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[Drug History][Drug History][Doctor] so what about alcohol use is that something that you used to do a lot [Patient] i did i did i mean i i still have a beer here and there everyday but not as much as i used to[SEP][Drug History][Doctor] okay and have you ever smoked before [Patient] i do smoke i smoke about one to two cigarettes per day i've cut down a lot but i'm just having a hard time kicking those less too[SEP][Discussion][Doctor] yeah yeah and that that's something i've got to work on too because hep c along with smoking you know both of those are n't are n't good so hopefully we can help you out you know if your pcp has n't prescribe something for you already and possibly we can we can do that for you as well [Patient] okay[SEP][Personal History][Doctor] so do you have any other medical conditions [Patient] no i'm actually other than that i just had my physical and i'm not taking any medications no i'm i'm pretty good otherwise[SEP][Family History][Doctor] okay and what conditions would you say run in your family [Patient] i have high blood pressure diabetes and depression[SEP]
|
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"Physical Examination",
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[
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[Acute Symptoms][Doctor] okay do you have any swelling in your lower extremities at all that you noticed [Patient] not if i'm on my feet for a long time i'll notice a little bit of swelling but otherwise no[SEP][Family History][Doctor] okay and then a couple other family history questions anybody in the family have kidney disease or significant high blood pressure [Patient] both my parents do have high blood pressure and one of them did have kidney disease[SEP][Therapeutic History][Doctor] okay okay and in the the the form that you filled out when you came in it says that you are on ten milligrams of norvasc daily and carvedilol twenty five milligrams twice a day is those the medicines you're on [Patient] yes i was also on lisinopril before but with the adjustments yeah those are the ones i'm on[SEP][Therapeutic History][Doctor] okay and so here's where i think we are going to go do you take any nonsteroidals like advil or motrin or aleve [Patient] yeah just once in a while for my like any knee pain or back pain that i have but again not like everyday[SEP][Drug History][Doctor] okay and then lastly what kind of alcohol intake do you have you know do you consider how many drinks a week is really what i'm looking for [Patient] i'll have a couple of beers during the week and like one or two on the weekends[SEP]
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[
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[Personal History][Doctor] okay the headache has has maybe made you feel uncomfortable and prevented your your exercise would you say or what [Patient] yes it has[SEP][Other Socials][Doctor] okay okay so you probably have n't been out golfing i remember you're a big golfer so not not lately uh so you know being [Patient] not lately[SEP][Other Socials][Doctor] being down being down here in florida we got ta get get some golf in so hey did you see the masters by the way a few weeks ago was n't that i do n't know did you happen to catch it [Patient] i did[SEP][Other Socials][Doctor] yeah that was crazy what a what a finish what an amazing what an amazing tournament right what do you think yeah yeah that's great well we'll we'll get you feeling better and get you back out there and now are you still working a lot on the computer ac or [Patient] i am[SEP][Other Socials][Doctor] carolyn okay yeah you're still working a lot on the computer for work okay are you taking breaks every hour or so you know get up stand around walk stand walk around that can be helpful [Patient] no i really do n't get the opportunity to[SEP]
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[Other Socials][Doctor] okay okay so you probably have n't been out golfing i remember you're a big golfer so not not lately uh so you know being [Patient] not lately[SEP][Other Socials][Doctor] being down being down here in florida we got ta get get some golf in so hey did you see the masters by the way a few weeks ago was n't that i do n't know did you happen to catch it [Patient] i did[SEP][Other Socials][Doctor] yeah that was crazy what a what a finish what an amazing what an amazing tournament right what do you think yeah yeah that's great well we'll we'll get you feeling better and get you back out there and now are you still working a lot on the computer ac or [Patient] i am[SEP][Other Socials][Doctor] carolyn okay yeah you're still working a lot on the computer for work okay are you taking breaks every hour or so you know get up stand around walk stand walk around that can be helpful [Patient] no i really do n't get the opportunity to[SEP][Physical Examination][Follow-up][Medication][Other Treatments][Diagnostic Testing][Reassessment][Acute Assessment][Doctor] hmmm okay understood alright well listen let's go ahead and examine you okay so so on your physical exam your physical exam is pretty normal unremarkable for the most part and you know few things a few exceptions so first of all on your heent exam your eye exam your extraocular motions are intact without pain you have a funduscopic exam that shows no papilledema that's good that just means there's no swelling in the back of your eye and on your neck exam you do have some posterior mild posterior paraspinal muscular tenderness in the cervical spine and in bilateral trapezius musculature as well and some tightness in those muscles as well and otherwise on your exam let's see your heart exam on your heart exam you have that grade three out of six systolic ejection murmur that's unchanged from your prior exam so it just means i hear some sounds in your heart as it's beating and i'm not too worried about that we'll watch that and otherwise normal heart exam and and your physical examination otherwise is normal and unremarkable and so now let's talk about my assessment and your plan so carolyn for your first problem of the headache i do think that you have a tension type headache and i think this because you've got some tension and tightness in your paraspinal muscles meaning the muscles around your neck and your shoulders and you know working at the computer i think is contributing to this and also probably the stress so you can continue to take that tylenol for the pain i'm also gon na give you a mild muscle relaxant i'll write you for flexeril five milligrams three times a day and you can take that that will help relax those muscles in your neck and that should help with the symptoms i want you to come back or give us a call if the headaches become more severe or suddenly worsen or you develop a fever but i do n't think that this is a a sign of a stroke or any bleeding in your brain or anything like that i think it's more related to tightness in your muscles in your neck now for your second problem of your diabetes mellitus let's continue you on the metformin five hundred milligrams i am going to order a hemoglobin a1c and also a cbc and a chem-12 to check some of your blood tests blood chemistries and so forth and we will continue you on the metformin i do want you to check your blood sugars daily and that will be very helpful so when you come back in a month i want you to bring those numbers with you we can talk about it again and please do try to get back into your exercise routine that's really gon na help you keep those blood sugars under control as well okay so how does that sound for a plan any other questions for me [Patient] well would it so only call if if it gets worse or not any better[SEP]
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[
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[Chitchat][Doctor] hey that's great and that's great to hear congratulations i'm so excited to hear about the new baby [Patient] yeah[SEP][Chitchat][Doctor] i i have a daughter myself have have you picked out any names [Patient] we're you know we're deciding between a few names but we're kinda just waiting to see her to see which name fits[SEP][Chitchat][Doctor] okay alright that sounds good well congratulations again i'm very excited for you and your and and your wife that that's this is great [Patient] thank you[SEP][Drug History][Doctor] so you mentioned you tried to quit before can you tell me a little bit about the methods that you used or or what you tried [Patient] yeah actually i just went cold turkey one day i woke up and i said you know i've had enough and i know that smoking is not good for me so i woke up and stopped and i actually did really well and i was able to quit smoking for almost a year and then things just started getting really stressful at work they started laying people off and i'm happy i still have a job but that also meant that i was responsible for more things so things just got stressful and i and just started picking it up again[SEP][Drug History][Doctor] well you are absolutely correct you know stress can often be a trigger for things like smoking and drinking have you thought what you would do this time when you encountered the stressful situations [Patient] yeah i i did n't think about that a lot actually and one thing is i have started learning and trying to do more meditation and then i also just recently joined the gym so i'm really looking forward to working out again[SEP]
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[
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[
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[Drug History][Doctor] so you mentioned you tried to quit before can you tell me a little bit about the methods that you used or or what you tried [Patient] yeah actually i just went cold turkey one day i woke up and i said you know i've had enough and i know that smoking is not good for me so i woke up and stopped and i actually did really well and i was able to quit smoking for almost a year and then things just started getting really stressful at work they started laying people off and i'm happy i still have a job but that also meant that i was responsible for more things so things just got stressful and i and just started picking it up again[SEP][Drug History][Doctor] well you are absolutely correct you know stress can often be a trigger for things like smoking and drinking have you thought what you would do this time when you encountered the stressful situations [Patient] yeah i i did n't think about that a lot actually and one thing is i have started learning and trying to do more meditation and then i also just recently joined the gym so i'm really looking forward to working out again[SEP][Discussion][Medication][Drug History][Doctor] okay well that's great to hear that you're getting back in the gym that will be good for your long term health too you know helping to maintain that type two diabetes you know those are really great strategies talking about gym for stress relief and and you know we have other products as well that you can use for an additional aid to help you stop smoking have you given any thought to using some type of smoking cessation aid at this time or or what do you think about that [Patient] you know i've had you know because i've been trying to do cold turkey and it's not working and some of my friends actually have mentioned using a patch and they they've had some success with that so i think i would i would probably wan na start with that[SEP][Discussion][Doctor] okay alright that that sounds good it's good that you've you've picked out one of those aids and have you thought of a quit date i mean we we really wan na talk about when you're gon na say this is the day [Patient] yeah you know next monday is actually my birthday so i think that's a good day[SEP][Chitchat][Doctor] that's a fantastic day and happy birthday coming up on monday [Patient] thank you[SEP]
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[Chitchat][Doctor] yeah you know what that's that's i am a biker and i know that once you get that into your you know you have loved doing that activity it's so frustrating when you ca n't it's almost like a it's almost like a dry it almost becomes a drug when you get up [Patient] exactly[SEP][Acute Symptoms][Doctor] okay so have you noticed any redness or swelling in your knees [Patient] no[SEP][Personal History][Doctor] okay and have you ever injured your knees before [Patient] you know despite how active i am i you know i've never[SEP]
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[
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[Personal History][Doctor] okay any history of endometriosis [Patient] any history of what[SEP][Personal History][Doctor] endometriosis [Patient] no[SEP][Family History][Doctor] okay how about any family history of any gynecological cancers [Patient] i was adopted[SEP][Physical Examination][Doctor] okay okay so i'm just gon na do a quick exam of your abdomen and then perform a vaginal exam okay [Patient] okay[SEP][Physical Examination][Doctor] alright okay so i do feel the mass on the where to go here okay [Patient] i did n't know you're gon na play a doctor today[SEP]
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[Acute Symptoms][Doctor] okay alright any loss in sensation [Patient] no i mean i i can still feel like i can still feel my foot[SEP][Other Socials][Doctor] okay alright that's good to hear so you were playing tennis is that what you normally do to work out [Patient] i do i'm trying to learn but i can not afford tennis less lessons so me and my friends just hit the balls back and forth i do sleep[SEP][Chitchat][Doctor] i love it absolutely yeah my dad one time took me to play racquet ball and i learned the very bruisy way that that was n't for me yeah [Patient] that scares me[SEP][Physical Examination][Doctor] it's it they they move pretty fast i'm not gon na lie alright so if you do n't mind i'm gon na go ahead and do my my physical exam i'm gon na be calling out some of my findings but if you have any questions go ahead stop me let me know but i will be explaining along the way okay [Patient] okay[SEP][Physical Examination][Doctor] alright so i've looked at your vitals and honestly they look great you know your blood pressure i see is one twenty five over seventy that's almost textbook respiratory rate we are seeing you at a smooth eighteen excuse me your temperature you're running normal ninety seven . one you're you're satting at a hundred percent so and then your pulse so that's interesting like you're you're going at like about sixty beats a minute so i think they're i think we're doing pretty well i'm gon na go ahead and listen to your heart on your heart exam i do n't appreciate any like murmur rub or gallop we have a nice regular rate and rhythm for your lung exam i do appreciate a little bit of stridor that's really interesting but i do n't hear any wheezes or rales so that's great for your i know this sounds weird but for your abdominal exam i do n't appreciate any rebound no guarding on your skin exam i do n't sorry like on your your head everything looks symmetrical your your mucosal membranes are normal you do n't feel hot to touch so that's great but i'm gon na do my foot exam okay so on the right foot there is some bruising of the plantar and dorsal aspects of the foot there is associated swelling when i touch on your midfoot here does it hurt [Patient] no uh uh[SEP]
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[Acute Symptoms][Doctor] okay so have you noticed any nausea chills fever [Patient] no fever some chills and i i just in so much pain i i ca n't eat and i do feel a little nauseous[SEP][Acute Symptoms][Therapeutic History][Doctor] okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain [Patient] yeah i've been taking tylenol i have had to try some ibuprofen i know you said to be careful with my blood pressure but i have been trying to do that because i'm just in so much pain and it's not really working[SEP][Acute Symptoms][Doctor] okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved [Patient] yeah usually usually about about three four days to pass it yeah[SEP][Acute Symptoms][Doctor] right so this is this is the looks like this is the third day [Patient] yeah[SEP][Acute Symptoms][Doctor] so we are getting close there [Patient] okay[SEP]
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[
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[Acute Symptoms][Physical Examination][Doctor] that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain [Patient] no chest pain[SEP][Acute Symptoms][Doctor] no chest pain are you having any belly pain [Patient] the back pain is starting to kind of go down into my groin but i would n't say any back pain i mean abdominal pain[SEP][Acute Symptoms][Physical Examination][Doctor] no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt [Patient] yes[SEP][Physical Examination][Doctor] okay i'm gon na press here on your back is that painful [Patient] yes[SEP]
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[Personal History][Doctor] mm-hmm [Patient] and i've been straining my urine and you know i do n't see anything in there[SEP][Vegetative History][Doctor] okay have you noticed any blood in your urine i know you've been draining probably take a good look at it has it been darker than usual [Patient] no not really not really darker[SEP][Family History][Doctor] okay so have you had kidney stones before and then you said your father had them but [Patient] i've never had a kidney stone my dad had them a lot but i've never had one[SEP][Physical Examination][Doctor] okay alright so let me do a quick exam of you your vital signs look good i do n't see any fever or your blood pressure and heart rate are fine so let me do a quick physical exam let me press here on your belly so on your examination of your abdomen there is no tenderness to to pain to palpation of the abdomen there is no rebound or guarding there is cva there is tenderness on the right side so that means [Patient] i have a stroke[SEP][Physical Examination][Doctor] can you repeat that [Patient] i did i have a stroke[SEP]
