DATEXIS/aci_bench_intent_annotated · Datasets at Hugging Face

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doctor: hi , martha . how are you ? patient: i'm doing okay . how are you ?	D2N001	0	[ "Greetings" ]	[ "Subjective" ]	hi , martha . how are you ?	0
doctor: i'm doing okay . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? patient: okay .	D2N001	1	[ "Chitchat" ]	[ "Null" ]	i'm doing okay . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ?	1
doctor: martha is a 50-year-old female with a past medical history significant for congestive heart failure , depression and hypertension who presents for her annual exam . so , martha , it's been a year since i've seen you . how are you doing ? patient: i'm doing well . i've been traveling a lot recently since things have , have gotten a bit lighter . and i got my , my vaccine , so i feel safer about traveling . i've been doing a lot of hiking . uh , went to washington last weekend to hike in northern cascades, like around the mount baker area .	D2N001	2	[ "Personal History" ]	[ "Subjective" ]	martha is a 50-year-old female with a past medical history significant for congestive heart failure , depression and hypertension who presents for her annual exam . so , martha , it's been a year since i've seen you . how are you doing ?	2
doctor: nice . that's great . i'm glad to hear that you're staying active , you know . i , i just love this weather . i'm so happy the summer is over . i'm definitely more of a fall person . patient: yes , fall foliage is the best .	D2N001	3	[ "Chitchat" ]	[ "Null" ]	nice . that's great . i'm glad to hear that you're staying active , you know . i , i just love this weather . i'm so happy the summer is over . i'm definitely more of a fall person .	3
doctor: yeah . um , so tell me , how are you doing with the congestive heart failure ? how are you doing watching your diet ? i know we've talked about watching a low sodium diet . are you doing okay with that ? patient: i've been doing well with that . i resisted , as much , as i could , from the tater tots , you know , the soft pretzels , the salty foods that i , i love to eat . and i've been doing a really good job .	D2N001	4	[ "Personal History" ]	[ "Subjective" ]	yeah . um , so tell me , how are you doing with the congestive heart failure ? how are you doing watching your diet ? i know we've talked about watching a low sodium diet . are you doing okay with that ?	4
doctor: okay , all right . well , i'm glad to hear that . and you're taking your medication ? patient: yes .	D2N001	5	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	okay , all right . well , i'm glad to hear that . and you're taking your medication ?	5
doctor: okay , good . and any symptoms like chest pains , shortness of breath , any swelling in your legs ? patient: no , not that i've noticed .	D2N001	6	[ "Personal History" ]	[ "Subjective" ]	okay , good . and any symptoms like chest pains , shortness of breath , any swelling in your legs ?	6
doctor: okay , all right . and then in terms of your depression , i know that we tried to stay off of medication in the past because you're on medications for your other problems . how are you doing ? and i know that you enrolled into therapy . is that helping ? or- patient: yeah , it's been helping a lot . i've been going every week , um , for the past year since my last annual exam . and that's been really helpful for me .	D2N001	7	[ "Personal History" ]	[ "Subjective" ]	okay , all right . and then in terms of your depression , i know that we tried to stay off of medication in the past because you're on medications for your other problems . how are you doing ? and i know that you enrolled into therapy . is that helping ? or-	7
doctor: okay . so , no , no issues , no feelings of wanting to harm yourself or hurt others ? patient: no , nothing like that .	D2N001	8	[ "Personal History" ]	[ "Subjective" ]	okay . so , no , no issues , no feelings of wanting to harm yourself or hurt others ?	8
doctor: okay , all right . and then in terms of your high blood pressure , i know that you and i have kind of battled in the past with you remembering to take some of your blood pressure medications . how are you doing with that ? patient: i'm still forgetting to take my blood pressure medication . and i've noticed when work gets more stressful , my blood pressure goes up .	D2N001	9	[ "Personal History" ]	[ "Subjective" ]	okay , all right . and then in terms of your high blood pressure , i know that you and i have kind of battled in the past with you remembering to take some of your blood pressure medications . how are you doing with that ?	9
doctor: okay . and , and so how has work going for you ? patient: it's been okay . it's been a lot of long hours , late nights . a lot of , um , you know , fiscal year end data that i've been having to pull . so , a lot of responsibility , which is good . but with the responsibility comes the stress .	D2N001	10	[ "Other Socials" ]	[ "Subjective" ]	okay . and , and so how has work going for you ?	10
doctor: yeah , okay , all right . i understand . um , all right . well , i know that you did a review of system sheet when you checked in with the nurse . i know that you were endorsing some nasal congestion from some of the fall pollen and allergies . any other symptoms , nausea or vomiting , abdominal pain , anything like that ? patient: no , nothing like that .	D2N001	11	[ "Acute Symptoms", "Vegetative History" ]	[ "Subjective" ]	yeah , okay , all right . i understand . um , all right . well , i know that you did a review of system sheet when you checked in with the nurse . i know that you were endorsing some nasal congestion from some of the fall pollen and allergies . any other symptoms , nausea or vomiting , abdominal pain , anything like that ?	11
doctor: no , okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ? patient: okay .	D2N001	12	[ "Physical Examination" ]	[ "Objective" ]	no , okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ?	12
doctor: hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it is a little elevated . you know , it could just , you could just be nervous . uh , let's look at some of the past readings . hey , dragon , show me the blood pressure readings . hey , dragon , show me the blood pressure readings . here we go . uh , so they are running on the higher side . um , y- you know , i , i do think that , you know , i'd like to see you take your medication a little bit more , so that we can get that under control a little bit better , okay ? patient: okay .	D2N001	13	[ "Physical Examination", "Medication" ]	[ "Objective", "Plan" ]	hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it is a little elevated . you know , it could just , you could just be nervous . uh , let's look at some of the past readings . hey , dragon , show me the blood pressure readings . hey , dragon , show me the blood pressure readings . here we go . uh , so they are running on the higher side . um , y- you know , i , i do think that , you know , i'd like to see you take your medication a little bit more , so that we can get that under control a little bit better , okay ?	13
doctor: so , i'm just gon na check out your heart and your lungs . and you know , let you know what i find , okay ? patient: okay .	D2N001	14	[ "Physical Examination" ]	[ "Objective" ]	so , i'm just gon na check out your heart and your lungs . and you know , let you know what i find , okay ?	14
doctor: okay . so , on your physical examination , you know , everything looks good . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which i've heard in the past , okay ? and on your lower extremities , i do appreciate one plus pitting edema , so you do have a little bit of fluid in your legs , okay ? patient: okay .	D2N001	15	[ "Physical Examination" ]	[ "Objective" ]	okay . so , on your physical examination , you know , everything looks good . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which i've heard in the past , okay ? and on your lower extremities , i do appreciate one plus pitting edema , so you do have a little bit of fluid in your legs , okay ?	15
doctor: let's go ahead , i wan na look at some of your results , okay ? hey , dragon , show me the echocardiogram . so , this is the result of the echocardiogram that we did last year . it showed that you have that low-ish pumping function of your heart at about 45 % . and it also sh- shows some mitral regurgitation , that's that heart murmur that i heard , okay ? um , hey , dragon , show me the lipid panel . so , looking at your lipid panel from last year , you know , everything , your cholesterol was like , a tiny bit high . but it was n't too , too bad , so i know you're trying to watch your diet . so , we'll repeat another one this year , okay ? patient: okay .	D2N001	16	[ "Lab Examination", "Radiology Examination", "Diagnostic Testing" ]	[ "Objective", "Plan" ]	let's go ahead , i wan na look at some of your results , okay ? hey , dragon , show me the echocardiogram . so , this is the result of the echocardiogram that we did last year . it showed that you have that low-ish pumping function of your heart at about 45 % . and it also sh- shows some mitral regurgitation , that's that heart murmur that i heard , okay ? um , hey , dragon , show me the lipid panel . so , looking at your lipid panel from last year , you know , everything , your cholesterol was like , a tiny bit high . but it was n't too , too bad , so i know you're trying to watch your diet . so , we'll repeat another one this year , okay ?	16
