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DATEXIS
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med_intent_classification

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do you have any questions ?
[ "Discussion" ]
[ "Plan" ]
3,600
you're welcome . so we'll see you in two to three weeks . have a good rest of your day .
[ "Follow-up" ]
[ "Plan" ]
3,601
okay okay and you've got a good pedal pulse so you know you can feel that and when i touch your feet you do n't have any numbness or tingling or anything like that
[ "Physical Examination" ]
[ "Objective" ]
3,602
. after a motor vehicle accident .
[ "Acute Symptoms" ]
[ "Subjective" ]
3,603
okay so now you mentioned that that happens somewhat a lot how frequently does this occur that you have these breathing type problems
[ "Personal History" ]
[ "Subjective" ]
3,604
great , great . no numbness or tingling in your hands ?
[ "Vegetative History" ]
[ "Subjective" ]
3,605
hi , roger . how are you ?
[ "Greetings" ]
[ "Subjective" ]
3,606
and what ankle was bothering you
[ "Acute Symptoms" ]
[ "Subjective" ]
3,607
i'm good . so le- are you ready to get started ?
[ "Chitchat" ]
[ "Null" ]
3,608
where are the headaches located and how would you describe that pain ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,609
hi jaqueline how are you i heard that you injured your ankle
[ "Greetings", "Acute Symptoms" ]
[ "Subjective" ]
3,610
that's good . any in- ... issues with abdominal pain ?
[ "Vegetative History" ]
[ "Subjective" ]
3,611
doctor: perfect . hey , dragon , finalize the note . why do n't you ...
[ "Chitchat" ]
[ "Null" ]
3,612
so , i'm gon na just take a listen to a few things and check some things out , and i'll let you know what i find , okay ?
[ "Physical Examination" ]
[ "Objective" ]
3,613
how do you feel about it
[ "Discussion", "Medication" ]
[ "Plan" ]
3,614
okay so little bit of limited range of motion as well as pain on both flexion and extension on the knee i'm gon na push on this a little bit looks like your mcmurray's test is negative just checking for a meniscus tear okay so let's talk a little bit about your plan what i am concerned about for your knee is it sounds like you have a torn or injured mcl i it's that inside tendon in your knee so i'm concerned about that since you're having trouble with weightbearing and you heard that pop so what i'm gon na do is i'm gon na put you in a straight leg brace and i'll prescribe some mobic you can start taking that as a a pain reliever and to try to get some of the swelling down i want you to ice your knee once an hour for about fifteen minutes but i'm also gon na send you out for an mri because we wan na make sure this is what happens see if there's any other damage to the knee does that sound good
[ "Physical Examination", "Medication", "Other Treatments", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,615
yeah that's a great question i'm gon na ask well my first off i want to see you back here in in seven days you know in a week i want you to make an appointment we're gon na relook at it we're gon na determine if that swelling got any worse and if we need to go on to potentially ordering like a cat scan or an mri of that knee to look and see if there was any significant damage to the ligament so that's for for sure for seven days you're not gon na be playing basketball now are you in a ligue or is that just you get like pick up basketball
[ "Discussion", "Follow-up", "Diagnostic Testing" ]
[ "Plan" ]
3,616
right there okay tell me what's worse here or here
[ "Physical Examination" ]
[ "Objective" ]
3,617
okay and were you able to ski down the hill or did you have to be taken down by the ski patrol
[ "Acute Symptoms" ]
[ "Subjective" ]
3,618
alright are you able to urinate
[ "Acute Symptoms" ]
[ "Subjective" ]
3,619
awesome .
[ "Personal History" ]
[ "Subjective" ]
3,620
is that where you would be kicking your leg out or something
[ "Other Socials" ]
[ "Subjective" ]
3,621
wow okay when was that
[ "Acute Symptoms" ]
[ "Subjective" ]
3,622
hi joyce , how are you ?
[ "Greetings" ]
[ "Subjective" ]
3,623
okay you're welcome i'll be in touch bye
[ "Chitchat" ]
[ "Null" ]
3,624
so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
3,625
okay you might wan na switch to maybe two or three times a day but you know that's something i'm glad that you are measuring are you taking your metformin
[ "Therapeutic History", "Personal History" ]
[ "Subjective" ]
3,626
it's called a calcineurin inhibitor . it's kinda like a steroid in that it calms inflammation .
