{"idx": 47, "inputs": "[doctor] hi billy how are you what's been going on the medical assistant told me that you're having some difficulty urinating [patient] yeah yeah i i did n't really wan na come in to talk about it's kinda weird but i think probably over the last six months i'm just not peeing right it just does n't seem to be normal [doctor] okay so let's talk a little bit about that now is your is your stream is your urination stream weak [patient] yeah i'd probably say so [doctor] okay and do you feel like you're emptying your bladder fully or do you feel like you still have some urine left in there when you when you finish [patient] most of the times i'm okay but sometimes if i stand there long enough i i can kinda go a little bit more so it's taking a while actually to just go to the bathroom [doctor] okay and are you waking up at night to go to the bathroom does it impact your sleep [patient] yeah i try to empty my bladder now right before i go to bed and and not drink anything but i'm still probably getting up three or four times a night to go to the bed [doctor] okay so you're getting up about three or four times a night and and how long has this been going on you said for about six months [patient] yeah six months to like this and it's probably been a little bit worse over the last six months and maybe it's been longer i just did n't want to bring it up [doctor] okay so you think it's been going on longer okay alright now how about have you had any burning when you urinate at all [patient] no it i do n't think it burns [doctor] no burning when you urinate okay and and any other any other issues any problems with your bowels any constipation issues [patient] hmmm no i i i had diarrhea last week but i think i ate something bad [doctor] okay and ever have you ever had any issues where you had what we call urinary retention where you could n't pee and you needed to have like a catheter inserted [patient] my gosh no [doctor] okay [patient] i'll do that [doctor] alright and have you ever seen a urologist i do n't think so you've been my patient for a while i do n't remember ever sending you but have you ever seen one [patient] i do n't think so [doctor] okay now tell me how are you doing with your with your heart when was the last time you saw doctor moore the cardiologist i know that you had the the stent placed in your right coronary artery about what was that twenty eighteen [patient] yeah sounds about right i think i just saw him in november he said everything was okay [doctor] he said everything was okay alright and so you have n't had any chest pain or shortness of breath you're still walking around doing your activities of daily living are you exercising [patient] kind of [doctor] kind of okay now from what i remember i remember you being a big college football fan are you as excited as i am that georgia beat alabama in the national championships [patient] yeah yeah i'm super excited [doctor] you do n't really seem that excited [patient] get the problem fixed because i have to be able to sit there and watch the whole game [doctor] yeah i i really do n't like nick saving i'm so i'm super happy that that the dogs pulled it out [patient] i do n't know if we can do friends anymore [doctor] are you in alabama fan [patient] maybe i'm actually originally not from georgia so [doctor] okay alright well i mean i i'm i'm a long horns fan but anyway well i digress let's talk a little bit about your diabetes how are how are you doing with your sugars are you watching your diet [patient] i'm trying to yeah i think they are okay [doctor] okay and are you still taking the metformin [patient] yep [doctor] you are okay alright now i wan na go ahead and just move on to a quick physical exam okay i'm gon na be calling out some of my exam findings and i'm gon na let you know what that means when i'm done okay alright i do have to do a rectal exam i apologize i'm just gon na be calling it out what what i what i appreciate okay so on your heart exam i do appreciate a slight three out of six systolic ejection murmur hurt at the left base on your lung exam your lungs are clear to auscultation bilaterally on your abdominal exam your abdomen is nontender and nondistended i do n't appreciate any masses or any rebound or guarding on your prostate exam i do appreciate an enlarged prostate i do n't appreciate any masses on physical exam so what what does that mean billy so that ultimately means that you know everything looks good you know you have that little heart murmur which i believe you you've had in the past but we're gon na go ahead and look into that you know your prostate seems a little bit enlarged to me on physical exam so let's talk about how we can go about and and remedy that okay so for your first problem of this you know difficulty urinating i wan na go ahead and just order some routine labs i wan na get a a psa that kind of that ultimately kinda looks for prostate cancer issues which i do n't think you have because we did n't really appreciate that on physical exam i wan na go ahead and we can try to start you on what we call flomax zero point four milligrams once a day you should take it at night because it can cause people to get a little bit dizzy if they take it in the morning so i would take it at night and i wan na go ahead and refer you to a urologist just to look into this more so we can go ahead and and get this problem solved for you okay i'm also gon na go ahead and just order some routine blood tests just to make sure that we are not missing anything do you have any questions about that and i wan na go ahead and order a urinalysis and a urine culture [patient] yeah so