doctor: um , so i wan na just go over a little bit about my assessment and my plan for you , okay ? so , for your first problem your congestive heart failure , um , i wan na continue you on your current medications . but i do wan na increase your lisinopril to 40 milligrams a day , just because your blood pressure's high . and you know , you are retaining a little bit of fluid . i also wan na start you on some lasix , you know , 20 milligrams a day . and have you continue to watch your , your diet , okay ? patient: okay .	D2N001	17	[ "Discussion", "Medication" ]	[ "Assessment", "Plan" ]	um , so i wan na just go over a little bit about my assessment and my plan for you , okay ? so , for your first problem your congestive heart failure , um , i wan na continue you on your current medications . but i do wan na increase your lisinopril to 40 milligrams a day , just because your blood pressure's high . and you know , you are retaining a little bit of fluid . i also wan na start you on some lasix , you know , 20 milligrams a day . and have you continue to watch your , your diet , okay ?	17
doctor: i also wan na repeat another echocardiogram , okay ? patient: all right .	D2N001	18	[ "Diagnostic Testing" ]	[ "Plan" ]	i also wan na repeat another echocardiogram , okay ?	18
doctor: hey , dragon , order an echocardiogram . from a depression standpoint , it sounds like you're doing really well with that . so , i'm , i'm really happy for you . i'm , i'm glad to see that you're in therapy and you're doing really well . i do n't feel the need to start you on any medications this year , unless you feel differently . patient: no , i feel the same way .	D2N001	19	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	hey , dragon , order an echocardiogram . from a depression standpoint , it sounds like you're doing really well with that . so , i'm , i'm really happy for you . i'm , i'm glad to see that you're in therapy and you're doing really well . i do n't feel the need to start you on any medications this year , unless you feel differently .	19
doctor: okay , all right . and then for your last problem your hypertension , you know , again i , i , i think it's out of control . but we'll see , i think , you know , i'd like to see you take the lisinopril as directed , okay ? uh , i want you to record your blood pressures within the patient , you know , take your blood pressure every day . record them to me for like , about a week , so i have to see if we have to add another agent , okay ? 'cause we need to get that under better control for your heart failure to be more successful , okay ? patient: okay .	D2N001	20	[ "Discussion", "Medication" ]	[ "Assessment", "Plan" ]	okay , all right . and then for your last problem your hypertension , you know , again i , i , i think it's out of control . but we'll see , i think , you know , i'd like to see you take the lisinopril as directed , okay ? uh , i want you to record your blood pressures within the patient , you know , take your blood pressure every day . record them to me for like , about a week , so i have to see if we have to add another agent , okay ? 'cause we need to get that under better control for your heart failure to be more successful , okay ?	20
doctor: do you have any questions ? , and i forgot . for your annual exam , you're due for a mammogram , so we have to schedule for that , as well , okay ? patient: okay .	D2N001	21	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	do you have any questions ? , and i forgot . for your annual exam , you're due for a mammogram , so we have to schedule for that , as well , okay ?	21
doctor: okay . do you have any questions ? patient: can i take all my pills at the same time ?	D2N001	22	[ "Discussion", "Medication" ]	[ "Plan" ]	okay . do you have any questions ?	22
doctor: yeah . you can certainly take them , you know , all at the same time , as long , as yeah , they're all one scale . you can take them all at the same time . just set an alarm- patient: okay .	D2N001	24	[ "Discussion", "Medication" ]	[ "Plan" ]	yeah . you can certainly take them , you know , all at the same time , as long , as yeah , they're all one scale . you can take them all at the same time . just set an alarm-	23
doctor: . some time during the day to take them , okay ? patient: that might help me remember better .	D2N001	25	[ "Discussion", "Medication" ]	[ "Plan" ]	. some time during the day to take them , okay ?	24
doctor: all right . that sounds good . all right , well , it's good to see you . patient: good seeing you too .	D2N001	26	[ "Chitchat" ]	[ "Null" ]	all right . that sounds good . all right , well , it's good to see you .	25
doctor: hey , dragon , finalize the note .	D2N001	27	[ "Chitchat" ]	[ "Null" ]	doctor: hey , dragon , finalize the note .	26
doctor: hi , andrew , how are you ? patient: hi . good to see you .	D2N002	0	[ "Greetings" ]	[ "Subjective" ]	hi , andrew , how are you ?	27
doctor: it's good to see you as well . so i know that the nurse told you about dax . i'd like to tell dax a little bit about you . patient: sure .	D2N002	1	[ "Chitchat" ]	[ "Null" ]	it's good to see you as well . so i know that the nurse told you about dax . i'd like to tell dax a little bit about you .	28
doctor: okay ? so , andrew is a 62-year-old male with a past medical history significant for a kidney transplant , hypothyroidism , and arthritis , who presents today with complaints of joint pain . andrew , what's going on with your joint ? what happened ? patient: uh , so , over the the weekend , we've been moving boxes up and down our basements stairs , and by the end of the day my knees were just killing me .	D2N002	2	[ "Acute Symptoms", "Personal History" ]	[ "Subjective" ]	okay ? so , andrew is a 62-year-old male with a past medical history significant for a kidney transplant , hypothyroidism , and arthritis , who presents today with complaints of joint pain . andrew , what's going on with your joint ? what happened ?	29
doctor: okay . is , is one knee worse than the other ? patient: equally painful .	D2N002	3	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . is , is one knee worse than the other ?	30
doctor: and did you , did you injure one of them ? patient: um , uh , i've had some knee problems in the past but i think it was just the repetition and the weight of the boxes .	D2N002	5	[ "Personal History" ]	[ "Subjective" ]	and did you , did you injure one of them ?	31
doctor: okay . all right . and , and what have you taken for the pain ? patient: a little tylenol . i iced them for a bit . nothing really seemed to help , though .	D2N002	6	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	okay . all right . and , and what have you taken for the pain ?	32
doctor: okay . all right . um , and does it prevent you from doing , like , your activities of daily living , like walking and exercising and things like that ? patient: uh , saturday night it actually kept me up for a bit . they were pretty sore .	D2N002	7	[ "Acute Symptoms", "Personal History" ]	[ "Subjective" ]	okay . all right . um , and does it prevent you from doing , like , your activities of daily living , like walking and exercising and things like that ?	33
doctor: mm-hmm . okay . and any other symptoms like fever or chills ? patient: no .	D2N002	8	[ "Acute Symptoms" ]	[ "Subjective" ]	mm-hmm . okay . and any other symptoms like fever or chills ?	34
doctor: joint pain ... i mean , like muscle aches ? patient: no .	D2N002	9	[ "Acute Symptoms" ]	[ "Subjective" ]	joint pain ... i mean , like muscle aches ?	35
doctor: nausea , vomiting , diarrhea ? patient: no .	D2N002	10	[ "Acute Symptoms", "Vegetative History" ]	[ "Subjective" ]	nausea , vomiting , diarrhea ?	36
doctor: anything like that ? patient: no .	D2N002	11	[ "Vegetative History" ]	[ "Subjective" ]	anything like that ?	37
doctor: okay . all right . now , i know that you've had the kidney transplant a few years ago for some polycystic kidneys . patient: mm-hmm .	D2N002	12	[ "Personal History" ]	[ "Subjective" ]	okay . all right . now , i know that you've had the kidney transplant a few years ago for some polycystic kidneys .	38
doctor: um , how are you doing with that ? i know that you told dr. gutierrez- patient: mm .	D2N002	13	[ "Personal History" ]	[ "Subjective" ]	um , how are you doing with that ? i know that you told dr. gutierrez-	39
doctor: . a couple of weeks ago . patient: yes .	D2N002	14	[ "Personal History" ]	[ "Subjective" ]	. a couple of weeks ago .	40
doctor: everything's okay ? patient: so far , so good .	D2N002	15	[ "Personal History" ]	[ "Subjective" ]	everything's okay ?	41
doctor: all right . and you're taking your immunosuppressive medications ? patient: yes , i am .	D2N002	16	[ "Therapeutic History" ]	[ "Subjective" ]	all right . and you're taking your immunosuppressive medications ?	42
doctor: okay . all right . um , and did they have anything to say ? i have n't gotten any reports from them , so ... patient: no , n- nothing out of the ordinary , from what they reported .	D2N002	17	[ "Therapeutic History" ]	[ "Subjective" ]	okay . all right . um , and did they have anything to say ? i have n't gotten any reports from them , so ...	43
doctor: okay . all right . um , and in terms of your hyperthyroidism , how are you doing with the synthroid ? are you doing okay ? patient: uh , yes , i am .	D2N002	18	[ "Personal History" ]	[ "Subjective" ]	okay . all right . um , and in terms of your hyperthyroidism , how are you doing with the synthroid ? are you doing okay ?	44
doctor: you're taking it regularly ? patient: on the clock , yes .	D2N002	19	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	you're taking it regularly ?	45
doctor: yes . okay . and any fatigue ? weight gain ? anything like that that you've noticed ? patient: no , nothing out of the ordinary .	D2N002	20	[ "Vegetative History" ]	[ "Subjective" ]	yes . okay . and any fatigue ? weight gain ? anything like that that you've noticed ?	46
doctor: okay . and just in general , you know , i know that we've kind of battled with your arthritis . patient: mm-hmm .	D2N002	21	[ "Personal History" ]	[ "Subjective" ]	okay . and just in general , you know , i know that we've kind of battled with your arthritis .	47