[ "Discussion", "Medication" ]
[ "Plan" ]
3,627
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
[ "Personal History" ]
[ "Subjective" ]
3,628
um , and we can always give you some pain medication if you , if you get some pain periodically with activity . how do you feel about that ? do you need some pain medication ?
[ "Discussion" ]
[ "Plan" ]
3,629
yeah . so i know it's annoying and distressing , but i think that's where we're at . it's annoying that you have the breast issue , and it's annoying that we have to follow them .
[ "Discussion" ]
[ "Plan" ]
3,630
okay . and do you just notice it in the hand , or does it seem to be going down the whole arm ?
[ "Acute Symptoms" ]
[ "Subjective" ]
3,631
alright brittany so i see that you are experiencing some right foot pain could you tell me what happened
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
3,632
doctor: all right . hey , dragon , order the medications and procedures discussed , and finalize the report . okay , come with me and we'll get you checked out .
[ "Chitchat" ]
[ "Null" ]
3,633
okay . and , and so how has work going for you ?
[ "Other Socials" ]
[ "Subjective" ]
3,634
okay . all right , well , let's talk a little bit about your epilepsy , okay ?
[ "Personal History" ]
[ "Subjective" ]
3,635
yes . what do you do for your acne in the morning ? and then what do you do at nighttime ?
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
3,636
okay and do you notice any any pain when you urinate or when you pee
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
3,637
any chest pain or shortness of breath ?
[ "Vegetative History" ]
[ "Subjective" ]
3,638
okay did you hit your head when you when this happened
[ "Personal History" ]
[ "Subjective" ]
3,639
i really think your liver enzymes are going to get better once you lose the weight , though .
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
3,640
so i see here that you hurt your right ankle can you tell me what happened
[ "Acute Symptoms" ]
[ "Subjective" ]
3,641
alright are you still having pain
[ "Acute Symptoms" ]
[ "Subjective" ]
3,642
alright okay well do you have any other questions for me
[ "Discussion" ]
[ "Plan" ]
3,643
no go ahead go ahead
[ "Acute Symptoms" ]
[ "Subjective" ]
3,644
doctor: thank you alright so at this point now i'm just gon na press the i'm gon na
[ "Chitchat" ]
[ "Null" ]
3,645
okay and then let's go ahead and examine you alright so mark your exam is pretty much you know for the most part normal with a few exceptions on your heart exam you still have a grade three out of six systolic ejection murmur and that's unchanged from prior exam we're watching that and so that just means i hear some some heart sounds as your heart is beating there i'm not too concerned about it as as that's not changed otherwise normal cardiovascular exam and your physical exam otherwise on your musculoskeletal exam on your right elbow you do have moderate lateral epicondylar tenderness of the right elbow and how about when i move this when i move your elbow like this does that hurt you
[ "Physical Examination" ]
[ "Objective" ]
3,646
really ?
[ "Therapeutic History" ]
[ "Subjective" ]
3,647
we're gon na go right to the front- . so when you touch that- hi , michelle , how are you ?
[ "Greetings" ]
[ "Subjective" ]
3,648
okay okay and how about any fevers
[ "Vegetative History" ]
[ "Subjective" ]
3,649
doctor: um , as far as the physical exam . scattered inflammatory papules and pustules across the upper back and posterior shoulders . there are less than 5 inflammatory papules on the forehead , cheeks , and chin . acne vulgaris is improved and well controlled on the face , but there is a mild flare on the back . recommend continuing current treatment plan for the face and initiation treatment with PanOxyl 10 % foaming wash to the back in the shower daily .
[ "Physical Examination", "Medication" ]
[ "Objective", "Plan" ]
3,650
as long as you do n't move your shoulder .
[ "Acute Symptoms" ]
[ "Subjective" ]
3,651
but you're taking your medication ?
[ "Therapeutic History" ]
[ "Subjective" ]
3,652
did you have any problems finding us ?
