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[Vegetative History][Doctor] great , great . no numbness or tingling in your hands ? [Patient] no .[SEP][Physical Examination][Doctor] fingers ? okay , good . all right , well , um , lem me do a quick exam if that's okay ? [Patient] okay .[SEP][Physical Examination][Doctor] deep breath . squeeze my fingers for me . feel me touch you here ? [Patient] yup .[SEP][Physical Examination][Doctor] can you touch down here ? [Patient] mm-hmm .[SEP][Physical Examination][Lab Examination][Doctor] can you push your leg out ? push this one up . pull it back . yeah , good . okay . so on my exam , um ... your exam's essentially normal , your lungs are clear , are- ... you do n't have any adenopathy in your neck , you do n't have any , um , uh , hyperthyroidism . um , your heart is regular without any murmurs . um , your grips are equal , neurologically intact , strength is good , pulses are good . so overall , um , your exam is fine . let's take a- a look at some of your labs and vital signs . [Patient] okay .[SEP]
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[Physical Examination][Doctor] can you touch down here ? [Patient] mm-hmm .[SEP][Physical Examination][Lab Examination][Doctor] can you push your leg out ? push this one up . pull it back . yeah , good . okay . so on my exam , um ... your exam's essentially normal , your lungs are clear , are- ... you do n't have any adenopathy in your neck , you do n't have any , um , uh , hyperthyroidism . um , your heart is regular without any murmurs . um , your grips are equal , neurologically intact , strength is good , pulses are good . so overall , um , your exam is fine . let's take a- a look at some of your labs and vital signs . [Patient] okay .[SEP][Discussion][Follow-up][Medication][Lab Examination][Reassessment][Doctor] hey dragon , show me the blood pressure . okay , so here in the office today it is a little bit elevated , okay ? so your blood pressure is a little bit high . so the results , um , do show that . um , hey dragon , show me the labs . okay , so good news is is your- your labs are all essentially normal , so the results of your labs are essentially normal , okay ? so ... um , my assessment is that your- ... you do have hypertension still . um , and i think we need to increase your blood pressure medicine a little bit , okay ? so i'm gon na increase your lisinopril to 10 milligrams a day , just once a day , um , but i'm gon na increase that a little bit , okay ? and then want you to check it and i'm gon na have you come back in a month and we'll see how you're doing with regards to that , okay ? [Patient] okay .[SEP][Discussion][Reassessment][Doctor] um , your second problem is your dep- depression , you're doing great , i do n't wan na change anything at this point . let's just stay- ... we'll change one thing with your high blood pressure- [Patient] mm-hmm .[SEP][Discussion][Medication][Doctor] so i do n't wan na change any other medications at this point in time , so let's just leave that as it is . [Patient] okay .[SEP]
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[Discussion][Medication][Doctor] uh , dizziness possibly , as well as , uh , one in 100 guys might develop tenderness in their chest , swollen breasts , or enlarged breasts . this is a rare side effect , um , called gynecomastia , and if it happens , you just cut the medication and you let me know , but it is very uncommon . [Patient] i'll definitely let you know if that happens .[SEP][Discussion][Doctor] okay . uh , we'll keep working at it until your blood pressure gets better . um , it can be tricky when your blood pressure starts to go up at a young age though , it is important to get it under control because it can lead to your heart getting bigger or enlarged . um , same thing that happens when you lift weights and your muscles get bigger , uh , and if your heart pumps against high blood pressure , it can eventually lead to heart failure . [Patient] i understand .[SEP][Discussion][Doctor] yeah , so getting that under control is really important to help prevent kidney failure , strokes , and- and things like that- that you're at high risk for with high blood pressure . [Patient] okay .[SEP][Discussion][Other Treatments][Doctor] um , the american heart association has a website called heart.org , it has a lot of really good information about blood pressure to teach- to teach you about it and how to control your diet with exercise . um , if you do your treadmill routinely for 30 minutes or so most days , that could be seven to 10 points off your blood pressure . [Patient] really ? i did n't realize that .[SEP][Discussion][Other Treatments][Doctor] yeah , yeah . it's very important to be active , lower your salt , and increase your potassium . um , the goal is to keep your salt under 2000 milligrams a day , the actual recommendation is- is 1500 milligrams per day , but most people have a hard time with that . um , so just take a look at the website and the dash diet information . um , that will give you a lot of tips and information to help you start learning about this stuff . [Patient] okay . i'll definitely check that out .[SEP]
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[Discussion][Doctor] all right . so , there they will look into secondary causes of your hypertension . they have access to newer procedure based technologies that can lower your blood pressure without medication , uh , for example , there is something called a renal , uh , denervation , uh , where they go inside the artery that feeds your kidney with almost like a little coil and heat that artery up . when they do that , they can block the nerve endings that get into your kidneys and lower your blood pressure . [Patient] that's interesting .[SEP][Discussion][Doctor] yeah . so , that procedure has been shown to lower blood pressure by 10 points . um , there are of course some risks , so not everyone is a candidate . uh , but we'll cross that road , uh , when we need to , and let's just- let's just see how you do with the addition of the medication . [Patient] sounds good to me .[SEP][Follow-up][Doctor] all right . so , we will see you in two weeks then . [Patient] sounds good . thanks doc .[SEP][Discussion][Doctor] yeah , you're welcome . let me know if you have any questions . [Patient] will do .[SEP][Chitchat][Doctor] all right . have a great day mr. roberts . [Patient] you too .[SEP]
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[Discussion][Other Treatments][Medication][Doctor] okay , and you can take it , but before you do , we want to try to reduce the triggers . uh , so watch out for greasy or fatty foods and sugary drinks . [Patient] okay , i can do that .[SEP][Discussion][Medication][Doctor] okay . and so , however , if it is not just these isolated inci- incidents and the symptoms are happening all the time , we could put you on a long term medication that would take ... that you would take every night . and so then you do n't have to use so much bentyl or the zofran . how do you feel about that ? [Patient] i was actually going to ask you about something like that to help avoid flares altogether .[SEP][Discussion][Medication][Doctor] yeah , there is . and it actually works on the chemicals in your brain that are causing your gut to be overly sensitive . one is called elavil , but the only drawback is that it can make you a little sleepy . how does that sound ? [Patient] that sounds like a much better plan .[SEP][Discussion][Doctor] okay , great . we can definitely do that . uh , just take it every night before bedtime . [Patient] okay , that sounds good . thank you so much .[SEP][Discussion][Follow-up][Doctor] you're welcome . and so i have gone ahead and sent your prescriptions to your pharmacy . just give us a call if you have any questions or need us for anything else . and then let's plan on touching base through mychart email in about a month to just check in to see how you're doing with symptoms . okay ? [Patient] okay , that sounds good . thank you .[SEP]
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[Discussion][Doctor] yep , that's right . [Patient] i do have a question for you though .[SEP][Discussion][Doctor] yeah , of course . [Patient] do you think i will be able to drive again ?[SEP][Discussion][Doctor] ah man , mr . watson , i knew you were gon na ask me that one . i think at this point it's unlikely that your movement speed will improve to the level that would be needed for you to pass the driver safety evaluation . now , i will say that i do occasionally have patients who surprise me by improving over a nine to 12 month range . and that , that definitely could be you . you could definitely pass it at that point . so if you improve and we can continue to talk about that then , ya know , i think it could be possible , um , and i'd be happy to recommend it . now , you could definitely also enroll in a driver safety program without my recommendation . so you could kind of do that preemptively , and then we could continue to watch for your improvement as we go . [Patient] okay . i kinda figured that anyway but i just thought i'd ask . i do n't like to burden anyone when i just need to run to the store but i also know that i need to be safe .[SEP][Discussion][Follow-up][Doctor] yeah , your safety is our number one priority and , ya know , i'm sure your daughters do n't mind as much , right , they want to keep you here and have you safe . but , i overall am very pleased with how much you have improved . and so , i'm sure when we talk again in three months , we'll continue to be on that upward trajectory or improvement . [Patient] i sure hope so , doc . [Patient Guest] we really appreciate all that you've done . do we make the appointment out front ?[SEP][Chitchat][Doctor] yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ? [Patient] thanks [Patient Guest] thank you .[SEP]
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[Conversation Start][SEP]
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[Physical Examination][Doctor] okay . well let me get a listen to your heart , go ahead and hop up here . [Patient] okay .[SEP][Physical Examination][Vegetative History][Doctor] use my general exam template . all right , go ahead and take some deep breaths . okay , good . any fever , cough , shortness of breath or sore throat ? [Patient] no .[SEP][Other Socials][Doctor] any recent travel or contact or exposure to the coronavirus ? [Patient] nope .[SEP][Therapeutic History][Doctor] have you received your coronavirus vaccine ? [Patient] yes , on february 9th .[SEP][Physical Examination][Doctor] okay , great . all right well i'm just going to look at your ankles and feet , i'm looking for any signs of swelling . [Patient] okay .[SEP]
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[
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[Discussion][Follow-up][Medication][Doctor] okay . if this sounds good though , we can go ahead get you started with the shot . i am looking and it looks like we have you coming back in on may 17th for your first shot , does that sound good ? [Patient] yeah , yeah , that sounds great . are there any possible side effects ?[SEP][Discussion][Medication][Doctor] yeah , some people will experience some nausea , headache , dizziness , anxi- anxiety , tiredness and trouble sleeping , but generally the side effects are mild and should go away within a few days . [Patient] okay .[SEP][Follow-up][Doctor] then we can schedule you for a follow-up in june to see how you are doing . [Patient] all right that sounds good .[SEP][Medication][Other Treatments][Drug History][Doctor] all right great . well otherwise stay with your current medicines , keep checking your blood pressure , and let's see if we can stop the alcohol for good . let us know if you have any questions or any issues come up after you receive the first dose . [Patient] all right , sounds good , thank you .[SEP][Chitchat][Doctor] you are welcome , have a good rest of your day . [Patient] you too .[SEP]
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[Acute Symptoms][Doctor] yep . nah , that does sound like a cause for concern . how long have you been with him ? [Patient] hmm , we've been dating for three years .[SEP][Acute Symptoms][Doctor] mm-hmm . [Patient] as far as , i can figure , he started cheating on me , i think , about three months ago .[SEP][Acute Symptoms][Doctor] uh- . um , okay . do you ... have you ever had an irregular pap smear ? [Patient] well , yeah , i did , but it was back whenever i was 20 or so . it has n't ... and i have n't had one since .[SEP][Acute Symptoms][Doctor] okay . and when was your last pap smear ? [Patient] uh , about six months ago . it came back normal , though .[SEP][Physical Examination][Doctor] okay . good , okay . well , let's see ... let's take a look at you , and then , we'll get some samples for std testing . okay ? [Patient] all right .[SEP]
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[Physical Examination][Doctor] okay , well come sit over here , and if you could take of your socks and shoes , and we'll take a look at your knee . and just to let you know , i have a service now that writes my note about the visit , so you'll hear me call things out and describe what i see fully . [Patient] okay , gotcha .[SEP][Physical Examination][Doctor] right , so let's check your leg . can you straighten it , and does it hurt ? [Patient] yeah , when i try to straighten it all the way it does .[SEP][Physical Examination][Doctor] okay , range of motion slightly diminished . i'm going to press here , okay ? and how about here , hmm , i see some pitting around the knee and ankle . normal capillary refill in the toes . does any of this area hurt ? [Patient] um , just kinda sore , like an old bruise ?[SEP][Medication][Diagnostic Testing][Reassessment][Doctor] so , i can feel that the knee is hot , and that means there's something going on , like some inflammation . so we can give you another steroid injection for that . i also want to get an x-ray of that knee , so we can see where all the swelling is coming from . [Patient] yeah . let's do it . sounds go to me .[SEP][Discussion][Referral][Doctor] okay , and did we set up physical therapy for you last time you were here ? [Patient] yeah , that was some years ago , but that was the other knee .[SEP]
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[Physical Examination][Doctor] okay , range of motion slightly diminished . i'm going to press here , okay ? and how about here , hmm , i see some pitting around the knee and ankle . normal capillary refill in the toes . does any of this area hurt ? [Patient] um , just kinda sore , like an old bruise ?[SEP][Medication][Diagnostic Testing][Reassessment][Doctor] so , i can feel that the knee is hot , and that means there's something going on , like some inflammation . so we can give you another steroid injection for that . i also want to get an x-ray of that knee , so we can see where all the swelling is coming from . [Patient] yeah . let's do it . sounds go to me .[SEP][Discussion][Referral][Doctor] okay , and did we set up physical therapy for you last time you were here ? [Patient] yeah , that was some years ago , but that was the other knee .[SEP][Referral][Diagnostic Testing][Other Treatments][Doctor] okay . so i think we'll set that up for you now . we'll also do an x-ray on that knee . i can send you for a physical therapy , and if nothing is helping , then we really might need to get a surgery consult to see what we can do with that knee . [Patient] okay , sounds like a plan .[SEP][Medication][Doctor] all right , so for today we'll go ahead and we'll give you the steroid shot . i'll try to see if i can get a little bit of fluid out before i do give you the injection . there might be no fluid , but i'll see if i can get anything out regardless . [Patient] okay . and that's a procedure you're going to do right now ?[SEP]
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[Chitchat][Doctor] yeah it's awesome [Patient] i like to get down near the river that's where i i like to catch especially around spring time[SEP][Chitchat][Doctor] that's great yeah next time you come in maybe you can bring in some of your pictures that'd be awesome to see [Patient] okay cool[SEP][Vegetative History][Doctor] so i'm just curious talking about your symptoms here have you had any fevers you mentioned something about nausea but have you actually vomited from those symptoms [Patient] there's times when the pain is really bad for a couple of days i've had some what i i would describe as low grade fevers and yes you're right i have feel nauseated but i have n't thrown up[SEP][Physical Examination][Doctor] okay so if it's okay with you i'm gon na go ahead and do a quick physical exam your vital signs look good today blood pressure was one twenty eight over eighty eight respiratory rate was sixteen your pulse rate was sixty eight you were afebrile today which is a good thing and your oxygen saturation on room air was ninety nine percent taking a listen to your heart here your heart is regular of rate and rhythm no i do n't hear any ectopic beats no clicks rubs or murmurs noted listening to your lungs here they are clear and equal bilaterally to auscultation now i'm gon na go ahead and do an an abdominal exam i do note positive bowel sounds soft nondistended abdomen however you are positive for some slight guarding there to the right upper quadrant but i do n't note any rebound tenderness now i'm gon na press slightly here beneath your ribs on the right hand side now take a breath in does that hurt when i press so i i see that you're guarded there so i'm gon na say that that it did hurt when i it did hurt when i [Patient] absolutely that hurts so much when you push right there[SEP]