doctor: you know , it's hard because you ca n't take certain medications 'cause of your kidney transplant . patient: sure .	D2N002	22	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	you know , it's hard because you ca n't take certain medications 'cause of your kidney transplant .	48
doctor: so other than your knees , any other joint pain or anything like that ? patient: every once in a while , my elbow , but nothing , nothing out of the ordinary .	D2N002	23	[ "Acute Symptoms" ]	[ "Subjective" ]	so other than your knees , any other joint pain or anything like that ?	49
doctor: okay . all right . now i know the nurse did a review of systems sheet when you checked in . any other symptoms i might have missed ? patient: no .	D2N002	24	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . all right . now i know the nurse did a review of systems sheet when you checked in . any other symptoms i might have missed ?	50
doctor: no headaches ? patient: no headaches .	D2N002	25	[ "Acute Symptoms" ]	[ "Subjective" ]	no headaches ?	51
doctor: anything like that w- ... okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so here in the office , your vital signs look good . you do n't have a fever , which is good . patient: mm-hmm .	D2N002	26	[ "Physical Examination" ]	[ "Objective" ]	anything like that w- ... okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so here in the office , your vital signs look good . you do n't have a fever , which is good .	52
doctor: your heart rate and your , uh , blood pressure look fine . i'm just gon na check some things out , and i'll let you know what i find , okay ? patient: perfect .	D2N002	27	[ "Physical Examination" ]	[ "Objective" ]	your heart rate and your , uh , blood pressure look fine . i'm just gon na check some things out , and i'll let you know what i find , okay ?	53
doctor: all right . does that hurt ? patient: a little bit . that's tender .	D2N002	28	[ "Physical Examination" ]	[ "Objective" ]	all right . does that hurt ?	54
doctor: okay , so on physical examination , on your heart exam , i do appreciate a little two out of six systolic ejection murmur- patient: mm-hmm .	D2N002	29	[ "Physical Examination" ]	[ "Objective" ]	okay , so on physical examination , on your heart exam , i do appreciate a little two out of six systolic ejection murmur-	55
doctor: . which we've heard in the past . okay , so that seems stable . on your knee exam , there is some edema and some erythema of your right knee , but your left knee looks fine , okay ? um , you do have some pain to palpation of the right knee and some decreased range of motion , um , on exam , okay ? so what does that mean ? so we'll go ahead and we'll see if we can take a look at some of these things . i know that they did an x-ray before you came in , okay ? patient: mm-hmm .	D2N002	30	[ "Physical Examination" ]	[ "Objective" ]	. which we've heard in the past . okay , so that seems stable . on your knee exam , there is some edema and some erythema of your right knee , but your left knee looks fine , okay ? um , you do have some pain to palpation of the right knee and some decreased range of motion , um , on exam , okay ? so what does that mean ? so we'll go ahead and we'll see if we can take a look at some of these things . i know that they did an x-ray before you came in , okay ?	56
doctor: so let's take a look at that . patient: sure .	D2N002	31	[ "Radiology Examination" ]	[ "Objective" ]	so let's take a look at that .	57
doctor: hey , dragon , show me the right knee x-ray . so here's the r- here's your right knee x-ray . this basically shows that there's good bony alignment . there's no acute fracture , which is not surprising , based on the history . patient: mm-hmm .	D2N002	32	[ "Radiology Examination" ]	[ "Objective" ]	hey , dragon , show me the right knee x-ray . so here's the r- here's your right knee x-ray . this basically shows that there's good bony alignment . there's no acute fracture , which is not surprising , based on the history .	58
doctor: okay ? hey , dragon , show me the labs . and here , looking at your lab results , you know , your white blood cell count is not elevated , which is good . you know , we get concerned about that in somebody who's immunocompromised . patient: mm-hmm .	D2N002	33	[ "Lab Examination" ]	[ "Objective" ]	okay ? hey , dragon , show me the labs . and here , looking at your lab results , you know , your white blood cell count is not elevated , which is good . you know , we get concerned about that in somebody who's immunocompromised .	59
doctor: and it looks like your kidney function is also very good . so i'm , i'm very happy about that . patient: yeah .	D2N002	34	[ "Lab Examination" ]	[ "Objective" ]	and it looks like your kidney function is also very good . so i'm , i'm very happy about that .	60
doctor: okay ? so i just wan na go over a little bit about my assessment and my plan for you . patient: mm-hmm .	D2N002	35	[ "Discussion" ]	[ "Assessment", "Plan" ]	okay ? so i just wan na go over a little bit about my assessment and my plan for you .	61
doctor: so for your knee pain , i think that this is an acute exacerbation of your arthritis , okay ? so i wan na go ahead and if ... and prescribe some ultram 50 milligrams every six hours as needed . patient: okay .	D2N002	36	[ "Medication", "Acute Assessment" ]	[ "Assessment", "Plan" ]	so for your knee pain , i think that this is an acute exacerbation of your arthritis , okay ? so i wan na go ahead and if ... and prescribe some ultram 50 milligrams every six hours as needed .	62
doctor: okay ? i also wan na go ahead and just order an autoimmune panel , okay ? hey , dragon , order an autoimmune panel . and you know , i , i want , i want you to just take it easy for right now , and if your symptoms continue , we'll talk about further imaging and possibly referral to physical therapy , okay ? patient: you got it .	D2N002	37	[ "Discussion", "Diagnostic Testing" ]	[ "Plan" ]	okay ? i also wan na go ahead and just order an autoimmune panel , okay ? hey , dragon , order an autoimmune panel . and you know , i , i want , i want you to just take it easy for right now , and if your symptoms continue , we'll talk about further imaging and possibly referral to physical therapy , okay ?	63
doctor: for your second problem , your hypothyroidism , i wan na go ahead and continue you on this ... on the synthroid , and i wan na go ahead and order some thyroid labs , okay ? patient: sure .	D2N002	38	[ "Follow-up", "Medication", "Reassessment" ]	[ "Assessment", "Plan" ]	for your second problem , your hypothyroidism , i wan na go ahead and continue you on this ... on the synthroid , and i wan na go ahead and order some thyroid labs , okay ?	64
doctor: hey , dragon , order a thyroid panel . and then for your last problem , the arthritis , you know , we just kinda talked about that . you know , it's gon na be a struggle for you because again , you ca n't take some of those anti-inflammatory medications because of your kidney transplant , so ... patient: mm-hmm .	D2N002	39	[ "Discussion", "Medication", "Diagnostic Testing", "Reassessment" ]	[ "Assessment", "Plan" ]	hey , dragon , order a thyroid panel . and then for your last problem , the arthritis , you know , we just kinda talked about that . you know , it's gon na be a struggle for you because again , you ca n't take some of those anti-inflammatory medications because of your kidney transplant , so ...	65
doctor: you know , let's see how we do over the next couple weeks , and again , we'll refer you to physical therapy if we need to , okay ? patient: you got it .	D2N002	40	[ "Follow-up" ]	[ "Plan" ]	you know , let's see how we do over the next couple weeks , and again , we'll refer you to physical therapy if we need to , okay ?	66
doctor: you have any questions ? patient: not at this point .	D2N002	41	[ "Discussion", "Chitchat" ]	[ "Plan" ]	you have any questions ?	67
doctor: okay . hey , dragon , finalize the note .	D2N002	42	[ "Chitchat" ]	[ "Null" ]	doctor: okay . hey , dragon , finalize the note .	68
doctor: hi , john . how are you ? patient: hey . well , relatively speaking , okay . good to see you .	D2N003	0	[ "Greetings" ]	[ "Subjective" ]	hi , john . how are you ?	69
doctor: good to see you as well . so i know the nurse told you about dax . i'm gon na tell dax a little bit about you . patient: okay .	D2N003	1	[ "Chitchat" ]	[ "Null" ]	good to see you as well . so i know the nurse told you about dax . i'm gon na tell dax a little bit about you .	70
doctor: so john is a 61-year-old male with a past medical history significant for kidney stones , migraines and reflux , who presents with some back pain . so john , what's going on with your back ? patient: uh , i'm feeling a lot of the same pain that i had when i had kidney stones about two years ago , so i'm a little concerned .	D2N003	2	[ "Acute Symptoms", "Personal History" ]	[ "Subjective" ]	so john is a 61-year-old male with a past medical history significant for kidney stones , migraines and reflux , who presents with some back pain . so john , what's going on with your back ?	71
doctor: yeah . and so wh- what side of your back is it on ? patient: uh , honestly , it shifts . it started from the right side and it kinda moved over , and now i feel it in the left side of my back .	D2N003	3	[ "Acute Symptoms" ]	[ "Subjective" ]	yeah . and so wh- what side of your back is it on ?	72
doctor: okay . and , um , how many days has this been going on for ? patient: the last four days .	D2N003	4	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . and , um , how many days has this been going on for ?	73
doctor: okay . and is ... is the pain coming and going ? patient: um , at first it was coming and going , and then for about the last 48 hours , it's been a constant , and it's ... it's been pretty bad .	D2N003	5	[ "Acute Symptoms" ]	[ "Subjective" ]	okay . and is ... is the pain coming and going ?	74
doctor: okay . and what have you taken for the pain ? patient: tylenol , but it really does n't seem to help .	D2N003	6	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	okay . and what have you taken for the pain ?	75