[ "Chitchat" ]
[ "Null" ]
3,653
good to see you as well . um , so i know that the nurse told you about dax . i'd like to tell dax about you .
[ "Chitchat" ]
[ "Null" ]
3,654
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 ?
[ "Lab Examination", "Radiology Examination", "Diagnostic Testing" ]
[ "Objective", "Plan" ]
3,655
and i wan na go ahead and prescribe meloxicam 15 milligrams once a day , and i'd like to refer you to physical therapy to kind of strengthen that area . now , if you're still having symptoms , i wan na go ahead and , uh , order an mri-
[ "Follow-up", "Medication", "Referral", "Diagnostic Testing" ]
[ "Plan" ]
3,656
um , any questions ?
[ "Chitchat", "Discussion" ]
[ "Plan" ]
3,657
it will be okay . so you have atrial fibrillation .
[ "Discussion", "Personal History" ]
[ "Subjective", "Plan" ]
3,658
you take digoxin . all right . any other questions for me ?
[ "Therapeutic History", "Discussion", "Chitchat" ]
[ "Subjective", "Plan" ]
3,659
so let's talk a little bit about my assessment and plan for you , okay ? so , for your first problem , um , your reflux and your nausea and vomiting , uh , i wan na go ahead and get a right upper quadrant ultrasound to rule out any gallstones , okay ? um , and then i'm gon na check some labs on you . okay ?
[ "Follow-up", "Diagnostic Testing", "Acute Assessment" ]
[ "Assessment", "Plan" ]
3,660
okay . all right , well , let's go ahead and do a quick physical exam . um , so looking at you , you do n't appear in any distress . um , your neck , there's no thyroid enlargement . uh , your heart i hear a three out of six , systolic ejection murmur , uh , that's stable . your lungs otherwise sound clear . your abdomen is soft , and you do have some pain to palpation of your lumbar spine . uh , and you've had decreased flexion of your back . uh , your lower extremity strength is good , and there's no edema . so let's go ahead and look at some of your results . hey , dragon , show me the ecg . okay , so that looks basically unchanged from last year , which is really good . hey , dragon , show me the lumbar spine x-ray . hey , dragon , show me the back x-ray . great . so this looks good . that's also stable from last year . okay . so let's go ahead and , you know , my , my plan for you at this time , you know , from a chronic back pain standpoint , if you need , um , you know , some more physical therapy , and i can refer you to physical therapy to help with those symptoms that are kind of lingering .
[ "Physical Examination", "Lab Examination", "Radiology Examination", "Referral", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
3,661
hey , dragon , show me the echocardiogram . so , i just wanted to go over the results of your last echocardiogram , that was about six months ago . that shows that you do have the low pumping function of , of your heart at about 45 % , which is not terrible . and it does show that you have some moderate mitral regurgitation . so , that's that slight heart murmur i heard in your exam , okay ? hey , dragon , show me the hemoglobin . and here , this is the hemoglobin that i was referring to . it's low at 8.2 , okay ? so , we'll have to talk a little bit about that , all right ? so , let me go over a little bit about my assessment and my plan for you , okay ? so , for you first problem this new anemia , uh , i wan na go ahead and send off some more labs and anemia profile , just to see exactly what type of anemia we're dealing with . i also wan na go and refer you back to the gastroenterologist for another evaluation , okay ? hey , dragon , order referral to gastroenterology . so , they're gon na do , uh , probably do an endoscopy and another colonoscopy on you . um , but again , i wan na send off those labs just to make sure that it's not something else , okay ?
[ "Lab Examination", "Radiology Examination", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,662
okay . all right . so , um ... you know , i know that you've had this reflux in the past . how are you doing with that ? are you still having a lot of reflux symptoms or do you feel like it's better since we've put you on the protonix ?
[ "Personal History", "Therapeutic History", "Vegetative History" ]
[ "Subjective" ]
3,663
that can certainly cause your blood sugar to be elevated . um , hey dragon , uh , show me the rapid strep . and you also have , uh , positive for strep . so i think we have some reasons as to why your blood sugar is so high . so my impression of you , you know , you have this hyperglycemia , which is probably related to some infections going on in your body . um , from a- a- a rapid strep standpoint we're gon na go ahead and treat you with penicillin or , i'm sorry , amoxicillin , 500 milligrams , three times a day . uh , make sure you take it all , even if you start feeling better , okay ?