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[Acute Symptoms][Doctor] okay and you said you're active you're out in the yard and things like that do you go on long walks at all or no [Patient] no no you know it's you know i just kinda feel like i've been just trying to take it easy lately[SEP][Acute Symptoms][Doctor] mm-hmm [Patient] but yeah most most of the stuff i've been doing is just kind of hanging around the house[SEP][Therapeutic History][Personal History][Doctor] okay alright so we talked a little bit about your diabetes let's talk about your heart disease now your heart disease you had a heart attack in twenty eighteen we put a stent into your right coronary artery you're still taking your medications for that you're still on your aspirin [Patient] i am yes yeah i do the baby aspirin every day[SEP][Acute Symptoms][Doctor] okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything [Patient] okay and do you have a podiatrist for your yearly foot exams[SEP][Physical Examination][Acute Assessment][Doctor] no i i i do n't okay alright alright well let's go ahead i wan na just do a quick physical exam i'm just gon na be calling out some of my exam findings so your vital signs here in the office you do n't have any fever so that's good your blood pressure is great it's like one twenty seven over eighty and your heart rate is nice and slow in the sixties on your neck exam i do n't appreciate any jugular venous distention or any carotid bruits on your lung exam your lungs are clear to auscultation bilaterally on your heart exam you do have a two out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do n't appreciate any palpable dorsalis pedis or posterior tibial pulses there is a two by three centimeter ulcerated lesion on the right lateral foot near the fifth metacarpal metatarsophalangeal joint there is no associated cellulitis does it hurt when i press here [Patient] no[SEP]
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[
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[Therapeutic History][Personal History][Doctor] okay alright so we talked a little bit about your diabetes let's talk about your heart disease now your heart disease you had a heart attack in twenty eighteen we put a stent into your right coronary artery you're still taking your medications for that you're still on your aspirin [Patient] i am yes yeah i do the baby aspirin every day[SEP][Acute Symptoms][Doctor] okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything [Patient] okay and do you have a podiatrist for your yearly foot exams[SEP][Physical Examination][Acute Assessment][Doctor] no i i i do n't okay alright alright well let's go ahead i wan na just do a quick physical exam i'm just gon na be calling out some of my exam findings so your vital signs here in the office you do n't have any fever so that's good your blood pressure is great it's like one twenty seven over eighty and your heart rate is nice and slow in the sixties on your neck exam i do n't appreciate any jugular venous distention or any carotid bruits on your lung exam your lungs are clear to auscultation bilaterally on your heart exam you do have a two out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do n't appreciate any palpable dorsalis pedis or posterior tibial pulses there is a two by three centimeter ulcerated lesion on the right lateral foot near the fifth metacarpal metatarsophalangeal joint there is no associated cellulitis does it hurt when i press here [Patient] no[SEP][Discussion][Acute Assessment][Referral][Medication][Other Treatments][Doctor] there is no pain to palpation of the right foot there is associated granulation tissue and some slight purulent discharge from the wound okay so what does all that mean that just means that you have this ulcer that's you know fairly sizable with i think we need to do some good wound care on it let's talk a little bit about my assessment and plan so you know i you have a nonhealing ulcer of your right foot so we need to do some studies on you to see if you have an adequate blood supply to heal this foot wound and since you since you probably do n't because of your diabetes you're here in a vascular surgeon's office we may have to go ahead and talk about being able to open up some of your arteries to improve the blood supply to your foot so that might mean getting a stent to one of your arteries in your legs to open up the blood supply it might mean mean that we might have to do some bypass surgery to to improve the blood supply to your foot in order to heal that that wound i do think that you'll be able to heal it i do n't think that we need to do anything drastic i want you to continue with your aspirin because that will help [Patient] any questions[SEP][Diagnostic Testing][Referral][Doctor] yeah i mean is this do we have to do any more tests or anything what are you we're gon na do an arterial ultrasound i'm going to go ahead and order an arterial ultrasound of your lower extremities to see what the blood supply is like and then i'm gon na go ahead and order a podiatry consult because i want them to see this wound and improve the wound care that you're doing and then for your next problem your diabetes i wan na go ahead and talk to your primary care physician we need to get your diabetes better controlled because that impacts your wound healing as well okay [Patient] sure[SEP]
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[
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[Family History][Doctor] little nauseated yeah that's we expected so have you do you have a family history of kidney stones i know some people when they have them like their parents have them stuff but [Patient] yeah my my dad had kidney stones i think he has passed a couple of them i'm not quite sure[SEP][Personal History][Doctor] alright and have you had any in the past or is this your first one [Patient] this is my first time i've never had this before[SEP][Personal History][Doctor] okay alright so we'll do we'll do an exam on you just to check you out so i guess you were in pain and stuff over the over the easter easter break there that [Patient] yeah yeah i had some pain over the weekend i saw my pediatrician this morning so they sent me over here they were concerned that i might have a kidney stone[SEP][Chitchat][Doctor] okay so i'm guessing you did n't get to go find the eggs on the easter egg hunt because of the you were in pain [Patient] not so much but i i got to participate a little bit i opened some eggs i just did n't go run around and find them[SEP][Physical Examination][Doctor] okay well i i'm lucky enough my friends had an adult easter hag hunt for me and so i was able to find a couple eggs yesterday myself so i i'm glad you were able to get a few of them alright so let's do that that physical exam on you so your vitals look good you do n't have any fever your blood pressure heart rate is fine so when i press here on your belly does that hurt [Patient] a little bit yeah[SEP]
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[Personal History][Doctor] alright and have you had any in the past or is this your first one [Patient] this is my first time i've never had this before[SEP][Personal History][Doctor] okay alright so we'll do we'll do an exam on you just to check you out so i guess you were in pain and stuff over the over the easter easter break there that [Patient] yeah yeah i had some pain over the weekend i saw my pediatrician this morning so they sent me over here they were concerned that i might have a kidney stone[SEP][Chitchat][Doctor] okay so i'm guessing you did n't get to go find the eggs on the easter egg hunt because of the you were in pain [Patient] not so much but i i got to participate a little bit i opened some eggs i just did n't go run around and find them[SEP][Physical Examination][Doctor] okay well i i'm lucky enough my friends had an adult easter hag hunt for me and so i was able to find a couple eggs yesterday myself so i i'm glad you were able to get a few of them alright so let's do that that physical exam on you so your vitals look good you do n't have any fever your blood pressure heart rate is fine so when i press here on your belly does that hurt [Patient] a little bit yeah[SEP][Physical Examination][Discussion][Other Treatments][Radiology Examination][Reassessment][Doctor] a little bit alright so on your exam of your abdomen there is mild pain and tenderness to palpation of the abdomen there's no rebound or guarding there is cva located near your flank tenderness on the right so that means that everything looks good but you do have what seems to be some inflammation of your kidney okay so we we were able to get a ct of your your side and it showed that you do have a stone measuring point five centimeters in size and it's located in the proximal right ureter and so that's that duck that passes from your kidney to your bladder alright i do n't see any evidence of hydronephrosis so that means that there's not obstructing ureter causing swelling in your kidney which is which is pretty good so let's talk a little bit about my assessment and plan so you do have that kidney stone on the right so what i'm recommending is i want you to push fluids just to help facilitate you passing that stone alright have you been taking in have you been drinking enough water do you think so far [Patient] probably not enough i drink some but[SEP]
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[Therapeutic History][Doctor] okay have you taken any medications safe for example tylenol or ibuprofen for the pain [Patient] no i feel like taking the medicine[SEP][Chitchat][Doctor] okay and then just out of curiosity you said you were doing some landscaping have you been over to landscapes warehouse new here in town my wife and i were just over there this last weekend and picked up a whole bunch of stuff you had a chance to make it over there yet [Patient] no not yet i heard about it though i might have to make a trip once my foot heals[SEP][Acute Symptoms][Doctor] alright that sounds good now just out of curiosity can you rate your pain for me right now zero being none ten being the worst pain you've ever been in your life [Patient] eleven out of ten[SEP][Acute Symptoms][Doctor] okay and then have you experienced any numbness or tingling of that foot since the incident [Patient] yeah the whole foot is numb[SEP]
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[Family History][Doctor] okay yeah so like that your brother does n't either [Patient] no i'm the only one who seems to be getting sick[SEP][Family History][Doctor] alright so i know you said you were trying to like help out your brother like what's going on with him [Patient] you know we've just been getting really busy and so he has been working around doing other things so i've just been helping him just cover the extra load[SEP][Family History][Doctor] mm-hmm okay alright do you have any other siblings [Patient] yeah there is actually ten of us[SEP][Chitchat][Doctor] wow okay that's that's a lot of siblings [Patient] yeah i'm okay[SEP][Chitchat][Doctor] maybe maybe we could we could always stick them in they could get some work done the holidays must be fun at your place [Patient] yeah we do n't need to hire any i mean have anyone else this is our family[SEP]
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[
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[Chitchat][Doctor] maybe maybe we could we could always stick them in they could get some work done the holidays must be fun at your place [Patient] yeah we do n't need to hire any i mean have anyone else this is our family[SEP][Personal History][Family History][Doctor] you're right keep it in the family okay so speaking of family do you have do you or anyone have a history of seasonal allergies [Patient] no no i have never had any problems with allergies[SEP][Drug History][Doctor] okay and do you smoke [Patient] i do n't smoke[SEP][Other Socials][Doctor] do you live with anybody who does [Patient] i do not[SEP][Chitchat][Doctor] okay alright so okay so now i i wan na go ahead and do my physical exam i'm gon na call out some of my findings just to make sure that i'm documenting everything and if you have any questions about what it is that i'm saying please feel free to ask okay [Patient] okay[SEP]
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] | 3,718
|
[Physical Examination][Doctor] if i go a little bit further to twenty degrees does that hurt [Patient] that hurts more yeah[SEP][Physical Examination][Doctor] okay if i push in on your big toe and move it back and forth does that hurt [Patient] yes it does and it it's almost like those joints that when you push it back it's almost like it's grinding a little bit too[SEP][Physical Examination][Doctor] okay if i push in between your big toe and your second toe here does that hurt [Patient] a little bit but not terrible[SEP][Physical Examination][Doctor] okay what about if i push on the other side here [Patient] yeah yeah right there on the outside of it absolutely[SEP]
|
[
"Acute Symptoms",
"Radiology Examination"
] |
[
"Subjective",
"Objective"
] | 3,719
|
[Acute Symptoms][Radiology Examination][Doctor] okay and i'm feeling a little bit of bone spur here as well let me let me get an x-ray [Patient] okay[SEP][Chitchat][Doctor] and after we take a peek at that we'll develop a plan [Patient] okay[SEP][Chitchat][Doctor] so at this point what would i do if i'm going out of the room and then coming back [Patient] you could hit pause or hit the stop button and just restart it the next time you come in[SEP][Radiology Examination][Doctor] okay alrighty so taking a look at your x-ray and you do have you you have a large spur there on the top of your big toe joint [Patient] oh[SEP][Acute Assessment][Doctor] and you've lost a lot of the cartilage [Patient] oh[SEP]
|
[
"Discussion",
"Acute Assessment",
"Other Treatments",
"Medication"
] |
[
"Assessment",
"Plan"
] | 3,720
|
[Personal History][Doctor] okay well very good i'm glad you're doing that good for you russell and and then please keep that up now tell me are you watching your salt intake and trying to change your diet [Patient] yeah so when i was in the hospital they said something about my way my heart pumps now[SEP][Vegetative History][Doctor] mm-hmm [Patient] it it's it's a little low and i might keep fluid on my legs if i'm not careful[SEP][Other Treatments][Doctor] there is a lot of salt and pizza and you know and you're gon na have to be able to avoid all the other salty foods as well so and i know that's hard but it's very important for your heart to be able to function at it's best right and you wan na be able to get out and walk you know walk take those walks again at the park and then you know do your photography so in order to do that we're gon na have to really cut back on those okay [Patient] well[SEP]
|
[
"Physical Examination",
"Discussion",
"Referral",
"Medication",
"Radiology Examination",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,721
|
[Physical Examination][Doctor] and i'm gon na look in your mouth too [Patient] okay[SEP][Acute Assessment][Doctor] and throat looks fine no tonsils [Patient] mm-hmm[SEP][Physical Examination][Doctor] lem me go ahead and have you lay back on the table and i'll take a listen to your stomach [Patient] okay[SEP][Physical Examination][Doctor] everything sounds okay i'm gon na feel around just to make sure everything feels normal [Patient] mm-hmm[SEP][Physical Examination][Doctor] everything feels fine and i'm gon na check reflexes and they're all normal [Patient] awesome[SEP]
|
[
"Follow-up",
"Other Treatments",
"Medication"
] |
[
"Plan"
] | 3,722
|
[Physical Examination][Doctor] everything sounds okay i'm gon na feel around just to make sure everything feels normal [Patient] mm-hmm[SEP][Physical Examination][Doctor] everything feels fine and i'm gon na check reflexes and they're all normal [Patient] awesome[SEP][Follow-up][Other Treatments][Medication][Doctor] it's really hard to do with actual patient so in terms of the asthma i think we could try a daily medication since it looks like you might be having a little bit of allergies maybe we can try some singulair mm-hmm and start with that once you are on that daily and you can continue to use the albuterol inhaler those side effects unfortunately you're right it's it's just one of the expected side effects with an albuterol inhaler i would recommend just what you're doing just sit down for a little bit after you take it and we will get you started on the singulair probably within about a month you should see a difference so i will have you come back in about six weeks and follow up and see how you're doing with that in terms of the mood is this new for you [Patient] yeah i think so like when i started this year[SEP][Discussion][Doctor] and it sounds like related to school expectations and the stress with saps and all of that [Patient] yeah[SEP][Referral][Doctor] okay let's consider having you start seeing a therapist i think that would be a good place to start [Patient] mm-hmm[SEP]
|
[
"Diagnostic Testing",
"Follow-up"
] |
[
"Plan"
] | 3,723
|
