my assessment and plan for your knee okay\n[patient] yeah\n[doctor] alright so for your your left knee pain i believe you you have a mcl strain or a medial collateral ligament that's the inside of your knee i think when you were running with your knee she had somehow twisted it and so you strained that ligament there so for that what i want to do i'm going to give you some pain medication that's not an nsaid so i will put you on some tramadol you can take fifty milligrams you can do that twice a day and then you can take that tylenol as needed for breakthrough pain alright i'm gon na put you in a knee immobilizer leg knee immobilizer and you can wear that for the next week i just wan na keep the knee from moving so it can heal a little bit and reduce some of the inflammation that you're seeing here and i also want you to ice it and you can do that three or four times a day for twenty thirty minutes at a time and that should help some of that swelling as well and i i you know i know your niece is gon na be upset but i just do n't want you to be running probably for the next three weeks with her just to help us get time to let allow the knee to heal so how does that sound\n[patient] that's alright how long do you think it'll be before i can like run or something like that\n[doctor] hmmm i think you'll be back to normal in about a month the strain does n't seem too bad but we just need to get you off of the knee so we can allow it to heal i mean once we do that you know along with you know the icing the mobilization and you taking the medication i think you'll be good to go in a month if you do feel like you're getting a little bit worse please feel free to call the office and we can get you in and possibly do more imaging such as an mri to you know to see if it's anything worse but i do n't think it is but just let us know how you feel in a couple of days\n[patient] okay alright thanks\n[doctor] alright any other questions\n[patient] no that's it\n[doctor] alright great thanks",
            "tgt": "HISTORY OF PRESENT ILLNESS\n\nAngela Powell is a pleasant 81-year-old female who presents to the clinic today for the evaluation of left knee pain. The onset of her pain began 1 week ago, when she was running around with her niece and fell. At the time of the injury, she heard a pop and believes that she twisted her knee. She reports that she has been limping since the injury. The patient locates her pain to the medial and lateral aspects of her knee. She rates her pain level as a 4 out of 10, however this is increasing. Her pain is described as a throbbing pain. The patient has been taking Tylenol, which has provided mild and temporary relief, as well as wrapping her knee with kinesiology tape. She states that she is unable to take ibuprofen secondary to an ulcer.\n\nPHYSICAL EXAM\n\nMSK: Examination of the left knee: Edema and effusion noted. Moderate ROM. Pain with flexion and extension of the knee. Negative Lachman's. Negative valgus and varus stress test.\n\nRESULTS\n\n4 views of the left knee were taken. These reveal no evidence of any fractures or dislocations. No other abnormalities are noted.\n\nASSESSMENT\n\nLeft knee pain, possible MCL strain.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have discussed with the patient that her x-rays did not reveal any signs of a tear. I have recommended that we treat the patient conservatively. The plan is to place the patient in a knee immobilizer to provide increased support for the next week. I have also prescribed the patient tramadol 50 mg to treat her pain. She can take Tylenol as needed for breakthrough pain. I have also advised her to ice her left knee 3 to 4 times a day for 20 to 30 minutes at a time. I have advised her to refrain from running for the next 3 weeks. If her pain does not improve with the immobilizer, I will recommend obtaining an MRI.\n",
            "file": "D2N167-aci"
        }
    ]
}