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[
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[
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[Personal History][Doctor] okay and any any other surgeries or any other medical problems [Patient] i mean i had a appendicitis so i had an appendectomy[SEP][Physical Examination][Vegetative History][Doctor] okay alright well i'm just gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so and last thing have you had any fever or chills since this happened at all [Patient] a slight headache but no no no fever[SEP][Personal History][Doctor] okay did you hit your head when you when this happened [Patient] a little bit[SEP][Personal History][Doctor] okay alright did you pass out [Patient] nope nope stayed conscious throughout[SEP]
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[Personal History][Therapeutic History][Doctor] okay and [Patient] and morning when i get up they are around one fifty[SEP][Personal History][Doctor] okay alright so it's been running a little bit high i know we checked your hemoglobin a1c last time and it was about seven . seven . i think and we had talked about you know improving your diet and improving some exercise but is this blood sugar been high and low or high and normal when you're especially in the last three weeks or has it been going on for longer than that [Patient] i would say about a month[SEP][Personal History][Therapeutic History][Doctor] okay alright and how is your blood pressure been at home since you've been taking since these episodes that you've been sick are you taking norvasc [Patient] yes i am but i keep them on some days because my blood pressure has been running somewhat on the low side[SEP][Personal History][Doctor] okay alright and right now it's about a hundred and twenty over seventy what how low does it go in the more when you check it [Patient] well there are sometimes in the lower nineties[SEP]
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[Personal History][Therapeutic History][Doctor] okay and [Patient] and morning when i get up they are around one fifty[SEP][Personal History][Doctor] okay alright so it's been running a little bit high i know we checked your hemoglobin a1c last time and it was about seven . seven . i think and we had talked about you know improving your diet and improving some exercise but is this blood sugar been high and low or high and normal when you're especially in the last three weeks or has it been going on for longer than that [Patient] i would say about a month[SEP][Personal History][Therapeutic History][Doctor] okay alright and how is your blood pressure been at home since you've been taking since these episodes that you've been sick are you taking norvasc [Patient] yes i am but i keep them on some days because my blood pressure has been running somewhat on the low side[SEP][Personal History][Doctor] okay alright and right now it's about a hundred and twenty over seventy what how low does it go in the more when you check it [Patient] well there are sometimes in the lower nineties[SEP][Physical Examination][Discussion][Diagnostic Testing][Reassessment][Acute Assessment][Doctor] okay alright well let me let me examine you here in a second and we'll think about you know what we need to do especially with your coughing and your shortness of breath okay so nita i'm i'm examining you now let's pretend i did my exam i'm just gon na verbalize some of my findings so i can put it into my chart okay and i'll explain what those things mean so on my exam you've got no jvd there is no swelling in your neck no carotid bruits your lung exam you've got some rails and some rhonchi on on more on the right side i do n't hear any wheezing right now there is some diminished breath sounds in the right side as well on your heart exam you've got two over successolic ejection murmur you've had that in the past that's unchanged from before the rest regular rate and rhythm otherwise your belly exam is nice and soft on your extremity exam you've got one plus nonpitting edema on both of your lower extremities on your on your ankles no calf tenderness no negative homan sign so what does all this mean so basically you've got you know you've got some sort of infection or something going on in your lungs that i can hear right now the rest of your exam is pretty much stable it's unchanged from before so let's talk about what we what we should do about this so for the for the first problem with the shortness of breath the first thing i wan na do is go ahead and get a chest x-ray for you okay you've been coughing up blood i also wan na send you to the emergency department to get some blood testing done i'm worried about a blood clot or something else going on so i wan na get a cat scan of your chest as well so i'm gon na go ahead and refer you to the emergency department i'll call them and and have you head over that way they can get a chest x-ray and a cat scan and some blood work as well and then we'll evaluate why you're having the shortness of breath and why you're coughing up this blood okay and then depending on what they find you may need you know it could be as simple as a pneumonia or it could be something a little bit more serious we may have to get you know start you know depending on what you find we will get the right treatment started any questions about that or can you drive to the emergency department from here or is that okay [Patient] yeah i can bike no problem i have no question[SEP]
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[Vegetative History][Doctor] so you know it's good [Patient] yeah[SEP][Discussion][Other Treatments][Doctor] alright well so i totally understand like baking and like the excitement of being able to give those to your family but we maybe wan na start cutting down on eating and taste testing ourselves is do you think that's something we could manage [Patient] yeah i know i need to get better on it i probably could use maybe a refresher on just managing what i should and should n't eat how like if i need to combine a protein you know if i do eat something a little bit sweet maybe pling a protein or something with it[SEP][Discussion][Other Treatments][Doctor] mm-hmm yeah that sounds like a [Patient] had some friends tell me something about that[SEP][Discussion][Other Treatments][Doctor] yeah that sounds like a great idea and i think if that's something that we can maybe discuss to get you in contact with someone who can offer you someone with a degree that can offer you some really good advice you know i do n't wan na as much as it's really helpful to have friends i do wan na be able to give you like a source of truth right [Patient] yeah i i had a diabetic consult a long time ago but yeah it it would be nice to see a dietitian again and go over those and maybe there is some new stuff too[SEP]
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[Physical Examination][Doctor] okay so moderate tenderness at the medial epicondyle when you turn like when you turn your wrist is if you're trying to open a door knob do you experience pain [Patient] no not really[SEP][Physical Examination][Doctor] alright so turning out no pain but when you turn your wrist inwards do you have any pain [Patient] yeah[SEP][Physical Examination][Doctor] okay so pain with resisted pronation of right forearm when you rest your arm on a table with the palm side up alright i want you to raise your hand by bending the wrist do you experiencing any pain [Patient] yeah that hurts[SEP][Physical Examination][Doctor] alright alright so when you are when i'm pressing here and like flexing your wrist are you experiencing any pain [Patient] yes[SEP][Physical Examination][Medication][Other Treatments][Acute Assessment][Doctor] alright pain with flexion and when bending the wrist alright when i listen to you you know i'm just gon na check your heart and lungs everything sounds sounds good no murmur no rub no gallop your lungs are clear bilaterally to bilaterally to auscultation i'm not noticing any rash for your at your elbow i do n't notice any bruising any swelling we do wan na note that tenderness but otherwise there is no discoloration no lesions so that's good your pulses and are equal bilaterally and i think i think we have an idea of what we are dealing with here okay so i'm gon na go ahead and give you my impression and plan for your your first problem like your primary problem that you are here for is right elbow pain it's consistent with medial epicondylitis and that it just means it's pain caused from overuse and damage to the tendons in your arm what we are gon na do is rest it i'm gon na order a sling for your right arm and you can wear this while you're awake well i want you to apply ice to your elbow for twenty minutes three times a day i'm going to i'm gon na ask you to take six hundred milligrams of ibuprofen that's three pills every six hours with food and you can take that for one week i know it's really important that you said that you have something that a gift that you wan na make for your son but we're gon na hold off on pottery for the next couple of weeks just to give your arm a chance to heal you know like it's awesome that you wan na be able to do these things for your family but sometimes you know your body is not where your where your where your heart is like where your heart and your head are right and then so [Patient] i'll i'll just let him know that that i maybe i'll take a picture of what i have so far[SEP]
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] | 3,817
|
[Physical Examination][Doctor] alright so turning out no pain but when you turn your wrist inwards do you have any pain [Patient] yeah[SEP][Physical Examination][Doctor] okay so pain with resisted pronation of right forearm when you rest your arm on a table with the palm side up alright i want you to raise your hand by bending the wrist do you experiencing any pain [Patient] yeah that hurts[SEP][Physical Examination][Doctor] alright alright so when you are when i'm pressing here and like flexing your wrist are you experiencing any pain [Patient] yes[SEP][Physical Examination][Medication][Other Treatments][Acute Assessment][Doctor] alright pain with flexion and when bending the wrist alright when i listen to you you know i'm just gon na check your heart and lungs everything sounds sounds good no murmur no rub no gallop your lungs are clear bilaterally to bilaterally to auscultation i'm not noticing any rash for your at your elbow i do n't notice any bruising any swelling we do wan na note that tenderness but otherwise there is no discoloration no lesions so that's good your pulses and are equal bilaterally and i think i think we have an idea of what we are dealing with here okay so i'm gon na go ahead and give you my impression and plan for your your first problem like your primary problem that you are here for is right elbow pain it's consistent with medial epicondylitis and that it just means it's pain caused from overuse and damage to the tendons in your arm what we are gon na do is rest it i'm gon na order a sling for your right arm and you can wear this while you're awake well i want you to apply ice to your elbow for twenty minutes three times a day i'm going to i'm gon na ask you to take six hundred milligrams of ibuprofen that's three pills every six hours with food and you can take that for one week i know it's really important that you said that you have something that a gift that you wan na make for your son but we're gon na hold off on pottery for the next couple of weeks just to give your arm a chance to heal you know like it's awesome that you wan na be able to do these things for your family but sometimes you know your body is not where your where your where your heart is like where your heart and your head are right and then so [Patient] i'll i'll just let him know that that i maybe i'll take a picture of what i have so far[SEP][Follow-up][Referral][Medication][Diagnostic Testing][Reassessment][Doctor] absolutely that's awesome and so it'll be like a a movie like coming soon to a shelf near you that's great for your second problem right we have this longstanding diabetes i want to increase your metformin to a thousand milligrams twice a day i know that you're saying you're having a hard time keeping up with that so i want you to do a good job of like checking and recording your blood sugars every day i do need you to follow up with me in a couple weeks i also wan na order something called an a1c since you are having a hard time with like the blood like the blood sugars everyday an a1c will give me a more accurate picture of like a longer period of time and then we might need to evaluate like what are what other options that we have if your sugars if we ca n't get them a bit more under control i do want you to follow up with me in a couple of weeks about the about your diabetes and for your third problem of hypertension we're just gon na continue you on your lisinopril at ten milligrams that's it seems to be doing it's job i'm really i'm really glad about that and it's probably due to the walking that you're doing i forgot to mention for your diabetes we are gon na i'm gon na recommend a a referral to diabetic counseling that way you can get like a bit more information on like the steps that you can take to help you with that [Patient] i was gon na ask you how about my x-ray the x-ray of my elbow how did that look[SEP]
|
[
"Discussion",
"Radiology Examination"
] |
[
"Plan",
"Objective"
] | 3,818
|
[Chitchat][Doctor] yeah okay [Patient] yeah[SEP][Physical Examination][Doctor] lay back on the stretcher for me for a second i'm gon na go ahead and and lift your legs for me or i'm gon na go ahead and lift your legs for you just relax i'm gon na start here on the right side when i lift that right leg up does that cause you significant pain or any pain at all [Patient] a little a little bit[SEP][Physical Examination][Doctor] okay let me come around let me lift up the left side if i lift that up does that cause [Patient] yeah yeah yeah that's that's[SEP][Acute Symptoms][Physical Examination][Doctor] i can see that gritts on your face so okay that's good and you know as i look at your lower extremities there is no pain or numbness or tingling in your feet or anything like that [Patient] hmmm no[SEP]
|
[
"Reassessment",
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Other Treatments",
"Referral",
"Medication"
] |
[
"Assessment",
"Plan"
] | 3,819
|
[Personal History][Doctor] okay when did you break your toe [Patient] i've broken it three times over the last ten years so it's just something that's a an annoyance but it was n't caused by this injury[SEP][Personal History][Doctor] okay so you do have some numbing and tingling but it's not new [Patient] right correct[SEP][Physical Examination][Doctor] alright alright well let's just go ahead and i'm gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so on your musculoskeletal exam on your right knee i do appreciate some slight edema you do have a slight effusion does it hurt when i press on the outside of your knee [Patient] no not physically[SEP][Physical Examination][Doctor] okay there is no pain to palpation of the right lateral knee i'm gon na be bending your knee in all sorts of positions does that hurt [Patient] only when you pull it to the outside[SEP]
|
[
"Physical Examination",
"Acute Assessment",
"Other Socials",
"Referral",
"Radiology Examination",
"Medication"
] |
[
"Assessment",
"Plan",
"Subjective",
"Objective"
] | 3,820
|
[Physical Examination][Doctor] yeah okay okay roll over here on my my stretcher for me and i want you to dangle your your feet over the edge and what i wan na do is i just wan na i'm gon na squeeze your left calf first and when i do that does that hurt on your left side [Patient] no[SEP][Physical Examination][Doctor] and i'm gon na squeeze on the right side anything there [Patient] no[SEP][Physical Examination][Doctor] okay okay well that's good your your thompson test is negative that's a really good finding and i just wan na continue pressing here on your right from your heel when i squeeze your heel does that cause significant pain at all [Patient] yeah[SEP][Physical Examination][Doctor] yeah okay and if i come up a little bit further as i i run up that achilles tendon does that hurt [Patient] that's real tender[SEP]
|
[
"Discussion",
"Medication",
"Referral",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] | 3,821
|
[Vegetative History][Doctor] alright so you've got neuropathy yeah that that that makes sense with the the diabetes so have you had any other symptoms like a fever chills any drainage coming from it [Patient] lately there has been a lot more drainage and i just feel a little more tired[SEP][Other Socials][Doctor] okay alright well that that sounds good so today is thursday so what do you have for the weekend [Patient] not too much i'll probably be walking around at the zoo on this ulcer all weekend and eating out and not doing anything my doctor wants me to do[SEP][Personal History][Doctor] no yeah i yeah i know you do have that diabetes i know your pcp probably would n't be excited about you you eating out and all that but you know hopefully we can we i can at least get your your foot a little bit better so your diabetes i know we talked a little bit earlier how is that going for you is it controlled you know what's your your blood sugars running [Patient] yeah they are running better than they were but they are still in the two hundreds so my doctor does n't like that my last a1c was about ten[SEP][Therapeutic History][Doctor] okay alright yeah i i you probably definitely need to get back with your pcp about that because the a1c is is pretty high and i know he probably had you on some medication and insulin and metformin and insulin just to try to to get that lower but [Patient] yes[SEP][Physical Examination][Doctor] you know we are here for your foot so let's let me take a look at that so we will do a quick exam of your foot so you do n't have any fever your vitals look good so on your your right foot exam i can see here you do have a one by two centimeter two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint i do see some yellow slough that's present with minimal granulation tissue you have no surrounding erythema or cellulitis and there is n't any evidence of fluid collection i do n't see necrosis so there is no dead tissue around it there's no odor and i i do n't appreciate any bony exposure and does it hurt when i touch it here [Patient] no[SEP]