[Acute Symptoms][Doctor] okay and then with your ibuprofen can you tell me what your pain level is [Patient] like a seven eight[SEP][Other Socials][Doctor] okay so how long have you been playing soccer [Patient] really since i was like four five i've been playing a long time[SEP][Chitchat][Doctor] well that's cool yeah we our our youngest daughter she is almost sixteen and she plays the inner marrial soccer league they are down at the rex center did is that where you started playing or did you guys did you start playing somewhere else [Patient] yeah just like this local town leak i started playing that way and then played all throughout school[SEP][Chitchat][Doctor] that's [Patient] high school teams[SEP][Acute Symptoms][Doctor] that's awesome so just out of curiosity with the left foot have you experienced anything like numbness or tingling or or any strange sensation [Patient] no i have not[SEP]
|
[
"Physical Examination",
"Radiology Examination",
"Acute Assessment",
"Other Treatments"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,724
|
[Physical Examination][Doctor] okay great and since this i'm the reason i'm asking all these questions i'm a little concerned about the inactivity with your your knee pain and you know how diabetes you need to be very you know active and and taking your medicine to keep that under control so you know may wan na continue to follow up with your pcp for that diabetes as we go through here and just watch your blood sugars extra as we go through that now i'm gon na go ahead and examine your your right knee and when i push on the outside does that hurt at all [Patient] no[SEP][Physical Examination][Doctor] okay and when i push on this inside where it's a little swollen does that hurt [Patient] yes[SEP][Acute Symptoms][Doctor] yeah okay i'm just gon na ask a question did you hear or feel a pop in your knee when you were doing this [Patient] i did not no[SEP][Acute Symptoms][Therapeutic History][Doctor] you did not okay okay what are you doing for the pain today [Patient] some exercises ice and mobic[SEP][Physical Examination][Doctor] okay okay so i'm gon na continue all of my exam when i go ahead and pull on your knee the first thing i'm looking at is i do see some ecchymosis and swelling on the inside of that right knee and when i push around that knee i can see that there is fluid in the knee a little bit of fluid in the knee we call that effusion so i can appreciate some of that effusion and that could be either fluid or blood at this point from the injury that you had now you do have pain with palpation on the medial aspect of that right knee and that's that's concerning for me when i'm gon na just i just wan na move your knee a little bit it does n't look like when i extend it and flex it that you have a full range of motion does it hurt a lot when i moved it back a little more than normal [Patient] yes it hurts[SEP]
|
[
"Physical Examination",
"Discussion",
"Medication",
"Other Treatments",
"Radiology Examination",
"Referral",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,725
|
[Vegetative History][Doctor] yeah absolutely i can see how that would that would increase your stress but like with that have you lost any weight because of your symptoms [Patient] no i wish unfortunately i've gained some weight[SEP][Vegetative History][Doctor] okay and do you have any other symptoms like abdominal pain nausea vomiting diarrhea [Patient] sometime my belly hurts up here[SEP][Vegetative History][Doctor] okay alright so epigastric pain alright any blood in your stool or dark dark tarry stool [Patient] not that i noticed[SEP][Physical Examination][Doctor] okay alright so i'm gon na go ahead and do my physical exam i'll be calling up my findings as i run through it if you have any questions please let me know alright so with your vital signs your blood pressure looks pretty decent we have it like one thirty three over seventy so that's fine your heart rate looks good you do n't have a fever i do notice that in your chart it looks like you have gained you know about like ten pounds over the last month so i i do understand when you say that you've experienced some weight gain your you're satting pretty well your o2 sat is at a hundred percent so and then your breathing rate is pretty normal at nineteen so i'm gon na go ahead and do my mouth exam there are no obvious ulcers or evidence of thrush present tonsils are midline your neck i do n't appreciate any adenopathy no thyroid thyromegaly on your abdomen it is nondistended active bowel sounds so when i press here on that top part of your stomach does it hurt [Patient] no i did that hurts[SEP][Physical Examination][Doctor] okay pain to palpation of epigastric area how about now [Patient] no[SEP]
|
[
"Discussion",
"Follow-up",
"Medication",
"Other Treatments",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment",
"Drug History"
] |
[
"Assessment",
"Plan",
"Subjective",
"Objective"
] | 3,726
|
[Acute Symptoms][Doctor] okay so let's talk real quick about your pain level zero being none ten being the worst pain you've been in in your life without any medication on board can you rate your pain for me [Patient] i would say it's about an eight[SEP][Acute Symptoms][Doctor] okay and then when you do take that ibuprofen or tylenol what what's your relief level what's your pain look like then [Patient] maybe a seven it it's a little[SEP][Other Socials][Doctor] okay now you mentioned going for a walk my wife and i've been on on back behind the new rex center where the new trails are have you guys been back there [Patient] we have n't yet but i'm sure we'll check it out ever since i feel like working at home during covid we we we take walks all the time[SEP][Chitchat][Doctor] yeah those those trails are great there's like five miles of regular flat trails and then there's a bunch of hiking trails that they've opened up as well it's a really great place man you guys need to get out there we'll get you fixed up and we'll get you back out there okay [Patient] awesome[SEP]
|
[
"Physical Examination",
"Discussion",
"Follow-up",
"Medication",
"Other Treatments",
"Radiology Examination",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,727
|
[Personal History][Doctor] okay alright so i just want to know i know some of my patients they have like bad ankles where they hurt the ankles all the time but have you ever injured this ankle before [Patient] so you know in high school i used to play a lot of soccer but and and like i had other injuries but i've never injured like this particular ankle before but because i used to play like all the time i knew what i was supposed to do but this is i also knew that it was it was time to come in[SEP][Acute Symptoms][Doctor] okay yeah yeah definitely if you if you ca n't walk on it we definitely good thing that you came in today and we were able to see you so have you experienced any numbness in your foot at all [Patient] no no numbness and i do n't think i've had like any tingling or anything like that[SEP][Physical Examination][Doctor] okay that that's good yeah it sounds like you have sensation there so yeah that that's really good so let me do a quick physical exam on you so i reviewed your vitals your blood pressure was one twenty over eighty which is good your heart rate your spo2 was ninety eight percent which is good that means you're you're getting all of your oxygen and so let me go ahead and look at your ankle real quick so when i press here does that hurt [Patient] yeah[SEP][Physical Examination][Doctor] alright what about here [Patient] yeah[SEP][Physical Examination][Doctor] okay so looking at your ankle and your right ankle exam on the skin there is ecchymosis so you have that bruising which you can see of the lateral [Patient] malleolus[SEP]
|
[
"Physical Examination",
"Personal History",
"Radiology Examination",
"Acute Assessment"
] |
[
"Assessment",
"Subjective",
"Objective"
] | 3,728
|
[Acute Symptoms][Therapeutic History][Doctor] okay have you had any any have you tried anything for pain for this have you tried any any medications at all [Patient] i've had ibuprofen it it helped some[SEP][Personal History][Doctor] okay got it alright well i'll i'll examine you in a second but before we do that let's talk about some of the other conditions that we're kinda following you for i'm looking at your problem list now and you've got a history of diabetes and you're on metformin five hundred milligram twice a day and your how are you doing with your blood sugars and your and your diet and exercise [Patient] yeah i i check my sugar two or three times a week most of the time it's in that one twenty to one forty range[SEP][Personal History][Doctor] okay we checked your hemoglobin a1c last time i'm looking at your records in epic and it showed that it was you know seven . one so it's it's it's good but it could be better any you know we talked about it controlling your diet or improving your diet and trying to have a balanced meal and not eating some of these sweets and high sugar items how is that going i know you had talked about your wife being a great cook and making cookies and that's hard to stay away from obviously how are things going with that [Patient] yeah she still makes cookies and i still eat them but you know we are trying to trying to do better trying to stay away from more of those carbs and focus on you know less carby less sweet stuff[SEP]
|
[
"Other Treatments",
"Diagnostic Testing"
] |
[
"Plan"
] | 3,729
|
[Personal History][Doctor] okay is that new or is that been going on for a while [Patient] well it it started maybe i do n't know a month or two after i started the norvasc[SEP][Personal History][Doctor] yeah i mean certainly it could be it is you know sometimes that medication can cause that so i'll i'll examine you in a second and see if we need to make any modifications okay [Patient] okay[SEP][Acute Symptoms][Doctor] alright so and your anything else bothering you today [Patient] no i'm we're doing okay i think[SEP][Physical Examination][Doctor] so let me examine you for a second i'm gon na go ahead and gabriel i'm gon na do my magic exam now let's pretend i i'm just gon na verbalize some of my findings as i do my exam and so [Patient] these are like my video visit exams[SEP]
|
[
"Physical Examination",
"Discussion",
"Medication",
"Referral",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,730
|
[Physical Examination][Doctor] okay alright on your skin exam i do appreciate some mild swelling and bruising that's really interesting since it's been two weeks with your knee are you able to bend it [Patient] yes[SEP][Physical Examination][Doctor] okay and then when you walked in on your gait i think i think i did appreciate a slight limp are you i i i i think you are you are protecting one of your knees does that sound familiar [Patient] yeah i waddle pretty pretty good now[SEP][Physical Examination][Doctor] okay alright and when you move your knee away from your body you're bending like your you're pulling it towards me does that hurt [Patient] yes[SEP][Physical Examination][Doctor] okay and then when you pull your knee back towards you does that hurt [Patient] no[SEP]
|
[
"Physical Examination",
"Medication",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,731
|
[Physical Examination][Doctor] all right , how about if i twist it a little bit that way . [Patient] that hurts a lot .[SEP][Physical Examination][Doctor] okay , okay . and how about down here ? do you feel me touch you down here ? [Patient] yes .[SEP][Physical Examination][Doctor] all right . any other pain down here in your calves ? [Patient] no .[SEP][Physical Examination][Doctor] no , okay . so on exam you do have some tenderness over the medial portion of your knee over the medial meniscus area . uh , there is no , uh , there is a little bit of tenderness when i flex your , uh , when i , uh , uh , do some valgus stressing on your , on your leg . um , you have normal sensation . so let's take a look at your x-rays . [Patient] okay .[SEP][Radiology Examination][Doctor] okay . hey dragon , show me the x-rays . so looking at the x-ray , um , of your left knee , uh , it appears to be there's no fractures there right now . i do n't see any , uh , there's a little bit of , uh , fluid , uh , but there is no , uh , there's no , um , fracture or there's no dislocation . everything else seems to be lined up properly , okay ? [Patient] okay .[SEP]
|
[
"Follow-up",
"Other Treatments",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] | 3,732
|
[Physical Examination][Doctor] so that sounds stable to me . on your back exam , you know , you do have some pain to palpation of the lumbar spine . and you have pain with flexion and extension of the back . and you have a negative straight leg raise , which is which is good . so , let's- let's just look at some of your results , okay ? [Patient] mm-hmm .[SEP][Lab Examination][Doctor] hey dragon ? show me the diabetes labs . okay , so ... in reviewing the results of your diabetes labs , your hemoglobin a1c is a little elevated at eight . i'd like to see it a little bit better , okay ? [Patient] sure .[SEP][Radiology Examination][Doctor] hey dragon ? show me the back x-ray . so in reviewing the results of your back x-ray , this looks like a normal x-ray . there's good bony alignment , there's normal uh- there's no fracture present . uh , so this is a normal x-ray of your back , which is not surprising based on- [Patient] mm-hmm .[SEP][Chitchat][Doctor] . the history , okay ? [Patient] mm-hmm .[SEP][Acute Assessment][Medication][Doctor] so let's just go ahead and we'll- we're going to go over , you know , my assessment and my plan for you . so for your first problem , your back pain . you know , i think you have a lumbar strain from the lifting . so , let's go ahead . we can prescribe you some meloxicam 15 mg once a day . [Patient] mm-hmm .[SEP]
|
[
"Referral",
"Medication"
] |
[
"Plan"
] | 3,733
|
[Physical Examination][Doctor] okay . let's do your exam . uh , so , it's this finger right here . and does it hurt here on your , on this joint up here ? [Patient] no .[SEP][Physical Examination][Doctor] okay . and how'bout right there ? no ? [Patient] no .[SEP][Physical Examination][Doctor] right here ? [Patient] that hurts .[SEP][Physical Examination][Doctor] all right . uh , can you bend your finger for me ? [Patient] yeah .[SEP][Physical Examination][Doctor] all right . and how about extend it ? all right . and can you touch your thumb with it ? [Patient] yes .[SEP]
|
[
"Physical Examination",
"Radiology Examination",
"Acute Assessment",
"Medication",
"Other Treatments"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,734
|
[Discussion][Diagnostic Testing][Doctor] yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system . [Patient] okay .[SEP][Discussion][Referral][Medication][Doctor] we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better . [Patient] all right .[SEP][Diagnostic Testing][Doctor] so let's go ahead , get your upper endoscopy and colonoscopy scheduled . [Patient] okay .[SEP][Personal History][Doctor] um , have you ever had any issue with sedation in the past ? [Patient] no , i was just sleepy afterwards .[SEP][Medication][Diagnostic Testing][Doctor] okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy . [Patient] okay . sounds like a plan .[SEP]
|
[
"Follow-up",
"Referral",
"Medication"
] |
[
"Plan"
] | 3,735
|
[Discussion][Referral][Medication][Doctor] we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better . [Patient] all right .[SEP][Diagnostic Testing][Doctor] so let's go ahead , get your upper endoscopy and colonoscopy scheduled . [Patient] okay .[SEP][Personal History][Doctor] um , have you ever had any issue with sedation in the past ? [Patient] no , i was just sleepy afterwards .[SEP][Medication][Diagnostic Testing][Doctor] okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy . [Patient] okay . sounds like a plan .[SEP][Follow-up][Referral][Medication][Doctor] all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work . [Patient] okay , that sounds great .[SEP]
|
[
"Discussion",
"Referral",
"Medication",
"Diagnostic Testing"
] |
[
"Plan"
] | 3,736
|
[Personal History][Doctor] um , have you ever had any issue with sedation in the past ? [Patient] no , i was just sleepy afterwards .[SEP][Medication][Diagnostic Testing][Doctor] okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy . [Patient] okay . sounds like a plan .[SEP][Follow-up][Referral][Medication][Doctor] all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work . [Patient] okay , that sounds great .[SEP][Discussion][Referral][Medication][Diagnostic Testing][Doctor] all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if you have any questions or worsening symptoms . we'll be happy to help you . [Patient] thank you .[SEP][Chitchat][Doctor] you're welcome . have a great day , have a great day ms. cooper . [Patient] you too .[SEP]
|
[
"Personal History",
"Therapeutic History",
"Lab Examination",
"Diagnostic Testing",
"Referral"
] |
[
"Plan",
"Subjective",
"Objective"
] | 3,737
|
[Therapeutic History][Personal History][Doctor] okay . let's see , do you have any other medical problems that you take medicine for ? [Patient] no i do n't have any medical problems and i do n't take any medicines . i tried tylenol a few times for the headaches but it did n't work , so i stopped .[SEP][Family History][Doctor] i see . anyone in your family have any history of diseases ? [Patient] i was adopted so i really have no idea .[SEP][Other Socials][Doctor] okay . um , what kind of work do you do ? and are you married ? [Patient] i work as a computer programmer and i've been married for 25 years . we just bought a small house .[SEP][Drug History][Doctor] that's nice . um , do you drink any alcohol , smoke , or use recreational drugs ? [Patient] nope . i do n't do any of those and never have .[SEP][Physical Examination][Doctor] okay . um , well let me take a good look at you . um , now you'll hear me calling out some details as i perform the examination . these will be noted for me in your record and i'll be happy to answer any questions you have once we're done . [Patient] sounds good , doc .[SEP]