[ "Medication", "Lab Examination", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,664
so , you know , my impression is is that you have this episode of chest pain , um , that could be related to severe hypertension or it could be related to some heart disease . so , what i'd like to go ahead and do is , number one , we'll put you on , um ... we'll change your blood pressure regimen . we'll put you on carvedilol , 25 milligrams twice a day . that helps with coronary disease as well as your pumping function of your heart . um , i wan na go ahead and order a cardiac catheterization on you and make sure that we do n't have any blockages in your heart arteries responsible for the chest pain . for the high blood pressure , we're gon na add the carvedilol and i want you to continue your lisinopril 10 milligrams a day and i wan na see , uh , how your blood pressure does on that regimen , okay ?
[ "Medication", "Diagnostic Testing", "Acute Assessment" ]
[ "Assessment", "Plan" ]
3,665
okay , all right , and so for your last ish issue , your- your epilepsy , you know , i think you saw your neurologist about three months ago , you must be due to see her again some time soon ?
[ "Reassessment", "Discussion", "Referral" ]
[ "Assessment", "Plan" ]
3,666
. along with this history of your congestive heart failure . but , let's go ahead and look at some of your results . hey , dragon , show me the ecg . so , this is , uh , a s- a stable ecg for you . this basically shows that you have some left ventricular hypertrophy which caused your congestive heart failure . um , let's go ahead and review your echocardiogram . hey , dragon , show me the echocardiogram . so , in reviewing the results of your echocardiogram , it shows that your pumping function of your heart is a little low , uh , but it's stable . and , you know , i think that we know this and we have you on the appropriate-
[ "Reassessment", "Radiology Examination" ]
[ "Objective" ]
3,667
so , that seems stable to me . um , on your lung exam , everything sounds nice and clear , and on your lower extremity exam , i do appreciate , you know , 1 to 2+ pitting edema in your legs , okay ? so , we'll have to just talk a little bit about your diet and decreasing the salt intake , okay ?
[ "Physical Examination", "Discussion" ]
[ "Objective", "Plan" ]
3,668
hey , dragon ? order an echocardiogram . and , for your third problem , your rotator cuff repair , i , i think you're doing really well with that . i would just continue with the exercises and , uh , i do n't think we need to intervene upon that anymore . it sounds like that's pretty much resolved , okay ?
[ "Referral", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
3,669
okay . well , my impression is that you- you probably have a contusion , but let's take a look at your x-ray first . hey , dragon . show me the x-ray . yeah , so if you look at this , this is a normal femur . um , really do n't see any evidence of a fracture or any swelling , so it's essentially , a normal x-ray . so , what we're going to do is , i'm going to start you on um an anti-inflammatory . it's going to be mobic 15 milligrams uh , once a day . i want you to use some ice for the pain , um , and it should , honestly , just being a contusion , get better in the next week or so . if it's not getting better , of course , come on back and- and see me .
[ "Medication", "Radiology Examination", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,670
. on that right shoulder . you've got uh , tenderness over your right shoulder . you've got normal pulses , and everything else is normal . any numbness or tingling in that right arm ?
[ "Acute Symptoms", "Acute Assessment" ]
[ "Subjective", "Assessment" ]
3,671
okay . so on exam you've got some tenderness over your lateral epicondyle . uh , you have some swelling there and some redness . uh , you have some pain with flexion , extension of your elbow as well . uh , and you have some pain on the dorsal aspect of your- of your forearm as well . okay ? so let's look at your x-rays . hey dragon , show me the x-rays . all right . your x-ray of your elbow-it looks like , i mean , the bones are lined up properly . there's no fracture- . it , uh , there's a little bit of swelling there on the lateral elbow but i do n't see any fracture , so that's good . so , looking at the x-ray and looking at your exam , uh , my diagnosis here would be lateral epicondylitis , and this is basically inflammation of this area where this tendon in- inserts . and probably that happened when you were moving those boxes . so we'll try some motrin , uh , about 800 milligrams every six hours . uh , i'll give you a sling for comfort , just so you can use it if- if it's causing a lot of pain .