|
[
"Discussion",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,822
|
[Vegetative History][Doctor] what are you for her toppings on pizza [Patient] pepperoni occasionally vegetables[SEP][Vegetative History][Doctor] mm-hmm alright but you know that pepperoni is pretty high in salt on top of a cheesy pizza right [Patient] i know i know i'm gon na work on it[SEP][Personal History][Doctor] okay so we are we are gon na have to negotiate some of these diet things and then especially since you have diabetes like have you been managing that well [Patient] my i've been watching my sugars yep because i do n't wan na go on insulin so i'm taking that metformin that's why i've been walking my dog i'm trying to stay active[SEP][Personal History][Doctor] okay okay so you know maybe this is just a situation of like where we are on the right path but probably need to step up a few things okay [Patient] okay[SEP][Physical Examination][Doctor] alright so i do want to do a quick physical exam so you are aware i'm going to be calling out my findings as i run through it alright [Patient] okay[SEP]
|
[
"Physical Examination",
"Discussion",
"Referral",
"Medication",
"Other Treatments",
"Radiology Examination",
"Diagnostic Testing",
"Reassessment",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,823
|
[Personal History][Therapeutic History][Doctor] yeah yeah you are on a fair amount of medications you know we do have you on those medications because you did have a heart attack about six months ago they put that that stent into your left anterior descending artery and so that's a major artery on the left side of your heart and so we need to keep those stents open and and kinda help your heart heal so it is gon na be very important for you to continue on those medications so you're still taking your aspirin and are you still taking the brilinta [Patient] yes and and fish oil[SEP][Therapeutic History][Doctor] and fish oil okay good now how are you doing with the crestor i know that that's you know that's the statin that's the cholesterol medication you were concerned that it might cause you to have some muscle aches are you taking that [Patient] i i think i'm doing good but i i am i feel like i i when i i guess the only complaint that i have is ever since i i do n't know if this is the heart attack or if this this is the the medication but when i stand up real fast i get really dizzy[SEP][Medication][Therapeutic History][Doctor] you get you get dizzy okay yeah you know we do have you on a what we call a beta-blocker metoprolol i think your dose is fifty milligrams once a day and you know sometimes it takes a little bit for your body to adjust to that but yes if you stand up too quickly it can cause you to be a little dizzy so [Patient] okay okay that makes sense okay that's good to know because i did n't know what what what the problem was so can i ask you a question regarding the stents[SEP][Personal History][Therapeutic History][Doctor] so the stents are permanent we do n't we do n't remove them so yep so that's why it's gon na be super important for you you know you're gon na be on aspirin for the rest of your life and then i'm gon na keep you on that brilinta for another six months that's gon na help prevent the that stent from clogging [Patient] okay okay do i need to ever replace the stents then[SEP]
|
[
"Referral",
"Medication",
"Diagnostic Testing"
] |
[
"Plan"
] | 3,824
|
[Medication][Therapeutic History][Doctor] you get you get dizzy okay yeah you know we do have you on a what we call a beta-blocker metoprolol i think your dose is fifty milligrams once a day and you know sometimes it takes a little bit for your body to adjust to that but yes if you stand up too quickly it can cause you to be a little dizzy so [Patient] okay okay that makes sense okay that's good to know because i did n't know what what what the problem was so can i ask you a question regarding the stents[SEP][Personal History][Therapeutic History][Doctor] so the stents are permanent we do n't we do n't remove them so yep so that's why it's gon na be super important for you you know you're gon na be on aspirin for the rest of your life and then i'm gon na keep you on that brilinta for another six months that's gon na help prevent the that stent from clogging [Patient] okay okay do i need to ever replace the stents then[SEP][Referral][Medication][Diagnostic Testing][Doctor] no i mean every so often the stents can become narrowed again but you know that's why you're seeing me your cardiologist so that i can follow you for that now if you start to have symptoms again of any chest pain like you had before or any shortness of breath when you start to exert yourself i want you to tell me and we might have to go ahead and send you for further testing to make sure that those stents are okay but typically if you continue to take the medication watch your diet that type of thing your stents will will stay open for a long time [Patient] okay alright that sounds good you know i have n't i had a i had i know you asked me to follow up with the dietitian because i had diabetes as well which probably contributed to my heart attack[SEP]
|
[
"Referral",
"Vegetative History"
] |
[
"Plan",
"Subjective"
] | 3,825
|
[Referral][Medication][Diagnostic Testing][Doctor] no i mean every so often the stents can become narrowed again but you know that's why you're seeing me your cardiologist so that i can follow you for that now if you start to have symptoms again of any chest pain like you had before or any shortness of breath when you start to exert yourself i want you to tell me and we might have to go ahead and send you for further testing to make sure that those stents are okay but typically if you continue to take the medication watch your diet that type of thing your stents will will stay open for a long time [Patient] okay alright that sounds good you know i have n't i had a i had i know you asked me to follow up with the dietitian because i had diabetes as well which probably contributed to my heart attack[SEP][Referral][Vegetative History][Doctor] okay that's okay yeah i certainly can help you with that now managing your diabetes is also going to play an important role in your coronary artery disease which it sounds like you already know that which is really good so i will put in another referral for diabetic education for you how are you doing watching your sweets i know that you know you do have an afinity for those chocolate chip cookies [Patient] it's okay my a1c was n't where i wanted but my glucose is coming in in about one thirty[SEP][Lab Examination][Doctor] okay what was the what was the a1c the hemoglobin a1c if you do n't mind me asking [Patient] i thought it was close to sixty[SEP]
|
[
"Other Treatments",
"Lab Examination"
] |
[
"Plan",
"Objective"
] | 3,826
|
[Discussion][Medication][Doctor] you can take tylenol [Patient] okay[SEP][Physical Examination][Doctor] yeah i can do that but i do wan na just do a physical exam on you okay so and looking here at your vital signs here you know your your vital signs look quite good you know your blood pressure is what right where it should be it's about one twenty seven over eighty which is great so you're doing a good job taking your metoprolol now in terms of on your neck exam i do n't appreciate any jugular venous distention or carotid bruits on your heart exam i do appreciate a slight three out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do appreciate some one plus nonpitting edema now what does that mean what does that mean jose so all of that means is that i do hear a little heart murmur on your heart which i've heard before in the past and it does n't it does n't look like you're retaining any fluid which is good but you do have a little puffiness in your legs which sometimes some of the medications can cause [Patient] yeah i do have that[SEP]
|
[
"Referral",
"Medication",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,827
|
[Physical Examination][Doctor] yeah i can do that but i do wan na just do a physical exam on you okay so and looking here at your vital signs here you know your your vital signs look quite good you know your blood pressure is what right where it should be it's about one twenty seven over eighty which is great so you're doing a good job taking your metoprolol now in terms of on your neck exam i do n't appreciate any jugular venous distention or carotid bruits on your heart exam i do appreciate a slight three out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do appreciate some one plus nonpitting edema now what does that mean what does that mean jose so all of that means is that i do hear a little heart murmur on your heart which i've heard before in the past and it does n't it does n't look like you're retaining any fluid which is good but you do have a little puffiness in your legs which sometimes some of the medications can cause [Patient] yeah i do have that[SEP][Referral][Medication][Reassessment][Doctor] so let's just go over a little bit about my assessment and and plan for you going forward so for your first problem of your coronary artery disease i think you're doing really well i wan na go ahead and refer you for cardiac rehab just so that you can be more active and have some confidence in in exercising again okay and i am gon na go ahead and refill your metoprolol your crestor forty milligrams once a day as well as the aspirin okay i do n't think we need to proceed with a a stress test or anything at this time but you know to let me know if you have any symptoms okay [Patient] okay[SEP][Chitchat][Doctor] okay for your [Patient] sounds really good[SEP][Referral][Reassessment][Doctor] good for your second problem of your stage three chronic kidney disease i am gon na reach out to doctor miller and make an appointment for you to be seen just because again i think it's important for you to follow up with your nephrologist okay [Patient] okay[SEP]
|
[
"Referral",
"Medication",
"Diagnostic Testing",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,828
|
[Acute Symptoms][Vegetative History][Doctor] okay alright understood you've not had any fever with that pain have you [Patient] no i have n't[SEP][Personal History][Doctor] okay alright and so how about your diabetes how's your diabetes been doing how your blood sugars been what low one hundreds two hundreds where where is it [Patient] i think it's been under control it's eight hundred so[SEP][Therapeutic History][Doctor] okay good and you're still taking the metformin five hundred milligrams once a day right no actually it looks like last visit we increased that to five hundred milligrams twice per day is that correct [Patient] yes that's probably helping me keeping it under control so[SEP][Personal History][Doctor] okay good good and then for your asthma have you had any recent asthma attacks and are you still taking the flovent twice a day and albuterol as needed for wheezing [Patient] yes but sometimes i forget you know i have n't had any asthma attacks lately so i just figured i could decrease[SEP][Personal History][Doctor] yep okay [Patient] i think that's a good decision though[SEP]
|
[
"Physical Examination",
"Discussion",
"Follow-up",
"Medication",
"Other Treatments",
"Diagnostic Testing",
"Reassessment",
"Acute Assessment",
"Drug History"
] |
[
"Assessment",
"Plan",
"Subjective",
"Objective"
] | 3,829
|
[Personal History][Therapeutic History][Doctor] okay that's good alright so we'll we'll do a physical exam on that elbow we'll take a look at it in a second but i do wan na talk to you about your your hypertension you came in today i know you have past medical history of hypertension came in today your blood pressure's a little bit high it was a one fifty over seven over ninety which is pretty high today i see you're on twenty of lisinopril have you been taking that daily [Patient] yes[SEP][Personal History][Reassessment][Doctor] okay so maybe you just have a little little white coat syndrome i know i have that myself and even though i'm a physician i i still do n't like to go to the doctor so i definitely understand how about your diet i know we talked a little bit about that before and you said kinda during the pandemic you fell off a little bit how you been doing that have you been lowering your salt intake [Patient] yeah but i only eat low salt items avoid adding salt to food kind of the whole whole family follows like a you know like a mediterranean diet[SEP][Therapeutic History][Doctor] okay yeah that's good that that's that's definitely good yeah i know a lot of people during the pandemic it was you know sitting at home and and eating more than we should but that's i'm very happy that you've been compliant and you have that low salt diet so let's talk about your diabetes i think you see here on on five hundred of metformin are you taking that as well daily [Patient] yes[SEP][Personal History][Doctor] okay and your blood sugars how have they been [Patient] since i do n't take insulin i do n't check it everyday when i have checked it it's usually running somewhere between eighty to a hundred[SEP]
|
[
"Medication",
"Diagnostic Testing",
"Vegetative History"
] |
[
"Plan",
"Subjective"
] | 3,830
|
[Personal History][Doctor] okay and your blood sugars how have they been [Patient] since i do n't take insulin i do n't check it everyday when i have checked it it's usually running somewhere between eighty to a hundred[SEP][Medication][Diagnostic Testing][Vegetative History][Doctor] okay yeah that's that's really good yeah so i that's that's pretty good so what we're gon na do we're gon na get a a1c just to see you know that range and it's possibility we can we can you know lower that metformin dosage but we will do that after your visit then we will take a look at that so lem me go ahead and will do that quick exam of your elbow but first i want to make sure you're not having any chest pain or anything like that [Patient] no[SEP][Vegetative History][Doctor] no belly pain [Patient] no[SEP][Physical Examination][Doctor] alright so listen to your lungs so your lungs are clear bilaterally listen to your heart so your heart exam you do still have that grade two out of six systolic ejection murmur but we know it about that before so let me take a look at your elbow so when i press right here on the back of your elbow is that painful [Patient] yes[SEP][Physical Examination][Doctor] alright so when i have you you you flex and extend it it's painful does that does that hurt [Patient] yes it does[SEP]
|
[
"Discussion",
"Medication",
"Other Treatments",
"Radiology Examination",
"Diagnostic Testing",
"Reassessment",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,831
|
[Personal History][Therapeutic History][Doctor] okay well that's good to hear so have you been watching your diet too and taking taking your pills since you've been home [Patient] yeah i've been doing just what they told me to do because i do n't wan na go back to the hospital[SEP][Personal History][Doctor] okay alright and we do n't want you to go back to the hospital it's never a good experience so you know being in a hospital it's better to be well and be at home and watching your chiefs play now have you bought a blood pressure cuff at home i know we talked about that [Patient] yes ma'am i finally did what you told me to do and i ordered one and it came last week i've been checking it about every other day and my blood pressure has been really good[SEP][Vegetative History][Doctor] good very good how about have you been having any shortness of breath or problems sleeping since you've been home [Patient] nope no shortness of breath i can get up and move around i do n't have any trouble and no problem sleeping i do have a good afternoon nap[SEP][Vegetative History][Doctor] good that's good you need to rest every now and then as well and now tell me have you had any chest pain [Patient] no chest pain at all since i've been home[SEP][Physical Examination][Doctor] okay alright very good alright well i'm gon na go ahead and do a quick physical exam on you here kevin and so i'm looking at your vital signs here and your blood pressure today is actually pretty good at one twenty eight over seventy two your vital signs also look good in general your heart rate's been nice at like seventy nine so that's very nice and normal your respiratory rate is twenty six that's probably because you're talking to me here but that's that's alright and then your o2 sat is ninety nine percent so that's good and now on your neck exam there is no jugular venous distention so that's good on your heart exam i appreciate a two out of six systolic ejection murmur which i have heard this before and it's stable so we will just keep on monitoring that okay now your lungs here lem me listen okay they're clear bilaterally and let me take a look at your legs real quick here kevin okay so your lower extremities they do show a trace of edema so that that's gon na be that we're gon na be able to help that with the water pills that you're taking okay [Patient] okay[SEP]
|
[
"Medication",