|
[
"Physical Examination",
"Diagnostic Testing",
"Acute Assessment",
"Radiology Examination"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,738
|
[Other Socials][Doctor] okay . um , what kind of work do you do ? and are you married ? [Patient] i work as a computer programmer and i've been married for 25 years . we just bought a small house .[SEP][Drug History][Doctor] that's nice . um , do you drink any alcohol , smoke , or use recreational drugs ? [Patient] nope . i do n't do any of those and never have .[SEP][Physical Examination][Doctor] okay . um , well let me take a good look at you . um , now you'll hear me calling out some details as i perform the examination . these will be noted for me in your record and i'll be happy to answer any questions you have once we're done . [Patient] sounds good , doc .[SEP][Physical Examination][Diagnostic Testing][Acute Assessment][Radiology Examination][Doctor] all right . the patient is alert , oriented to time , place , and person . affect is appropriate and speech is fluent . cranial nerve examination is grossly intact . no focal , motor , or sensory deficit in the upper or lower extremities . visual acuity and eye movements are normal . pupils are equal and reactive . visual field testing reveals bitemporal hemianopia . and color vision is normal . all right , mr. ward . i'm going to review these pictures from the mri with you . um , now this appears to be a benign pituitary adenoma , but there's no way to be sure without sending the removed adenoma to pathology to make the diagnosis , which we will do . um , here you can see it's a well defined mass . and it's pressing right here on what we call the optic chiasm . and today when i was having you look at my fingers , you could n't see them off to the sides , that's what we call bitemporal hemianopia . and explains why you have been bumping into door frames . [Patient] yeah i never noticed that i could n't see out of the side until you did that test , and you closed one eye with both eyes . i really could n't tell .[SEP][Acute Assessment][Other Treatments][Doctor] no because you're having this vision loss from the mass compressing the optic chiasm , the only option we have is to do surgery . [Patient] okay , i understand . do you think i'll regain my vision ?[SEP]
|
[
"Diagnostic Testing",
"Referral",
"Other Treatments"
] |
[
"Plan"
] | 3,739
|
[Acute Assessment][Doctor] so let's talk about your symptoms real quick . obviously , with the chest discomfort , we worry about heart issues , but i'm reassured that those were ruled out with all the testing they did in the er . um , other potential causes could be anxiety , esophagitis , which is irritation of the esophagus . but typically with these , um ... but typically , these cause the pain that would last for a long time rather than that isolated incident like you had . um , it's also possible that you had intense heartburn for a few days . [Patient] well , since you mention anxiety , i was going through a really stressful job transition right around the time this happened .[SEP][Acute Assessment][Doctor] okay . that's good to know . so stress from this could be , um ... could be , uh ... could be very well have contributed to your condition . [Patient] okay .[SEP][Discussion][Diagnostic Testing][Doctor] so we could do an , uh , egd or upper endoscopy to take a look at your esophagus and stomach . this would allow us to look for esophagitis . but your symptoms occurred three months ago and you have n't had any additional episodes , so likely if it were esophagitis , it's already healed by the point ... by this point , and we would n't be able to see anything . the other option is just to continue to monitor , uh , for any additional symptoms at which point we could do the egd . uh , with you being asymptomatic for so long right now , i'm comfortable with that option . but what do you think ? [Patient] i'd like to hold off on the egd and wait to see if i have more symptoms .[SEP][Follow-up][Diagnostic Testing][Doctor] that sounds good . um , so you can call the office if you have any additional episodes of pain or any other symptoms you're concerned about . if that happens , we'll get you scheduled for an egd to take a look . if not , you can follow up with me ... follow up with me as needed for any other gi complaints . [Patient] okay .[SEP][Discussion][Doctor] all right ? if you do n't have any questions for me , i'll walk you out to the check-out desk . [Patient] no . that's it . thank you .[SEP]
|
[
"Personal History",
"Acute Assessment",
"Discussion"
] |
[
"Assessment",
"Plan",
"Subjective"
] | 3,740
|
[Physical Examination][Doctor] all right . please use my physical exam template . um , i wan na take a quick listen to her heart and lungs . i'll look in her ears too . and she can sit , she can just sit on your lap . [Patient Guest] okay .[SEP][Chitchat][Doctor] all right . that's it . [Patient Guest] all right , that was n't too bad .[SEP][Discussion][Diagnostic Testing][Follow-up][Doctor] hmm . so , let's complete the ultrasound today . i'll call you with the results . if it's normal , you wo n't need to see me again , but if it's abnormal , you can see me in kennesaw . [Patient Guest] okay , that sounds good .[SEP][Discussion][Doctor] okay . we'll determine what the next steps are if there are any , after we see her results . [Patient Guest] all right , sounds good . thank you .[SEP][Chitchat][Doctor] you're welcome . the nurse will be in to have you complete some paperwork , and give you instructions for the ultrasound . we'll talk soon . [Patient Guest] all right . thank you , and have a good day .[SEP]
|
[
"Physical Examination",
"Acute Assessment",
"Follow-up"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,741
|
[Acute Symptoms][Therapeutic History][Doctor] okay so so far have you taken anything for the pain [Patient] just taking some ibuprofen just for some swelling[SEP][Acute Symptoms][Doctor] okay that's it what would you say your pain score is a out of ten with ten being the worst pain you ever felt [Patient] i would say that when i'm stationary i do n't really feel a lot of pain but if i start doing some mobility i would say probably a four five[SEP][Acute Symptoms][Doctor] about a four okay and how long ago did you say this was is this happened this injury [Patient] it's been a week now[SEP][Personal History][Therapeutic History][Doctor] a week okay alright alright so we will take a look i'll do a physical exam of your knee in a second but i do want to check up you do have a past medical history of hypertension i'm seeing here you're on twenty milligrams of lisinopril when you came in today your blood pressure was a little bit high it was one fifty over seventy so have you been taking your medications regularly [Patient] yes i have[SEP][Personal History][Doctor] okay so you might have a little white coat syndrome i know some of my patients definitely do have that so what about your diet i know we talked a little bit before about you reducing your sodium intake to about twenty three hundred milligrams per per day i know you were during the pandemic your diet got out of little bit out of control so how have you been doing how have you been doing with that [Patient] i definitely need some help there i have not have not made some some changes[SEP]
|
[
"Physical Examination",
"Other Treatments"
] |
[
"Plan",
"Objective"
] | 3,742
|
[Vegetative History][Doctor] no shortness of breath just wan na make sure [Patient] no[SEP][Physical Examination][Doctor] okay so i'm just gon na listen to your lungs here your lungs are clear bilaterally i do n't hear any wheezes or crackles listen to your heart so on your heart exam i do still hear that grade two out of six systolic ejection murmur and you already had that and so we we knew about that already so lem me look at your knee here so when i press here on the inside of your knee does that hurt [Patient] a little bit[SEP][Physical Examination][Doctor] little bit how about when i press on the outs the outside gon na press on the outside is that painful [Patient] no[SEP][Physical Examination][Doctor] no alright so i'm gon na have you flex your knee is that painful [Patient] yeah that's uncomfortable[SEP][Physical Examination][Doctor] that's uncomfortable and extend it so that's painful [Patient] yeah yes[SEP]
|
[
"Physical Examination",
"Medication",
"Other Treatments",
"Radiology Examination",
"Reassessment",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,743
|
[Acute Symptoms][Therapeutic History][Doctor] alright and and did that help [Patient] it does take the edge off but i still have some pain[SEP][Other Socials][Doctor] okay well i'm sorry to hear that you know you know renovating the basement it can be quite a task and it can take a toll on you [Patient] yeah i mean it's been fun but yeah i think it really did take a toll on me[SEP][Chitchat][Doctor] yeah what what are you doing with your basement are you are you doing like a a man cave or [Patient] yeah yeah that's exactly right[SEP][Acute Symptoms][Doctor] that is awesome great well that sounds like fun i hope you get to set it up just the way you you would like for your man cave to be so congratulations to you there so tell me have you experienced any kind of numbness in your arms or in your hands [Patient] no no numbness or tingling[SEP][Physical Examination][Doctor] okay alright so let's just go ahead and do a quick physical exam on you here i did review your vitals everything here looks good now lem me take a look at your shoulder alright now on your left shoulder exam you have limited active and passive range of motion and how does that feel here [Patient] that hurts[SEP]
|
[
"Physical Examination",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,744
|
[Therapeutic History][Doctor] and are you taking your metformin [Patient] yes yes that's along with the blood pressure medicine morning and night[SEP][Vegetative History][Doctor] okay alright so are you are you eating like late at night or anything like that [Patient] no we usually eat by six[SEP][Physical Examination][Doctor] okay okay alright well hopefully we can get you to feeling better okay so i want to do a quick physical exam really check that knee out so your vital signs look good they they look alright your temperature is ninety eight . two your pulse is seventy two respirations are sixteen blood pressure is one twenty two over seventy so that looks fine i'm gon na go ahead and take a listen to your heart and lungs so on your heart exam it's a nice regular rate and rhythm but i appreciate a slight two over six systolic ejection murmur at the left base here on your lung exam your lungs are clear to auscultation bilaterally okay now let's take a quick look at that knee so does it hurt when i press on it [Patient] no[SEP][Physical Examination][Doctor] okay can you bend your knee and straighten it out [Patient] yes[SEP][Physical Examination][Doctor] okay i'm gon na do some maneuvers and i'm gon na just gon na call out my findings on this okay on your right knee exam no ecchymosis or edema no effusion no pain to palpation of the of the left medial knee is there any decreased range of motion do you feel you feel like you're you're able to fully move that as you should the same as the other knee [Patient] yeah[SEP]
|
[
"Medication",
"Radiology Examination",
"Referral",
"Reassessment",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,745
|
[Vegetative History][Doctor] okay and when you mention drinking and eating is do you feel like anything is getting stuck there [Patient] no i do n't feel like anything is getting stuck right now and i have n't been i have been eating but not as much as i normally would[SEP][Other Socials][Doctor] okay okay alright and how are you doing as far as like just emotionally and mentally how are you doing i'm just talking a little bit about your support systems [Patient] the nursing staff and the office has been very good to help you know with anything that i need as far as support so just since we are just getting started so far on the journey i do feel like i have support and mentally you know still feel strong[SEP][Other Socials][Doctor] okay and how about with family or friends have you been able to turn to anyone [Patient] i do have good family members that have been supportive and they have come to my treatment with me[SEP][Vegetative History][Doctor] okay excellent excellent and so right now you're on a combination of two different chemotherapies the cisplestan as well as the eupside and you had your last treatment just a few days ago but you're saying right now you've been able to tolerate the nausea and the fatigue [Patient] yes i have n't had any nausea but you know just slight fatigue it does n't seem to be overwhelming[SEP]
|
[
"Physical Examination",
"Discussion",
"Medication",
"Radiology Examination",
"Reassessment",
"Other Treatments"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,746
|
[Personal History][Doctor] yeah i do you know why she checked these levels in the first place that you've been having problems getting frequent infections [Patient] yeah yeah i had a recent physical and she did this as part of her my physical i do tend to get infections but i do n't know i i'm so used to it so i do n't know if this is more than usual in the wintertime i get a lot of colds and they do seem to i always say that my colds kind of linger for a long time but i do n't know if it's more than usual[SEP][Personal History][Doctor] okay how about any abdominal infections [Patient] diarrhea no[SEP][Personal History][Doctor] frequently [Patient] no not that i can not that i say can think of[SEP][Family History][Doctor] okay what about your family are are anyone in your family that you know have immune deficiencies [Patient] no my family is actually pretty healthy[SEP][Personal History][Doctor] okay and how about do you have any other medical conditions [Patient] yeah my pcp just started me on metformin i just got diagnosed with type two diabetes[SEP]
|
[
"Family History",
"Other Socials"
] |
[
"Subjective"
] | 3,747
|
[Discussion][Doctor] but you know everything in moderation i mean just you know you just need to be careful you ca n't does n't have to go away [Patient] right[SEP][Personal History][Doctor] but have you ever needed to receive a blood transfusion or blood products [Patient] no i actually tried to give blood but they i did n't qualify because i had recently traveled internationally[SEP][Other Socials][Doctor] okay where did you go [Patient] i was in zambia[SEP][Chitchat][Doctor] hmmm i heard that's beautiful [Patient] it's so beautiful it's so beautiful i had a great time[SEP][Physical Examination][Vegetative History][Doctor] okay well let me let me go ahead and do a physical examination here i reviewed your vitals you know that the the assistants collected when you first came in including your weight and everything looks good there there is no fever there there is nothing that i'm concerned about there now on your heart exam you have a nice regular rate and rhythm and i do n't appreciate any murmurs that's kind of those extra sounds that i would hear and that that all sounds good on lungs lung exam your lungs are clear there's no wheezes rales or rhonchi now on your neck exam i do n't appreciate any lymph lymphadenopathy swollen lymph glands and then let me just go ahead and i wan na press on your belly a little bit is that tender anywhere that i press it does n't seem like you making any facial [Patient] no[SEP]
|
[
"Physical Examination",
"Discussion",
"Acute Assessment",
"Lab Examination"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,748
|
[Personal History][Doctor] sure yeah okay so you're taking your meds mostly we talked about getting you a blood pressure cuff at home did you end up getting one of those [Patient] no i have n't got one yet i know i needed to get one[SEP][Vegetative History][Doctor] yeah that's that will be good if you can take your blood pressures at home and definitely track those what about any problems with shortness of breath lately [Patient] just like i said when i was walking outside it helped a little bit but again i just walked it off[SEP][Vegetative History][Doctor] sure any problems sleeping [Patient] no i sleep like a rock[SEP][Vegetative History][Doctor] good good to hear have you had any chest pain [Patient] slightly here or there but i thought it was just heartburn[SEP][Physical Examination][Drug History][Doctor] sure okay alright let me do a quick physical exam your blood pressure is pretty good in the office today it looks like it's one twenty eight over seventy two your other vital signs look good on your neck exam there is no jugular venous distention on your heart exam just gon na take a listen here i do appreciate a two out of six systolic ejection murmur but i heard that before and that is stable your lungs you want to take a deep breath for me lungs are clear bilaterally now i know we talked about you stopping smoking a a couple of years ago i have here have you kept up with that [Patient] i've been pretty good on it very once every week maybe just one[SEP]
|
[
"Medication",
"Other Treatments",
"Radiology Examination",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,749
|