doctor: yeah . okay . and do you have any blood in your urine ? patient: um , uh , it ... i think i do . it's kind of hard to detect , but it does look a little off-color .	D2N003	7	[ "Acute Symptoms", "Vegetative History" ]	[ "Subjective" ]	yeah . okay . and do you have any blood in your urine ?	76
doctor: okay . all right . um , and have you had , uh , any other symptoms like nausea and vomiting ? patient: um , if i'm doing something i'm ... i'm , uh , like exerting myself , like climbing the three flights of stairs to my apartment or running to catch the bus , i feel a little dizzy and a little light headed , and i ... i still feel a little bit more pain in my abdomen .	D2N003	8	[ "Acute Symptoms", "Vegetative History" ]	[ "Subjective" ]	okay . all right . um , and have you had , uh , any other symptoms like nausea and vomiting ?	77
doctor: okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago . patient: i've been pretty diligent about taking the meds . i ... i wan na make sure i stay on top of that , so i've been pretty good with that .	D2N003	9	[ "Personal History", "Therapeutic History" ]	[ "Subjective" ]	okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago .	78
doctor: okay , so no issues with the migraine ? patient: none whatsoever .	D2N003	10	[ "Personal History" ]	[ "Subjective" ]	okay , so no issues with the migraine ?	79
doctor: okay . and how about your ... your acid reflux ? how are you doing with ... i know you were making some diet changes . patient: yeah , i've been pretty good with the diet , but with the pain i have been having, it has been easier to call and have something delivered. so i have been ordering a lot of take-out and fast food that can be delivered to my door so i don't have to go out and up and down the steps to get it myself. but other than that , it's been pretty good .	D2N003	11	[ "Personal History" ]	[ "Subjective" ]	okay . and how about your ... your acid reflux ? how are you doing with ... i know you were making some diet changes .	80
doctor: okay . are you staying hydrated ? patient: yes .	D2N003	12	[ "Vegetative History" ]	[ "Subjective" ]	okay . are you staying hydrated ?	81
doctor: okay . all right . okay , well , let's go ahead and , uh , i know the nurse did a review of systems , you know , with you , and i know that you're endorsing some back pain and a little bit of dizziness , um , and some blood in your urine . any other symptoms ? you know , muscle aches , chest pain ... uh , body aches , anything like that ? patient: i have some body aches because i think i'm ... i'm favoring , um , my back when i'm walking because of the pain , like i kinda feel it in my muscles , but not out of the ordinary and not surprised 'cause i remember that from two years ago .	D2N003	13	[ "Acute Symptoms", "Personal History" ]	[ "Subjective" ]	okay . all right . okay , well , let's go ahead and , uh , i know the nurse did a review of systems , you know , with you , and i know that you're endorsing some back pain and a little bit of dizziness , um , and some blood in your urine . any other symptoms ? you know , muscle aches , chest pain ... uh , body aches , anything like that ?	82
doctor: okay . all right . well , let's go ahead and ... and look at your vital signs today . hey , dragon ? show me the blood pressure . yeah , so your blood pressure's a little high today . that's probably because you're in some pain , um , but let ... let me just take a listen to your heart and lungs , and i'll let you know what i find , okay ? patient: sure .	D2N003	14	[ "Physical Examination" ]	[ "Objective" ]	okay . all right . well , let's go ahead and ... and look at your vital signs today . hey , dragon ? show me the blood pressure . yeah , so your blood pressure's a little high today . that's probably because you're in some pain , um , but let ... let me just take a listen to your heart and lungs , and i'll let you know what i find , okay ?	83
doctor: okay , so on ... on physical exam , you do have some , uh , cda tenderness on the right-hand side , meaning that you're tender when i ... when i pound on that . patient: mm-hmm .	D2N003	15	[ "Physical Examination" ]	[ "Objective" ]	okay , so on ... on physical exam , you do have some , uh , cda tenderness on the right-hand side , meaning that you're tender when i ... when i pound on that .	84
doctor: um , and your abdomen also feels a little tender . you have some tenderness of the palpation of the right lower quadrant , but other than that , your heart sounds nice and clear and your lungs are clear as well . so let's go ahead and take a look at some of your results , okay ? patient: sure .	D2N003	16	[ "Physical Examination" ]	[ "Objective" ]	um , and your abdomen also feels a little tender . you have some tenderness of the palpation of the right lower quadrant , but other than that , your heart sounds nice and clear and your lungs are clear as well . so let's go ahead and take a look at some of your results , okay ?	85
doctor: hey , dragon ? show me the creatinine . so we ... we drew a creatinine when you came in here because i was concerned about the kidney stones . it ... it is uh ... it is up slightly , which might suggest that you have a little bit of a obstruction there of one- patient: mm-hmm .	D2N003	17	[ "Lab Examination" ]	[ "Objective" ]	hey , dragon ? show me the creatinine . so we ... we drew a creatinine when you came in here because i was concerned about the kidney stones . it ... it is uh ... it is up slightly , which might suggest that you have a little bit of a obstruction there of one-	86
doctor: . of the stones . okay ? hey , dragon . show me the abdominal x-rays . okay , and there might be a question of a ... uh , of a stone there lower down , uh , but we'll wait for the official read there . so the , uh , abdominal x-rays show a possible kidney stone , okay ? patient: okay .	D2N003	18	[ "Lab Examination", "Radiology Examination" ]	[ "Objective" ]	. of the stones . okay ? hey , dragon . show me the abdominal x-rays . okay , and there might be a question of a ... uh , of a stone there lower down , uh , but we'll wait for the official read there . so the , uh , abdominal x-rays show a possible kidney stone , okay ?	87
doctor: so let's talk a little bit about my assessment and plan for you . so , for your first problem , your back pain , i think you're having a recurrence of your kidney stones . so i wan na go ahead and order a ct scan without contrast of your abdomen and pelvis . okay ? patient: mm-hmm .	D2N003	19	[ "Diagnostic Testing", "Acute Assessment" ]	[ "Assessment", "Plan" ]	so let's talk a little bit about my assessment and plan for you . so , for your first problem , your back pain , i think you're having a recurrence of your kidney stones . so i wan na go ahead and order a ct scan without contrast of your abdomen and pelvis . okay ?	88
doctor: and i'm also gon na order you some ultram 50 milligrams as needed every six hours for pain . does that sound okay ? patient: okay .	D2N003	20	[ "Medication", "Acute Assessment" ]	[ "Assessment", "Plan" ]	and i'm also gon na order you some ultram 50 milligrams as needed every six hours for pain . does that sound okay ?	89
doctor: hey , dragon ? order ultram 50 milligrams every six hours as needed for pain . and i want you to push fluids and strain your urine . i know that you're familiar with that . patient: yes , i am .	D2N003	21	[ "Medication", "Acute Assessment" ]	[ "Assessment", "Plan" ]	hey , dragon ? order ultram 50 milligrams every six hours as needed for pain . and i want you to push fluids and strain your urine . i know that you're familiar with that .	90
doctor: for your next problem , for your migraines , let's continue you on the imitrex . and for your final problem , uh , for your reflux , uh , we have you on the protonix 40 milligrams a day . do you need a refill of that ? patient: actually , i do need a refill .	D2N003	22	[ "Medication", "Reassessment" ]	[ "Assessment", "Plan" ]	for your next problem , for your migraines , let's continue you on the imitrex . and for your final problem , uh , for your reflux , uh , we have you on the protonix 40 milligrams a day . do you need a refill of that ?	91
doctor: okay . hey , dragon ? order a refill of protonix 40 milligrams daily . okay . so the nurse will be in soon , and she'll help you get the cat scan scheduled . and i'll be in touch with you in ... in a day or so . patient: perfect .	D2N003	23	[ "Medication", "Diagnostic Testing" ]	[ "Plan" ]	okay . hey , dragon ? order a refill of protonix 40 milligrams daily . okay . so the nurse will be in soon , and she'll help you get the cat scan scheduled . and i'll be in touch with you in ... in a day or so .	92
doctor: if your symptoms worsen , just give me a call , okay ? patient: you got it .	D2N003	24	[ "Discussion", "Follow-up" ]	[ "Plan" ]	if your symptoms worsen , just give me a call , okay ?	93
doctor: take care . patient: thank you .	D2N003	25	[ "Chitchat" ]	[ "Null" ]	take care .	94
doctor: hey ... hey , dragon ? finalize the note .	D2N003	26	[ "Chitchat" ]	[ "Null" ]	doctor: hey ... hey , dragon ? finalize the note .	95
doctor: hi , james , how are you ? patient: hey , good to see you .	D2N004	0	[ "Greetings" ]	[ "Subjective" ]	hi , james , how are you ?	96
doctor: it's good to see you , too . so , i know the nurse told you about dax . patient: mm-hmm .	D2N004	1	[ "Chitchat" ]	[ "Null" ]	it's good to see you , too . so , i know the nurse told you about dax .	97
doctor: i'd like to tell dax a little bit about you . patient: sure .	D2N004	2	[ "Chitchat" ]	[ "Null" ]	i'd like to tell dax a little bit about you .	98
doctor: james is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes who presents today with back pain . patient: mm-hmm .	D2N004	3	[ "Acute Symptoms", "Personal History" ]	[ "Subjective" ]	james is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes who presents today with back pain .	99