[ "Physical Examination", "Radiology Examination", "Acute Assessment", "Discussion", "Medication", "Other Treatments" ]
[ "Objective", "Assessment", "Plan" ]
3,672
hey , dragon , show me the hemoglobin . yeah , so your hemoglobin is 8.2 , which is quite low for somebody of your height and weight , so we'll have to look into that a , a little bit further . i know that they did the endoscopy in the emergency room . hey , dragon , show me the endoscope results . good . so it looks like you had some gastritis , which is just inflammation of your stomach and they also found a slight polyp , which i know that they biopsied and the results are pending at this time . um , so , you may have had some bleeding from the gastritis . it's not usual for people to have bleeding from that . um , okay , well , hey , dragon , show me the anemia panel . okay . anyway , okay . well , vincent , i think , you know , in terms of , my impression of you is that you've had this newfound anemia and for that , i think that we should go ahead and put you on protonix , 40 milligrams , once a day to help with the gastritis . does that sound okay to you ?
[ "Reassessment", "Radiology Examination", "Lab Examination", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
3,673
hey , hey , dragon , order protonix , 40 milligrams , once a day . and i'd like you to try to cut down on your caffeine 'cause that can also irritate your stomach . try not to take any ibuprofen and try to cut down on any alcohol intake , okay ?
[ "Other Treatments", "Medication", "Drug History" ]
[ "Plan" ]
3,674
this is philip gutierrez , date of birth 1/12/71 . he is a 50-year-old male here for a second opinion regarding the index finger on the right hand . he had a hyperextension injury of that index finger during a motor vehicle accident in march of this year . he was offered an injection of the a1 polyregion , but did not want any steroid because of the reaction to dexamethasone , which causes his heart to race . he was scheduled to see dr. alice davis , which it does n't appear he did . he had an mri of that finger , because there was concern about a capsular strain plus or minus rupture of , quote , " fds tendon , " end quote . he has been seen at point may orthopedics largely by the physical therapy staff and a pr , pa at that institution . at that practice , an mri was obtained on 4/24/2021 , which showed just focal soft tissue swelling over the right index mcp joint , partial-thickness tear of the right fds , and fluid consistent with tenosynovitis around the fdp and fds tendons . radial and ulnar collateral ligaments of the index mcp joint were intact , as the mcp joint capsule . extensor tendons also deemed intact . his x-rays , four views of the right hand today , show no bony abnormalities , joint congruency throughout all lesser digits on the right hand , no soft tissue shadows of concern , no arthritis . hi , how are you , mr . gutierrez ?
[ "Personal History", "Greetings", "Radiology Examination" ]
[ "Subjective", "Objective" ]
3,675
okay , okay . so all the hurt , it seems , is stretching , because you have n't been doing this for so long . so , you know what i mean ? so , um , you're going to have to start really doing that .
[ "Discussion", "Acute Assessment", "Other Treatments" ]
[ "Assessment", "Plan" ]
3,676
so for mr . gutierrez , just put that he has a post-traumatic rather severe stenosing tenosynovitis of his right index finger , and the plan is steroid injection today , do a trigger injection , but i'm using a cc of betamethasone . so , mr . gutierrez , do you have , um , therapy scheduled or set up ?
[ "Discussion", "Acute Assessment", "Referral", "Medication" ]
[ "Assessment", "Plan" ]
3,677
next patient is paul edwards , date of birth is january 15th 1962 . so he's a 59 year old hiv positive gentleman here for hypogonadism . patient was last seen on november 24th 2020 . his notable things are number one , he is on 1 milliliter every 10 days , uh , his levels were less than 300 to begin with . he's on finasteride currently . he also takes cialis daily so he takes all his pills just from me . um , patient's other area of concern is gynecomastia which is ... which we will discuss with him today . his last psa was 0.66 and his last testosterone was greater than 1,500 . hey , how are you today ?