[Acute Symptoms][Therapeutic History][Doctor] okay and what have you taken for the pain [Patient] i have taken some tylenol but it has n't really helped[SEP][Vegetative History][Doctor] okay and do you have any nausea vomiting any fever chills [Patient] i feel nauseated but i'm not vomiting[SEP][Family History][Doctor] okay is anyone in your in your family had kidney stones [Patient] yes my father had them[SEP][Personal History][Doctor] and have you had kidney stones before [Patient] yeah so i i've i've had them but i've been able to pass them but this is taking a lot longer[SEP][Physical Examination][Doctor] okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay [Patient] okay[SEP]
|
[
"Physical Examination",
"Diagnostic Testing",
"Acute Assessment",
"Follow-up",
"Other Treatments",
"Radiology Examination",
"Medication"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,750
|
[Acute Symptoms][Doctor] okay and you mentioned that it had some stinging and it was a bit uncomfortable are you experiencing any pain right now [Patient] yeah it was it was stinging initially like i had just done something small but at this point it's it's really like throbbing it's almost like there is a fire poker in the bottom of my foot now and then the inside of my calf muscle is really hard and i've noticed that every time that i push that i feel it all the way up to my knee behind my kneecap and then noticed that i've been coughing a lot the last two days and then i've noticed that i've had like difficult time catching my breath when i'm walking around the house and so it's almost like two different things going on at this point[SEP][Personal History][Doctor] okay so now i see here in your record that you have some that you're diabetic and have some diabetic neuropathy as well how's your blood sugars been running i'm i'm assuming kind of all over the place over the last i'm gon na say probably three or four weeks can you tell me about that [Patient] yeah my my a1c is six point seven it's pretty well controlled[SEP][Other Socials][Doctor] okay now i know this was caused by a new pair of shoes you had mentioned before to your pcp and he relayed this to me that you really like to go on hikes you and your wife have been hiking have you gone to the new trails that that were just opened up here behind the park [Patient] yeah we actually hiked to charlie's bunion about a week before this i've had a new pair of diabetic shoes and inserts i get those every year i changed the inserts every three or four months i mean i've been in cruise control as far as that goes for some time i did get a new pair of shoes the prosthetist told me to check my feet every day for the first week or two which we did i did go hiking about the third or fourth day and i think that might be what caused it as i just went too far when we were hiking but yeah the trails are the trails are gorgeous they're open it's time to to be outside and i'm sorta stuck with this right now[SEP][Physical Examination][Doctor] absolutely yeah my wife and i like to go back there and and hike those trails as well so i'm gon na do a quick physical exam for your vital signs i do recognize a slight fever however your vitals themselves look good now on your foot exam i do recognize the necrotic wound on your heel as you mentioned it is present it's approximately two by two centimeters i i do recognize the sloughing of the of the tissue as well as what looks like cellulitis around the area as well as erythemia so now unfortunately i do also smell the odor you are correct it is it does it is odds but i do not appreciate any bony exposure now on vascular exam i do have bilateral palpable pulses femorally and popliteal pulses are present however i do n't recognize a palpable pulse dorsalis pedis or posterior tibial however i did use the doppler and they are present via doppler now i'm gon na press on the actual affected area of the wound do you have any pain there [Patient] i do n't feel that right there[SEP]
|
[
"Follow-up",
"Medication",
"Radiology Examination",
"Diagnostic Testing",
"Reassessment",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,751
|
[Personal History][Doctor] okay and do you do you know on average how they're running are they running below like one fifty or [Patient] yeah it's definitely running below that[SEP][Personal History][Doctor] okay your blood sugars are running below [Patient] it's it's probably with with with the metformin it seems to be you know one twenty[SEP][Physical Examination][Doctor] good your blood sugars are running in the one twenties that's really good okay alright well i wan na just go ahead and do a quick physical exam okay so i'm looking here at your vital signs and your vital signs look really good i do think you're doing a good job with taking your lisinopril your blood pressure's about one twenty two over seventy right now which is right where we want it your heart rate is nice and slow at sixty seven again which is right where we want it and i do n't appreciate any fever today you you have a normal temperature at ninety eight . four which is really good so i'm just gon na be going ahead and calling out some physical exam findings and i'm gon na let you know what that means when i'm done okay so on your heart exam your heart is in a nice regular rate and rhythm i do n't appreciate any murmur rub or gallop on your lung exam your lungs are nice and clear to auscultation bilaterally on your right knee exam i do appreciate some erythema and edema as well as an area of fluctuance over your right patella now does it hurt when i press [Patient] it's a little bit sore[SEP][Physical Examination][Doctor] okay there is pain to palpation of the right anterior knee and i'm just gon na bend your knee up and down does that hurt at all [Patient] no no it's just more of the typical grinding that i would feel[SEP]
|
[
"Physical Examination",
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Medication"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,752
|
[Vegetative History][Doctor] and you were endorsing that insomnia . any other issues , chest pain , shortness of breath , anything ? [Patient] no .[SEP][Physical Examination][Doctor] all right . well lets go ahead and do a quick physical exam . [Patient] mm-hmm .[SEP][Physical Examination][Doctor] hey dragon , show me the vital signs . so your vital signs here in the office they look really good . i'm just going to listen to your heart and lungs and let you know what i find . [Patient] sure .[SEP][Physical Examination][Doctor] okay . on physical examination everything looks good . you know your lungs are nice and clear . your heart sounds good . you know you do have some weakness of your lower extremities . the right is about 4 out of 5 , the left is about 3 out of 5 . but you reflexes are really good so i'm , i'm encouraged by that . and you do have some , you know , arthritic changes of the right knee . [Patient] mm-hmm .[SEP][Chitchat][Doctor] um , so let's go over some of your results , okay ? [Patient] sure .[SEP]
|
[
"Discussion",
"Medication",
"Radiology Examination",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,753
|
[Physical Examination][Doctor] all right . well lets go ahead and do a quick physical exam . [Patient] mm-hmm .[SEP][Physical Examination][Doctor] hey dragon , show me the vital signs . so your vital signs here in the office they look really good . i'm just going to listen to your heart and lungs and let you know what i find . [Patient] sure .[SEP][Physical Examination][Doctor] okay . on physical examination everything looks good . you know your lungs are nice and clear . your heart sounds good . you know you do have some weakness of your lower extremities . the right is about 4 out of 5 , the left is about 3 out of 5 . but you reflexes are really good so i'm , i'm encouraged by that . and you do have some , you know , arthritic changes of the right knee . [Patient] mm-hmm .[SEP][Chitchat][Doctor] um , so let's go over some of your results , okay ? [Patient] sure .[SEP][Discussion][Medication][Radiology Examination][Reassessment][Doctor] hey dragon , show me the right knee x-ray . and here's the x-ray of your right knee , which shows some changes from arthritis , but otherwise that looks good . so let's talk a little bit about my assessment and plan . from an osteoporosis standpoint , we'll go ahead and order , you know , re- continue on the fosamax . do you need a refill on that ? [Patient] actually i do .[SEP]
|
[
"Discussion",
"Referral",
"Medication",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,754
|
[Physical Examination][Doctor] okay . let's go ahead . i want to move on to a physical exam . [Patient] mm-hmm .[SEP][Physical Examination][Doctor] hey , dragon ? show me the vital signs . so here in the office , you know , your vital signs look good . your , your pulse ox ... that's your oxygenation level ... looks good . so i'm encouraged by that with you just sitting here , okay ? i'm gon na go ahead and do another , uh , just check you over . i'll let you know what i find . [Patient] mm-hmm .[SEP][Physical Examination][Doctor] okay . all right . so , on your exam things look okay . so , i do n't appreciate any jugular venous distension or any carotid bruits on your neck exam . on your heart exam , i do appreciate a slight 3 out of 6 systolic ejection murmur . on your lung exam , i do appreciate some crackles , bilaterally , at the bases . and on your lower extremity exam i do appreciate 1+ pitting edema . so what does all that mean ? so , i do think that you're retaining some fluid . it's probably from some of the dietary indiscretion . [Patient] mm-hmm .[SEP][Radiology Examination][Doctor] but i wan na go ahead and look at some of the results , okay ? i had the nurse do a chest x-ray on you before we came in , okay ? hey , dragon ? show me the test x-ray . so i reviewed the results of your chest x-ray and it looks good . there's no e- evidence of any airspace disease , but that does n't mean that you still ca n't be retaining some fluid , okay ? [Patient] okay .[SEP][Lab Examination][Doctor] hey , dragon ? show me the labs . and your labs look okay . you know , you do n't have an elevated white blood cell count so i'm not really concerned about infection . we saw the chest x-ray , there's no pneumonia , so that's good . [Patient] mm-hmm .[SEP]
|
[
"Medication",
"Other Treatments",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] | 3,755
|
[Personal History][Doctor] good for you . um ... have you ever had any surgeries before ? [Patient] yes , i had my appendix out when i was seven .[SEP][Physical Examination][Radiology Examination][Doctor] okay . um , let's look at your x-ray together . hey , dragon , show me the last x-ray . all right . so looking at your right hand here , and that index finger looks great . so all the joints , bones are in the right places , no fractures , so you've got a normal right hand x-ray . um , let's go ahead and check your finger out . now does it hurt when i push on your finger like this ? [Patient] yes .[SEP][Physical Examination][Doctor] does it hurt when i pull your finger like this ? [Patient] yes .[SEP][Physical Examination][Doctor] does it hurt when i squeeze over this joint here ? [Patient] yes . please do n't do that .[SEP][Physical Examination][Doctor] does it hurt when i squeeze over this ? [Patient] yes .[SEP]
|
[
"Discussion",
"Follow-up",
"Medication",
"Other Treatments",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] | 3,756
|
[Vegetative History][Doctor] okay . wonderful . okay . so i know you did a review of systems sheet with the nurse , and i know you endorse , you know , this back pain . um , do you have any other symptoms ? fever , chills , congestion , cough , chest pain , shortness of breath ? [Patient] i have a little bit of nasal congestion , but that's just from my seasonal allergies .[SEP][Physical Examination][Doctor] okay . all right . well , let's go ahead . i want to do a quick physical exam on you . [Patient] okay .[SEP][Physical Examination][Doctor] okay ? hey , dragon , show me the vital signs . so good- you know , here in the office , your vital signs look great . your blood pressure's really well controlled , which is good . so that's a good job . so i'm going to take a listen to your heart and lungs . i'm going to examine your back , and i'm going to let you know what i find . okay ? [Patient] okay .[SEP][Physical Examination][Doctor] okay . all right . so on physical examination , you know , everything looks good . you know , on your heart exam , i do hear that slight two out of six systolic ejection murmur , but you've had that before . that seems stable to me . on your back exam , you do have some pain to palpation on the right lateral aspect of your lumbar spine , and you do have pain with flexion and extension as well , and you have a negative straight leg raise . so what does that mean ? so we're going to go over that . okay ? let's ... let me look at some of your results , though , first . okay ? [Patient] okay .[SEP][Radiology Examination][Doctor] we did an x-ray before you saw me , so let's look at that . hey , dragon , show me the back x-ray . so looking here at this x-ray of the lumbar spine , everything looks good . there's good boney alignment . there's no obvious fracture , you know , which is not surprising based on your history . okay ? [Patient] hmm .[SEP]
|
[
"Medication",
"Lab Examination",
"Referral",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,757
|
[Physical Examination][Doctor] do n't forget to breathe little one . okay . let's try the front too . [Patient Guest] yeah , it's okay buddy .[SEP][Physical Examination][Doctor] excellent . he's doing excellent . next let's- let's check out those ears . [Patient Guest] okay .[SEP][Physical Examination][Doctor] let's try to make sure you do n't tip all the way over . [Patient Guest] dino , you're doing so good .[SEP][Physical Examination][Doctor] all right . ears look okay . we're going to slide you forward so you do n't bump your head when i lay you down . [Patient Guest] hey , you're- hey you're okay . you're okay .[SEP][Physical Examination][Doctor] okay , you can go ahead and sit him back up if you like . [Patient Guest] all right . thank you .[SEP]
|
[
"Acute Assessment",
"Other Treatments",
"Medication"
] |
[
"Assessment",
"Plan"
] | 3,758
|
[Conversation Start][SEP]
|
[
"Acute Symptoms",
"Therapeutic History",
"Personal History",
"Other Socials",
"Family History",
"Greetings"
] |
[
"Subjective"
] | 3,759
|
[Personal History][Doctor] okay . perfect . let me just get logged in , here . have you met with anyone before about a breast reduction ? [Patient] no , i have n't .[SEP][Personal History][Doctor] okay . and how long have you been considering this ? [Patient] it's probably been about six or seven years . but i mean , it's always been in the back of my mind .[SEP][Personal History][Doctor] well , i perform a lot of breast reduction surgeries , pretty much every week , so it is a very common procedure . [Patient] okay , that's reassuring .[SEP][Personal History][Doctor] yeah . so what i wan na do first is just get a little bit of history about the sort of symptoms that you're having . and then i'll do a quick exam . [Patient] okay . that sounds good .[SEP][Other Socials][Doctor] and then we'll talk more about the surgery and what it entails . and , um , at this point , who is your insurance provider ? [Patient] i have blue cross blue shield . well , actually , my husband just accepted a new job , and i will be on his plan , uh , which i believe is not going to be blue cross , but it may be changing .[SEP]
|
[
"Discussion",
"Other Socials"
] |
[
"Plan",
"Subjective"
] | 3,760
|
[Conversation Start][SEP]
|
[
"Physical Examination",
"Personal History",
"Greetings",
"Lab Examination"
] |
[
"Subjective",
"Objective"
] | 3,761
|
[Discussion][Other Treatments][Doctor] that would be 125 ounces of water a day and you should avoid drinking sugary drinks like mountain dew . [Patient] okay . is there any food i should n't eat ?[SEP][Discussion][Other Treatments][Doctor] great question . you should avoid food rich in sodium oxalate and animal protein . so that would be salty , processed food because they're high in sodium . ideally , you should consume less than 1,000 milligrams of sodium a day and reduce the amount of beef , poultry , fish , and pork . [Patient] what's oxalate ?[SEP][Discussion][Other Treatments][Doctor] it's an organic acid found in plants , that when digested , it binds to minerals that stones are formed from . foods like spinach , chocolate , beets , rhubarb and soy products . [Patient] well , i'll do whatever it takes to try to avoid getting these stones again .[SEP][Chitchat][Doctor] great . and here's a handout that you can look over . it goes over the dietary recommendations and what to avoid . [Patient] okay , good . i like to have things in writing to help me remember .[SEP][Discussion][Follow-up][Doctor] perfect . well , if you have any more questions . if you do n't have any more questions , you're all set . i wo n't need to see you back until next year , as long as you do n't have any more issues like bleeding or pain . if you do have any issues , you can always call the office sooner . and if you experience any severe pain or bright red blood in your urine , you should go to the emergency room . [Patient] all right . well , let's hope we do n't have to do either of those and i see you next year .[SEP]
|
[
"Physical Examination",
"Acute Assessment",
"Reassessment"
] |
[
"Assessment",
"Objective"
] | 3,762
|
