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aci_bench_intent_annotated

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doctor: so , james , what happened to your back ? patient: uh , i was golfing and i hurt my back when i went for my backswing .
D2N004
4
[ "Acute Symptoms" ]
[ "Subjective" ]
so , james , what happened to your back ?
100
doctor: okay . and did you feel a pop or a strain immediately or ? patient: i f- felt the pop , and i immediately had to hit the ground . i had to just try and do anything to loosen up my back .
D2N004
5
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . and did you feel a pop or a strain immediately or ?
101
doctor: okay . and how long ago did this happen ? patient: this was saturday morning .
D2N004
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . and how long ago did this happen ?
102
doctor: okay . so , about four days ago ? patient: mm-hmm .
D2N004
7
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . so , about four days ago ?
103
doctor: okay . um , and what have you taken for the pain ? patient: uh , i took some tylenol . i took some ibuprofen .
D2N004
8
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay . um , and what have you taken for the pain ?
104
doctor: mm-hmm . patient: i tried ice . i tried heat , but nothing really worked .
D2N004
9
[ "Therapeutic History" ]
[ "Subjective" ]
mm-hmm .
105
doctor: okay . and , h- how are you feeling now ? are you still in the same amount of pain ? patient: uh , by monday morning , it loosened up a little bit , but it's still pretty sore .
D2N004
10
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . and , h- how are you feeling now ? are you still in the same amount of pain ?
106
doctor: okay . any other symptoms like leg weakness , pain in one leg , numbing or tingling ? patient: uh , i actually felt , um ... i had a struggle in my right foot like dropped foot . i had some struggling with my right leg . i felt that for a while , and it got a little bit better this morning but not much .
D2N004
11
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . any other symptoms like leg weakness , pain in one leg , numbing or tingling ?
107
doctor: okay . all right . um , so , are you ... how are you doing walking around ? patient: uh , uh , uh , i'm , i'm not going anywhere fast or doing anything strenuous but i can walk around a little bit .
D2N004
12
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . all right . um , so , are you ... how are you doing walking around ?
108
doctor: all right . okay . um , and any history with your back in the past ? patient: i actually had surgery about 10 years ago on my lower back .
D2N004
14
[ "Personal History" ]
[ "Subjective" ]
all right . okay . um , and any history with your back in the past ?
109
doctor: okay . all right . now , tell me a little bit about your , your heart failure . you know , i have n't seen you in a while . patient: mm-hmm .
D2N004
15
[ "Personal History" ]
[ "Subjective" ]
okay . all right . now , tell me a little bit about your , your heart failure . you know , i have n't seen you in a while .
110
doctor: how are you doing with your diet ? patient: um , been pretty good t- taking my medications , watching my diet , trying to , uh , trying to exercise regularly , too .
D2N004
16
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
how are you doing with your diet ?
111
doctor: okay . so , you're avoiding the salty foods like we had talked about ? patient: yes .
D2N004
17
[ "Vegetative History" ]
[ "Subjective" ]
okay . so , you're avoiding the salty foods like we had talked about ?
112
doctor: okay . and any weight gain or swelling in your legs recently ? patient: a little bit of weight gain over the summer but nothing , nothing too radical , nothing more than five pounds .
D2N004
18
[ "Personal History", "Vegetative History" ]
[ "Subjective" ]
okay . and any weight gain or swelling in your legs recently ?
113
doctor: okay . all right . and any problems laying flat while you go to bed ? patient: no .
D2N004
19
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . all right . and any problems laying flat while you go to bed ?
114
doctor: okay . uh , and lastly , what about your diabetes ? how are you doing with , with that diet ? i remember you have somewhat of a sweet tooth . patient: yeah .
D2N004
20
[ "Personal History" ]
[ "Subjective" ]
okay . uh , and lastly , what about your diabetes ? how are you doing with , with that diet ? i remember you have somewhat of a sweet tooth .
115
doctor: jelly beans ? patient: i love jelly beans , yeah , yeah . that's been a struggle , but i'm getting through it .
D2N004
21
[ "Chitchat" ]
[ "Null" ]
jelly beans ?