[ "Acute Symptoms", "Personal History", "Therapeutic History", "Lab Examination" ]
[ "Subjective", "Objective" ]
3,678
i do n't know , i have n't honestly seen many guys over the years that have cholesterol problems and this . i mean there's a big correlation between diabetic control and testosterone replacement , meaning those who get good levels of their test see their diabetic control improve .
[ "Discussion", "Lab Examination" ]
[ "Objective", "Plan" ]
3,679
so let me see . i've been doing one of two things at every one , and everyone is great so it depends more on timing availability of their or for the colonoscopy . we can send you to dr. martin for the surgery who is at county surgical services down here or the other option is valley medical , and they do it at springfield .
[ "Discussion", "Diagnostic Testing", "Referral", "Other Treatments" ]
[ "Plan" ]
3,680
doctor: all right , assessment and plan . chronic chf . mixed presentation . had a exacerbation of cf , chf earlier in the spring . we switched her from a furosemide to torsemide and symptomatically she is doing a lot better . she's about 3 , 3 and a half pounds down in weight . breathing is non-labored . going to repeat ekg today but otherwise continue with her current regimen . labs checked and creatinine is appropriate . uh number 2 , pre-op examination . she is , she's having a right knee replacement end of june . also , she would like to have a colonoscopy performed which we'll try to have done at uh bartley regional , rightley regional hospital in the next month , uh , prior to a change in her insurance . this is just a screening colonoscopy that she is overdue for . no family history of colon cancer . uh the next one is diabetes . a1c is 5.1 on the last check so no need for further a1c today . she may need another one prior to her surgery next month though . thanks .
[ "Family History", "Medication", "Diagnostic Testing", "Reassessment" ]
[ "Subjective", "Assessment", "Plan" ]
3,681
okay . um , so whatever you are doing you can just keep doing it , and i'm going to set you up for the epidural and imaging study , um , just so i know right where to put the medicine . and i will follow up with you after s- um , that's in . we can do the shot , just to make sure your arm is feeling better . sound good ?
[ "Discussion", "Medication", "Diagnostic Testing", "Follow-up" ]
[ "Plan" ]
3,682
doctor: physical exam , elderly white gentleman presents in a wheelchair . no apparent distress . per the template , down through neuro- neurologic . one plus bilateral biceps . triceps brachioradialis . reflexes bilateral all negative . follow up and take out the lower extremities . gait not assessed today . strength and sensation is per the template . uh , upper and lower extremities . musculoskeletal , he is non-tender over his cervical spine . he does have mildly restricted cervical exte- extension . right and left lateral rotation which is symmetric , which gives him mild lateral neck pain but no radi- radicular pain . spurling's maneuver is benign . paragraph , diagnostics . cervical x-ray 6421 . cervical x-ray reveals significant disc degeneration at c56 , and to a lower extent c45 and c34 . significant lower lumbar facet arthropathy c67 and c7-t1 is difficult to visualize in the current x-rays . paragraph , impression . number one , left upper extremity neuropathy suspicious for cervical radicularopathy . possible contribution of peripheral neuropathy . number two , neck pain in the setting of arthritis disc degeneration . paragraph , plan . i suspect that this is a flare of cervical radicularopathy . i'm going to set him up for a cervical mri , and we'll tentatively plan for a left c7-t1 epidural afterwards , although the exact location will be pending the mri results . he'll continue his home exercise program as well as twice a day gabapentin . we'll follow up with him afterwards to determine his level of relief . he denies any blood thinners .
[ "Acute Symptoms", "Physical Examination", "Personal History", "Therapeutic History", "Medication", "Follow-up", "Diagnostic Testing", "Other Treatments" ]
[ "Subjective", "Objective", "Assessment", "Plan" ]
3,683
good . if you'd hop up here on the table , we're just going to do a physical exam . well , mr. walker , overall you're doing well . i'm going to order an echocardiogram and a stress test . i also recommend that you follow up with cardiology , i think dr. vincent sanchez would be a great fit for you .