[Physical Examination][Doctor] yeah , it does sounds kind of weird , right ? it's when your heart does n't beat with the correct rhythm , and whatever rhythm it does n't have a pattern to it . so , it's part of the atrial fibrillation . [Patient] wow , that sounds like a mess .[SEP][Physical Examination][Doctor] yeah , it's not ideal . but , many people have a-fib are able to keep it under control with medicine and lifestyle changes . [Patient] agh , i see . that's good to know .[SEP][Physical Examination][Doctor] okay . so , s1 slightly accentuated , no s3 . i'm going to touch your belly , and does any of that hurt . [Patient] nope .[SEP][Physical Examination][Doctor] how about there ? and your feet ? [Patient] no , not really .[SEP][Physical Examination][Doctor] okay , great . and trace peripheral edema on extremities . all right ms. sanchez , you can sit up now . so , it looks like your heart valves are working well and you are recovering from the surgery nicely . [Patient] good .[SEP]
|
[
"Therapeutic History",
"Radiology Examination"
] |
[
"Subjective",
"Objective"
] | 3,763
|
[Discussion][Medication][Doctor] yeah , agreed . okay . and , um , so couple other things real quick . so it looked like your blood pressure looked really good today . so we're not going to change your amlodipine or lisinopril . so just continue taking those as you are currently . [Patient] okay , good .[SEP][Discussion][Medication][Doctor] and then , it also looks like you're taking about 20 milligrams of simvastatin for your lipids . and i will pr- , um , defer to your pcp . however , given you are having leg pain in both your legs , and given your age and no history of coronary artery d- , artery disease , it is possible that you might be able to stop your statin . [Patient] really ?[SEP][Discussion][Doctor] yeah , um , possibly . he would have to evaluate you , but it is certainly something to discuss with him . so i will send over the results of the echocardiogram and also my recommendations and then you guys can talk about the statin . [Patient] okay , that sounds great . thank you .[SEP][Medication][Reassessment][Doctor] you're welcome . and then , um , lastly , your hyperthyroidism , uh , i see you're taking levothyroxine . and again , no change here and you can just keep taking that as you have them . [Patient] okay , i will .[SEP][Discussion][Follow-up][Diagnostic Testing][Doctor] all right . so we will see you back here in about three or four weeks to discuss the results and your next steps . um , and we'll , uh , take care of your echocardiogram today . um , any questions ? [Patient] not that i can think of . thank you so much . and i think it looks good .[SEP]
|
[
"Physical Examination",
"Acute Assessment",
"Reassessment",
"Diagnostic Testing",
"Follow-up",
"Therapeutic History"
] |
[
"Assessment",
"Plan",
"Subjective",
"Objective"
] | 3,764
|
[Chitchat][Doctor] hmmm yeah i'm not a big cat person [Patient] no neither[SEP][Acute Symptoms][Doctor] do you do you have any symptoms now well which is [Patient] no[SEP][Chitchat][Doctor] mm-hmm [Patient] okay[SEP]
|
[
"Physical Examination",
"Acute Assessment",
"Radiology Examination",
"Medication"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,765
|
[Personal History][Doctor] okay so you think this is more of a long term injury [Patient] no he was just thinking about it hurting when he thought about raking but it did n't[SEP][Personal History][Doctor] okay alright and have you noticed any any prior pain with with the back [Patient] i do n't want to take this away you better go back to talking to him[SEP][Physical Examination][Doctor] that's alright let's see how it turns out okay so how about if you if i push down on both your feet like this can you push back up on my hands [Patient] can you repeat that[SEP][Physical Examination][Doctor] if i'm pushing down on your feet can you push push your feet back [Patient] i[SEP][Physical Examination][Doctor] alright so your dorsiflexion is normal looks like pulses are equal in all extremities you said you had a little bit of a tingling sensation in which leg [Patient] that would be my right leg[SEP]
|
[
"Discussion",
"Medication",
"Radiology Examination",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,766
|
[Personal History][Reassessment][Doctor] okay and that makes sense alright so as far as your diabetes you know and i think that's probably a a major cause of this not being able to heal how well are how well is that controlled [Patient] i take my medication but i do n't check my sugar all the time[SEP][Chitchat][Doctor] okay do you [Patient] i'm not really sure how[SEP][Personal History][Doctor] okay do you know what your last a1c is i'm pretty sure you doc talk to you about it [Patient] i think they told me it was around ten[SEP][Physical Examination][Doctor] around ten okay yeah that that's that's definitely pretty high yeah you definitely if your if your pcp has n't gotten created treatment plan for you definitely need to go back and see them so you can get that controlled alright so let me do a quick physical exam on your foot here today your vital signs look normal you do n't have a fever so let me just take a look at your foot so on your foot exam there is a one by two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint there is some redness some drainage present you have some edema around it there is fluid like you said that's coming out of it i do n't see any necrosis you do n't have any odor and i do n't appreciate any bony exposure so it pretty much is like you said it's it's red it's swollen i think you have an infection in there as well so when i touch it does that hurt [Patient] no i i feel like increased pressure but it's not distinct[SEP]
|
[
"Discussion",
"Medication",
"Other Treatments",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,767
|
[Vegetative History][Doctor] okay got it and no bleeding or i'm sure it's a little swollen probably [Patient] yeah it's swollen but no bleeding[SEP][Personal History][Doctor] well i'll have you take off your shoes in a second we'll examine you in a second but since you're here and i wanted to talk about some of your other things that you know we have n't i have n't seen you in a year so let's talk about your history of diabetes as well are you taking the metformin how's your blood sugars been how how're you managing that any issues with that [Patient] no they've been pretty stable[SEP][Personal History][Doctor] you're checking your sugars regularly as well [Patient] yes[SEP]
|
[
"Discussion",
"Diagnostic Testing",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,768
|
[Personal History][Doctor] you're checking your sugars regularly as well [Patient] yes[SEP][Discussion][Diagnostic Testing][Reassessment][Doctor] okay your hemoglobin a1c last time i looked at epic was about six . eight which is really good so i think you're doing a great job we had talked about you know cutting off the sweets and sugars and stuff like that and exercising so it sounds like you're you're you're doing a pretty good job with that have you seen the ophthalmologist recently for your eye exam for your diabetes checkup or no [Patient] i am due for one of those in the next couple of weeks[SEP][Discussion][Diagnostic Testing][Doctor] okay alright so we'll so you do you already have an appointment or do you need to make an appointment for that [Patient] i have an appointment[SEP][Discussion][Medication][Doctor] perfect excellent okay and how is your blood pressure been i know we watching it your blood pressure today looks pretty good it's about one seventy over i'm sorry one twenty over seventy you're taking norvasc any issues with that any do you need any refills or anything [Patient] i need a refill on that yes[SEP]
|
[
"Physical Examination",
"Discussion",
"Other Treatments",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,769
|
[Personal History][Doctor] alright so like is it a specific diet i just wan na make sure like are you on like the keto diet [Patient] no[SEP][Physical Examination][Doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and do a quick physical exam as i mentioned before your blood pressure is a little high as i listen to your heart i do like it's got a nice regular rate and rhythm i do n't appreciate any murmur when i listen to your lungs they sound clear bilaterally i would like to look at your knee though so when i press here on the outside does it hurt [Patient] little bit[SEP][Physical Examination][Doctor] okay and then when i press on the inside does it hurt [Patient] no[SEP][Physical Examination][Doctor] alright can you bend your knee and straighten it [Patient] i can i think that's all i can i can bend[SEP][Physical Examination][Doctor] mm-hmm alright so are you having problems walking can you bear weight [Patient] i can but i have a little bit of a limp[SEP]
|
[
"Reassessment",
"Physical Examination",
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Referral",
"Radiology Examination",
"Medication"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,770
|
[Other Socials][Doctor] okay alright well i hope you're not working too much and then you'll able to at least find some time with the family [Patient] yeah i'm i yeah i tend to be a workaholic but yes i i am working on that[SEP][Chitchat][Doctor] okay well i hope kids are doing okay [Patient] they are thank you[SEP][Family History][Doctor] okay good so tell me what conditions what kind of conditions run in your family like is there do you have hypertension diabetes or [Patient] yeah all of all of the above[SEP][Physical Examination][Doctor] okay and depression okay alright well let's go ahead and do a quick physical exam on you here i reviewed your vitals and everything there looks good so that's good and now on general appearance you appear in no distress and no jaundice on skin exam let me go ahead and listen to your heart here great on your heart exam you have a nice regular rate and rhythm with a two out of six six systolic murmur appreciate appreciated that's that has n't changed from last year so we will just continue to monitor that monitor that as well okay [Patient] okay[SEP]
|
[
"Physical Examination",
"Lab Examination",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,771
|
[Chitchat][Doctor] i used to get tumor guy but i i really kinda moved over to nike [Patient] hmmm[SEP][Chitchat][Doctor] that's good you know it is running is a great exercise [Patient] it is[SEP][Personal History][Doctor] so have you had any let's get back to the exam here have you had a recent mri of your brain i saw one from a few years ago but as doctor white said anything about getting a more a recent mri [Patient] yeah she was gon na put one in but she wanted me to see you first and urgently so they have n't called me yet for the mri[SEP][Physical Examination][Doctor] okay so that's good we i think we'll we will follow up with that mri but let's go ahead and take a do a quick physical exam here i reviewed your vitals that the the assistant collected when you came in and everything there looks good including your blood pressure you know with symptoms like that that's one of those things that i'd be concerned about [Patient] okay[SEP][Physical Examination][Doctor] now on your heart exam it sounds like it's normal sinus rhythm with no murmurs rubs or gallops so that's good as i listen i'm gon na go ahead and look here in your eyes the funduscopic exam shows papilledema and that's just some of swelling behind there in the eye and this let me do a a neurological exam this will take a few minutes you get up to follow my instructions as we go through that okay on neurological exam your cranial nerves one through twelve are intact including a normal cranial reflex and just went to watch you walk across the room here okay turn around come back and okay so on musculoskeletal exam your gait is normal [Patient] okay go ahead sorry[SEP]
|
[
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Referral"
] |
[
"Assessment",
"Plan"
] | 3,772
|
[Physical Examination][Doctor] okay positive pain to palpation of the soft tissues of the neck what about when i press on your back or your shoulders [Patient] no that's fine[SEP][Physical Examination][Doctor] okay so when you flex your neck when you're touching your chin to your chest does that hurt [Patient] mm-hmm[SEP][Physical Examination][Doctor] alright positive pain with flexion what about when you move it back [Patient] yeah that hurts worse[SEP][Physical Examination][Doctor] okay okay severe positive pain to extension okay so can you turn your head from side to side does that hurt [Patient] yeah a little bit[SEP][Physical Examination][Doctor] okay positive pain with rotation and then can you touch your ear to your shoulders [Patient] no[SEP]
|
[
"Discussion",
"Referral",
"Medication",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] | 3,773
|
[Personal History][Therapeutic History][Doctor] okay and but your blood sugars are a bit off you know maybe those the cadberry eggs so how about your asthma how has that been doing you know have you had any asthma attacks you're still taking flovent twice a day and the albuterol as needed [Patient] yeah knock on wood i my asthma is pretty much under control[SEP][Personal History][Therapeutic History][Doctor] okay excellent excellent alright and i recall you know just kinda review a few things i i think you've got an allergy to penicillin is that correct [Patient] that's correct yes[SEP][Personal History][Doctor] okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct [Patient] yes that's right[SEP][Physical Examination][Doctor] okay and then let's go ahead and examine you alright so mark your exam is pretty much you know for the most part normal with a few exceptions on your heart exam you still have a grade three out of six systolic ejection murmur and that's unchanged from prior exam we're watching that and so that just means i hear some some heart sounds as your heart is beating there i'm not too concerned about it as as that's not changed otherwise normal cardiovascular exam and your physical exam otherwise on your musculoskeletal exam on your right elbow you do have moderate lateral epicondylar tenderness of the right elbow and how about when i move this when i move your elbow like this does that hurt you [Patient] kills[SEP][Physical Examination][Doctor] okay sorry about that so you've got moderate pain with passive range of motion of the right elbow there is no palpable joint effusion and now what if i press against your wrist like so does that hurt you [Patient] yeah it hurts a little bit[SEP]
|
[
"Personal History",
"Radiology Examination",
"Vegetative History"
] |
[
"Subjective",
"Objective"
] | 3,774
|
[Personal History][Therapeutic History][Doctor] okay excellent excellent alright and i recall you know just kinda review a few things i i think you've got an allergy to penicillin is that correct [Patient] that's correct yes[SEP][Personal History][Doctor] okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct [Patient] yes that's right[SEP][Physical Examination][Doctor] okay and then let's go ahead and examine you alright so mark your exam is pretty much you know for the most part normal with a few exceptions on your heart exam you still have a grade three out of six systolic ejection murmur and that's unchanged from prior exam we're watching that and so that just means i hear some some heart sounds as your heart is beating there i'm not too concerned about it as as that's not changed otherwise normal cardiovascular exam and your physical exam otherwise on your musculoskeletal exam on your right elbow you do have moderate lateral epicondylar tenderness of the right elbow and how about when i move this when i move your elbow like this does that hurt you [Patient] kills[SEP][Physical Examination][Doctor] okay sorry about that so you've got moderate pain with passive range of motion of the right elbow there is no palpable joint effusion and now what if i press against your wrist like so does that hurt you [Patient] yeah it hurts a little bit[SEP][Personal History][Radiology Examination][Vegetative History][Doctor] okay alright sorry so that's you have mild pain with resisted extension of the right wrist as well okay otherwise normal unremarkable exam and let's talk about your results now so your right elbow x-ray today shows no acute fracture or other bony abnormality so that's good there's no malalignment or sign of joint effusion and otherwise it's a normal right elbow x-ray so that's reassuring okay and hey you know i meant to ask you you know and do you have any history of fever recently you know along with the elbow pain you had noticed a fever [Patient] no i do n't think so[SEP]
|
[
"Discussion",
"Follow-up",
"Medication",
"Referral",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] | 3,775
|
[Physical Examination][Doctor] okay so i'm looking here i think last after your last visit you got a1c now was six . seven so it's a little bit high it's gone down a little bit since you were first diagnosed with the type two diabetes a year ago so i'm glad we're making progress with that as well alright so i'm just gon na do a quick physical exam on you before i do just wan na make sure are you having any chest pain today [Patient] no[SEP][Physical Examination][Doctor] alright any any belly pain [Patient] no[SEP][Physical Examination][Doctor] alright so i'm gon na listen to your lungs your lungs are clear bilaterally i do n't hear any crackles listen to your heart so on your heart exam i do hear that grade two out of six systolic ejection murmur and we already knew about that previously so it has n't gotten any worse so that's good so i'm gon na just press here in your abdomen because that you did have those kidney stones does that hurt [Patient] no[SEP][Physical Examination][Doctor] alright i'm gon na press here on your back [Patient] no pain[SEP]
|
[
"Physical Examination",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,776
|