116
doctor: okay . all right . um , and you're watching your blood sugars at home ? patient: mm-hmm . i monitor it regularly . not always, i can forget, , but i'm pretty good about my measuring it .
D2N004
22
[ "Personal History" ]
[ "Subjective" ]
okay . all right . um , and you're watching your blood sugars at home ?
117
doctor: okay . and you are still on your metformin ? patient: yes .
D2N004
23
[ "Therapeutic History" ]
[ "Subjective" ]
okay . and you are still on your metformin ?
118
doctor: okay . all right . all right . now , i know the nurse did a review of symptoms sheet when you checked in . patient: mm-hmm .
D2N004
24
[ "Discussion" ]
[ "Objective" ]
okay . all right . all right . now , i know the nurse did a review of symptoms sheet when you checked in .
119
doctor: i know that you were endorsing the back pain- patient: mm-hmm .
D2N004
25
[ "Acute Symptoms" ]
[ "Subjective", "Objective" ]
i know that you were endorsing the back pain-
120
doctor: . and maybe a little weakness in your right leg . um , any other symptoms ? i know we went through a lot . patient: no .
D2N004
26
[ "Acute Symptoms" ]
[ "Subjective" ]
. and maybe a little weakness in your right leg . um , any other symptoms ? i know we went through a lot .
121
doctor: okay . um , so , i wan na go ahead and move on to a physical exam , okay ? patient: mm-hmm .
D2N004
27
[ "Discussion" ]
[ "Objective" ]
okay . um , so , i wan na go ahead and move on to a physical exam , okay ?
122
doctor: hey , dragon , show me the vital signs . so , here in the office , you know , your vital signs look great . they look completely normal , which , which is really good . patient: good .
D2N004
28
[ "Physical Examination" ]
[ "Objective" ]
hey , dragon , show me the vital signs . so , here in the office , you know , your vital signs look great . they look completely normal , which , which is really good .
123
doctor: okay ? so , i'm just gon na check you out , and i'm gon na let you know what i find , okay ? patient: mm-hmm .
D2N004
29
[ "Discussion" ]
[ "Objective" ]
okay ? so , i'm just gon na check you out , and i'm gon na let you know what i find , okay ?
124
doctor: lean up . okay . all right . so , on your physical exam , everything seems fine . patient: good .
D2N004
30
[ "Physical Examination" ]
[ "Objective" ]
lean up . okay . all right . so , on your physical exam , everything seems fine .
125
doctor: on your heart exam , i do appreciate a 2 out of 6 systolic ejection murmur , which we've heard in the past- patient: mm-hmm .
D2N004
31
[ "Physical Examination" ]
[ "Objective" ]
on your heart exam , i do appreciate a 2 out of 6 systolic ejection murmur , which we've heard in the past-
126
doctor: . so that's stable . patient: okay .
D2N004
32
[ "Physical Examination" ]
[ "Objective" ]
. so that's stable .
127
doctor: on your back exam , you do have some pain to palpation of the lumbar 5 or lumbar spine- patient: mm-hmm .
D2N004
33
[ "Physical Examination" ]
[ "Objective" ]
on your back exam , you do have some pain to palpation of the lumbar 5 or lumbar spine-
128
doctor: at the level of l5 . patient: okay .
D2N004
34
[ "Physical Examination" ]
[ "Objective" ]
at the level of l5 .
129
doctor: you have , you know , decreased range of motion with flexion and extension , and , um , you have a positive straight leg raise . uh , for your strength , you do have a 4 out of 5 on your right and 5 out of 5 on your left . so , what does that mean ? what does all that mean ? so , that basically means that , you know , i , i think that you probably , you know , have injured your , your back with a muscle strain , but we're gon na look at some of your results , okay ? patient: okay , sure .
D2N004
35
[ "Physical Examination", "Acute Assessment" ]
[ "Objective", "Assessment" ]
you have , you know , decreased range of motion with flexion and extension , and , um , you have a positive straight leg raise . uh , for your strength , you do have a 4 out of 5 on your right and 5 out of 5 on your left . so , what does that mean ? what does all that mean ? so , that basically means that , you know , i , i think that you probably , you know , have injured your , your back with a muscle strain , but we're gon na look at some of your results , okay ?