"Other Treatments",
"Radiology Examination",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,832
|
[Chitchat][Doctor] well you i guess you'll be watching it for a while instead of playing it though [Patient] i well i hope not not for too long[SEP][Acute Symptoms][Doctor] yeah we'll we'll see what we can do just to get you back out there again okay so tell me have you experienced any kind of numbness in your foot at all [Patient] no not that no i have n't had any numbness[SEP][Physical Examination][Doctor] okay alright very good well let me go ahead and do a physical exam on you real quick here let me take a look at your vital signs good good everything here looks good lem me go ahead and take a look at your right ankle real quick i'm just gon na pull your pant leg up here and then look look at it now on the skin here there is ecchymosis and that's bruising this bruising gregory and over the lateral malleolus associated swelling now lem me go ahead and just feel around here how does that feel [Patient] that hurts[SEP]
|
[
"Physical Examination",
"Acute Assessment",
"Other Treatments",
"Radiology Examination"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,833
|
[Vegetative History][Doctor] okay you know if your friends come over if they smoke too or what okay [Patient] nope[SEP][Family History][Doctor] okay now tell me is there any history at all of like maybe heart disease or sudden death you know like early early in those your family's years [Patient] well come to think of it i did have my my grandparents told me that that i had a cousin that died and and he was only like forty four or forty five[SEP]
|
[
"Physical Examination",
"Referral",
"Other Treatments",
"Diagnostic Testing",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,834
|
[Acute Symptoms][Doctor] okay and how long have you been having this [Patient] probably maybe three months[SEP][Acute Symptoms][Therapeutic History][Doctor] okay and what seemed to bring it on anything exacerbated or relieve it [Patient] it mainly happens when i'm walking i like to try and walk but lately i just have n't been able to keep up with it because i'm having this pain[SEP][Acute Symptoms][Doctor] alright and well how would you describe this pain it's like a dull pain sharp pain stabbing pain how would you describe it [Patient] i would say it's dull it's kinda like a pressure[SEP][Acute Symptoms][Doctor] okay and does it go anywhere or radiate any place [Patient] no[SEP][Vegetative History][Doctor] okay alright but no chest pain right now no shortness of breath no sweats or clamminess or anything like that right now [Patient] nothing right now[SEP]
|
[
"Personal History",
"Therapeutic History",
"Lab Examination"
] |
[
"Subjective",
"Objective"
] | 3,835
|
[Personal History][Vegetative History][Doctor] okay got it and any nausea vomiting or diarrhea or anything like that with your diabetes or any side effects from your medications the metformin [Patient] no[SEP][Personal History][Therapeutic History][Doctor] okay alright good and i saw also there was a record in your i was looking at your record before previously before i walked in you also had we've been checking your blood pressure but but i think you've been into several other clinicians and they had documented high blood pressure have you noticed any findings with that or have you know have anybody talked about high blood pressure with you or mentioned that because we do n't have it in our system here yet but i did add it in today but we do n't have you on any medications yet for that [Patient] no i mean i do n't know doc no one told me about high blood pressure do i have high blood pressure[SEP][Personal History][Doctor] well i think the last time you were in the clinic and one of the clinics said the referrals the your blood pressure was elevated so they had mentioned that i noticed a trend in your blood pressure it's been running on a little bit on the high side we have n't really diagnosed you with that yet but i think we are something that we should definitely consider looking at your trend of your blood pressure readings over the last you know a few years [Patient] okay do you think that could be causing me my my chest pain[SEP][Personal History][Doctor] it certainly could be contributing to that it certainly could be a factor that we need to look at so [Patient] someone had told me before[SEP][Discussion][Medication][Other Treatments][Doctor] yeah me too but we we can we can definitely you know get you started on some monitoring devices for that and also maybe start you on some some diet control things that we can do to help with the blood pressure and maybe start you on some blood pressure medications if we need to okay [Patient] okay sounds good[SEP]
|
[
"Physical Examination",
"Discussion",
"Referral",
"Medication",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,836
|
[Discussion][Medication][Other Treatments][Doctor] yeah me too but we we can we can definitely you know get you started on some monitoring devices for that and also maybe start you on some some diet control things that we can do to help with the blood pressure and maybe start you on some blood pressure medications if we need to okay [Patient] okay sounds good[SEP][Physical Examination][Discussion][Referral][Medication][Diagnostic Testing][Acute Assessment][Doctor] so let me examine you elizabeth for a second for the because we're running out of time here for a second so i'm gon na go ahead and do my exam we got ta just did my magical exam and i'm gon na go ahead and verbalize some of my findings just so i can get it documented in my note okay and i'll explain things as we go along so there is no jvd there is no swelling in your neck there's no carotid bruits your lung exam is clear i do n't hear any crackles or rhonchi your heart exam you do have a two over six systolic ejection murmur you had that in the past otherwise it's regular rate and rhythm your pulses are equal your belly exam is nice and soft your no tenderness no guarding no masses that i can feel on your belly and your back exam is fine your extremity exam you have a little bit of swelling in your lower legs one plus nonpitting edema or swelling in the in your in your ankle area here no calf tenderness so what does all this mean i'll explain that in a second so basically your exam is pretty normal except for you have a little bit of swelling in your legs so you know with this chest pain i'm a little bit so the first diagnosis that we talk about is this chest pain i'm worried about my suspicion is you have something called unstable angina especially considering your history of diabetes and the suspected history of high blood pressure and your family history of of heart disease in the past as well i'm i'm gon na go ahead and refer you to cardiology i reviewed your ekg today so that looks normal so that's good no other signs of a heart attack but i am worried that you may have some sort of a blockage going on that's causing this chest pain i'm gon na go ahead and start you on some aspirin daily i'm also gon na give you a prescription just a baby aspirin you can take eighty one milligrams once a day and also i'm gon na give you a prescription for nitroglycerin it's a it's a little pill you split underneath your tongue if you have this chest pain if it does n't go away after one or two pills i want you to go to the hospital call nine one one and go to the hospital but we will try to get you into cardiology the next week and get you set up for some sort of a stress test to look at your heart okay any questions about that [Patient] so anytime i have a chest pain even if i'm just like walking i have to take that pill[SEP][Discussion][Medication][Doctor] yeah if you if you stop walking the chest pain goes away you do n't have to take the pill but if you are walking or you stop and the chest pain does not go away i would take the pill and see if it goes away if it does not [Patient] how long like how long do i wait to see if it goes away[SEP][Discussion][Medication][Doctor] about five minutes so you can take it up to three pills every five minutes and if it does n't go away then i would you know go to the hospital and get this checked out because i worry about with this chest pain that you're having making sure it does n't lead to a heart attack those chest pain could be a you know a a a sign that you may be having some less blood flow to your heart and we need to get that checked out pretty quickly [Patient] okay[SEP][Chitchat][Doctor] alright [Patient] mm-hmm[SEP]
|
[
"Discussion",
"Follow-up",
"Medication",
"Other Treatments",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,837
|
[Physical Examination][Doctor] okay so there is midline tenderness at the l4 l5 disk space with right sided lumbar paravertebral tenderness alright so are you able to bend forward [Patient] yes[SEP][Physical Examination][Doctor] alright and are you able to bend backward [Patient] yes[SEP][Physical Examination][Doctor] alright do either of those actions cause you pain [Patient] bending forward[SEP][Physical Examination][Doctor] okay so pain with lumbar flexion and so i'm gon na have you lie down and we're gon na do i'm sorry okay and then i see that a supine straight leg test is positive alright so for your neurological exam you said that you are experiencing pain radiating down radiating down your left leg correct [Patient] yes[SEP][Physical Examination][Doctor] alright when i touch are there any like decreased sensation [Patient] no[SEP]
|
[
"Discussion",
"Medication",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,838
|
[Acute Symptoms][Therapeutic History][Doctor] alright and has the has the ibuprofen been helping you at all [Patient] i ca n't take ibuprofen[SEP][Acute Symptoms][Therapeutic History][Doctor] i mean i'm sorry the tylenol [Patient] no it's okay but the tylenol it helps like a little bit but you know like it's it's got like a time limit right so by the time and i'm not supposed to take it like more than like every like four hours or something like that but by hour or two like it it hurts again[SEP][Acute Symptoms][Therapeutic History][Doctor] okay yeah that yeah you ca n't take too much of that tylenol because it'll it'll mess up your liver definitely [Patient] right[SEP][Physical Examination][Doctor] alright so go ahead and do a quick exam on your knee here so when i press here does that hurt [Patient] yeah like when you press on the inside that hurts a lot[SEP][Physical Examination][Radiology Examination][Doctor] okay alright i'm gon na do a couple of other other maneuvers here for your knee so on your left knee exam i do appreciate some edema you also have some effusion some fluid in the knee you have moderate range of motion so you're able to move it a little bit but not all the way i also see you have some pain on flexion and extension of the knee even negative lachman's test and a negative valgus and varus test as well so all that to say is i do n't think anything is is torn in your knee based on the your physical exam so we did do a x-ray of your left knee and luckily it was normal so there is no fractures no bony abnormalities so everything is good there so let me talk to you little bit about my assessment and plan for your knee okay [Patient] yeah[SEP]
|
[
"Discussion",
"Medication",
"Other Treatments",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] | 3,839
|
[Personal History][Doctor] then in terms of your depression , how are you doing ? i know that we did n't start you on medication , since you're on a bunch of other medications . what- what are your strategies for dealing with that and how are you doing ? [Patient] so last year i started therapy and i've been going once a week and that's really helped .[SEP][Other Socials][Doctor] okay , all right , great . and how is your support system ? [Patient] really great . my boyfriend , my mom , and my brother are- are s- , amazing and they're all super close to me , so it's been , it's been good .[SEP][Vegetative History][Doctor] okay , well great . so i know you did a review of system sheet when you checked in and i know that you had the headache and the lightheadedness yesterday . do you have any other symptoms at this time , chest pain , shortness of breath , anything like that ? [Patient] uh , i have a little bit of nasal congestion , but that's just from my seasonal allergies .[SEP][Physical Examination][Doctor] okay , all right . well i want to go ahead and do a quick physical exam , okay ? [Patient] okay .[SEP][Physical Examination][Doctor] hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it does look a little elevated still , so we'll have to talk about that . so i'm just gon na listen to your heart and your lungs and we'll go from there okay ? [Patient] okay .[SEP]
|
[
"Physical Examination",
"Reassessment"
] |
[
"Assessment",
"Objective"
] | 3,840
|
[Physical Examination][Doctor] hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it does look a little elevated still , so we'll have to talk about that . so i'm just gon na listen to your heart and your lungs and we'll go from there okay ? [Patient] okay .[SEP][Physical Examination][Reassessment][Doctor] so on physical examination , i- i do n't appreciate any carotid bruits in your neck . your heart on your heart exam , it does show that you have a slight two out of six systolic ejection murmur . your , there , your lung exam shows nice clear lungs bilaterally and you do have some trace pitting edema to your lower extremities bilaterally . so what that means is , you know , i- i think ultimately , uh , you know we just need to get your blood pressure under better control , okay ? [Patient] mm-hmm .[SEP][Lab Examination][Doctor] um , uh , let me just go ahead , i want to take a look at some of your results , okay ? [Patient] okay .[SEP][Radiology Examination][Doctor] hey , dragon , show me the ecg . yeah , so in reviewing the results of your ekg , it looks the same as last year . um , you do have just blood , those changes from your chronic high blood pressure that we'll address , okay ? hey , dragon , show me the echocardiogram . and this is just the echocardiogram from just a few months ago that just , you know , show that you have that slightly leaky heart valve , nothing to do for it , and that the heart murmur is stable , okay ? [Patient] okay .[SEP][Medication][Reassessment][Doctor] so let's just talk a little bit about , you know , my assessment and my plan for you . so , for your first problem , your high blood pressure , it's not controlled at this time , so i want to go ahead and increase the lisinopril to 40 milligrams once a day . i want you to continue to check your blood pressures and report them to me through the patient portal and we'll have to make adjustments if necessary and maybe have to add a second agent , okay ? [Patient] okay .[SEP]
|
[
"Discussion",
"Follow-up",
"Medication",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,841
|
[Therapeutic History][Doctor] okay and everything's working out well with the protonix ? [Patient] yes .[SEP][Personal History][Doctor] okay . and then i know you had the cataract surgery about three months ago , your vision is okay ? [Patient] that was about four and a half months ago and it's been actually great ever since .[SEP][Physical Examination][Doctor] okay , great . all right , well , we're gon na go ahead and do a quick physical exam . i wan na see your vital signs first . [Patient] sure .[SEP][Physical Examination][Doctor] hey dragon , show me the vital signs . okay , so looking here , everything looks quite good . your oxygenation is perfect , which is wonderful . let me just take a listen . deep breath . another one . good . so , on your physical exam , your neck is nice and supple . i do n't appreciate any jugular venous distension . your heart is in a regular rhythm , i do n't hear any murmur . your lungs do have a slight wheeze , expiratory wheeze , bilaterally . i can hear it every time you breathe and i see trace lower extremity edema in your lower extremities . [Patient] so what does all that mean ?[SEP][Radiology Examination][Doctor] you know , you , uh , i'm not quite sure yet but we're gon na review some of your results . hey dragon , show me the chest x-ray . so looking here , this is a very normal chest x-ray . um , i do n't see any pulmonary edema , there's no pneumonia , so we're viewing your chest x-ray as , it's a norm- it's normal . [Patient] good .[SEP]
|
[
"Acute Assessment",
"Lab Examination",
"Medication"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,842
|
[Physical Examination][Doctor] all right . okay . all right . so , on physical exam , you know , i , i do n't appreciate anything cervical lymphadenopathy . your heart sounds really good , but i do hear a , a slight two out of six systolic heart , uh , murmur , um , systolic ejection murmur on your heart exam . your lungs sound clear . your abdomen ... you know , you did have a little tenderness to palpation in your right lower quadrant on your abdominal exam , uh , but i do n't appreciate any lower extremity edema . so , all that means it that we , you know , we hear that heart murmur , which we heard in the past , um , and your belly had some tenderness , so we'll have to talk about that a little bit , uh , going forward , okay ? [Patient] okay .[SEP][Lab Examination][Doctor] let's look at some of your results , okay ? [Patient] mm-hmm .[SEP][Lab Examination][Doctor] hey , dragon , show me the hemoglobin . so , here , looking at this , you know , your hemoglobin level is 8.2. somebody like you should have a hemoglobin o- of about 13 , 14 , okay ? [Patient] okay .[SEP][Lab Examination][Doctor] so , we need to investigate why it's low . hey , dragon , show me the anemia labs . okay . so , looking here at your labs , uh , everything looks good from , from this standpoint . i think some of your anemia labs are still pending at this time that's part of the workup . [Patient] mm-hmm .[SEP][Diagnostic Testing][Acute Assessment][Doctor] so , let's go over a little bit about the assessment and plan for you . so , you know , your main problem , this abnormal lab , this low hemoglobin that we found , so , you're anemic and we nee- ... you know , i'm waiting for those anemia labs to come back to find out exactly , you know , what type of anemia you have . i'd like to go ahead and schedule you for an endoscopy a- and a colonoscopy just to make sure that you're not bleeding from your , inside your belly , okay ? um , and i'm ... i'll be in touch when those labs come back to see what further workup we need to do , okay ? [Patient] mm-hmm .[SEP]