[Discussion][Other Treatments][Doctor] because i think that's a major factor of us eventually getting you off of all medications [Patient] hmmm[SEP][Discussion][Reassessment][Doctor] and then for your diabetes i'm just keep you on that on that five hundred of metformin okay i think you're doing well with that as well also but i do want you to start taking your blood sugars if you can take them before every meal [Patient] okay[SEP][Discussion][Other Treatments][Doctor] just to gauge where you are so you can tell how much food you should actually be be eating [Patient] okay[SEP][Chitchat][Doctor] alright [Patient] i can try that[SEP][Discussion][Doctor] so how does that that sound [Patient] that sounds like a plan when should i come back and see you[SEP]
|
[
"Follow-up",
"Personal History"
] |
[
"Plan",
"Subjective"
] | 3,777
|
[Drug History][Doctor] okay now i really need you to be truthful when you answer these next questions this is important for taking a good history do you smoke any type of cigarette or tobacco product and have you ever smoked or do you smoke marijuana on a regular basis [Patient] no i've never smoked and i do n't vape either or yeah i do n't smoke cigarettes or marijuana[SEP][Vegetative History][Doctor] okay and then you said you do n't vape so no vaping or e-cigarette use at all [Patient] hmmm hmmm[SEP][Other Socials][Drug History][Doctor] okay and then are you routinely in an area where there is a lot of airborne particular like smoking in bars or around any type of of you know like race tracks or anything like that [Patient] sometimes i go to the bars with some friends and yeah the smoking does irritate me[SEP][Physical Examination][Doctor] okay thank you for sharing that with me so if it's okay with you i'd like to go ahead and do a quick physical exam [Patient] okay[SEP]
|
[
"Physical Examination",
"Follow-up",
"Medication",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,778
|
[Other Socials][Doctor] yeah i'm sorry yep probably now at the peak of you know just learning it and being able to do more with it this comes and this happens right [Patient] exactly[SEP][Family History][Doctor] well let's see what we can do for you here so you can go out into the you know the golf course again now do you tell me do you have any family members with spine conditions [Patient] no i ca n't recall any family members[SEP][Vegetative History][Doctor] okay alright and do you smoke [Patient] not now i i quit about twenty years ago[SEP][Physical Examination][Doctor] okay alright well alright well i like to do a quick physical exam on you here [Patient] okay[SEP][Physical Examination][Doctor] i'm gon na go ahead here i reviewed your vitals and they overall look pretty good so that's a good sign now on your musculoskeletal back exam there is no overlying erythema and that just means redness or ecchymosis and that just means bruising of the skin now there is midline tenderness at l4 l5 disk space with right-sided lumbar paravertebral tenderness so do me a favor and i'm gon na just have you you know bend forward and straighten up a bit [Patient] okay that's painful[SEP]
|
[
"Physical Examination",
"Discussion",
"Medication",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,779
|
[Acute Symptoms][Doctor] your right knee okay and i know that it sounds like you were on a motor boat as you were you know water skiing but did you hear anything pop or feel anything pop when it happened [Patient] no it just felt like something stretched and then it swelled up some afterwards[SEP][Acute Symptoms][Doctor] okay and were you i assume that you were were you able to get out of the water by yourself or did you need some assistance [Patient] i was able to get out but it was very sore to climb up and you know any kind of squatting or bending is really pretty sore[SEP][Personal History][Doctor] yeah okay and have you ever injured this knee before [Patient] no that was the first time[SEP][Other Socials][Doctor] that was the first time okay where do you have a boat what lake do you have it on lake [Patient] lake martin[SEP][Other Socials][Doctor] okay nice and so you're a frequent water skier [Patient] yeah i try to go every weekend when we can[SEP]
|
[
"Chitchat",
"Other Socials"
] |
[
"Null",
"Subjective"
] | 3,780
|
[Acute Symptoms][Therapeutic History][Doctor] okay and [Patient] putting a cold pack on it[SEP][Acute Symptoms][Therapeutic History][Doctor] okay and has that helped at all [Patient] yeah that's helped a fair amount it's still pretty sore though[SEP][Personal History][Doctor] okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here [Patient] i had my tonsils out[SEP][Physical Examination][Doctor] okay you had your tonsils out okay alright well let me go ahead i wan na do a just a quick physical exam i'm gon na go ahead and be calling out some of my clinical exam findings and i'll let you know what that means when i'm done okay so looking at your vital signs here in the office it does look like you're doing a really good job managing your blood pressure your blood pressure is up is about one twenty over seventy seven today here in the office and that's with you probably in a little bit of pain so that's good and on your neck exam i do n't appreciate any lymphadenopathy on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are clear to auscultation bilaterally on your musculoskeletal exam on your right knee i do appreciate some ecchymosis some edema there is an effusion present does it hurt when i press [Patient] yeah that's sore[SEP][Physical Examination][Doctor] okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt [Patient] yeah do n't do that anymore[SEP]
|
[
"Physical Examination",
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Referral",
"Medication"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,781
|
[Drug History][Doctor] okay that's good i also see here that you marked down that you were a previous smoker and and when when did you when did you stop smoking [Patient] i stopped smoking probably about seven years ago[SEP][Drug History][Doctor] okay that's good and i'm glad to hear that you were able to to to stop and and stay tobacco free that that's great to hear do you have any pain or any shortness of breath or anything like that [Patient] no not at all[SEP][Family History][Doctor] okay and i would like to talk about your familial history here for just a second do you have any family history of lung cancer or any other type of malignancies [Patient] no lung cancer my mom did have breast cancer but she is doing well now[SEP][Personal History][Doctor] okay alright and then things like lung infections or pneumonia do you have any previous history of that [Patient] no no not not anything that i'm aware of[SEP]
|
[
"Physical Examination",
"Discussion",
"Follow-up",
"Radiology Examination",
"Acute Assessment",
"Drug History",
"Other Treatments"
] |
[
"Assessment",
"Plan",
"Subjective",
"Objective"
] | 3,782
|
[Vegetative History][Doctor] okay yeah i mean i think we all like to lose a little bit of weight but yeah it's a it says it's a struggle so no no chest pain or shortness of breath with this [Patient] no[SEP][Personal History][Therapeutic History][Doctor] okay so i i'm gon na you know we'll talk about that in a second i'll look at your throat as well and see what we need to do but it sounds like we may have to send you to a specialist to take a look at that and see if there is something causing this how about how are you doing with your diabetes by the way since i have n't seen you in a while i know we have you on metformin five hundred milligrams twice a day we checked your hemoglobin a1c last time was seven . four we talked about improving your diet and exercise how are things going [Patient] i think they're going great i mean i'm taking my meds i'm sticking to them and i feel pretty good otherwise[SEP][Personal History][Doctor] okay are you checking your blood sugars in the morning or are you checking those at all [Patient] yeah i do i mean once in a while i i'm in a hurry and i skip it but i have to say i probably do so about eighty percent of the time[SEP][Personal History][Doctor] and how are the numbers looking [Patient] they're looking you know okay they are all within you know the range that we are targeting[SEP][Vegetative History][Doctor] okay alright and any any no nausea vomiting or diarrhea or any other side effects from the metformin or anything like that [Patient] no[SEP]
|
[
"Discussion",
"Personal History",
"Therapeutic History",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Subjective"
] | 3,783
|
[Personal History][Therapeutic History][Doctor] okay so i i'm gon na you know we'll talk about that in a second i'll look at your throat as well and see what we need to do but it sounds like we may have to send you to a specialist to take a look at that and see if there is something causing this how about how are you doing with your diabetes by the way since i have n't seen you in a while i know we have you on metformin five hundred milligrams twice a day we checked your hemoglobin a1c last time was seven . four we talked about improving your diet and exercise how are things going [Patient] i think they're going great i mean i'm taking my meds i'm sticking to them and i feel pretty good otherwise[SEP][Personal History][Doctor] okay are you checking your blood sugars in the morning or are you checking those at all [Patient] yeah i do i mean once in a while i i'm in a hurry and i skip it but i have to say i probably do so about eighty percent of the time[SEP][Personal History][Doctor] and how are the numbers looking [Patient] they're looking you know okay they are all within you know the range that we are targeting[SEP][Vegetative History][Doctor] okay alright and any any no nausea vomiting or diarrhea or any other side effects from the metformin or anything like that [Patient] no[SEP][Discussion][Personal History][Therapeutic History][Reassessment][Doctor] okay good so i think we should probably repeat your hemoglobin a1c it sounds like you've you know you've improved your diet and it sounds like you've you're following the regimen so maybe the numbers will be better this time and we do n't have to change your medication so that will be awesome how are you doing with your blood pressure i know we have you on norvasc we asked that you check it like you know once a week or more than that if you have time blood pressure looks good today in the office it's about one fifty i'm sorry one twenty over fifty right now so no nothing here in the office how are things at home [Patient] i get there now every once in a while you know the lower numbers a little bit you know higher but it's not you know usually it's either close or or on on range[SEP]
|
[
"Physical Examination",
"Discussion",
"Referral",
"Medication",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,784
|
[Chitchat][Doctor] absolutely okay totally understand that glad to hear that you're back out on the court playing with your son how is he doing by the way [Patient] he is doing great he is doing great i mean you know he is a big step kurry fan so he likes to keep up shots from from way out past the three point line and he is only ten and tiny so it's it's not a good idea for him to do that but he is doing really well and i'm just happy he's tried every sport and basketball's really what took so i'm just really happy that he has a sport and loves and couple of his buddies playing to lead with him so it's just makes me happy that he's found something he really enjoys[SEP][Physical Examination][Doctor] good good to hear alright well let's take a look at that ankle it looks like it's pretty swollen so let me just do a quick exam on that right now alright so looks like the outside of your ankle if i push on that does that hurt pretty bad [Patient] yeah yes[SEP][Physical Examination][Doctor] okay so exquisite tenderness tenderness laterally and then if i push here does that hurt too [Patient] yeah a little bit[SEP][Physical Examination][Doctor] okay so some tenderness over the medial deltoid region so swelling on the lateral side of the ankle no epidermolysis skin is intact looks like you have brisk capillary refill no horrible malalignment so alright can you can you stand on it did you say that you're having trouble walking at all [Patient] yeah i mean i can stand on it and i ca n't walk on it it just it hurts and it feels like i'm going to possibly injure it more just because it does n't feel particularly solid[SEP][Physical Examination][Doctor] sure so it does n't quite feel stable [Patient] yeah[SEP]
|
[
"Other Treatments",
"Radiology Examination",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,785
|
[Other Socials][Doctor] so okay and what's your support like at home who is who is able to help out are you still doing that kind of hobbling around on crutches or [Patient] yeah now my husband is home with me but he also works a job where he is gone quite a bit so it's just me and the kids[SEP][Personal History][Therapeutic History][Doctor] okay alright and did the ski patrol give you crutches i i see you have them here with you okay alright great and are you otherwise generally healthy [Patient] yes[SEP][Personal History][Doctor] okay and no high blood pressure diabetes anything like that [Patient] mm-hmm[SEP][Physical Examination][Doctor] no okay alright and well i i wan na go ahead let me just do a quick physical exam i'm gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay alright so on your heart exam your heart sounds in a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are nice and clear to auscultation and remind me what knee did you injure again [Patient] my right knee[SEP][Physical Examination][Doctor] your right knee okay so on your right knee examination i do appreciate some edema and an effusion over the right knee does it hurt when i press [Patient] yes[SEP]
|
[
"Acute Symptoms",
"Physical Examination",
"Therapeutic History",
"Radiology Examination",
"Diagnostic Testing",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Subjective",
"Objective"
] | 3,786
|
[Therapeutic History][Doctor] okay . i- i know that we had given you some clobetasol for your scalp . is that- so that's doing okay ? [Patient] yeah , that's doing a lot better .[SEP][Physical Examination][Doctor] okay , great . um , all right , well , i'd like to go ahead and do a physical exam on you . [Patient] okay .[SEP][Physical Examination][Doctor] let's first look at your vital signs . hey , dragon , show me the vital signs . great , so everything looks good from that perspective . um , so looking at you , i do n't appreciate any cervical lymphadenopathy . your heart is a nice regular rate and rhythm , and your lungs sound really clear . on your right elbow , you do have some edema and inflammation of your right olecranon and there's some tenderness and an effusion right there . so um , does that hurt when i press it ? [Patient] yeah , that does hurt .[SEP][Physical Examination][Doctor] okay , and when i turn your arm , do you have pain ? [Patient] yeah , that hurts a bit too .[SEP][Physical Examination][Doctor] okay , so she has pain- to palpation of the olecranon bursa and pain with pronation and supination . and when you flex- and when you bend it and straighten it , does that hurt ? [Patient] yeah , it does and it's a bit stiff too .[SEP]
|
[
"Physical Examination",
"Medication",
"Lab Examination",
"Diagnostic Testing",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,787
|
[Physical Examination][Doctor] okay , great . um , all right , well , i'd like to go ahead and do a physical exam on you . [Patient] okay .[SEP][Physical Examination][Doctor] let's first look at your vital signs . hey , dragon , show me the vital signs . great , so everything looks good from that perspective . um , so looking at you , i do n't appreciate any cervical lymphadenopathy . your heart is a nice regular rate and rhythm , and your lungs sound really clear . on your right elbow , you do have some edema and inflammation of your right olecranon and there's some tenderness and an effusion right there . so um , does that hurt when i press it ? [Patient] yeah , that does hurt .[SEP][Physical Examination][Doctor] okay , and when i turn your arm , do you have pain ? [Patient] yeah , that hurts a bit too .[SEP][Physical Examination][Doctor] okay , so she has pain- to palpation of the olecranon bursa and pain with pronation and supination . and when you flex- and when you bend it and straighten it , does that hurt ? [Patient] yeah , it does and it's a bit stiff too .[SEP][Physical Examination][Medication][Lab Examination][Diagnostic Testing][Reassessment][Doctor] okay , so pain with flexion and extension of the right arm . uh , your abdomen is nice and soft , and there's no lower extremity edema . uh , let's go ahead and take a look at some of your labs . you know , you have a lot of arthritis for someone so young , so we had sent off that autoimmune panel . hey , dragon . show me the autoimmune labs . hey , dragon . show me the autoimmune profile . hey , dragon . show me the esr . okay , so that's good . hey , dragon . show me the uric acid . okay . all right , well , good . that's great . so , you know , it does n't look like you have any systemic arthritis , or sys- systemic inflammatory in process going on . so , my impression of you at this time is that from a gout standpoint , everything is nice and stable . i think that we should continue you on the colchicine 0.6 milligrams twice a day as needed for flare-ups of your gout . um , and then for your osteoarthritis , i'd like to go ahead and order a right elbow x-ray . hey , dragon . order a right elbow x-ray , and then i'd like to prescribe some meloxicam 15 milligrams once a day for the pain and the swelling . [Patient] okay .[SEP]
|
[
"Discussion",
"Medication",
"Referral",
"Diagnostic Testing"
] |
[
"Plan"
] | 3,788
|