130
doctor: hey , dragon , show me the back x-ray . so , in reviewing the results of your back x-ray , this is a normal x-ray of your lumbar spine . there's good boney alignment . i do n't see any abnormality there , which is not surprising based on the history , okay ? hey , dragon , show me the diabetic labs . and this is just ... i just wanted to check your last , uh , diabetic labs that we did on you . uh , it looks like your hemoglobin a1c has been a little high at 8 . i'd like to see that a little bit lower around 7 , okay ? patient: okay .
D2N004
36
[ "Lab Examination", "Radiology Examination" ]
[ "Objective" ]
hey , dragon , show me the back x-ray . so , in reviewing the results of your back x-ray , this is a normal x-ray of your lumbar spine . there's good boney alignment . i do n't see any abnormality there , which is not surprising based on the history , okay ? hey , dragon , show me the diabetic labs . and this is just ... i just wanted to check your last , uh , diabetic labs that we did on you . uh , it looks like your hemoglobin a1c has been a little high at 8 . i'd like to see that a little bit lower around 7 , okay ?
131
doctor: um , so , let's just talk a little bit about my assessment and my plan for you . um , so , for your first problem , i think you have an acute lumbar , um , strain . patient: mm-hmm .
D2N004
37
[ "Acute Assessment" ]
[ "Assessment" ]
um , so , let's just talk a little bit about my assessment and my plan for you . um , so , for your first problem , i think you have an acute lumbar , um , strain .
132
doctor: and i wan na go ahead and prescribe meloxicam 15 milligrams once a day , and i'd like to refer you to physical therapy to kind of strengthen that area . now , if you're still having symptoms , i wan na go ahead and , uh , order an mri- patient: mm-hmm .
D2N004
38
[ "Follow-up", "Medication", "Referral", "Diagnostic Testing" ]
[ "Plan" ]
and i wan na go ahead and prescribe meloxicam 15 milligrams once a day , and i'd like to refer you to physical therapy to kind of strengthen that area . now , if you're still having symptoms , i wan na go ahead and , uh , order an mri-
133
doctor: . just to make sure that you do n't have any disc herniation or anything like that , okay ? patient: that's fine .
D2N004
39
[ "Discussion" ]
[ "Plan" ]
. just to make sure that you do n't have any disc herniation or anything like that , okay ?
134
doctor: how does that sound ? patient: no problem .
D2N004
40
[ "Chitchat" ]
[ "Null" ]
how does that sound ?
135
doctor: hey , dragon , order meloxicam 15 milligrams once a day . for your next problem , your type 2 diabetes , i would like to increase your metformin to 1,000 milligrams twice daily- patient: mm-hmm .
D2N004
41
[ "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
hey , dragon , order meloxicam 15 milligrams once a day . for your next problem , your type 2 diabetes , i would like to increase your metformin to 1,000 milligrams twice daily-
136
doctor: . and i wan na go ahead and order another hemoglobin a1c in a couple weeks , or , i'm sorry , a couple months . patient: okay .
D2N004
42
[ "Follow-up", "Diagnostic Testing" ]
[ "Plan" ]
. and i wan na go ahead and order another hemoglobin a1c in a couple weeks , or , i'm sorry , a couple months .
137
doctor: all right ? hey , dragon , order a hemoglobin a1c . and for your congestive heart failure , uh , i think you're doing really well with it . um , you know , i wan na just continue you on your current medications , your lisinopril and your lasix . now , do you need a refill- patient: actually , i-
D2N004
43
[ "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
all right ? hey , dragon , order a hemoglobin a1c . and for your congestive heart failure , uh , i think you're doing really well with it . um , you know , i wan na just continue you on your current medications , your lisinopril and your lasix . now , do you need a refill-
138
doctor: of the lisinopril ? patient: actually , i do .
D2N004
44
[ "Medication" ]
[ "Plan" ]
of the lisinopril ?
139
doctor: okay . hey , dragon , order a refill of lisinopril 20 milligrams once a day . and so , the nurse will come in . she's gon na help you get checked out . i wan na see you again in a couple weeks , okay ? patient: that's fine .