|
[
"Referral",
"Medication",
"Reassessment",
"Drug History"
] |
[
"Assessment",
"Plan",
"Subjective"
] | 3,843
|
[Acute Symptoms][Vegetative History][Doctor] okay , all right . well i'm glad that you talked about that with me today , um , i know the nurse did a review of systems sheet with you , and , you know , you're obviously endorsing this- this chest pressure . um , have you had any other symptoms , i know the- the other ones that you have n't had , but any lower extremity edema , or muscle aches , or fever chills ? [Patient] no , nothing like that , but i have had a little bit of congestion , um , just from allergies , because of the pollen .[SEP][Vegetative History][Doctor] okay , so you're endorsing some nasal congestion ? [Patient] yeah .[SEP][Physical Examination][Doctor] all right , well let's go ahead and we'll do a physical exam , okay ? [Patient] okay .[SEP][Physical Examination][Doctor] hey dragon ? show me the vital signs . so here your vital signs look really good , i'm- i'm happy to see that your blood pressure is under- under good control , and your oxygenation is fine , so i'm just gon na take a listen to your heart and lungs , and i'll let you know if i find anything , okay ? [Patient] okay .[SEP][Physical Examination][Doctor] okay , so in physical exam your heart has a slight three out of six systolic ejection murmur , which we've heard before . your lungs are nice and clear , uh , i do n't appreciate any carotid bruits , and- and you have no lower extremity edema , you have healed , uh , surgical scars on your- on your , uh , right wrist . um , so let's go ahead , i wan na look at some of your results , okay ? [Patient] okay .[SEP]
|
[
"Reassessment",
"Diagnostic Testing",
"Radiology Examination",
"Medication"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,844
|
[Other Socials][Doctor] okay . all right . and you're able to exercise ? [Patient] yes .[SEP][Other Socials][Doctor] okay . before you got sick . [Patient] that's correct . that's correct .[SEP][Physical Examination][Doctor] okay . all right . well , let's go ahead , i want to do a quick physical exam . okay ? [Patient] you got it .[SEP][Physical Examination][Doctor] hey dragon , show me the vital signs . so , here it ... your vital signs look great . your oxygenation is 96 % . so that's very good . okay ? uh , i'm just going to check out your heart and lungs , and i'll let you know what i find . okay ? [Patient] sure .[SEP][Physical Examination][Acute Assessment][Doctor] okay . so on exam , you do have some cervical lymphadenopathy . and your lungs have bilateral ronchi in them , um , and some wheezing . so , what that means is , you know , you have a little infection . you probably have a little bit of a cold , and you have some lymph nodes that are swollen , and some congestion in your lungs , like you said . let's go ahead and take a look at some of your results . okay ? [Patient] mm-hmm .[SEP]
|
[
"Reassessment",
"Acute Assessment",
"Lab Examination"
] |
[
"Assessment",
"Objective"
] | 3,845
|
[Other Socials][Doctor] okay . before you got sick . [Patient] that's correct . that's correct .[SEP][Physical Examination][Doctor] okay . all right . well , let's go ahead , i want to do a quick physical exam . okay ? [Patient] you got it .[SEP][Physical Examination][Doctor] hey dragon , show me the vital signs . so , here it ... your vital signs look great . your oxygenation is 96 % . so that's very good . okay ? uh , i'm just going to check out your heart and lungs , and i'll let you know what i find . okay ? [Patient] sure .[SEP][Physical Examination][Acute Assessment][Doctor] okay . so on exam , you do have some cervical lymphadenopathy . and your lungs have bilateral ronchi in them , um , and some wheezing . so , what that means is , you know , you have a little infection . you probably have a little bit of a cold , and you have some lymph nodes that are swollen , and some congestion in your lungs , like you said . let's go ahead and take a look at some of your results . okay ? [Patient] mm-hmm .[SEP][Reassessment][Acute Assessment][Lab Examination][Doctor] hey dragon , show me the lipid panel . so your cholesterol , for the most part , is really good . i think you're doing a good job . uh , i do n't think you have to make any changes right now . um , hey dragon , show me the covid test . turns out you're positive for ... for covid . so the results of your po- your covid test are positive . [Patient] okay .[SEP]
|
[
"Therapeutic History",
"Acute Assessment",
"Other Treatments"
] |
[
"Assessment",
"Plan",
"Subjective"
] | 3,846
|
[Physical Examination][Doctor] hey dragon , show me the vital signs . so , here it ... your vital signs look great . your oxygenation is 96 % . so that's very good . okay ? uh , i'm just going to check out your heart and lungs , and i'll let you know what i find . okay ? [Patient] sure .[SEP][Physical Examination][Acute Assessment][Doctor] okay . so on exam , you do have some cervical lymphadenopathy . and your lungs have bilateral ronchi in them , um , and some wheezing . so , what that means is , you know , you have a little infection . you probably have a little bit of a cold , and you have some lymph nodes that are swollen , and some congestion in your lungs , like you said . let's go ahead and take a look at some of your results . okay ? [Patient] mm-hmm .[SEP][Reassessment][Acute Assessment][Lab Examination][Doctor] hey dragon , show me the lipid panel . so your cholesterol , for the most part , is really good . i think you're doing a good job . uh , i do n't think you have to make any changes right now . um , hey dragon , show me the covid test . turns out you're positive for ... for covid . so the results of your po- your covid test are positive . [Patient] okay .[SEP][Therapeutic History][Acute Assessment][Other Treatments][Doctor] so , i know you were vaccinated . you probably have a , a , a very , um , low-level positivity . so let's talk about that . so for your first problem , uh , is your covid infection . and i think the vaccine has helped you . it seems to be very mild at this time . your oxygenation is really good . i want you to quarantine for t- for 10 days , so , uh , try to avoid your other household family members . okay ? [Patient] okay .[SEP][Follow-up][Other Treatments][Doctor] and you're going to have to take off work . um , if your symptoms worsen , i want you to call me . [Patient] okay .[SEP]
|
[
"Reassessment",
"Diagnostic Testing",
"Follow-up",
"Other Treatments",
"Medication"
] |
[
"Assessment",
"Plan"
] | 3,847
|
[Acute Symptoms][Personal History][Doctor] all right . so , natalie is a 39-year-old female , here today for a check-up for an abnormal lab . she's got a history of high blood pressure , diabetes , and acl repair . so , tell me what's going on . [Patient] so , uh , i got some re- routine blood work done last week and , uh , they said that my blood sugars were , were high , so that i should come in , um , and talk to you and get some more work done and , and , uh , see why that is .[SEP][Acute Symptoms][Vegetative History][Doctor] okay . well , were you having any symptoms at all or just , we had some blood work done routinely ? uh , any chest pain , shortness of breath ? any nausea , vomiting , or diarrhea ? [Patient] no , no symptoms . uh , so i was a little shocked when i came back high and , and elevated , so hopefully we can figure out what's going on .[SEP][Therapeutic History][Doctor] we've been , kind of , checking on this for a while and you've been on metformin . we actually increased your dose last time- [Patient] yup .[SEP][Therapeutic History][Doctor] so right now you're on 100 , 1,000 milligrams a day , correct ? [Patient] correct . yup .[SEP][Acute Symptoms][Doctor] okay . all right . no , uh , no difficulty urinating or burning when you urinate at all ? [Patient] nope .[SEP]
|
[
"Acute Symptoms",
"Reassessment",
"Lab Examination"
] |
[
"Assessment",
"Subjective",
"Objective"
] | 3,848
|
[Therapeutic History][Doctor] we've been , kind of , checking on this for a while and you've been on metformin . we actually increased your dose last time- [Patient] yup .[SEP][Therapeutic History][Doctor] so right now you're on 100 , 1,000 milligrams a day , correct ? [Patient] correct . yup .[SEP][Acute Symptoms][Doctor] okay . all right . no , uh , no difficulty urinating or burning when you urinate at all ? [Patient] nope .[SEP][Acute Symptoms][Reassessment][Lab Examination][Doctor] okay . all right . um , hey , dragon , show me the hemoglobin a1c . so in reviewing your , that's the lab that we checked after when i saw before i walked in . it says 8.1 , which is elevated , so i think we need to do a maybe a better job with adjusting your medication . how are you doing with your diet for your diabetes ? [Patient] my diet's been really great lately . i've been avoiding sugars , um , been really watching , uh , my weight and power walking every day , so i was a little surprised when the , the blood work came back that i- i had , um , an elevated , uh , test .[SEP][Acute Symptoms][Doctor] okay . and , uh , have you had any , uh , any other , are you checking your blood sugars in the morning or your fasting blood sugars ? [Patient] yes , i am .[SEP]
|
[
"Acute Symptoms",
"Reassessment"
] |
[
"Assessment",
"Subjective"
] | 3,849
|
[Acute Symptoms][Other Socials][Doctor] and you're pretty physically active and doing exercises ? [Patient] yeah . i've been power walking about , at least 30 minutes every day .[SEP][Acute Symptoms][Physical Examination][Doctor] okay . great . well , let's review , uh , some of your vital signs . hey , dragon , show me the vitals . all right . blood pressure looks good right now . your oxygen level's great . uh , your temperature's good . so i know you checked in with the review of systems with my assistant before coming in . uh , anything else bothering you today except for the abnormal blood work ? no chest pain ? no shortness of breath ? [Patient] no , nothing like that ?[SEP][Acute Symptoms][Doctor] no headaches ? no belly pain ? [Patient] no .[SEP][Chitchat][Doctor] good . great . well , let me examine you , okay ? [Patient] okay .[SEP][Physical Examination][Doctor] alright . just gon na listen to your heart here . no belly pain ? [Patient] nope .[SEP]
|
[
"Physical Examination",
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Follow-up",
"Other Treatments",
"Medication"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,850
|
[Acute Symptoms][Physical Examination][Doctor] okay . great . well , let's review , uh , some of your vital signs . hey , dragon , show me the vitals . all right . blood pressure looks good right now . your oxygen level's great . uh , your temperature's good . so i know you checked in with the review of systems with my assistant before coming in . uh , anything else bothering you today except for the abnormal blood work ? no chest pain ? no shortness of breath ? [Patient] no , nothing like that ?[SEP][Acute Symptoms][Doctor] no headaches ? no belly pain ? [Patient] no .[SEP][Chitchat][Doctor] good . great . well , let me examine you , okay ? [Patient] okay .[SEP][Physical Examination][Doctor] alright . just gon na listen to your heart here . no belly pain ? [Patient] nope .[SEP][Physical Examination][Discussion][Diagnostic Testing][Acute Assessment][Follow-up][Other Treatments][Medication][Doctor] okay . so on exam , uh , your hent or your neck exam is fine . your , uh , your eyes look fine . your lungs are clear . i do hear a systolic ejection murmur , about three over six . your belly's nice and soft . no swelling in your legs or extremities right now . so let's talk about some of the issues today . all right . for the first issue , for the diabetes , since your hemoglobin a1c is is elevated , uh , and you're already on 1,000 milligrams of metformin , i think we should add , uh , jardiance , uh , 10 milligrams a day . uh , so that's a new medication . we'll start that . i do want you to , uh follow your diet pretty , uh , aggressively . i wan na see if we can get that hemoglobin a1c down the next time . i'm also gon na add some labs today to see what that , to see a lipid panel and some other blood work . hey , dragon , order a cbc , cmp , and a lipid panel . and i'll go ahead and prescribe the jardiance , 10 milligrams a day . hey , dragon , prescribe , uh , order jardiance , 10 milligrams a day . all right . for the high blood pressure , i think you're doing great . you're on lisinopril for that , so i think that we should continue that . uh , we'll re-check it again next time and you are monitoring that at home , correct ? [Patient] yes , i am .[SEP]
|
[
"Reassessment",
"Follow-up",
"Other Treatments"
] |
[
"Assessment",
"Plan"
] | 3,851
|
[Chitchat][Doctor] and i'll let you know what i find . okay ? [Patient] okay .[SEP][Physical Examination][Acute Assessment][Doctor] okay . good . all right . so , on physical examination , i , i do n't hear any carotid bruits in your neck , which is really good . you know , your heart exam , i do hear a slight 2/6 systolic ejection murmur , which i've heard in the past , so that's stable . uh , your lungs are nice and clear , and you do have , you know , 1+ pitting edema bilaterally in your lower extremities . [Patient] okay .so , what does that mean ?[SEP][Acute Assessment][Doctor] you know , i , i think , you know , you're doing a ... it sounds like a doing a good job watching your diet . you could ... you just are retaining a little bit of fluid , maybe just from standing all day . [Patient] okay .[SEP][Chitchat][Doctor] okay ? let's take a look at some of your results . okay ? [Patient] okay .[SEP][Acute Assessment][Lab Examination][Doctor] hey , dragon . show me the endoscope results . so , this was the endoscopy that you had last year when you were having all that pain . it just showed that you had had some mild gastritis . so , it's good to hear that that , you know , protonix is helping you a lot . okay ? [Patient] okay . okay .[SEP]
|
[
"Reassessment",
"Discussion",
"Other Treatments",
"Medication"
] |
[
"Assessment",
"Plan"
] | 3,852
|
[Physical Examination][Doctor] hey dragon . show me the vital signs . so here in the office . i agree . your blood pressure looks good . uh , i think you're doing a good job with that so keep up the good work . i'm gon na go ahead and take a listen to your heart and lungs , i'll let you know what i find . [Patient] sure .[SEP][Acute Assessment][Doctor] all right . so on physical examination , everything looks pretty good , so on your neck exam , i do n't appreciate any carotid bruits . on your heart exam i do appreciate a slight two out of six systolic ejection murmur heard at the left base , which we've heard in the past . [Patient] mm-hmm .[SEP][Acute Assessment][Doctor] your lungs are nice and clear and you do have uh one plus non-pitting edema bilaterally in your lower extremities . so what does all that mean ? it just means i heard a little sound in your heart , which you know is n't anything clinically significant . we had looked into that last year . [Patient] mm-hmm .[SEP][Acute Assessment][Doctor] you do have a little swelling in your legs but that might just be from your your diet recently , okay . [Patient] sure .[SEP][Acute Assessment][Lab Examination][Doctor] i wan na just take a look at some of your results . hey dragon , show me the ekg . so i just had the nurse do an ekg on you before you came in just to make sure we were n't missing anything . you're in your 60's we have some risk factors . everything looks good . [Patient] mm-hmm .[SEP]
|
[
"Reassessment",
"Discussion",
"Lab Examination"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,853
|
[Acute Assessment][Doctor] all right . so on physical examination , everything looks pretty good , so on your neck exam , i do n't appreciate any carotid bruits . on your heart exam i do appreciate a slight two out of six systolic ejection murmur heard at the left base , which we've heard in the past . [Patient] mm-hmm .[SEP][Acute Assessment][Doctor] your lungs are nice and clear and you do have uh one plus non-pitting edema bilaterally in your lower extremities . so what does all that mean ? it just means i heard a little sound in your heart , which you know is n't anything clinically significant . we had looked into that last year . [Patient] mm-hmm .[SEP][Acute Assessment][Doctor] you do have a little swelling in your legs but that might just be from your your diet recently , okay . [Patient] sure .[SEP][Acute Assessment][Lab Examination][Doctor] i wan na just take a look at some of your results . hey dragon , show me the ekg . so i just had the nurse do an ekg on you before you came in just to make sure we were n't missing anything . you're in your 60's we have some risk factors . everything looks good . [Patient] mm-hmm .[SEP][Reassessment][Discussion][Lab Examination][Doctor] there's no evidence that i'm concerned about anything at this time . hey dragon , show me the diabetes logs . so on your diabetic labs , your hemoglobin a1c is elevated . it's at eight . i'd like to see it closer to six . now some of them might be having to do with the holidays that type of thing but i still think that we need to get that under better control . [Patient] sure .[SEP]