[Acute Symptoms][Doctor] good . so , pretty much status quo except for those things that we've been working on , right ? [Patient] yep .[SEP][Physical Examination][Doctor] okay , good . all right . well , let me do a quick physical exam , okay ? [Patient] okay .[SEP][Physical Examination][Doctor] okay , squeeze my finger here . good . can you feel me touch out here ? [Patient] yep .[SEP][Physical Examination][Doctor] okay . and , can you feel me touch you down here ? [Patient] yep .[SEP][Physical Examination][Doctor] okay . no swelling . push your leg out . good . pull it back . mm-hmm . go . good . okay . so , on my exam , um , essentially , your exam is normal . your , um , heart is regular . you do have that grade 2 , um , systolic ejection fraction back ejection murmur that you , um , that we've heard in the past . okay ? so , um , we definitely know that's there . that's unchanged , okay ? um , your lungs are clear . um , your grips are equal . neurovascular's intact . you do n't have any carotid bruits in your neck , no thyromegaly . no edema . um , pulses are good , so essentially , your exam is , is essentially normal . let's take a look at some of your lab work , okay ? [Patient] okay .[SEP]
|
[
"Therapeutic History",
"Lab Examination"
] |
[
"Subjective",
"Objective"
] | 3,789
|
[Physical Examination][Doctor] okay . no swelling . push your leg out . good . pull it back . mm-hmm . go . good . okay . so , on my exam , um , essentially , your exam is normal . your , um , heart is regular . you do have that grade 2 , um , systolic ejection fraction back ejection murmur that you , um , that we've heard in the past . okay ? so , um , we definitely know that's there . that's unchanged , okay ? um , your lungs are clear . um , your grips are equal . neurovascular's intact . you do n't have any carotid bruits in your neck , no thyromegaly . no edema . um , pulses are good , so essentially , your exam is , is essentially normal . let's take a look at some of your lab work , okay ? [Patient] okay .[SEP][Therapeutic History][Lab Examination][Doctor] hey , dragon , show me the hemoglobin a1c . okay , so , blood sugars have been elevated . your hemoglobin a1c is elevated as well , so that tells me your blood sugars have been a little bit out of control . you're still taking the metformin , correct ? [Patient] yes , i am .[SEP][Therapeutic History][Doctor] okay , and you take that twice a day ? [Patient] yep .[SEP][Physical Examination][Discussion][Reassessment][Doctor] okay . um , uh , hey , dragon ? show me the vital signs . okay , good news here is your blood pressure's good . everything , um , there is fine . so , um , so , my assessment is , is , um , your first problem is diabetes . it's a little out of control . we'd like that hemoglobin a1c to be under seven , um , at least . you know , preferably , under six . [Patient] mm-hmm .[SEP][Discussion][Medication][Other Treatments][Doctor] so , um , uh , i'm not gon na change your medication . i think this is diet related , so i want you to try to cut down on the snacking and additional sweets , okay ? [Patient] yeah .[SEP]
|
[
"Discussion",
"Follow-up",
"Medication",
"Other Treatments"
] |
[
"Plan"
] | 3,790
|
[Physical Examination][Doctor] hey , dragon , show me the vital signs . good , here in the office , everything looks great with your vital signs . i think that's great , so i'm just gon na take a listen to your heart and your lungs , and take a look at your elbow and , and we'll go from there , okay ? [Patient] okay .[SEP][Physical Examination][Doctor] all right , so , so on physical examination of your left elbow , you do have some erythema and edema of your left elbow . does it hurt when i touch ? [Patient] yeah , it does .[SEP][Physical Examination][Doctor] okay , he ... she has some pain to palpation of the olecranon . of the left olecra- olecranon , and it is warm to palpation . um , can you straighten your elbow for me ? [Patient] yeah , it , it hurts , and it's , uh , it's a bit stiff .[SEP][Physical Examination][Doctor] okay , so she has pain with flexion and extension of the left elbow . there's a palpable right ... or s- ... palpable left radial pulse . okay , um , so let's go over ... i just wan na take a look at some of your results , okay ? [Patient] okay .[SEP][Radiology Examination][Doctor] hey , dragon , show me the left elbow x-ray . hey , dragon , show me the elbow x-ray . hey , dragon , show me the left arm x-ray . okay , so , in reviewing the results of your left arm x-ray , there's no evidence of any elbow fracture , which is not surprising , okay ? hey , dragon , show me the endoscopy results . hey , dragon , show me the endoscopy . okay , well , your recent endoscopy showed that you ... hey , dragon , show me the endoscope . all right , so here it looks like , you know ... your endoscopy results look like you had an episode of gastritis . that's for your , your peptic ulcer disease , and so everything , you know ... you took your , your protonix , and i think everything resolved at that point , okay . [Patient] okay .[SEP]
|
[
"Discussion",
"Other Treatments",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] | 3,791
|
[Acute Symptoms][Doctor] okay . all right . and , have you had any headaches ? [Patient] i have had some headaches . i do n't know if that's just because of more stress at work or , um , because of the high blood pressure .[SEP][Acute Symptoms][Doctor] okay . all right . so , you've had some headaches . have you had any chest pain , shortness of breath , anything like that ? [Patient] no , nothing like that .[SEP][Personal History][Doctor] okay . um , and , you know , i know that you've had a kidney transplant a few years ago . [Patient] yes .[SEP][Personal History][Doctor] everything is okay with that ? [Patient] everything's been good and solid there .[SEP][Therapeutic History][Doctor] and you're taking all of your auto , um , i- um , your immunosuppression medications ? [Patient] yes , i am .[SEP]
|
[
"Physical Examination",
"Personal History",
"Lab Examination"
] |
[
"Subjective",
"Objective"
] | 3,792
|
[Acute Symptoms][Doctor] okay . all right . so , you've had some headaches . have you had any chest pain , shortness of breath , anything like that ? [Patient] no , nothing like that .[SEP][Personal History][Doctor] okay . um , and , you know , i know that you've had a kidney transplant a few years ago . [Patient] yes .[SEP][Personal History][Doctor] everything is okay with that ? [Patient] everything's been good and solid there .[SEP][Therapeutic History][Doctor] and you're taking all of your auto , um , i- um , your immunosuppression medications ? [Patient] yes , i am .[SEP][Physical Examination][Personal History][Lab Examination][Doctor] all right . so , let's go ahead and we'll do a quick physical exam . so , looking at you , you do n't appear any distress . your neck is nice and supple . your heart is irregular rate and rhythm . i do hear a slight , uh , two out of six systolic ejection murmur . your lungs are clear . i do see the scar on the left , uh , left plank for your kidney transplant which is healed . and you have no lower extremity edema . so , let's go ahead and look at some of your results , okay ? [Patient] okay .[SEP]
|
[
"Reassessment",
"Radiology Examination",
"Lab Examination"
] |
[
"Assessment",
"Objective"
] | 3,793
|
[Physical Examination][Personal History][Lab Examination][Doctor] all right . so , let's go ahead and we'll do a quick physical exam . so , looking at you , you do n't appear any distress . your neck is nice and supple . your heart is irregular rate and rhythm . i do hear a slight , uh , two out of six systolic ejection murmur . your lungs are clear . i do see the scar on the left , uh , left plank for your kidney transplant which is healed . and you have no lower extremity edema . so , let's go ahead and look at some of your results , okay ? [Patient] okay .[SEP][Reassessment][Radiology Examination][Lab Examination][Doctor] hey , dragon , show me the creatinine . so , your kidney function looks really good . so , that's really promising after your transplant . hey , dragon , show me the ekg . and your ekg looks great , uh , perfectly normal , so that's good . um , so , my impression of you at this time ... , let me see your blood pressure . [Patient] okay .[SEP][Lab Examination][Doctor] hey , dragon , show me the blood pressure . yeah , and you're right , it- [Patient] hm .[SEP][Discussion][Acute Assessment][Medication][Doctor] . it is high . so , there is something that we can do for that . so , let's go ahead and we'll put you on ... so , my impression of you is that your , your blood pressure is high and the norvasc is n't controlling it . and , you know , we can definitely get it under better control . so , what i would like to do is prescribe you coreg 25 milligrams , twice a day . and that will help bring your blood pressure down , okay ? [Patient] okay .[SEP][Diagnostic Testing][Medication][Doctor] hey , dragon , order carvedilol 25 milligrams , twice a day . uh , i'd also like to go ahead and , uh , get a lipid panel and some routine labs on you just to make sure that everything is okay . [Patient] yeah .[SEP]
|
[
"Diagnostic Testing",
"Medication",
"Reassessment",
"Follow-up"
] |
[
"Assessment",
"Plan"
] | 3,794
|
[Physical Examination][Radiology Examination][Doctor] okay , yeah that lumbar fusion . um , let's take an x-ray . hey . or let's look at an x-ray . hey dragon , show me the latest x-ray . okay , we can see where you had your fusion , t4 here on the x-ray . but i do n't see anything that looks , um , significantly abnormal . it does n't appear to have any compression fractures or anything like that . so , it's essentially , except for the fusion , a normal exam . let me do your exam for you here . can i have you stand up please ? does it hurt when i twist you that way ? [Patient] yes .[SEP][Physical Examination][Doctor] okay . you can sit back down . if i lift your leg here , does that bother you ? [Patient] no .[SEP][Physical Examination][Doctor] how 'bout when i lift this leg ? [Patient] no .[SEP][Physical Examination][Doctor] any pain shooting down your legs when i do that ? [Patient] no .[SEP][Physical Examination][Doctor] okay . and can you feel me touching down here . [Patient] yes .[SEP]
|
[
"Acute Symptoms",
"Therapeutic History",
"Acute Assessment"
] |
[
"Assessment",
"Subjective"
] | 3,795
|
[Physical Examination][Doctor] okay . um , so let's go ahead , and we'll ... i'm gon na do a quick physical exam . [Patient] okay .[SEP][Physical Examination][Lab Examination][Doctor] hey , dragon , show me the vital signs . so i'm looking here at your vital signs . they look great . you do n't have a fever at that ... at this time , so that's really encouraging . i'm just gon na check you out , and , uh , i'm gon na listen to your heart and lungs and look for any rashes and let you know what i find , okay ? [Patient] okay .[SEP][Physical Examination][Doctor] okay , so on physical examination , you know , you do have some swelling of your , uh , elbow joints bilaterally . um , does it hurt when i touch them ? [Patient] yeah , it does .[SEP][Acute Symptoms][Physical Examination][Doctor] okay , so she has pain to palpation to both elbow joints . um , and on your skin examination , you do have a bull's-eye rash on your , um , abdomen on the left-hand side . um , it's , it's warm to palpation . any pain with that ? [Patient] no , no pain for that .[SEP][Physical Examination][Lab Examination][Doctor] non-tender to palpation , no evidence of cellulitis . um , and the rest of , you know , the rest of your exam is pretty normal , okay ? so let me just go over some of the results with you , okay ? [Patient] okay .[SEP]
|
[
"Discussion",
"Diagnostic Testing",
"Lab Examination"
] |
[
"Plan",
"Objective"
] | 3,796
|
[Physical Examination][Lab Examination][Doctor] non-tender to palpation , no evidence of cellulitis . um , and the rest of , you know , the rest of your exam is pretty normal , okay ? so let me just go over some of the results with you , okay ? [Patient] okay .[SEP][Discussion][Diagnostic Testing][Lab Examination][Doctor] hey , dragon , show me the lyme titer . so you can see here , you know , in reviewing the results of your lyme titer , it is elevated . so we're gon na go ahead and do some further testing , but we're gon na , you know , we're gon na look into that , okay ? [Patient] okay .[SEP][Acute Assessment][Lab Examination][Doctor] hey , dragon , show me the labs . and in reviewing the results of your labs , everything else looks good . so again , you know , you do n't have an elevated white blood cell count or anything like that . so i think we got this early enough , and we can go ahead and , and treat it , okay ? [Patient] okay .[SEP][Discussion][Acute Assessment][Medication][Doctor] so i wan na talk a little bit about , you know , my assessment and my plan for you . so for your first problem , this newly diagnosed lyme disease , i wan na go ahead and prescribe you doxycycline , 100 milligrams twice a day . you have to take it for three weeks , okay ? [Patient] okay .[SEP][Discussion][Follow-up][Referral][Doctor] i'm gon na just touch base with an infectious disease doctor to make sure that there's not anything else that we need to do , okay ? and i wan na see you again next week for a follow-up for this , okay ? [Patient] okay .[SEP]
|
[
"Reassessment",
"Discussion",
"Diagnostic Testing"
] |
[
"Assessment",
"Plan"
] | 3,797
|
[Vegetative History][Doctor] okay . any nausea or vomiting , chest pains , shortness of breath ? [Patient] no , but i do have high blood pressure , um , but i , i monitor that and i've been taking medication for that , and that has n't elevated , um , in any way since the joint pain .[SEP][Personal History][Therapeutic History][Doctor] okay . all right . so , yeah , i see on here that you do take norvasc , five mg a day and you've been taking that every day- [Patient] yes .[SEP][Physical Examination][Doctor] okay . um , and , um , so let's go ahead and do a quick physical exam on you . so , hey dragon , show me the blood pressure . your blood pressure's actually pretty high today , so you might be a little nervous here , which is not uncommon . [Patient] yeah .[SEP][Physical Examination][Radiology Examination][Doctor] um , so , looking at you , your , your neck is nice and soft , there's no enlarged thyroid . your heart has a regular rate and rhythm . your lungs are clear . your abdomen is nice and soft , but looking at your knees , on your left knee you do have a slight erythema and edema . there is a small efusion present over your left knee . um , you have some decrease flexion and extension of your knee , but your strength in your lower extremities is good . uh , so let's go ahead and look at some of your results . i know that we did some x-rays when you came in . [Patient] yeah .[SEP][Radiology Examination][Doctor] hey dragon , show me the left knee x-ray . okay , so looking at this , this is an , this is a normal x-ray of your left knee , so you may just have a little bit of a strain going on in your , in your knees there . [Patient] okay .[SEP]
|
[
"Discussion",
"Medication",
"Lab Examination",
"Referral",
"Diagnostic Testing",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,798
|
[Personal History][Therapeutic History][Doctor] okay . all right . so , yeah , i see on here that you do take norvasc , five mg a day and you've been taking that every day- [Patient] yes .[SEP][Physical Examination][Doctor] okay . um , and , um , so let's go ahead and do a quick physical exam on you . so , hey dragon , show me the blood pressure . your blood pressure's actually pretty high today , so you might be a little nervous here , which is not uncommon . [Patient] yeah .[SEP][Physical Examination][Radiology Examination][Doctor] um , so , looking at you , your , your neck is nice and soft , there's no enlarged thyroid . your heart has a regular rate and rhythm . your lungs are clear . your abdomen is nice and soft , but looking at your knees , on your left knee you do have a slight erythema and edema . there is a small efusion present over your left knee . um , you have some decrease flexion and extension of your knee , but your strength in your lower extremities is good . uh , so let's go ahead and look at some of your results . i know that we did some x-rays when you came in . [Patient] yeah .[SEP][Radiology Examination][Doctor] hey dragon , show me the left knee x-ray . okay , so looking at this , this is an , this is a normal x-ray of your left knee , so you may just have a little bit of a strain going on in your , in your knees there . [Patient] okay .[SEP][Discussion][Medication][Lab Examination][Referral][Diagnostic Testing][Reassessment][Doctor] uh , let's look at some of your labs , 'cause i know that you have the diabetes . hey dragon , show me the labs . so , here your white blood cell count is not elevated , so i'm not concerned about an infection or anything like that . um , hey dragon , show me the diabetes' labs . okay and , and your a1c is a little elevated , but it's not , it's not terrible , so i think for right now we'll just continue you on the current regimen . um , so my plan from you , for you in terms of the joint pain , um , i'd like to go ahead and , you know , we'll just send some autoimmune labs to work , work up your left knee pain and , uh , we'll work for you to do some physical therapy and i'd like to go ahead and give you anti-inflammatory medication to help with the pain . does that sound okay ? [Patient] that sounds great .[SEP]
|
[
"Discussion",
"Follow-up",
"Medication",
"Referral",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,799
|
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