D2N004
45
[ "Follow-up", "Medication" ]
[ "Plan" ]
okay . hey , dragon , order a refill of lisinopril 20 milligrams once a day . and so , the nurse will come in . she's gon na help you get checked out . i wan na see you again in a couple weeks , okay ?
140
doctor: um , any questions ? patient: not at this point .
D2N004
46
[ "Chitchat", "Discussion" ]
[ "Plan" ]
um , any questions ?
141
doctor: okay . hey , dragon , finalize the note .
D2N004
47
[ "Chitchat" ]
[ "Null" ]
doctor: okay . hey , dragon , finalize the note .
142
doctor: hey , ms. hill . nice to see you . patient: hi , dr. james , good to see you .
D2N005
0
[ "Greetings" ]
[ "Subjective" ]
hey , ms. hill . nice to see you .
143
doctor: hey , dragon , i'm seeing ms. hill . she's a 41-year-old female , and what brings you in today ? patient: um , i am having a lot of pain at the end of my right middle finger .
D2N005
1
[ "Greetings" ]
[ "Subjective" ]
hey , dragon , i'm seeing ms. hill . she's a 41-year-old female , and what brings you in today ?
144
doctor: what did you do ? patient: a little embarrassing . um , i got rear-ended , slow motor , uh , vehicle accident , and i got really angry with the person who hit me , so i went to flip him the bird , but i was a little too enthusiastic and i hit the ceiling of the car .
D2N005
2
[ "Acute Symptoms" ]
[ "Subjective" ]
what did you do ?
145
doctor: okay . when did this happen ? patient: uh , it was saturday , so about four , five days ago .
D2N005
3
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . when did this happen ?
146
doctor: five days ago . what were you doing ? were you , like , stopped at a stoplight ? a stop sign ? patient: yes . so i was stopped at a four-way stop , and it was not my turn to go . there were other cars going , and the person behind me just was n't watching . i think they were texting and rear-ended me .
D2N005
4
[ "Acute Symptoms" ]
[ "Subjective" ]
five days ago . what were you doing ? were you , like , stopped at a stoplight ? a stop sign ?
147
doctor: how much damage to your car ? patient: uh , not too much . the , the trunk crumpled up a little bit .
D2N005
5
[ "Chitchat" ]
[ "Null" ]
how much damage to your car ?
148
doctor: okay . and no other injuries ? just the finger ? patient: just the middle finger .
D2N005
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . and no other injuries ? just the finger ?
149
doctor: so you would've escaped this accident without any injuries ? patient: yes . uh , i'm not proud .
D2N005
7
[ "Acute Symptoms" ]
[ "Subjective" ]
so you would've escaped this accident without any injuries ?
150
doctor: okay . um , so four days of right middle finger pain- patient: yes .
D2N005
8
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . um , so four days of right middle finger pain-
151
doctor: . after a motor vehicle accident . patient: yes .
D2N005
9
[ "Acute Symptoms" ]
[ "Subjective" ]
. after a motor vehicle accident .
152
doctor: all right . um , let's look at your x-ray . hey , dragon , show me the last x-ray . so what i'm seeing here is on the tip of this middle finger , you actually have a fracture . so you have a distal phalanx fracture in the middle finger . very ... patient: great .
D2N005
10
[ "Acute Assessment", "Radiology Examination" ]
[ "Objective", "Assessment" ]
all right . um , let's look at your x-ray . hey , dragon , show me the last x-ray . so what i'm seeing here is on the tip of this middle finger , you actually have a fracture . so you have a distal phalanx fracture in the middle finger . very ...
153
doctor: very interesting . let me check it out . um , so does it hurt when i push right here ? patient: yes .
D2N005
11
[ "Acute Symptoms", "Physical Examination" ]
[ "Subjective", "Objective" ]
very interesting . let me check it out . um , so does it hurt when i push right here ?
154
doctor: and does that hurt ? patient: very much so .
D2N005
12
[ "Acute Symptoms", "Physical Examination" ]
[ "Subjective", "Objective" ]
and does that hurt ?
155
doctor: what about down here ? patient: no .
D2N005
13
[ "Acute Symptoms", "Physical Examination" ]
[ "Subjective", "Objective" ]
what about down here ?