|
[
"Acute Assessment",
"Referral"
] |
[
"Assessment",
"Plan"
] | 3,854
|
[Acute Symptoms][Doctor] okay . and do you experience any loss of sensation in your hands or fingers ? [Patient] uh , like , like feeling something ? no , not that i can think of really . in general , they might be less sensitive than they should be , but i can still feel . they gave me some nerve pain medicine , but i have n't been taking it like i should be .[SEP][Personal History][Doctor] okay . looks like your medical history is notable for chronic kidney disease , gout , hypertension , anxiety , gerd , and diabetes . [Patient] well , i had pre-diabetes , but i got in under control changing my diet .[SEP][Therapeutic History][Drug History][Doctor] okay . good . and are you still on the carvedilol 25 milligrams two times a day for hypertension and lexapro 10 milligrams a day for anxiety ? looks like your allergic to sulfa drugs as well . is that correct ? [Patient] yeah , i'm still taking those and sulfa just causes me to break out in a rash .[SEP][Personal History][Doctor] and no history of thyroid issues , right ? [Patient] nope .[SEP][Chitchat][Doctor] all right . thank you ms. taylor . i'll be right back for your exam . i want to look up that medication you mentioned for your nerve pain . [Patient] all right . thanks .[SEP]
|
[
"Physical Examination",
"Discussion",
"Diagnostic Testing",
"Acute Assessment",
"Personal History",
"Other Treatments",
"Referral",
"Vegetative History"
] |
[
"Assessment",
"Plan",
"Subjective",
"Objective"
] | 3,855
|
[Personal History][Doctor] okay . have you ever had an upper endoscopy ? [Patient] i think maybe when i was younger .[SEP][Personal History][Doctor] but not in the last 10 years ? [Patient] no .[SEP][Therapeutic History][Doctor] have you ever tried any medication other than omeprazole ? [Patient] um , at one point i was on omeprazole and ranititine -dine . it did help . but other than that , those are the only medications i have taken .[SEP][Physical Examination][Doctor] okay . have a seat here , and let me listen to your heart and lungs , and then we can talk about a plan for you . [Patient] okay .[SEP][Physical Examination][Doctor] so normal physical exam per my new patient template , except for well-healed abdominal surgical scars noted . what's the surgical scar here on your abdomen from ? [Patient] i always forget about that surgery . i had it when i was a baby . my mom said my intestines were twisted , so i had to have surgery when i was around one month old .[SEP]
|
[
"Discussion",
"Personal History",
"Medication",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Subjective"
] | 3,856
|
[Personal History][Doctor] but not in the last 10 years ? [Patient] no .[SEP][Therapeutic History][Doctor] have you ever tried any medication other than omeprazole ? [Patient] um , at one point i was on omeprazole and ranititine -dine . it did help . but other than that , those are the only medications i have taken .[SEP][Physical Examination][Doctor] okay . have a seat here , and let me listen to your heart and lungs , and then we can talk about a plan for you . [Patient] okay .[SEP][Physical Examination][Doctor] so normal physical exam per my new patient template , except for well-healed abdominal surgical scars noted . what's the surgical scar here on your abdomen from ? [Patient] i always forget about that surgery . i had it when i was a baby . my mom said my intestines were twisted , so i had to have surgery when i was around one month old .[SEP][Discussion][Personal History][Medication][Reassessment][Doctor] hm , gotcha . okay . so let's talk about what you have going on . from what you've told me , it sounds like you've had a several-year history of gerd , which is the medical term for acid reflux . and recently your symptoms have been poorly controlled with the omeprazole , 40 milligrams twice daily . you've been having heartburn despite taking this medication , correct ? [Patient] yes .[SEP]
|
[
"Other Treatments",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,857
|
[Other Treatments][Reassessment][Doctor] and you've identified trigger foods like spicy foods , carbonated bev- beverages , citrus , and tomato-based foods , but you have n't cut these foods out of your diet completely yet . so the first thing i'd try is changing your diet because these foods can exacerbate your gerd , even though you're taking the ppi . [Patient] okay , yeah , i could definitely do a better job of avoiding those foods .[SEP][Discussion][Doctor] great . so stress is another trigger that we need to address . high stress can cause worsening of your symptoms . [Patient] yeah , stress and anxiety are definitely big problems for me .[SEP][Discussion][Medication][Doctor] so working on that may help with your gerd . additionally , we can consider trying a different ppi since the only one you've tried up to this point is omeprazole . if you're okay with this , we can switch your omeprazole to nexium . [Patient] that's fine with me . i'm definitely open to trying whatever .[SEP][Discussion][Medication][Diagnostic Testing][Doctor] perfect . i will send a prescription for nexium 40 milligrams twice daily to your pharmacy on file . i'll also recommend that you have a procedure called a egd , or upper endoscopy , to look for potential causes of the gerd . we'd sedate you and then pass a small camera through your mouth , down your throat , through your stomach , and end in the small intestines . we'd look for any ulcers or signs of precancerous or cancerous conditions that we can take biopsies at the same time if we see anything . [Patient] okay . can i schedule that today ?[SEP][Follow-up][Doctor] yeah . you can get scheduled at checkout desk . i'll have you follow up with me in the office for the egd so we can discuss the results and talk about how you're doing with the dietary , stress , and medication changes . how does all of that sound ? [Patient] that sounds good .[SEP]
|
[
"Discussion",
"Medication",
"Diagnostic Testing",
"Reassessment",
"Vegetative History"
] |
[
"Assessment",
"Plan",
"Subjective"
] | 3,858
|
[Physical Examination][Doctor] good . let me take a quick listen to you . [Patient] okay .[SEP][Physical Examination][Doctor] all right . go ahead and take a few deep breaths . and breathe normally . now take several deep breaths . and two more . okay , good . you can relax . any pain or discomfort anywhere ? [Patient] nope .[SEP][Chitchat][Doctor] great . so here are my thoughts . [Patient] okay .[SEP][Personal History][Doctor] you may recall it was extremely hot during that period leading up to you going to the hospital . i do n't know if you were inside for the most part ? [Patient] yeah , it was pretty hot , was n't it ? and i go out a bit , but i do tend to stay in more when it's hot .[SEP][Discussion][Doctor] okay . well , if you do get dehydrated even just a little bit it can lead to further , um , or worsening constipation issues . [Patient] mm-hmm .[SEP]
|
[
"Diagnostic Testing",
"Follow-up",
"Referral"
] |
[
"Plan"
] | 3,859
|
[Discussion][Medication][Doctor] well , my thoughts are that you actually should be vaccinated . i think you are high risk . if you get covid it's not going to be good for you . [Patient] okay .[SEP][Discussion][Medication][Doctor] and i think it's safe . i mean , i understand and hear you . all of these stories out there about this , uh , regarding the vaccine . but i've seen all the bad things that could happen from covid . people have died in my practice , and i do n't disagree that if you got covid you'd probably be okay . [Patient] yeah .[SEP][Discussion][Doctor] but i would consider you as someone that would make me a little bit concerned . i have had healthy people die from covid . [Patient] mm-hmm .[SEP][Discussion][Medication][Doctor] i've had some people get really , really sick from it . so personally , i believe that this vaccine is completely safe . i really think that . [Patient] all of them ?[SEP]
|
[
"Therapeutic History",
"Discussion",
"Medication"
] |
[
"Plan",
"Subjective"
] | 3,860
|
[Discussion][Doctor] yeah . right now the numbers are low . even with the delta variant , when it starts mutating , it's actually good because it becomes more contagious , but less deadly . [Patient] okay .[SEP][Discussion][Doctor] so that's what's gon na happen with covid . that's what's mo- most of the science supports and this is how most pandemics end , is that the virus starts losing its potency . [Patient] sure .[SEP][Chitchat][Doctor] but think about it , and if you have any more questions you can certainly let me know , okay ? [Patient] will do .[SEP][Discussion][Doctor] all right . anything else we can discuss today ? [Patient] nope . i think i'm all set . thank you .[SEP][Follow-up][Doctor] you're welcome . so we'll see you in two to three weeks . have a good rest of your day . [Patient] thanks , you too .[SEP]
|
[
"Personal History",
"Therapeutic History",
"Lab Examination",
"Diagnostic Testing",
"Follow-up"
] |
[
"Plan",
"Subjective",
"Objective"
] | 3,861
|
[Discussion][Doctor] yeah , those , um , are the types of , of jobs that take a good three months until you're kind of ready to get back to doing that kind of labor-intensive work . [Patient] okay , and driving now ?[SEP][Discussion][Doctor] uh , we have plenty of data that says normal reflex time is returned at six weeks , and then your return to driving is determined by when you're ready and feel safe to be driving . [Patient] okay .[SEP][Follow-up][Doctor] yeah . so hang tight . anna will bring that note back in to you , and we'll talk in six weeks . [Patient] all right , that sounds good .[SEP][Discussion][Referral][Doctor] uh , but keep working hard on , on pt in the meantime though . [Patient] i definitely will . thank you .[SEP][Chitchat][Doctor] all right , have a good rest of your day . [Patient] you as well .[SEP]
|
[
"Physical Examination",
"Radiology Examination",
"Reassessment"
] |
[
"Assessment",
"Objective"
] | 3,862
|
[Personal History][Doctor] goodness . okay . then what happened ? [Patient Guest] yeah . so i took her back again and they did more testing . i think they did an ultrasound or something , and that's where they found that one kidney was bigger .[SEP][Personal History][Doctor] okay . [Patient Guest] um , then at that time they told us to followup with our primary the next day , which we did . um , but he was heading out on vacation , so he only saw her for a brief 10 minutes and then we were out the door . so she was still throwing up , in a lot of pain , so i took work off to help her .[SEP][Personal History][Doctor] wow . okay . [Patient Guest] uh , we took her down to jacksonville , where they did see her and basically told us the same thing , that they did n't think one of her kidneys was working at all . they called it atrophic and that it was a lot smaller than the other one .[SEP][Personal History][Doctor] all right-y . then- then what happened ? [Patient Guest] yeah . then , um , they found cysts or something on her kidney and ovaries and maybe some other places . her lymph nodes were swollen and they found some infection . um , they told us to followup with her doctor , which we figured since she was still sick .[SEP][Personal History][Doctor] okay . and then when you followed up with your doctor , what happened then ? [Patient Guest] yeah . it did n't seem to be getting any better within a day or two , so we followed back up with her doctor , who was , of course , still out of town with no one to see her in his place . so we ended up coming to atlanta . we stayed here for about four days . um , they did see her and treated her .[SEP]
|
[
"Acute Symptoms",
"Personal History",
"Chitchat"
] |
[
"Null",
"Subjective"
] | 3,863
|
[Acute Symptoms][Personal History][Chitchat][Doctor] okay . i am so sorry for all of that back and forth , but glad to know that there was some light at the end of that tunnel . [Patient Guest] thank you . and then after they saw her , she did seem to get a little better . she has n't had any more throwing up or anything since , but she still complains about a lot of pain in her stomach .[SEP][Acute Symptoms][Doctor] mhm . okay . [Patient Guest] yeah . and she mentions burning too , especially when she eats and stuff like that .[SEP][Personal History][Doctor] all right-y . okay . well , that was a really good review . so , ashley , before all of this , would you say that , all in all , you were a pretty healthy child ? [Patient Guest] she is , yeah . before that , she was completely fine . uh , they said they think at some point she had a severe infection that might've affected her kidney .[SEP][Therapeutic History][Personal History][Doctor] got you . okay . [Patient Guest] so one other thing , too , um , when she was four years old she was in the hospital three or four times , sometimes for three days at a time . i do n't think they did any tests to see what the infection was or even where it was coming from . um , they just gave her fluids and antibiotic and they would send us home .[SEP][Personal History][Doctor] hmm . okay . [Patient Guest] yeah . and so a week or two later , she would have a fever and symptoms and basically the same thing . we went through that for a couple of months , and then it just stopped . so she had no problem since , but the doctor suspects that she's had kidney problems since then . so we just wan na see if she's all right or if she ... if it needs to be taken out maybe . we wan na do whatever needs to be done .[SEP]
|
[
"Therapeutic History",
"Chitchat"
] |
[
"Null",
"Subjective"
] | 3,864
|
[Physical Examination][Doctor] okay so no pain with flexion how about if you stand back up [Patient] no[SEP][Physical Examination][Doctor] okay no pain with extension either does it hurt while you're just standing here [Patient] yes[SEP][Physical Examination][Doctor] okay so pain when you're weightbearing does it hurt when i push right here on the left side [Patient] yes[SEP][Physical Examination][Doctor] pain with palpation to the left side around the l5 how about on the right side [Patient] no[SEP][Acute Symptoms][Doctor] no pain with palpation to the right side okay i'm just gon na push down on your feet can you push back up on my hands [Patient] yes[SEP]
|
[
"Acute Assessment",
"Other Treatments",
"Radiology Examination"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,865
|
[Chitchat][Doctor] uh okay so do you have a favorite restaurant you like to go to [Patient] i do mcdonalds is one of my favorite here in arlington[SEP][Chitchat][Doctor] that sounds good what what do you what's your favorite there [Patient] they have a great egg plant parmajon one of my favorite so i just go ahead and go with that[SEP][Chitchat][Doctor] that sounds really nice very good [Patient] it's just[SEP][Drug History][Doctor] yeah okay well so it looks like you're still smoking a pack of cigarettes a day [Patient] yes i tried to stop smoking every now and then but it's still been hard to totally stop[SEP][Personal History][Doctor] okay and how is your blood pressure been doing are you keeping up with your medication [Patient] i take my blood pressure when i can remember to do so[SEP]
|
[
"Physical Examination",
"Discussion",
"Acute Assessment",
"Medication"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,866
|
[Chitchat][Doctor] no it's not at north point [Patient] maybe i do n't know[SEP][Chitchat][Doctor] do you or do you like going to colorado [Patient] hmmm kind of a time[SEP][Vegetative History][Doctor] okay alright okay alright well let's go ahead and do a quick physical exam okay so i looked here at your vital signs and have you had any fever chills or anything like that since this happened [Patient] i've had a fever it hits the pain hits[SEP][Vegetative History][Doctor] you've had a fever how high was your fever [Patient] like two hundred[SEP][Physical Examination][Doctor] that's not a fever alright okay so lem me go ahead you looking at your vital signs you do n't have a fever now your temperature is ninety eight . six your blood pressure is fine at one eighteen over seventy seven and your heart rate looks good at seventy seven beats per minute on your right ankle exam there is some edema and erythema on the lateral malleolus on the right hand side there is associated ecchymosis and a few excoriations does it hurt when i press on it [Patient] yes[SEP]
|
[
"Physical Examination",
"Radiology Examination",
"Acute Assessment"
] |
[
"Assessment",
"Objective"
] | 3,867
|
[Chitchat][Doctor] do you or do you like going to colorado [Patient] hmmm kind of a time[SEP][Vegetative History][Doctor] okay alright okay alright well let's go ahead and do a quick physical exam okay so i looked here at your vital signs and have you had any fever chills or anything like that since this happened [Patient] i've had a fever it hits the pain hits[SEP][Vegetative History][Doctor] you've had a fever how high was your fever [Patient] like two hundred[SEP][Physical Examination][Doctor] that's not a fever alright okay so lem me go ahead you looking at your vital signs you do n't have a fever now your temperature is ninety eight . six your blood pressure is fine at one eighteen over seventy seven and your heart rate looks good at seventy seven beats per minute on your right ankle exam there is some edema and erythema on the lateral malleolus on the right hand side there is associated ecchymosis and a few excoriations does it hurt when i press on it [Patient] yes[SEP][Physical Examination][Radiology Examination][Acute Assessment][Doctor] there is pain to palpation of the right lateral malleolus there is decreased flexion and extension of the right ankle as well as internal and external rotation there is no apparent injury to the knee or the foot okay so what does that mean jacqueline seem awfully giggling right now so what does that mean so i took a i had the nurse do an x-ray on you before i came in and reviewing the results of your right ankle x-ray shows that you have no acute fracture or bony abnormality which is good you just have a some soft tissue injury so let's talk a little bit about my assessment and plan so for [Patient] really[SEP]