doctor: hi , martha . how are you ? patient: i'm doing okay . how are you ?

D2N001

0

[ "Greetings" ]

[ "Subjective" ]

hi , martha . how are you ?

0

doctor: i'm doing okay . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? patient: okay .

D2N001

1

[ "Chitchat" ]

[ "Null" ]

i'm doing okay . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ?

1

doctor: martha is a 50-year-old female with a past medical history significant for congestive heart failure , depression and hypertension who presents for her annual exam . so , martha , it's been a year since i've seen you . how are you doing ? patient: i'm doing well . i've been traveling a lot recently since things have , have gotten a bit lighter . and i got my , my vaccine , so i feel safer about traveling . i've been doing a lot of hiking . uh , went to washington last weekend to hike in northern cascades, like around the mount baker area .

D2N001

2

[ "Personal History" ]

[ "Subjective" ]

martha is a 50-year-old female with a past medical history significant for congestive heart failure , depression and hypertension who presents for her annual exam . so , martha , it's been a year since i've seen you . how are you doing ?

2

doctor: nice . that's great . i'm glad to hear that you're staying active , you know . i , i just love this weather . i'm so happy the summer is over . i'm definitely more of a fall person . patient: yes , fall foliage is the best .

D2N001

3

[ "Chitchat" ]

[ "Null" ]

nice . that's great . i'm glad to hear that you're staying active , you know . i , i just love this weather . i'm so happy the summer is over . i'm definitely more of a fall person .

3

doctor: yeah . um , so tell me , how are you doing with the congestive heart failure ? how are you doing watching your diet ? i know we've talked about watching a low sodium diet . are you doing okay with that ? patient: i've been doing well with that . i resisted , as much , as i could , from the tater tots , you know , the soft pretzels , the salty foods that i , i love to eat . and i've been doing a really good job .

D2N001

4

[ "Personal History" ]

[ "Subjective" ]

yeah . um , so tell me , how are you doing with the congestive heart failure ? how are you doing watching your diet ? i know we've talked about watching a low sodium diet . are you doing okay with that ?

4

doctor: okay , all right . well , i'm glad to hear that . and you're taking your medication ? patient: yes .

D2N001

5

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

okay , all right . well , i'm glad to hear that . and you're taking your medication ?

5

doctor: okay , good . and any symptoms like chest pains , shortness of breath , any swelling in your legs ? patient: no , not that i've noticed .

D2N001

6

[ "Personal History" ]

[ "Subjective" ]

okay , good . and any symptoms like chest pains , shortness of breath , any swelling in your legs ?

6

doctor: okay , all right . and then in terms of your depression , i know that we tried to stay off of medication in the past because you're on medications for your other problems . how are you doing ? and i know that you enrolled into therapy . is that helping ? or- patient: yeah , it's been helping a lot . i've been going every week , um , for the past year since my last annual exam . and that's been really helpful for me .

D2N001

7

[ "Personal History" ]

[ "Subjective" ]

okay , all right . and then in terms of your depression , i know that we tried to stay off of medication in the past because you're on medications for your other problems . how are you doing ? and i know that you enrolled into therapy . is that helping ? or-

7

doctor: okay . so , no , no issues , no feelings of wanting to harm yourself or hurt others ? patient: no , nothing like that .

D2N001

8

[ "Personal History" ]

[ "Subjective" ]

okay . so , no , no issues , no feelings of wanting to harm yourself or hurt others ?

8

doctor: okay , all right . and then in terms of your high blood pressure , i know that you and i have kind of battled in the past with you remembering to take some of your blood pressure medications . how are you doing with that ? patient: i'm still forgetting to take my blood pressure medication . and i've noticed when work gets more stressful , my blood pressure goes up .

D2N001

9

[ "Personal History" ]

[ "Subjective" ]

okay , all right . and then in terms of your high blood pressure , i know that you and i have kind of battled in the past with you remembering to take some of your blood pressure medications . how are you doing with that ?

9

doctor: okay . and , and so how has work going for you ? patient: it's been okay . it's been a lot of long hours , late nights . a lot of , um , you know , fiscal year end data that i've been having to pull . so , a lot of responsibility , which is good . but with the responsibility comes the stress .

D2N001

10

[ "Other Socials" ]

[ "Subjective" ]

okay . and , and so how has work going for you ?

10

doctor: yeah , okay , all right . i understand . um , all right . well , i know that you did a review of system sheet when you checked in with the nurse . i know that you were endorsing some nasal congestion from some of the fall pollen and allergies . any other symptoms , nausea or vomiting , abdominal pain , anything like that ? patient: no , nothing like that .

D2N001

11

[ "Acute Symptoms", "Vegetative History" ]

[ "Subjective" ]

yeah , okay , all right . i understand . um , all right . well , i know that you did a review of system sheet when you checked in with the nurse . i know that you were endorsing some nasal congestion from some of the fall pollen and allergies . any other symptoms , nausea or vomiting , abdominal pain , anything like that ?

11

doctor: no , okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ? patient: okay .

D2N001

12

[ "Physical Examination" ]

[ "Objective" ]

no , okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ?

12

doctor: hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it is a little elevated . you know , it could just , you could just be nervous . uh , let's look at some of the past readings . hey , dragon , show me the blood pressure readings . hey , dragon , show me the blood pressure readings . here we go . uh , so they are running on the higher side . um , y- you know , i , i do think that , you know , i'd like to see you take your medication a little bit more , so that we can get that under control a little bit better , okay ? patient: okay .

D2N001

13

[ "Physical Examination", "Medication" ]

[ "Objective", "Plan" ]

hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it is a little elevated . you know , it could just , you could just be nervous . uh , let's look at some of the past readings . hey , dragon , show me the blood pressure readings . hey , dragon , show me the blood pressure readings . here we go . uh , so they are running on the higher side . um , y- you know , i , i do think that , you know , i'd like to see you take your medication a little bit more , so that we can get that under control a little bit better , okay ?

13

doctor: so , i'm just gon na check out your heart and your lungs . and you know , let you know what i find , okay ? patient: okay .

D2N001

14

[ "Physical Examination" ]

[ "Objective" ]

so , i'm just gon na check out your heart and your lungs . and you know , let you know what i find , okay ?

14

doctor: okay . so , on your physical examination , you know , everything looks good . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which i've heard in the past , okay ? and on your lower extremities , i do appreciate one plus pitting edema , so you do have a little bit of fluid in your legs , okay ? patient: okay .

D2N001

15

[ "Physical Examination" ]

[ "Objective" ]

okay . so , on your physical examination , you know , everything looks good . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which i've heard in the past , okay ? and on your lower extremities , i do appreciate one plus pitting edema , so you do have a little bit of fluid in your legs , okay ?

15

doctor: let's go ahead , i wan na look at some of your results , okay ? hey , dragon , show me the echocardiogram . so , this is the result of the echocardiogram that we did last year . it showed that you have that low-ish pumping function of your heart at about 45 % . and it also sh- shows some mitral regurgitation , that's that heart murmur that i heard , okay ? um , hey , dragon , show me the lipid panel . so , looking at your lipid panel from last year , you know , everything , your cholesterol was like , a tiny bit high . but it was n't too , too bad , so i know you're trying to watch your diet . so , we'll repeat another one this year , okay ? patient: okay .

D2N001

16

[ "Lab Examination", "Radiology Examination", "Diagnostic Testing" ]

[ "Objective", "Plan" ]

let's go ahead , i wan na look at some of your results , okay ? hey , dragon , show me the echocardiogram . so , this is the result of the echocardiogram that we did last year . it showed that you have that low-ish pumping function of your heart at about 45 % . and it also sh- shows some mitral regurgitation , that's that heart murmur that i heard , okay ? um , hey , dragon , show me the lipid panel . so , looking at your lipid panel from last year , you know , everything , your cholesterol was like , a tiny bit high . but it was n't too , too bad , so i know you're trying to watch your diet . so , we'll repeat another one this year , okay ?

16

doctor: um , so i wan na just go over a little bit about my assessment and my plan for you , okay ? so , for your first problem your congestive heart failure , um , i wan na continue you on your current medications . but i do wan na increase your lisinopril to 40 milligrams a day , just because your blood pressure's high . and you know , you are retaining a little bit of fluid . i also wan na start you on some lasix , you know , 20 milligrams a day . and have you continue to watch your , your diet , okay ? patient: okay .

D2N001

17

[ "Discussion", "Medication" ]

[ "Assessment", "Plan" ]

um , so i wan na just go over a little bit about my assessment and my plan for you , okay ? so , for your first problem your congestive heart failure , um , i wan na continue you on your current medications . but i do wan na increase your lisinopril to 40 milligrams a day , just because your blood pressure's high . and you know , you are retaining a little bit of fluid . i also wan na start you on some lasix , you know , 20 milligrams a day . and have you continue to watch your , your diet , okay ?

17

doctor: i also wan na repeat another echocardiogram , okay ? patient: all right .

D2N001

18

[ "Diagnostic Testing" ]

[ "Plan" ]

i also wan na repeat another echocardiogram , okay ?