156
doctor: okay . so generally , your exam is normal other than you've got tenderness over your distal phalanx of your right middle finger . um , so your diagnosis is distal phalanx fracture of the middle finger or the third finger . and i'm gon na put you on a little bit of pain medicine just to help , just , like , two days' worth . okay , so tramadol , 50 milligrams , every six hours as needed for pain . i'm gon na dispense eight of those . patient: okay .
D2N005
14
[ "Discussion", "Acute Assessment", "Medication" ]
[ "Assessment", "Plan" ]
okay . so generally , your exam is normal other than you've got tenderness over your distal phalanx of your right middle finger . um , so your diagnosis is distal phalanx fracture of the middle finger or the third finger . and i'm gon na put you on a little bit of pain medicine just to help , just , like , two days' worth . okay , so tramadol , 50 milligrams , every six hours as needed for pain . i'm gon na dispense eight of those .
157
doctor: and then , um , i'm gon na put you in a finger splint and have you come back in two weeks to get a follow-up x-ray . any questions for me ? patient: yes . so i'm taking digoxin for afib . will the tramadol be okay with that ?
D2N005
15
[ "Discussion", "Diagnostic Testing", "Follow-up", "Other Treatments" ]
[ "Plan" ]
and then , um , i'm gon na put you in a finger splint and have you come back in two weeks to get a follow-up x-ray . any questions for me ?
158
doctor: it will be okay . so you have atrial fibrillation . patient: yes .
D2N005
16
[ "Discussion", "Personal History" ]
[ "Subjective", "Plan" ]
it will be okay . so you have atrial fibrillation .
159
doctor: you take digoxin . all right . any other questions for me ? patient: no , that's it . thank you .
D2N005
17
[ "Therapeutic History", "Discussion", "Chitchat" ]
[ "Subjective", "Plan" ]
you take digoxin . all right . any other questions for me ?
160
doctor: you're welcome . hey , dragon , go ahead and finalize the recording , and , uh , come with me . we'll get you checked out .
D2N005
18
[ "Chitchat" ]
[ "Null" ]
doctor: you're welcome . hey , dragon , go ahead and finalize the recording , and , uh , come with me . we'll get you checked out .
161
doctor: hi , anna . how are you ? patient: i'm doing okay . how are you ?
D2N006
0
[ "Greetings" ]
[ "Subjective" ]
hi , anna . how are you ?
162
doctor: i'm doing okay . so i know the nurse told you about dax . i'd like to tell dax a little bit about you . patient: all right .
D2N006
1
[ "Chitchat" ]
[ "Null" ]
i'm doing okay . so i know the nurse told you about dax . i'd like to tell dax a little bit about you .
163
doctor: so , anna is a 44-year-old female with a past medical history significant for arthritis , gout , and reflux , who presents today for follow up of her chronic problems . so , anna , it's been probably about six months since i've seen you . how are you doing ? patient: i'm doing okay . um , my arthritis is starting to get better . um , i've been trying to move my body , doing pilates , lifting weights , um , and that's , kind of , helped me build up some muscle , so the joint pain is , has been going away .
D2N006
2
[ "Personal History" ]
[ "Subjective" ]
so , anna is a 44-year-old female with a past medical history significant for arthritis , gout , and reflux , who presents today for follow up of her chronic problems . so , anna , it's been probably about six months since i've seen you . how are you doing ?
164
doctor: okay . yeah . i know you were having , you know , some problems with your right knee , uh , and we sent you for physical therapy . so , so that's going well ? patient: yeah . the physical therapy's gone really well . i've built up my strength back and it's been really great .
D2N006
3
[ "Personal History" ]
[ "Subjective" ]
okay . yeah . i know you were having , you know , some problems with your right knee , uh , and we sent you for physical therapy . so , so that's going well ?
165
doctor: okay . so you feel like you're able to walk a little bit further now ? patient: yup . i'm walking about a mile , a mile and a half a day .
D2N006
4
[ "Personal History" ]
[ "Subjective" ]
okay . so you feel like you're able to walk a little bit further now ?
166
doctor: okay . great . that's good . i'm glad to hear that . okay . and then , in terms of your gout , um , how are you doing with that ? i know you had an episode of gout of your , your right first big toe , um , about two months ago . how are you doing with that ? patient: i'm doing , doing well . the medication helped it , you know , go down and go away . hopefully , , it does n't come back .