sounds good have you seen that commercial for that super batter prostate stuff does that work [doctor] well i think the data it's it's i'm not really sure if it works or not i'm not that familiar with it let's just go ahead and stick with flomax and that's why we are gon na refer you to the urologist so that they can go ahead and talk to you about you know the most current treatment options for you okay [patient] alright [doctor] alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that [patient] nope [doctor] okay and then for your third problem of your diabetes it sounds like you're doing really well let's go ahead and continue you on the metformin a thousand milligrams twice a day we will go ahead and order a hemoglobin a1c to see if we need to make any adjustments to that and i'm gon na see you again in about three to four weeks okay i want you to call me or message me in the patient portal if you have any concerns [patient] alright when is the urologist gon na call me [doctor] i'm gon na reach out i'm gon na reach out to them now and see if they can get you in this week [patient] sounds good [doctor] okay alright well great it was good to see you bye [doctor] i could just hit it and i can just talk and then i'm just", "target": "ASSESSMENT AND PLAN\n\n1. Difficulty urinating.\n - Medical Reasoning: The patient presents today with approximately a 6 month history of difficulty with urination. His prostate also felt slightly enlarged on exam today.\n - Patient Education and Counseling: The patient was advised that there were no concerning symptoms of prostate cancer appreciated on his physical exam today.\n - Medical Treatment: We will order routine labs including a PSA to rule out prostate cancer. We will also refer him to a urologist for further evaluation as well as order a urinalysis and urine culture. We will start him on Flomax 0.4 mg once at night to avoid dizziness.\n \n 2. Coronary artery disease.\n - Medical Reasoning: The patient had a 3/6 systolic ejection murmur heard at the left base on exam today. This has been heard on his exams in the past.\n - Medical Treatment: We will order an echocardiogram to follow up on his murmur. We will also order a lipid panel. He will continue Lipitor 40 mg a day, aspirin and metoprolol.\n \n 3. Diabetes.\n - Medical Reasoning: The patient is currently doing well with his diabetes.\n - Medical Treatment: We will continue him on metformin 1000 mg twice a day. A hemoglobin A1c will be ordered to see if any medication adjustments are needed.\n \n "} {"idx": 105, "inputs": "[doctor] patient's name is diana scott . date of birth , 12/8/1920 . the date of service is 7/9/2021 . this is a new patient note . [doctor] good afternoon . how are you today ? [patient] i'm good , thank you . [doctor] good . well , what brings you in to see me today ? [patient] well , my doctor says that i have a heart murmur . [doctor] okay . [patient] so i do n't know how big a heart murmur i have , or really even what it is . [doctor] okay . so how long have you had that for ? do you have any idea , or is that completely new as far as you know ? [patient] yeah , she said it's a new worrisome heart murmur . so of course , i'm worried as well . [doctor] got it . okay . and are you having any symptoms at all ? [patient] i do n't think so . i do n't know what symptoms i should be having . [doctor] okay . well , so you are 100 , so we ca n't really get around that one . so i expect that you probably do n't move quite as fast as maybe you used to ? [patient] no , i definitely do n't . [doctor] okay . and do you notice that you have any chest pain or f- feel shortness of breath ? [patient] no , i do n't have any chest pain . um , my problem is i have severe pains in my legs , and so she had me going for a chest x-ray , and that was just last week . [doctor] okay . [patient] and so i started taking pain pills for my legs . [doctor] okay , got it , for the legs . and do you feel short of breath at all ? [patient] if i walk too fast or too long , or if i tried to drink a whole glass of water without stopping , then yeah , i do get short of breath that way . [doctor] okay . and how far can you walk before you feel short of breath or sort of overly fatigued ? [patient] well , i do have a walker now , so i do n't know . maybe when i walk to the end of the driveway or i walk around the culdesac . [doctor] got it . all right . [patient] so it is n't that bothersome to me at all . um , maybe more if i try to overdo it . [doctor] okay . [patient] then i , um , i get short of breath if i do overdo it though . [doctor] okay , got it . and so how different would you say , um , that the symptoms are now compared to like six months ago or a year ago ? [patient] i would say probably 70 to 80 % from about six months ago . before that i did n't notice anything at all . [doctor] okay . so do you feel like it's mainly the leg pain that seems to limit you ? [patient] my legs have been severe for about a month now . [doctor] okay . and how about , do you feel lightheaded or dizzy at all ? [patient] yeah . so i do take a pill for that when it does get bad . [doctor] okay . [patient] yeah , and i do n't take it every day , only when i do feel dizzy . [doctor] okay . and so how about any passing out at all ? [patient] no . [doctor] okay , good . and how about irregular heartbeats ? do you ever feel like your heart is going too fast or like it skips a beat ? [patient] i do n't notice it at all . [doctor] okay , great . and how about any swelling in the legs at all ? [patient] yeah , my ankles swell . [doctor] okay . and how long has this been going on ? [patient] um , i would say for probably