|
[
"Discussion",
"Medication",
"Other Treatments",
"Referral",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] | 3,868
|
[Discussion][Medication][Doctor] okay alright so it's really gon na be really important for you to go ahead and continue to take these medications to prevent that stent from clogging again okay or prevent that stent from closing because we do n't want you to have another heart attack okay [Patient] okay yeah[SEP][Personal History][Doctor] okay and how about watching your diet are you able to watch your salt intake i know that you really liked a good pizza every now and again are you [Patient] yeah i i have eaten pizza a few times what i'm trying to do is really be diligent and eat well throughout the week and then i have had pizza a few times on the weekends is that okay[SEP][Discussion][Other Treatments][Doctor] you can have a piece here and there you know the pumping function of your heart was pretty normal when i saw from the hospital your ejection fraction that's the pumping function of your heart was at about fifty percent which is you know low normal but not bad so that's good so okay just i would just watch your salt intake okay [Patient] okay yeah i've been eating a lot of vegetables and and chicken without salt on it[SEP][Chitchat][Doctor] okay great and then you know i i'm i'm glad that you're taking it easy now remind me this might cause you some anxiety were the denver denver nuggets swept or did they end up winning are they still in the nba playoffs i forget i know that you are a denver nuggets fan [Patient] i am yeah they they are not sweep they were down three games but they wanted the last one so there is a there is a chance for it come back but they they play again tomorrow[SEP][Chitchat][Doctor] okay yeah i'm a self expand and and we just swept the brooklyn net so i was really excited about that [Patient] congrats that that's that's always good to sweep the nuts no one no one likes them[SEP]
|
[
"Physical Examination",
"Discussion",
"Medication",
"Radiology Examination",
"Diagnostic Testing",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,869
|
[Radiology Examination][Doctor] so did you already have x-rays of this knee today [Patient] yes[SEP][Chitchat][Doctor] okay do i go into that to [Patient] yeah[SEP][Radiology Examination][Doctor] look at the x-rays do you or just stop here you can okay okay and so what would what would happen now you would you could pause it [Patient] you're only cup of this[SEP][Acute Assessment][Radiology Examination][Doctor] let's take a look at your pictures here and alright so this looks pretty just looking at it looks pretty normal looks pretty healthy you can see how i all the edges of the bones here look pretty good i do n't see any bone spurs of that i do n't see anything broken everything looked looks pretty good kneecap's tracking good you can see the space here there's no real space there that's actually cartilage so that looks pretty healthy and you can see the other side looks both both look the same so x-rays look i do n't see anything obvious on that but looking at your knee here you may have hit that tibia bone and kinda pushed that bone back it feels to me like you may very well have sprained your or injured your posterior cruciate ligament that's what it's feeling like [Patient] hmmm[SEP][Diagnostic Testing][Other Treatments][Doctor] i'm not gon na know that for sure or if there is other things going on in there but i think getting an mri scan to look at what you may have done inside there i'm pretty suspicious though that you may have injured that ligament if that's the only thing you did very rarely is this gon na need surgery okay so this may be something we wan na get you into a brace here get you into some therapy and get all your motion back and get your strength back and then maybe check it back in a in a few weeks and see because a lot of times those ligaments can tighten back up it's it's odd for just an isolated posterior ligament to need surgery [Patient] mm-hmm[SEP]
|
[
"Discussion",
"Diagnostic Testing",
"Other Treatments"
] |
[
"Plan"
] | 3,870
|
[Personal History][Doctor] okay that's not [Patient] average[SEP][Therapeutic History][Doctor] that's not too bad you might have a little white coat syndrome you seeing me today because it's a little bit high today so you're on that two . five of norvasc have you been taking that [Patient] yes[SEP][Personal History][Doctor] okay that's good how about your diet how is that going i know you were having a little trouble before your sot intake was a little bit high [Patient] i think i'm doing okay so[SEP][Personal History][Therapeutic History][Doctor] alright so as far as your diabetes your last time you came in let's say look at your a1c result it was a seven . two you were on the five hundred of metformin so what have your blood sugars been running [Patient] i do n't really check them[SEP]
|
[
"Discussion",
"Medication",
"Diagnostic Testing",
"Vegetative History"
] |
[
"Plan",
"Subjective"
] | 3,871
|
[Personal History][Doctor] okay got it and how about your blood pressure how has that been running at home are you checking your blood pressures daily still and how how your how how have your blood pressures been [Patient] i have not been checking them daily i i probably check it about two or three times a week[SEP][Discussion][Medication][Therapeutic History][Doctor] okay okay not not too bad it does look like you're a little bit elevated today i i maybe i'm just making you nervous though so i hope not so are you but you're still on lisinopril twenty milligrams per day correct it looks like you might be running low do you need a refill of that [Patient] yeah actually i was going to ask you about that if i could get a refill that would be great[SEP][Personal History][Doctor] sure we can do that and so okay but you are still taking that twenty milligrams per day correct [Patient] correct[SEP][Physical Examination][Doctor] okay and alright fair enough so so let's go ahead and and examine you now karen so on your physical exam pretty normal and and unremarkable for the most part on your on your heart exam i do hear that grade three out of six systolic ejection murmur that you've still got that's unchanged from prior exam that just means i hear some heart sounds you know as i'm listening to your heart there i'm not too concerned about that we'll watch that otherwise normal cardiovascular exam and then your your abdominal exam gastrointestinal exam you have some tenderness in the right upper quadrant i would say mild to moderate tenderness and now if you take a deep breath does that and i press here does that hurt you [Patient] yes[SEP]
|
[
"Physical Examination",
"Referral",
"Diagnostic Testing",
"Acute Assessment",
"Vegetative History"
] |
[
"Assessment",
"Plan",
"Subjective",
"Objective"
] | 3,872
|
[Discussion][Medication][Therapeutic History][Doctor] okay okay not not too bad it does look like you're a little bit elevated today i i maybe i'm just making you nervous though so i hope not so are you but you're still on lisinopril twenty milligrams per day correct it looks like you might be running low do you need a refill of that [Patient] yeah actually i was going to ask you about that if i could get a refill that would be great[SEP][Personal History][Doctor] sure we can do that and so okay but you are still taking that twenty milligrams per day correct [Patient] correct[SEP][Physical Examination][Doctor] okay and alright fair enough so so let's go ahead and and examine you now karen so on your physical exam pretty normal and and unremarkable for the most part on your on your heart exam i do hear that grade three out of six systolic ejection murmur that you've still got that's unchanged from prior exam that just means i hear some heart sounds you know as i'm listening to your heart there i'm not too concerned about that we'll watch that otherwise normal cardiovascular exam and then your your abdominal exam gastrointestinal exam you have some tenderness in the right upper quadrant i would say mild to moderate tenderness and now if you take a deep breath does that and i press here does that hurt you [Patient] yes[SEP][Physical Examination][Referral][Diagnostic Testing][Acute Assessment][Vegetative History][Doctor] okay yeah you have i would call an equivocal murphy's sign in the right upper quadrant on your abdominal examination as well the rest of your abdomen is soft and no significant tenderness you have no tenderness in the right lower quadrant with deep palpation and you have no cva tenderness on your back exam as well and so we will talk about about that i am a little bit concerned about the tenderness that that i find on your abdominal exam the remainder of your exam karen is pretty normal and unremarkable and and so that's good let's let's talk about my assessment and your plan so first of all for your first problem of abdominal pain you you do seem to have acute abdominal pain with right upper quadrant tenderness that i'm concerned maybe a sign of some gallstones or possibly even an infection in your gallbladder so i'm gon na order some blood tests and an ultrasound today i'm gon na order a cbc chem twelve urinalysis a pregnancy test and also right upper quadrant ultrasound and so we will we will get those tests done right away i'm gon na keep you here we'll see how those look fortunately we've got the facilities for those and if we need to send you to the emergency department based on those results we will i do n't want you to eat anything right now okay in case we find something that might require surgery alright unlikely but it's possible and then okay you know karen i meant to ask you on your history one thing by chance have you had a fever along with this abdominal pain [Patient] i've had some chills but no documented fevers[SEP]
|
[
"Discussion",
"Medication",
"Other Treatments",
"Reassessment",
"Drug History"
] |
[
"Assessment",
"Plan",
"Subjective"
] | 3,873
|
[Therapeutic History][Doctor] alright well we we definitely got ta got ta get your your diet a little bit better i know after the pandemic a lot of people you know went crazy with the diet myself included but i know we got ta get you get back in because for your diabetes i'm looking at your a1c and we we checked it and it was a a seven point two which is not so good right now so have you been taking i think you're on metformin five hundred milligrams daily [Patient] i do but i got ta take it sometimes it upsets my stomach and so i just kinda skip it[SEP][Personal History][Doctor] okay so yeah we definitely got ta get you to to take it we could try something else just if you're having interaction with that medication what about your blood sugars are they taking those daily [Patient] no every once in a while[SEP][Personal History][Doctor] every once in a while what have they been doing every once in a while when when you do take them [Patient] probably about a hundred and fifty or so[SEP][Physical Examination][Doctor] okay so we got to get those down too so we will talk about getting you consult nutrition just try to get you a better diet i think you know we wan na get you off the medications totally but you know we got ta get you on the right track here alright so let me do a quick physical exam on you i'm gon na check your your your lungs lungs sound good check your heart so listen to your heart you still do have that grade two out of systolic ejection murmur alright but we we knew about that already you've had that for a couple of years so i'm not really worried about that at this at this time so let me take a look at your knee here so when i press right here on the inside the right knee is that painful [Patient] ow[SEP][Physical Examination][Doctor] ow alright and let me have you bend it straighten it it's painful [Patient] a little yes[SEP]
|
[
"Physical Examination",
"Medication",
"Other Treatments",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,874
|
[Personal History][Doctor] okay so yeah we definitely got ta get you to to take it we could try something else just if you're having interaction with that medication what about your blood sugars are they taking those daily [Patient] no every once in a while[SEP][Personal History][Doctor] every once in a while what have they been doing every once in a while when when you do take them [Patient] probably about a hundred and fifty or so[SEP][Physical Examination][Doctor] okay so we got to get those down too so we will talk about getting you consult nutrition just try to get you a better diet i think you know we wan na get you off the medications totally but you know we got ta get you on the right track here alright so let me do a quick physical exam on you i'm gon na check your your your lungs lungs sound good check your heart so listen to your heart you still do have that grade two out of systolic ejection murmur alright but we we knew about that already you've had that for a couple of years so i'm not really worried about that at this at this time so let me take a look at your knee here so when i press right here on the inside the right knee is that painful [Patient] ow[SEP][Physical Examination][Doctor] ow alright and let me have you bend it straighten it it's painful [Patient] a little yes[SEP][Physical Examination][Medication][Other Treatments][Radiology Examination][Diagnostic Testing][Acute Assessment][Doctor] a little bit alright i'm gon na do a couple of maneuvers here so your your right knee exam shows that you do have pain to palpation of the medial aspect of that right knee also have some edema some little bit of swelling some ecchymosis as well you do have a negative varus and valgus test of my maneuvers and you know i i do see a little bit of of swelling swelling little redness as well in that knee so we did get an x-ray of your knee your right knee luckily it was normal so there's no fractures no bony abnormalities which is good so you did n't break anything so based on my your based on your x-ray and your exam you have a mcl tear well mcl strain i apologize mcl is straight i do n't know if you have a tear yet we got ta do yeah we had to have to do a mri for that but basically means you twisted your knee when you're playing basketball right and so that ligament is strained or torn just to have to get an mri to determine if it is or not in the time being i want you to continue to take that tylenol just to help with that pain i'm also gon na prescribe you some meloxicam fifteen milligrams just to help with the pain and swelling i'm gon na put you in a knee immobilizer and i want you to stay off of that for the next couple of weeks and we're gon na get a mri as well for that knee how does that sound [Patient] that's okay[SEP]
|
[
"Discussion",
"Follow-up",
"Referral",
"Medication",
"Other Treatments",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,875
|
[Therapeutic History][Doctor] okay great great you're still using that pill box that we suggested i think you had a pretty good system going there maybe maybe you're using that app now to take to keep track of one when to take your medicine are you doing that [Patient] yes yeah i've i've used the pillbox and then tried the app it was a little confusing but i'm i'm pretty much on on track with staying on my medication schedule pretty accurately[SEP][Other Socials][Doctor] that's great i think i think i remember you saying it was tricky to get that app set up but then your grandson helped you with it and those kids amazing what they can do these days right anything like that i always trust them my kids before me so hey by the way how did he do in his softball or in his in his little league tournament last month i think you said he had a big tournament coming up how did that go [Patient] they they did great they they got all the way to the finals and then the team that the team that beat them was probably a little older a little bit more season but they had a great time[SEP][Therapeutic History][Doctor] wow wow how fun that's fantastic well congrats good stuff alright well listen so so you're still taking your your lisinopril how about for your hyperlipidemia your your high cholesterol there are you still taking that atorvastatin [Patient] yes[SEP][Personal History][Doctor] okay excellent and your osteoarthritis i know you've been you know a golfer in the past and you know you wan na get out on the course and things is that still under control are you able to get out and and and walk the full course and things still [Patient] most of the time you know there are times when the weather changes that i have to maybe play less play less or or skip a day[SEP][Therapeutic History][Doctor] yeah yeah but you're still okay well you're still able to get out and then you're kinda taking i think you're taking some tylenol for for you know mild mild pain and changing your activity as needed is that right [Patient] correct[SEP]
|
[
"Physical Examination",
"Discussion",
"Follow-up",
"Medication",
"Diagnostic Testing",
"Reassessment",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,876
|