D2N006
5
[ "Personal History" ]
[ "Subjective" ]
okay . great . that's good . i'm glad to hear that . okay . and then , in terms of your gout , um , how are you doing with that ? i know you had an episode of gout of your , your right first big toe , um , about two months ago . how are you doing with that ?
167
doctor: okay . and are you taking the allopurinol that i prescribed ? patient: yes .
D2N006
6
[ "Therapeutic History" ]
[ "Subjective" ]
okay . and are you taking the allopurinol that i prescribed ?
168
doctor: okay . and no issues with that ? patient: nope .
D2N006
7
[ "Therapeutic History" ]
[ "Subjective" ]
okay . and no issues with that ?
169
doctor: okay . great . um , no further flare ups ? patient: no .
D2N006
8
[ "Personal History" ]
[ "Subjective" ]
okay . great . um , no further flare ups ?
170
doctor: okay . great . all right . and then , you know , how about your reflux ? we had placed you on , um , omeprazole , you know , to help with some of those symptoms and i know that you were gon na do some dietary modifications . how are you doing with that ? patient: so , i started to make some dietary modifications . unfortunately , i have n't cut the stone out quite yet . um , i've still been having some episodes and , and throwing up in the mornings , um , things like that .
D2N006
9
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
okay . great . all right . and then , you know , how about your reflux ? we had placed you on , um , omeprazole , you know , to help with some of those symptoms and i know that you were gon na do some dietary modifications . how are you doing with that ?
171
doctor: you're throwing up in the morning ? patient: yup .
D2N006
10
[ "Vegetative History" ]
[ "Subjective" ]
you're throwing up in the morning ?
172
doctor: like , just , like , reflux into your throat or are you actually vomiting ? patient: um , actually vomiting .
D2N006
11
[ "Vegetative History" ]
[ "Subjective" ]
like , just , like , reflux into your throat or are you actually vomiting ?
173
doctor: okay . that's a problem . patient: yup .
D2N006
12
[ "Chitchat" ]
[ "Null" ]
okay . that's a problem .
174
doctor: all right . well , um , let's talk about any other symptoms that you might have . have you had any abdominal pain ? um , diarrhea ? um , do you feel like your belly's bigger than usual ? patient: um , the , the first and the last . so , i've been having some abdominal pain and then i feel like i'm bloated all the time .
D2N006
13
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
all right . well , um , let's talk about any other symptoms that you might have . have you had any abdominal pain ? um , diarrhea ? um , do you feel like your belly's bigger than usual ?
175
doctor: okay . and when was your last bowel movement ? patient: uh , probably two days ago .
D2N006
14
[ "Vegetative History" ]
[ "Subjective" ]
okay . and when was your last bowel movement ?
176
doctor: okay . was it normal ? patient: yes .
D2N006
15
[ "Vegetative History" ]
[ "Subjective" ]
okay . was it normal ?
177
doctor: okay . any blood ? patient: no .
D2N006
16
[ "Vegetative History" ]
[ "Subjective" ]
okay . any blood ?
178
doctor: okay . all right . and any weight loss ? anything like that ? patient: no , not that i've noticed .
D2N006
17
[ "Vegetative History" ]
[ "Subjective" ]
okay . all right . and any weight loss ? anything like that ?
179
doctor: okay . and any fever or chills ? patient: no .
D2N006
18
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . and any fever or chills ?
180
doctor: okay . all right . uh , well , sounds like we just did the review of systems with you . it sounds like you're endorsing this , you know , nausea , vomiting , abdominal distension . um , any other symptoms ? patient: no .
D2N006
19
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
okay . all right . uh , well , sounds like we just did the review of systems with you . it sounds like you're endorsing this , you know , nausea , vomiting , abdominal distension . um , any other symptoms ?
181
doctor: no ? okay . all right . well , i wan na go ahead and do a quick physical exam . okay ? hey , dragon , show me the vital signs . all right . well , your , your vital signs here look quite good . all right . so , i'm , i'm reassured by that . i'm just gon na check out your heart and lungs and your belly and , and l- let you know what i find , okay ? patient: okay .