[ "Physical Examination", "Diagnostic Testing", "Acute Assessment", "Referral" ]
[ "Objective", "Assessment", "Plan" ]
3,684
yes , sir . now you are due for your mmr and i'm recommend you get the shingles vaccine as well . you have completed your covid-19 , so that's good . now i'm going to have , uh ... have you return in about a year for your wellness visit . we'll see you back sooner if needed after i review all those labs and those other studies . do you have any other questions for me ?
[ "Discussion", "Diagnostic Testing", "Follow-up", "Medication" ]
[ "Plan" ]
3,685
great . okay , the nurse will , uh , be back in a minute to give you mmr today , and the front desk will line up a time to do the shingles vaccine next month .
[ "Diagnostic Testing", "Follow-up", "Medication" ]
[ "Plan" ]
3,686
doctor: all right , i used my general physical exam template for respiratory notate : pursed lip breathing , low exhalation phase , clear to oscillation , no wheezing . uh , genitalia notate : right testicle with two to three millimeters palpable nodule does not feel as if it will ... does not feel as if with the epididymis or variococele ; left testicle , normal ; no hernia . all other portions of the physical exam are normal default . assessment history of the aortic aneurysm repair : the patient underwent and aortic valve replacement and ascending aortic aneurysm repair on 1/20/2013 . he is doing well overall and currently asymptomatic . he is currently not seen by cardiology routinely . suggest the following up and suggested vincent sanchez as his physician . we will perform an echocardiogram , eh , slash , stress test . elevated alkaline phosphatase level . most recent cmd showed elevation at 156 . this could be related to his liver but most likely re- related to his bone health . i've ordered an alkaline phosphatase and again a gt . lung field abnormal finding on exona ... excuse me , on examination . the patient has been noted to purse his lips while breathing . he was found himself ... he has found himself feeling more fatigued at the end of the day . he does bicycle around 20 to 30 miles at a time . his exhal- exhalation phase is low on exam , and i've ordered pfts today to further ... for further evaluation . the right testicular nodule is about two to three millimeters , i've noted on the exam . there's no hernia palpable , and i have suggested reaching out to ro ... urology for a possible ultrasound . preventative health : the most recent blood work was reviewed with no significant abnormalaries ... abnormalities other than the cmv . uh , we will perform mmr titer today . i have suggested the shingles vaccine and he is fully vaccinated against covid-19 . patient will return , uh , for a follow-up in one year for a wellness visit , sooner if needed . he is to call with any questions or concerns .
[ "Reassessment", "Physical Examination", "Diagnostic Testing", "Follow-up", "Personal History", "Referral", "Medication" ]
[ "Subjective", "Objective", "Assessment", "Plan" ]
3,687
all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam . okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further .
[ "Physical Examination", "Diagnostic Testing" ]
[ "Objective", "Plan" ]
3,688
doctor: please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border . for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin . primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance . after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .
[ "Physical Examination", "Diagnostic Testing", "Acute Assessment", "Other Treatments" ]
[ "Objective", "Assessment", "Plan" ]
3,689
okay . and for family history , it looks like there's high blood pressure , diabetes , thyroid disease , heart disease , kidney disease and gastric ulcers . for your current medications , it does n't look like you're taking anything at this time . and you're allergic to percocet , vicodin and regulin . and it looks like you've had intentional weight loss ?
[ "Family History", "Personal History", "Therapeutic History" ]
[ "Subjective" ]
3,690
doctor: thank you so much , you as well . deep tendon reflex is one plus throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list ? next radiographs , mr arthrogram of the right hip done june 3rd 2021 show high grade condromalacia involving the interosuperior right acetabulum with subchondral marrow edema and cyst formation . next paragraph plan . options include low impact exercise program , use of an nsaid and use of a cane to offload the right . we discussed that she'd like to proceed with the cortisone injection in right hip joint . i explained the risks of injection , including needles , sterile and covid . she understood and decided to proceed with the injection . she will follow up with me in three months for another injection if needed . end of dictation .