18

doctor: hey , dragon , order an echocardiogram . from a depression standpoint , it sounds like you're doing really well with that . so , i'm , i'm really happy for you . i'm , i'm glad to see that you're in therapy and you're doing really well . i do n't feel the need to start you on any medications this year , unless you feel differently . patient: no , i feel the same way .

D2N001

19

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

hey , dragon , order an echocardiogram . from a depression standpoint , it sounds like you're doing really well with that . so , i'm , i'm really happy for you . i'm , i'm glad to see that you're in therapy and you're doing really well . i do n't feel the need to start you on any medications this year , unless you feel differently .

19

doctor: okay , all right . and then for your last problem your hypertension , you know , again i , i , i think it's out of control . but we'll see , i think , you know , i'd like to see you take the lisinopril as directed , okay ? uh , i want you to record your blood pressures within the patient , you know , take your blood pressure every day . record them to me for like , about a week , so i have to see if we have to add another agent , okay ? 'cause we need to get that under better control for your heart failure to be more successful , okay ? patient: okay .

D2N001

20

[ "Discussion", "Medication" ]

[ "Assessment", "Plan" ]

okay , all right . and then for your last problem your hypertension , you know , again i , i , i think it's out of control . but we'll see , i think , you know , i'd like to see you take the lisinopril as directed , okay ? uh , i want you to record your blood pressures within the patient , you know , take your blood pressure every day . record them to me for like , about a week , so i have to see if we have to add another agent , okay ? 'cause we need to get that under better control for your heart failure to be more successful , okay ?

20

doctor: do you have any questions ? , and i forgot . for your annual exam , you're due for a mammogram , so we have to schedule for that , as well , okay ? patient: okay .

D2N001

21

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

do you have any questions ? , and i forgot . for your annual exam , you're due for a mammogram , so we have to schedule for that , as well , okay ?

21

doctor: okay . do you have any questions ? patient: can i take all my pills at the same time ?

D2N001

22

[ "Discussion", "Medication" ]

[ "Plan" ]

okay . do you have any questions ?

22

doctor: yeah . you can certainly take them , you know , all at the same time , as long , as yeah , they're all one scale . you can take them all at the same time . just set an alarm- patient: okay .

D2N001

24

[ "Discussion", "Medication" ]

[ "Plan" ]

yeah . you can certainly take them , you know , all at the same time , as long , as yeah , they're all one scale . you can take them all at the same time . just set an alarm-

23

doctor: . some time during the day to take them , okay ? patient: that might help me remember better .

D2N001

25

[ "Discussion", "Medication" ]

[ "Plan" ]

. some time during the day to take them , okay ?

24

doctor: all right . that sounds good . all right , well , it's good to see you . patient: good seeing you too .

D2N001

26

[ "Chitchat" ]

[ "Null" ]

all right . that sounds good . all right , well , it's good to see you .

25

doctor: hey , dragon , finalize the note .

D2N001

27

[ "Chitchat" ]

[ "Null" ]

doctor: hey , dragon , finalize the note .

26

doctor: hi , andrew , how are you ? patient: hi . good to see you .

D2N002

0

[ "Greetings" ]

[ "Subjective" ]

hi , andrew , how are you ?

27

doctor: it's good to see you as well . so i know that the nurse told you about dax . i'd like to tell dax a little bit about you . patient: sure .

D2N002

1

[ "Chitchat" ]

[ "Null" ]

it's good to see you as well . so i know that the nurse told you about dax . i'd like to tell dax a little bit about you .

28

doctor: okay ? so , andrew is a 62-year-old male with a past medical history significant for a kidney transplant , hypothyroidism , and arthritis , who presents today with complaints of joint pain . andrew , what's going on with your joint ? what happened ? patient: uh , so , over the the weekend , we've been moving boxes up and down our basements stairs , and by the end of the day my knees were just killing me .

D2N002

2

[ "Acute Symptoms", "Personal History" ]

[ "Subjective" ]

okay ? so , andrew is a 62-year-old male with a past medical history significant for a kidney transplant , hypothyroidism , and arthritis , who presents today with complaints of joint pain . andrew , what's going on with your joint ? what happened ?

29

doctor: okay . is , is one knee worse than the other ? patient: equally painful .

D2N002

3

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . is , is one knee worse than the other ?

30

doctor: and did you , did you injure one of them ? patient: um , uh , i've had some knee problems in the past but i think it was just the repetition and the weight of the boxes .

D2N002

5

[ "Personal History" ]

[ "Subjective" ]

and did you , did you injure one of them ?

31

doctor: okay . all right . and , and what have you taken for the pain ? patient: a little tylenol . i iced them for a bit . nothing really seemed to help , though .

D2N002

6

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

okay . all right . and , and what have you taken for the pain ?

32

doctor: okay . all right . um , and does it prevent you from doing , like , your activities of daily living , like walking and exercising and things like that ? patient: uh , saturday night it actually kept me up for a bit . they were pretty sore .

D2N002

7

[ "Acute Symptoms", "Personal History" ]

[ "Subjective" ]

okay . all right . um , and does it prevent you from doing , like , your activities of daily living , like walking and exercising and things like that ?

33

doctor: mm-hmm . okay . and any other symptoms like fever or chills ? patient: no .

D2N002

8

[ "Acute Symptoms" ]

[ "Subjective" ]

mm-hmm . okay . and any other symptoms like fever or chills ?

34

doctor: joint pain ... i mean , like muscle aches ? patient: no .

D2N002

9

[ "Acute Symptoms" ]

[ "Subjective" ]

joint pain ... i mean , like muscle aches ?

35

doctor: nausea , vomiting , diarrhea ? patient: no .

D2N002

10

[ "Acute Symptoms", "Vegetative History" ]

[ "Subjective" ]

nausea , vomiting , diarrhea ?

36

doctor: anything like that ? patient: no .

D2N002

11

[ "Vegetative History" ]

[ "Subjective" ]

anything like that ?

37

doctor: okay . all right . now , i know that you've had the kidney transplant a few years ago for some polycystic kidneys . patient: mm-hmm .

D2N002

12

[ "Personal History" ]

[ "Subjective" ]

okay . all right . now , i know that you've had the kidney transplant a few years ago for some polycystic kidneys .

38

doctor: um , how are you doing with that ? i know that you told dr. gutierrez- patient: mm .

D2N002

13

[ "Personal History" ]

[ "Subjective" ]

um , how are you doing with that ? i know that you told dr. gutierrez-

39

doctor: . a couple of weeks ago . patient: yes .

D2N002

14

[ "Personal History" ]

[ "Subjective" ]

. a couple of weeks ago .

40

doctor: everything's okay ? patient: so far , so good .

D2N002

15

[ "Personal History" ]

[ "Subjective" ]

everything's okay ?

41

doctor: all right . and you're taking your immunosuppressive medications ? patient: yes , i am .

D2N002

16

[ "Therapeutic History" ]

[ "Subjective" ]

all right . and you're taking your immunosuppressive medications ?

42

doctor: okay . all right . um , and did they have anything to say ? i have n't gotten any reports from them , so ... patient: no , n- nothing out of the ordinary , from what they reported .

D2N002

17

[ "Therapeutic History" ]

[ "Subjective" ]

okay . all right . um , and did they have anything to say ? i have n't gotten any reports from them , so ...

43

doctor: okay . all right . um , and in terms of your hyperthyroidism , how are you doing with the synthroid ? are you doing okay ? patient: uh , yes , i am .

D2N002

18

[ "Personal History" ]

[ "Subjective" ]

okay . all right . um , and in terms of your hyperthyroidism , how are you doing with the synthroid ? are you doing okay ?

44

doctor: you're taking it regularly ? patient: on the clock , yes .

D2N002

19

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

you're taking it regularly ?

45

doctor: yes . okay . and any fatigue ? weight gain ? anything like that that you've noticed ? patient: no , nothing out of the ordinary .

D2N002

20

[ "Vegetative History" ]

[ "Subjective" ]

yes . okay . and any fatigue ? weight gain ? anything like that that you've noticed ?

46

doctor: okay . and just in general , you know , i know that we've kind of battled with your arthritis . patient: mm-hmm .

D2N002

21

[ "Personal History" ]

[ "Subjective" ]

okay . and just in general , you know , i know that we've kind of battled with your arthritis .

47

doctor: you know , it's hard because you ca n't take certain medications 'cause of your kidney transplant . patient: sure .

D2N002

22

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

you know , it's hard because you ca n't take certain medications 'cause of your kidney transplant .

48

doctor: so other than your knees , any other joint pain or anything like that ? patient: every once in a while , my elbow , but nothing , nothing out of the ordinary .

D2N002

23

[ "Acute Symptoms" ]

[ "Subjective" ]

so other than your knees , any other joint pain or anything like that ?

49

doctor: okay . all right . now i know the nurse did a review of systems sheet when you checked in . any other symptoms i might have missed ? patient: no .

D2N002

24

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . all right . now i know the nurse did a review of systems sheet when you checked in . any other symptoms i might have missed ?