D2N006
20
[ "Physical Examination" ]
[ "Objective" ]
no ? okay . all right . well , i wan na go ahead and do a quick physical exam . okay ? hey , dragon , show me the vital signs . all right . well , your , your vital signs here look quite good . all right . so , i'm , i'm reassured by that . i'm just gon na check out your heart and lungs and your belly and , and l- let you know what i find , okay ?
182
doctor: all right . so , on physical examination , you know , everything looks good . your heart sounds good . your lungs sound good . you know , on your abdominal exam , you do have some pain to your right upper quadrant when i press on it , um , and there's no rebound or guarding and there's no peritoneal signs and your right knee does show a little bit of , uh , an effusion there and there's , uh , some slight pain to palpation and some decreased range of motion . so what does that mean , you know ? that means that you have some findings on your belly exam that concern me about your gall bladder , okay ? so , we'll have to look into that and then , um , your right knee looks a little swollen , but you know , we know you have some arthritis there , okay ? patient: okay .
D2N006
21
[ "Physical Examination" ]
[ "Objective" ]
all right . so , on physical examination , you know , everything looks good . your heart sounds good . your lungs sound good . you know , on your abdominal exam , you do have some pain to your right upper quadrant when i press on it , um , and there's no rebound or guarding and there's no peritoneal signs and your right knee does show a little bit of , uh , an effusion there and there's , uh , some slight pain to palpation and some decreased range of motion . so what does that mean , you know ? that means that you have some findings on your belly exam that concern me about your gall bladder , okay ? so , we'll have to look into that and then , um , your right knee looks a little swollen , but you know , we know you have some arthritis there , okay ?
183
doctor: let's take a look at some of your results . hey , dragon , show me the autoimmune panel . hey , dragon , show me the autoimmune labs . okay . so looking at your autoimmune panel here , you know , we sent that because , you know , you're young and you have , you know , arthritis and gout and that type of thing and everything seemed to be fine . patient: okay .
D2N006
22
[ "Lab Examination" ]
[ "Objective" ]
let's take a look at some of your results . hey , dragon , show me the autoimmune panel . hey , dragon , show me the autoimmune labs . okay . so looking at your autoimmune panel here , you know , we sent that because , you know , you're young and you have , you know , arthritis and gout and that type of thing and everything seemed to be fine .
184
doctor: hey , dragon , show me the right knee x-ray . so , looking here at your right knee x-ray , you know , there's no fracture or anything , but you know , it does show that you do have that residual arthritis there , um , that we're , you know , we're working on improving so that we do n't have to do some type of surgery or intervention , okay ? patient: okay .
D2N006
23
[ "Radiology Examination" ]
[ "Objective" ]
hey , dragon , show me the right knee x-ray . so , looking here at your right knee x-ray , you know , there's no fracture or anything , but you know , it does show that you do have that residual arthritis there , um , that we're , you know , we're working on improving so that we do n't have to do some type of surgery or intervention , okay ?
185
doctor: so let's talk a little bit about my assessment and plan for you , okay ? so , for your first problem , um , your reflux and your nausea and vomiting , uh , i wan na go ahead and get a right upper quadrant ultrasound to rule out any gallstones , okay ? um , and then i'm gon na check some labs on you . okay ? patient: okay .
D2N006
24
[ "Follow-up", "Diagnostic Testing", "Acute Assessment" ]
[ "Assessment", "Plan" ]
so let's talk a little bit about my assessment and plan for you , okay ? so , for your first problem , um , your reflux and your nausea and vomiting , uh , i wan na go ahead and get a right upper quadrant ultrasound to rule out any gallstones , okay ? um , and then i'm gon na check some labs on you . okay ?
186
doctor: i want you to continue on the omeprazole , 40 milligrams , once a day and continue with those dietary modifications . um , for your second problem , your gout , um , you know , everything seems controlled right now . let's continue you on the allopurinol , 100 milligrams , once a day . um , do you need a refill of that ? patient: yes , i do actually .
D2N006
25
[ "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
i want you to continue on the omeprazole , 40 milligrams , once a day and continue with those dietary modifications . um , for your second problem , your gout , um , you know , everything seems controlled right now . let's continue you on the allopurinol , 100 milligrams , once a day . um , do you need a refill of that ?