[ "Radiology Examination", "Physical Examination", "Medication", "Discussion", "Follow-up" ]
[ "Objective", "Assessment", "Plan" ]
3,691
yeah and then for your diabetes as long as you're here it sounds like you're managing that pretty well but i do wan na get a recheck on your hemoglobin a1c and then i'm also i'm going to get a refill on the metformin that you have been taking five hundred milligrams so you can keep taking that as well so do you have any other questions for me
[ "Medication", "Therapeutic History", "Diagnostic Testing", "Reassessment" ]
[ "Subjective", "Assessment", "Plan" ]
3,692
yeah and looks like you have good hand grip let me see so on the neurovascular exam of your left arm your capillary refill is less than three seconds and your sensation is is intact to light touch
[ "Discussion", "Diagnostic Testing", "Acute Assessment", "Referral", "Radiology Examination" ]
[ "Objective", "Assessment", "Plan" ]
3,693
goodness well you know you we need to probably stop eating those now
[ "Other Treatments", "Vegetative History" ]
[ "Subjective", "Plan" ]
3,694
okay alright well let's do a quick physical exam here so your vital signs your blood pressure looks pretty good today at one twenty eight over seventy two your temperature is ninety eight . seven and your heart rate is seventy two your respirations are eighteen your oxygen saturation looks pretty good at at ninety six percent okay now on your neck exam there is no jugular venous distention on your heart exam i appreciate a two over six systolic ejection murmur which i've heard before and so it's stable and your lungs are clear bilaterally and your lower extremities show just trace edema now now we since we did the echocardiogram i reviewed those results and it does show a preserved ef of fifty five percent abnormal diastolic filling and mild-to-moderate mitral regurgitation so let me tell you a little bit about my assessment and plan so for your first problem for your congestive heart failure it sounds like this was caused by dietary indiscretion and some uncontrolled hypertension so i want you to continue on your bumex two milligrams once daily continue to watch your diet and avoid salty foods might try keeping that log we talked about with your blood pressures and what you've eaten if if your blood pressure seems a little high also weigh yourself daily and call me if you gain three pounds in two days okay
[ "Physical Examination", "Follow-up", "Medication", "Other Treatments", "Radiology Examination", "Reassessment", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
3,695
and i also want you to see a nutritionist to give you some education about what foods you can eat okay now for your second problem for i know this sounds like this is just for you and so for your second problem for your hypertension i want you to continue on the cozaar one hundred milligrams daily continue on the norvasc five milligrams once daily also and i'm going to order a renal artery ultrasound just to be sure we're not missing anything and then like maybe you know some renal artery stenosis or something and so so for your third problem for your kidney disease i wan na get some more labs to make sure you tolerate this the new medications and then i'll see you again in three months do you have any questions
[ "Follow-up", "Medication", "Other Treatments", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
3,696
same thing okay so you do have a bilateral positive tinel's sign so so here's here's where i'm at i think your your diagnosis is beginning to have some bilateral carpal tunnel syndrome usually we see that with repetitive actions such as the landscaping the heavy labor and you you know your your clinical exam and and history sound like it's a carpal tunnel syndrome i do want to order so where are we gon na go from here i would like to order a a study it's called an emg where it it measures some of that electrical impulses down into your fingers we will follow up with that but as far as your treatment so the treatment for carpal tunnel syndrome is really some activity modification now i know you are a landscaper is there any way that you could be work to have some lighter work during the time
[ "Physical Examination", "Discussion", "Diagnostic Testing", "Acute Assessment", "Other Treatments" ]
[ "Objective", "Assessment", "Plan" ]
3,697
okay that would be good so that's i i just want you to kinda eliminate that the active repetitive motions that you're doing all the time just for a couple weeks i'm also gon na give you a wrist splint to wear and that should help and i'd like you to take ibuprofen six hundred milligrams every six hours and then i wan na see you back here in the office in two weeks and in that two week period i think we're gon na see if there's need for any other intervention if i need to do more diagnostic testing or if there is a possibly looking at a surgical intervention to release that pressure that's on the nerves in that hand does that sound like a a good plan for you
[ "Discussion", "Diagnostic Testing", "Follow-up", "Other Treatments", "Medication" ]
[ "Plan" ]
3,698
okay so just you know i need to ask do you have a history of iv drug use or you know have known any hep c partners
[ "Other Socials", "Drug History", "Drug History" ]
[ "Subjective" ]
3,699