50

doctor: no headaches ? patient: no headaches .

D2N002

25

[ "Acute Symptoms" ]

[ "Subjective" ]

no headaches ?

51

doctor: anything like that w- ... okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so here in the office , your vital signs look good . you do n't have a fever , which is good . patient: mm-hmm .

D2N002

26

[ "Physical Examination" ]

[ "Objective" ]

anything like that w- ... okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so here in the office , your vital signs look good . you do n't have a fever , which is good .

52

doctor: your heart rate and your , uh , blood pressure look fine . i'm just gon na check some things out , and i'll let you know what i find , okay ? patient: perfect .

D2N002

27

[ "Physical Examination" ]

[ "Objective" ]

your heart rate and your , uh , blood pressure look fine . i'm just gon na check some things out , and i'll let you know what i find , okay ?

53

doctor: all right . does that hurt ? patient: a little bit . that's tender .

D2N002

28

[ "Physical Examination" ]

[ "Objective" ]

all right . does that hurt ?

54

doctor: okay , so on physical examination , on your heart exam , i do appreciate a little two out of six systolic ejection murmur- patient: mm-hmm .

D2N002

29

[ "Physical Examination" ]

[ "Objective" ]

okay , so on physical examination , on your heart exam , i do appreciate a little two out of six systolic ejection murmur-

55

doctor: . which we've heard in the past . okay , so that seems stable . on your knee exam , there is some edema and some erythema of your right knee , but your left knee looks fine , okay ? um , you do have some pain to palpation of the right knee and some decreased range of motion , um , on exam , okay ? so what does that mean ? so we'll go ahead and we'll see if we can take a look at some of these things . i know that they did an x-ray before you came in , okay ? patient: mm-hmm .

D2N002

30

[ "Physical Examination" ]

[ "Objective" ]

. which we've heard in the past . okay , so that seems stable . on your knee exam , there is some edema and some erythema of your right knee , but your left knee looks fine , okay ? um , you do have some pain to palpation of the right knee and some decreased range of motion , um , on exam , okay ? so what does that mean ? so we'll go ahead and we'll see if we can take a look at some of these things . i know that they did an x-ray before you came in , okay ?

56

doctor: so let's take a look at that . patient: sure .

D2N002

31

[ "Radiology Examination" ]

[ "Objective" ]

so let's take a look at that .

57

doctor: hey , dragon , show me the right knee x-ray . so here's the r- here's your right knee x-ray . this basically shows that there's good bony alignment . there's no acute fracture , which is not surprising , based on the history . patient: mm-hmm .

D2N002

32

[ "Radiology Examination" ]

[ "Objective" ]

hey , dragon , show me the right knee x-ray . so here's the r- here's your right knee x-ray . this basically shows that there's good bony alignment . there's no acute fracture , which is not surprising , based on the history .

58

doctor: okay ? hey , dragon , show me the labs . and here , looking at your lab results , you know , your white blood cell count is not elevated , which is good . you know , we get concerned about that in somebody who's immunocompromised . patient: mm-hmm .

D2N002

33

[ "Lab Examination" ]

[ "Objective" ]

okay ? hey , dragon , show me the labs . and here , looking at your lab results , you know , your white blood cell count is not elevated , which is good . you know , we get concerned about that in somebody who's immunocompromised .

59

doctor: and it looks like your kidney function is also very good . so i'm , i'm very happy about that . patient: yeah .

D2N002

34

[ "Lab Examination" ]

[ "Objective" ]

and it looks like your kidney function is also very good . so i'm , i'm very happy about that .

60

doctor: okay ? so i just wan na go over a little bit about my assessment and my plan for you . patient: mm-hmm .

D2N002

35

[ "Discussion" ]

[ "Assessment", "Plan" ]

okay ? so i just wan na go over a little bit about my assessment and my plan for you .

61

doctor: so for your knee pain , i think that this is an acute exacerbation of your arthritis , okay ? so i wan na go ahead and if ... and prescribe some ultram 50 milligrams every six hours as needed . patient: okay .

D2N002

36

[ "Medication", "Acute Assessment" ]

[ "Assessment", "Plan" ]

so for your knee pain , i think that this is an acute exacerbation of your arthritis , okay ? so i wan na go ahead and if ... and prescribe some ultram 50 milligrams every six hours as needed .

62

doctor: okay ? i also wan na go ahead and just order an autoimmune panel , okay ? hey , dragon , order an autoimmune panel . and you know , i , i want , i want you to just take it easy for right now , and if your symptoms continue , we'll talk about further imaging and possibly referral to physical therapy , okay ? patient: you got it .

D2N002

37

[ "Discussion", "Diagnostic Testing" ]

[ "Plan" ]

okay ? i also wan na go ahead and just order an autoimmune panel , okay ? hey , dragon , order an autoimmune panel . and you know , i , i want , i want you to just take it easy for right now , and if your symptoms continue , we'll talk about further imaging and possibly referral to physical therapy , okay ?

63

doctor: for your second problem , your hypothyroidism , i wan na go ahead and continue you on this ... on the synthroid , and i wan na go ahead and order some thyroid labs , okay ? patient: sure .

D2N002

38

[ "Follow-up", "Medication", "Reassessment" ]

[ "Assessment", "Plan" ]

for your second problem , your hypothyroidism , i wan na go ahead and continue you on this ... on the synthroid , and i wan na go ahead and order some thyroid labs , okay ?

64

doctor: hey , dragon , order a thyroid panel . and then for your last problem , the arthritis , you know , we just kinda talked about that . you know , it's gon na be a struggle for you because again , you ca n't take some of those anti-inflammatory medications because of your kidney transplant , so ... patient: mm-hmm .

D2N002

39

[ "Discussion", "Medication", "Diagnostic Testing", "Reassessment" ]

[ "Assessment", "Plan" ]

hey , dragon , order a thyroid panel . and then for your last problem , the arthritis , you know , we just kinda talked about that . you know , it's gon na be a struggle for you because again , you ca n't take some of those anti-inflammatory medications because of your kidney transplant , so ...

65

doctor: you know , let's see how we do over the next couple weeks , and again , we'll refer you to physical therapy if we need to , okay ? patient: you got it .

D2N002

40

[ "Follow-up" ]

[ "Plan" ]

you know , let's see how we do over the next couple weeks , and again , we'll refer you to physical therapy if we need to , okay ?

66

doctor: you have any questions ? patient: not at this point .

D2N002

41

[ "Discussion", "Chitchat" ]

[ "Plan" ]

you have any questions ?

67

doctor: okay . hey , dragon , finalize the note .

D2N002

42

[ "Chitchat" ]

[ "Null" ]

doctor: okay . hey , dragon , finalize the note .

68

doctor: hi , john . how are you ? patient: hey . well , relatively speaking , okay . good to see you .

D2N003

0

[ "Greetings" ]

[ "Subjective" ]

hi , john . how are you ?

69

doctor: good to see you as well . so i know the nurse told you about dax . i'm gon na tell dax a little bit about you . patient: okay .

D2N003

1

[ "Chitchat" ]

[ "Null" ]

good to see you as well . so i know the nurse told you about dax . i'm gon na tell dax a little bit about you .

70

doctor: so john is a 61-year-old male with a past medical history significant for kidney stones , migraines and reflux , who presents with some back pain . so john , what's going on with your back ? patient: uh , i'm feeling a lot of the same pain that i had when i had kidney stones about two years ago , so i'm a little concerned .

D2N003

2

[ "Acute Symptoms", "Personal History" ]

[ "Subjective" ]

so john is a 61-year-old male with a past medical history significant for kidney stones , migraines and reflux , who presents with some back pain . so john , what's going on with your back ?

71

doctor: yeah . and so wh- what side of your back is it on ? patient: uh , honestly , it shifts . it started from the right side and it kinda moved over , and now i feel it in the left side of my back .

D2N003

3

[ "Acute Symptoms" ]

[ "Subjective" ]

yeah . and so wh- what side of your back is it on ?

72

doctor: okay . and , um , how many days has this been going on for ? patient: the last four days .

D2N003

4

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . and , um , how many days has this been going on for ?

73

doctor: okay . and is ... is the pain coming and going ? patient: um , at first it was coming and going , and then for about the last 48 hours , it's been a constant , and it's ... it's been pretty bad .

D2N003

5

[ "Acute Symptoms" ]

[ "Subjective" ]

okay . and is ... is the pain coming and going ?

74

doctor: okay . and what have you taken for the pain ? patient: tylenol , but it really does n't seem to help .

D2N003

6

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

okay . and what have you taken for the pain ?

75

doctor: yeah . okay . and do you have any blood in your urine ? patient: um , uh , it ... i think i do . it's kind of hard to detect , but it does look a little off-color .

D2N003

7

[ "Acute Symptoms", "Vegetative History" ]

[ "Subjective" ]

yeah . okay . and do you have any blood in your urine ?