[Vegetative History][Doctor] okay and have you had any congestion anything like that cough runny nose [Patient] yeah i thought maybe because you know now it's springtime and i tend to get my allergies but it it's it's very different and i've not actually had any like runny nose or cough or congestion along with the headache[SEP][Physical Examination][Doctor] okay if you tap on your forehead do you have any tenderness [Patient] right here[SEP][Physical Examination][Doctor] okay if you tap down here on these bones your cheek bones any tenderness there [Patient] a little bit not as much as i guess if i tap up here[SEP][Physical Examination][Doctor] okay and then if you kinda push on your neck around here any tenderness [Patient] it it's a little tender but it's not it is a little bit i'd say[SEP]
|
[
"Physical Examination",
"Medication",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,877
|
[Physical Examination][Doctor] okay if you tap on your forehead do you have any tenderness [Patient] right here[SEP][Physical Examination][Doctor] okay if you tap down here on these bones your cheek bones any tenderness there [Patient] a little bit not as much as i guess if i tap up here[SEP][Physical Examination][Doctor] okay and then if you kinda push on your neck around here any tenderness [Patient] it it's a little tender but it's not it is a little bit i'd say[SEP][Physical Examination][Medication][Reassessment][Doctor] okay okay so you do n't have any frontal sinus tenderness no maxillary sinus tenderness it sounds like you do n't have any lymphadenopathy that would just be if your lymph nodes were tender so yeah you know let's just talk about a few things that i wan na do and then i want you to actually come in and and be seen by doctor ruth so first off your headache i think taking tylenol is great you can keep taking that you know your lisinopril you're on twenty milligrams once a day which is a medium dose but i think we can increase that so for your hypertension and your headaches i'm gon na have you increase your lisinopril to forty milligrams once a day [Patient] okay[SEP]
|
[
"Discussion",
"Referral",
"Diagnostic Testing",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,878
|
[Personal History][Doctor] okay so there is a smoker at home you know that does that does affect you so we might have to have a conversation with your brother and anybody else but it's good to know that people are n't sick i do see here though that you have kind of a a history of recurrent strep like you you seem to be having these sore throats a lot i think it says that you've had four in the last five months is that correct [Patient] yeah strep and bfs i'm not quite sure what it is just seems to come on you know i get this sore throat and fibroid i'm told i have strep[SEP][Physical Examination][Doctor] i okay i respect that and i'm glad that you you listen to him at the end of the day that's always a good thing alright so now that we've gotten like kind of a lot of the history out of the way i do want to do my physical exam is that okay [Patient] sure[SEP][Physical Examination][Doctor] alright so when i look in your throat like i'm not noticing any erythema no swelling your tonsils are midline so those look good when i'm feeling here on your neck i'm not appreciating any like lymphadenopathy no cervical adenopathy and like i wan na check those things because i just wan na make sure i'm not seeing any physical signs of like any kind of strep right now right i do n't want i wan na make sure you're not having an infection when i listen to your lungs i do n't appreciate any wheezes rales rhonchi that means i'm not hearing funky sounds your heart sounds great no murmur no rub no gallop when i press on your back remember you told me you had that left back pain when i press on it does it hurt [Patient] no[SEP][Physical Examination][Doctor] okay alright great no tenderness on palpation when i press on your abdomen are you feeling any pain [Patient] no[SEP]
|
[
"Discussion",
"Referral",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Assessment",
"Plan"
] | 3,879
|
[Personal History][Therapeutic History][Doctor] okay every other day alright and then are you also now i know you also have some diabetes so are you how are you doing with that one are you pretty much taking your metformin everyday [Patient] hmmm i probably take it when i take my other medicine like every other day[SEP][Physical Examination][Personal History][Doctor] every other day okay so i do see that you know the nurse took your your vital signs this morning that your blood pressure is running quite a bit high it was like one seventy two over ninety eight so that's that's really a little higher than where we want it to be especially that you're on your medication but what we're gon na do is we're gon na take i'm gon na take a look at you real quick and then we can discuss you know maybe there's some changes that we can do in terms of your current regimen how about diet and your have you been sticking with that low sodium diet at all [Patient] no i love mcdonald's i eat it all the time[SEP][Vegetative History][Doctor] i love mcdonald's too my favorite is big mac i do n't know about you but i got ta have my big mac with those large fries which you what's your favorite mcdonald's treat there [Patient] i need to think of what fully of fish i love flare of fish[SEP][Other Socials][Doctor] well at least you're eating the fish but but they can be very high in sodium especially the fast foods so we'll have to talk about maybe they can look at you know some some diet changes as well so the other thing is for your for your blood sugar here i see that you know you're running a bit high as well it looks like you're like you're about one seventy this morning and i i i i assume that you were fasting last night is that right okay so that's that's a little higher than what we want it's not bad it's below two hundred but it's getting kinda close to the borderline from where our limit is so we will take we take a look at that and also we'll figure out what we can do with that as well alright so at this point how about are you how is how is work how is life it's been good otherwise how's the family [Patient] they are good i did eat a lot of my kids easter candy over the weekend so maybe that's why my sugar is high[SEP][Other Socials][Doctor] okay alright great alright alright just just around easter okay not not too much during the the year hopefully [Patient] yeah i try[SEP]
|
[
"Physical Examination",
"Discussion",
"Follow-up",
"Medication",
"Other Treatments",
"Acute Assessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,880
|
[Chitchat][Doctor] it was amazing my wife and i went over there the other day and when we walked downstairs it was like i was walking into a scene out of saprano's [Patient] mm-hmm[SEP][Chitchat][Doctor] but the food was amazing it was the best egg plant parmer's john i've i've ever had where really super excited about going back there here very very soon [Patient] yeah i had the bio marsal and it was my gosh it was to die for[SEP][Drug History][Drug History][Doctor] i'll have to get that next time i go so in reviewing your paperwork here it looks like you made mention that you smoke are you still smoking about a pack a day [Patient] yeah i i tried i've tried i've done hypnosis i've done lozenges i've done chewing gum and i get real close but you know i'll just go out one evening without the wife and and the next thing i know i'm i'm you know buying a cigarette off of somebody and it's it's really hard for me to get that stopped[SEP][Therapeutic History][Drug History][Doctor] yeah i i appreciate that but it's really gon na be important that you try to to either cut back or quit smoking altogether now that leads me into my next concern here it looks like you have a history of high blood pressure and i'm just wondering are you are you taking your blood pressure medication as prescribed and and are you checking your blood pressures on a regular basis [Patient] i'm glad you just mentioned that because i have n't taken my blood pressure pill for a while it's up in the cupboard and it's back in that corner and i just i ca n't forget to take it[SEP]
|
[
"Therapeutic History",
"Physical Examination"
] |
[
"Subjective",
"Objective"
] | 3,881
|
[Chitchat][Doctor] it was amazing my wife and i went over there the other day and when we walked downstairs it was like i was walking into a scene out of saprano's [Patient] mm-hmm[SEP][Chitchat][Doctor] but the food was amazing it was the best egg plant parmer's john i've i've ever had where really super excited about going back there here very very soon [Patient] yeah i had the bio marsal and it was my gosh it was to die for[SEP][Drug History][Drug History][Doctor] i'll have to get that next time i go so in reviewing your paperwork here it looks like you made mention that you smoke are you still smoking about a pack a day [Patient] yeah i i tried i've tried i've done hypnosis i've done lozenges i've done chewing gum and i get real close but you know i'll just go out one evening without the wife and and the next thing i know i'm i'm you know buying a cigarette off of somebody and it's it's really hard for me to get that stopped[SEP][Therapeutic History][Drug History][Doctor] yeah i i appreciate that but it's really gon na be important that you try to to either cut back or quit smoking altogether now that leads me into my next concern here it looks like you have a history of high blood pressure and i'm just wondering are you are you taking your blood pressure medication as prescribed and and are you checking your blood pressures on a regular basis [Patient] i'm glad you just mentioned that because i have n't taken my blood pressure pill for a while it's up in the cupboard and it's back in that corner and i just i ca n't forget to take it[SEP][Therapeutic History][Physical Examination][Doctor] okay it's really gon na be important that you take your medication for your blood pressure as prescribed i'd really like to see you start doing that today and then let's let's go ahead and and let's set that that pill bottle down on the counter and see if that does n't help you remember to take that blood pressure medicine if it's okay with you i would like to do a a quick physical exam on your eyes i'm gon na go ahead and take off your glasses and put your chin here in the chin rest for me [Patient] okay that's a bright light[SEP]
|
[
"Physical Examination",
"Acute Assessment",
"Medication"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,882
|
[Vegetative History][Doctor] no fever alright what about any other symptoms like any body aches any sore throat sinus pain [Patient] well i mean now that you mentioned it like every time i swallow it hurts it does n't feel like i have a cold because it hurts down here more in my chest but every time i swallow it it's really painful[SEP][Vegetative History][Doctor] okay so when you are swallowing i know some of my patients feel this do you feel like the food is getting stuck [Patient] no the food is not getting stuck it just hurts[SEP][Vegetative History][Doctor] okay what about when you're you're taking liquids are you able to take in both hydrocort liquids [Patient] i mean i definitely feel like over the weekend i have n't been taking it as much because it hurt so much but i i am able to i am able to drink and i've been taking ensure and things like that i had a milk shake[SEP][Other Socials][Doctor] okay that's that's that's that's good yeah we we definitely want you to to take in as much liquid as possible best especially since you're on the chemotherapy and the radiation just so you wo n't get dehydrated because that will make you feel a lot worse if you are dehydrated okay so on a on a mental emotional standpoint i know you said you have your husband with you how you doing with that you have the support that you need you need to speak to me though [Patient] it's very helpful you know as you can understand i'm just like devastated when i got this diagnosis and i'm just i'm just trying to figure everything out and but he is very good and my daughter is is very helpful too and i you know i think for the most part i'm very fortunate to have them[SEP][Therapeutic History][Doctor] okay so how how are you feeling on your chemo see you're on a combination of sysplatin and a topicide you had your last dose a few days ago any nausea any fatigue from that [Patient] i was a little nauseated and tired but i took the zofran that you prescribed and that seemed to help and you know i i got some rest it's it's it's been okay[SEP]
|
[
"Physical Examination",
"Medication",
"Therapeutic History",
"Radiology Examination",
"Reassessment",
"Other Treatments"
] |
[
"Assessment",
"Plan",
"Subjective",
"Objective"
] | 3,883
|
[Vegetative History][Doctor] okay so when you are swallowing i know some of my patients feel this do you feel like the food is getting stuck [Patient] no the food is not getting stuck it just hurts[SEP][Vegetative History][Doctor] okay what about when you're you're taking liquids are you able to take in both hydrocort liquids [Patient] i mean i definitely feel like over the weekend i have n't been taking it as much because it hurt so much but i i am able to i am able to drink and i've been taking ensure and things like that i had a milk shake[SEP][Other Socials][Doctor] okay that's that's that's that's good yeah we we definitely want you to to take in as much liquid as possible best especially since you're on the chemotherapy and the radiation just so you wo n't get dehydrated because that will make you feel a lot worse if you are dehydrated okay so on a on a mental emotional standpoint i know you said you have your husband with you how you doing with that you have the support that you need you need to speak to me though [Patient] it's very helpful you know as you can understand i'm just like devastated when i got this diagnosis and i'm just i'm just trying to figure everything out and but he is very good and my daughter is is very helpful too and i you know i think for the most part i'm very fortunate to have them[SEP][Therapeutic History][Doctor] okay so how how are you feeling on your chemo see you're on a combination of sysplatin and a topicide you had your last dose a few days ago any nausea any fatigue from that [Patient] i was a little nauseated and tired but i took the zofran that you prescribed and that seemed to help and you know i i got some rest it's it's it's been okay[SEP][Physical Examination][Medication][Therapeutic History][Radiology Examination][Reassessment][Other Treatments][Doctor] okay that's good so let me do a quick physical exam on you just gon na check your vitals here so your vitals are normal your pulse ox is okay so everything's good with that so i'm gon na feel your neck on your neck exam i do n't appreciate any cervical lymphadenopathy no subclavicular adenopathy your heart exam regular rate and rhythm no murmur your lung exam so i do notice some crackles in your lungs bilaterally that's just a faint sound we hear when you take a deep breath so that could mean you have some fluid in there and that is to be expected due to your lung cancer diagnosis so i'm gon na look at your skin exam so on your skin exam on your chest i do see some erythema on the anterior aspect of your chest on the left side and that could be due to that radiation sometimes patients do get a radiation burn and it's it'll get better with time especially once you're done with the the radiation treatment and on your extremity it there is no lower extremity edema in your legs so prior to coming to see me you did get a chest x-ray it looks like you do have mild radiation umitis that means you have inflammation of your lungs due to the radiation so let's talk a little bit about my assessment and plan for you so your first diagnosis you know is is the lung cancer so we are gon na continue you on that chemo regimen on that you do have continue on that that current radiation doses i think you're on forty five grade yep you're on that and then when the when the regimen's complete we'll do some more testing and hopefully we can see a resection of that tumor so that has just gotten little smaller and we can go inside and and take it out so for your second diagnosis the radiation pneumonitis i'm gon na prescribe you a low dose steroid prednisone forty milligrams one tablet a day for five days have you been on on a steroids before [Patient] no i've only ever heard bad things about them they make people jittery and gain weight[SEP]
|
[
"Discussion",
"Medication",
"Other Treatments",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 3,884
|
[Personal History][Doctor] okay alright and i'm reading here it looks like you've had them before as well right [Patient] i have yeah i passed some by myself and i've had to have surgery a couple of times as well[SEP][Personal History][Doctor] okay so the ones that you passed by yourself how many days would you say it would take to to pass [Patient] usually within within a week i manage to to get them out[SEP][Other Socials][Doctor] okay alright so you got anything fun plan for the weekend [Patient] just getting this pain under control[SEP][Physical Examination][Doctor] okay well that that sounds like a good plan we can definitely help you out with that alright so i'm gon na do a quick physical exam on you looks like your blood pressure is a little bit elevated and i think that's probably because you're in pain and that's understandable everything else looks fine so on pressing on your abdomen does that hurt [Patient] no no no pain[SEP][Physical Examination][Doctor] alright so press here in the back and your cva does that back here in [Patient] yeah it's a little tender yeah it's little tender[SEP]
|
[
"Physical Examination",
"Discussion",
"Medication",
"Radiology Examination",
"Reassessment"
] |
[
"Assessment",
"Plan",
"Objective"
] | 3,885
|
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