187
doctor: hey , dragon , order allopurinol , 100 milligrams , once daily . and then from your last problem , your arthritis , i'm very pleased with how your right knee is doing and i want you to continue pilates and using the knee and let me know if you have any issues and we can , and we can talk about further imaging or intervention at that time , okay ? patient: okay .
D2N006
26
[ "Discussion", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
hey , dragon , order allopurinol , 100 milligrams , once daily . and then from your last problem , your arthritis , i'm very pleased with how your right knee is doing and i want you to continue pilates and using the knee and let me know if you have any issues and we can , and we can talk about further imaging or intervention at that time , okay ?
188
doctor: any questions ? patient: uh , no . that's it .
D2N006
27
[ "Chitchat" ]
[ "Null" ]
any questions ?
189
doctor: okay . great . hey , dragon , finalize the note .
D2N006
28
[ "Chitchat" ]
[ "Null" ]
doctor: okay . great . hey , dragon , finalize the note .
190
doctor: and why is she here ? annual exam . okay . all right . hi , sarah . how are you ? patient: good . how are you ?
D2N007
0
[ "Greetings" ]
[ "Subjective" ]
and why is she here ? annual exam . okay . all right . hi , sarah . how are you ?
191
doctor: i'm good . are you ready to get started ? patient: yes , i am .
D2N007
1
[ "Chitchat" ]
[ "Null" ]
i'm good . are you ready to get started ?
192
doctor: okay . so sarah is a 27-year-old female here for her annual visit . so , sarah , how have you been since the last time i saw you ? patient: i've been doing better . um , i've been struggling with my depression , um , a bit more just because we've been trapped really inside and remotely over the past year , so i've been struggling , um , off and on with that .
D2N007
2
[ "Personal History" ]
[ "Subjective" ]
okay . so sarah is a 27-year-old female here for her annual visit . so , sarah , how have you been since the last time i saw you ?
193
doctor: okay . uh , and from looking at the notes , it looks like we've had you on , uh , prozac 20 milligrams a day . patient: yes .
D2N007
3
[ "Therapeutic History" ]
[ "Subjective" ]
okay . uh , and from looking at the notes , it looks like we've had you on , uh , prozac 20 milligrams a day .
194
doctor: are , are you taking that ? patient: i am taking it . i think it's just a lot has been weighing on me lately .
D2N007
4
[ "Therapeutic History" ]
[ "Subjective" ]
are , are you taking that ?
195
doctor: okay . um , and do you feel like you need an increase in your dose , or do you ... what are you thinking ? do you think that you just need to deal with some stress or you wan na try a , a different , uh , medication or ... patient: i think the , the medication has helped me in the past , and maybe just increasing the dose might help me through this patch .
D2N007
5
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay . um , and do you feel like you need an increase in your dose , or do you ... what are you thinking ? do you think that you just need to deal with some stress or you wan na try a , a different , uh , medication or ...
196
doctor: okay . all right . and , and what else has been going on with you ? i know that you've had this chronic back pain that we've been dealing with . how's that , how's that going ? patient: uh , i've been managing it . it's still , um , here nor there . just , just keeps , um , it really bothers me when i sit for long periods of time at , at my desk at work . so i have ... it helps when i get up and move , but it gets really stiff and it hurts when i sit down for long periods of time .
D2N007
6
[ "Personal History" ]
[ "Subjective" ]
okay . all right . and , and what else has been going on with you ? i know that you've had this chronic back pain that we've been dealing with . how's that , how's that going ?
197
doctor: okay , and do you get any numbing or tingling down your legs or any pain down leg versus the other ? patient: a little bit of numbing , but nothing tingling or hurting down my legs .
D2N007
7
[ "Acute Symptoms" ]
[ "Subjective" ]
okay , and do you get any numbing or tingling down your legs or any pain down leg versus the other ?
198
doctor: okay , and does the , um , do those symptoms improve when you stand up or change position ? patient: yeah , it does .
D2N007
8
[ "Acute Symptoms" ]
[ "Subjective" ]
okay , and does the , um , do those symptoms improve when you stand up or change position ?
199