76

doctor: okay . all right . um , and have you had , uh , any other symptoms like nausea and vomiting ? patient: um , if i'm doing something i'm ... i'm , uh , like exerting myself , like climbing the three flights of stairs to my apartment or running to catch the bus , i feel a little dizzy and a little light headed , and i ... i still feel a little bit more pain in my abdomen .

D2N003

8

[ "Acute Symptoms", "Vegetative History" ]

[ "Subjective" ]

okay . all right . um , and have you had , uh , any other symptoms like nausea and vomiting ?

77

doctor: okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago . patient: i've been pretty diligent about taking the meds . i ... i wan na make sure i stay on top of that , so i've been pretty good with that .

D2N003

9

[ "Personal History", "Therapeutic History" ]

[ "Subjective" ]

okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago .

78

doctor: okay , so no issues with the migraine ? patient: none whatsoever .

D2N003

10

[ "Personal History" ]

[ "Subjective" ]

okay , so no issues with the migraine ?

79

doctor: okay . and how about your ... your acid reflux ? how are you doing with ... i know you were making some diet changes . patient: yeah , i've been pretty good with the diet , but with the pain i have been having, it has been easier to call and have something delivered. so i have been ordering a lot of take-out and fast food that can be delivered to my door so i don't have to go out and up and down the steps to get it myself. but other than that , it's been pretty good .

D2N003

11

[ "Personal History" ]

[ "Subjective" ]

okay . and how about your ... your acid reflux ? how are you doing with ... i know you were making some diet changes .

80

doctor: okay . are you staying hydrated ? patient: yes .

D2N003

12

[ "Vegetative History" ]

[ "Subjective" ]

okay . are you staying hydrated ?

81

doctor: okay . all right . okay , well , let's go ahead and , uh , i know the nurse did a review of systems , you know , with you , and i know that you're endorsing some back pain and a little bit of dizziness , um , and some blood in your urine . any other symptoms ? you know , muscle aches , chest pain ... uh , body aches , anything like that ? patient: i have some body aches because i think i'm ... i'm favoring , um , my back when i'm walking because of the pain , like i kinda feel it in my muscles , but not out of the ordinary and not surprised 'cause i remember that from two years ago .

D2N003

13

[ "Acute Symptoms", "Personal History" ]

[ "Subjective" ]

okay . all right . okay , well , let's go ahead and , uh , i know the nurse did a review of systems , you know , with you , and i know that you're endorsing some back pain and a little bit of dizziness , um , and some blood in your urine . any other symptoms ? you know , muscle aches , chest pain ... uh , body aches , anything like that ?

82

doctor: okay . all right . well , let's go ahead and ... and look at your vital signs today . hey , dragon ? show me the blood pressure . yeah , so your blood pressure's a little high today . that's probably because you're in some pain , um , but let ... let me just take a listen to your heart and lungs , and i'll let you know what i find , okay ? patient: sure .

D2N003

14

[ "Physical Examination" ]

[ "Objective" ]

okay . all right . well , let's go ahead and ... and look at your vital signs today . hey , dragon ? show me the blood pressure . yeah , so your blood pressure's a little high today . that's probably because you're in some pain , um , but let ... let me just take a listen to your heart and lungs , and i'll let you know what i find , okay ?

83

doctor: okay , so on ... on physical exam , you do have some , uh , cda tenderness on the right-hand side , meaning that you're tender when i ... when i pound on that . patient: mm-hmm .

D2N003

15

[ "Physical Examination" ]

[ "Objective" ]

okay , so on ... on physical exam , you do have some , uh , cda tenderness on the right-hand side , meaning that you're tender when i ... when i pound on that .

84

doctor: um , and your abdomen also feels a little tender . you have some tenderness of the palpation of the right lower quadrant , but other than that , your heart sounds nice and clear and your lungs are clear as well . so let's go ahead and take a look at some of your results , okay ? patient: sure .

D2N003

16

[ "Physical Examination" ]

[ "Objective" ]

um , and your abdomen also feels a little tender . you have some tenderness of the palpation of the right lower quadrant , but other than that , your heart sounds nice and clear and your lungs are clear as well . so let's go ahead and take a look at some of your results , okay ?

85

doctor: hey , dragon ? show me the creatinine . so we ... we drew a creatinine when you came in here because i was concerned about the kidney stones . it ... it is uh ... it is up slightly , which might suggest that you have a little bit of a obstruction there of one- patient: mm-hmm .

D2N003

17

[ "Lab Examination" ]

[ "Objective" ]

hey , dragon ? show me the creatinine . so we ... we drew a creatinine when you came in here because i was concerned about the kidney stones . it ... it is uh ... it is up slightly , which might suggest that you have a little bit of a obstruction there of one-

86

doctor: . of the stones . okay ? hey , dragon . show me the abdominal x-rays . okay , and there might be a question of a ... uh , of a stone there lower down , uh , but we'll wait for the official read there . so the , uh , abdominal x-rays show a possible kidney stone , okay ? patient: okay .

D2N003

18

[ "Lab Examination", "Radiology Examination" ]

[ "Objective" ]

. of the stones . okay ? hey , dragon . show me the abdominal x-rays . okay , and there might be a question of a ... uh , of a stone there lower down , uh , but we'll wait for the official read there . so the , uh , abdominal x-rays show a possible kidney stone , okay ?

87

doctor: so let's talk a little bit about my assessment and plan for you . so , for your first problem , your back pain , i think you're having a recurrence of your kidney stones . so i wan na go ahead and order a ct scan without contrast of your abdomen and pelvis . okay ? patient: mm-hmm .

D2N003

19

[ "Diagnostic Testing", "Acute Assessment" ]

[ "Assessment", "Plan" ]

so let's talk a little bit about my assessment and plan for you . so , for your first problem , your back pain , i think you're having a recurrence of your kidney stones . so i wan na go ahead and order a ct scan without contrast of your abdomen and pelvis . okay ?

88

doctor: and i'm also gon na order you some ultram 50 milligrams as needed every six hours for pain . does that sound okay ? patient: okay .

D2N003

20

[ "Medication", "Acute Assessment" ]

[ "Assessment", "Plan" ]

and i'm also gon na order you some ultram 50 milligrams as needed every six hours for pain . does that sound okay ?

89

doctor: hey , dragon ? order ultram 50 milligrams every six hours as needed for pain . and i want you to push fluids and strain your urine . i know that you're familiar with that . patient: yes , i am .

D2N003

21

[ "Medication", "Acute Assessment" ]

[ "Assessment", "Plan" ]

hey , dragon ? order ultram 50 milligrams every six hours as needed for pain . and i want you to push fluids and strain your urine . i know that you're familiar with that .

90

doctor: for your next problem , for your migraines , let's continue you on the imitrex . and for your final problem , uh , for your reflux , uh , we have you on the protonix 40 milligrams a day . do you need a refill of that ? patient: actually , i do need a refill .

D2N003

22

[ "Medication", "Reassessment" ]

[ "Assessment", "Plan" ]

for your next problem , for your migraines , let's continue you on the imitrex . and for your final problem , uh , for your reflux , uh , we have you on the protonix 40 milligrams a day . do you need a refill of that ?

91

doctor: okay . hey , dragon ? order a refill of protonix 40 milligrams daily . okay . so the nurse will be in soon , and she'll help you get the cat scan scheduled . and i'll be in touch with you in ... in a day or so . patient: perfect .

D2N003

23

[ "Medication", "Diagnostic Testing" ]

[ "Plan" ]

okay . hey , dragon ? order a refill of protonix 40 milligrams daily . okay . so the nurse will be in soon , and she'll help you get the cat scan scheduled . and i'll be in touch with you in ... in a day or so .

92

doctor: if your symptoms worsen , just give me a call , okay ? patient: you got it .

D2N003

24

[ "Discussion", "Follow-up" ]

[ "Plan" ]

if your symptoms worsen , just give me a call , okay ?

93

doctor: take care . patient: thank you .

D2N003

25

[ "Chitchat" ]

[ "Null" ]

take care .

94

doctor: hey ... hey , dragon ? finalize the note .

D2N003

26

[ "Chitchat" ]

[ "Null" ]

doctor: hey ... hey , dragon ? finalize the note .

95

doctor: hi , james , how are you ? patient: hey , good to see you .

D2N004

0

[ "Greetings" ]

[ "Subjective" ]

hi , james , how are you ?

96

doctor: it's good to see you , too . so , i know the nurse told you about dax . patient: mm-hmm .

D2N004

1

[ "Chitchat" ]

[ "Null" ]

it's good to see you , too . so , i know the nurse told you about dax .

97

doctor: i'd like to tell dax a little bit about you . patient: sure .

D2N004

2

[ "Chitchat" ]

[ "Null" ]

i'd like to tell dax a little bit about you .

98

doctor: james is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes who presents today with back pain . patient: mm-hmm .

D2N004

3

[ "Acute Symptoms", "Personal History" ]

[ "Subjective" ]

james is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes who presents today with back pain .

99

Datasets:

DATEXIS
/

aci_bench_intent_annotated

Collection including DATEXIS/aci_bench_intent_annotated

"Where does it hurt" - Medical Intent Classification