six months . but it goes up and down , and sometimes it's worse than other times . [doctor] okay . and how about any recent weight gain or anything else like that ? [patient] um , i lost a little bit of weight , but i still weigh a 120 pounds , but i normally weigh about 130 pounds . [doctor] mm-hmm . okay . [patient] um , but that's been going down gradually for about a year . [doctor] okay . and then how about any fevers , chills or anything else that's , that's going on that you can think of ? [patient] no . [doctor] good . so mainly it sounds like you came in , um , mostly because of the murmur . is that right ? and sort of just kind of seeing what things look like ? [patient] yeah , that and i feel overly tired because i take all that medication . [doctor] okay . and so fatigue as well . and have you ever had any testing of your heart done ? [patient] i'm not really sure . [doctor] okay . it does look like you've had a decent number of sh- , uh , surgeries here , ? [patient] yeah , you name it . [doctor] all right . well , i wo n't make you repeat them since i do have a good record . um , but just give me just a second and i'm going to enter the ones we need , okay ? all right . got them . and then , are you taking all the medicines that you went through with madison ? [patient] yes . [doctor] okay , good . and looking at your family history , it looks like maybe your brother had a heart attack . is that correct ? [patient] it was actually my son , not my brother . [doctor] okay , i'll make that adjustment . [patient] um , but my brother did have a stroke . but that was because he had gotten sugar diabetes , and my eldest sister did have a heart problem as well . [doctor] okay , i see . [patient] yeah , so heart problems kinda run in the family . [doctor] okay . all right . well , it looks like also that you never smoked . that's excellent . and then no allergies to medicines that you know of , is that correct ? [patient] correct . [doctor] all right . well , let's do a quick exam . [patient] all right . sounds good . [doctor] all right . well , for physical exam , please use the regular template . all right , please just breathe normally . great . and now take a few deep breaths for me . all right . do you feel okay ? are you feeling any dizziness or anything ? [patient] no , i feel fine . [doctor] okay , great . all right . well , that is it for the exam . [patient] okay . [doctor] all right . so what i'm thinking is , let's go ahead and schedule you for an echocardiogram . it's a very common test and it just takes a picture of your heart . and it'll let me see how well your heart is actually working . [patient] okay . [doctor] and i can order that for today . um , do you have time to complete that ? it should n't take too long . [patient] yes , that's fine . i have time . [doctor] okay , great . so we will complete that today , um , to assess your overall cardiac structure and function , as well as , uh , the valve view of where diseased . [patient] okay . [doctor] and some hospital outcomes and what we might suggest to fix that out , i'll go over that . so one possible suspicion i'm having is it's called , um , aortic stenosis , and that just means that one of your main valves of your heart has narrowed a bit and the valve does n't really open , um , quite fully . and this could just reduce or block the blood flow from your heart into the main artery of your body , and that's called the aorta , into the rest of your body . [patient] okay . [doctor] and if this is severe , then we might wan na perform a procedure called the transcatheter aortic valve replacement , or we just call it tavr . and it is a minimally invasive procedure to replace the valve . [patient] well , i would have to think about that . i'm not too sure i'd wan na do that , given my age of all . [doctor] yeah , sure , no problem . and we do n't have to make any decisions today , just , you know , wanted to go over a couple of these things . um , but sometimes we can also perform a surgical aortic valve replacement , or it's called an savr . but really , because of your age and medical history , um , unfortunately , that would n't be a good option for you . [patient] i see . okay . well , i guess we'll see , um , what you see from , from the , um , test . [doctor] yeah , agreed . okay . and , um , so couple other things real quick . so it looked like your blood pressure looked really good today . so we're not going to change your amlodipine or lisinopril . so just continue taking those as you are currently . [patient] okay , good . [doctor] and then , it also looks like you're taking about 20 milligrams of simvastatin for your lipids . and i will pr- , um , defer to your pcp . however , given you are having leg pain in both your legs , and given your age and no history of coronary artery d- , artery disease , it is possible that you might be able to stop your statin . [patient] really ? [doctor] yeah , um , possibly . he would have to evaluate you , but it is certainly something to discuss with him . so i will send over the results of the echocardiogram and also my recommendations and then you guys can talk about the statin . [patient] okay , that sounds great . thank you . [doctor] you're welcome . and then , um , lastly , your hyperthyroidism , uh , i see you're taking levothyroxine . and again , no change here and you can just keep taking that as you have them . [patient] okay , i will . [doctor] all right . so we will see you back here in about three or four weeks to discuss the results and your next steps . um , and we'll , uh , take care of your echocardiogram today . um , any questions ? [patient] not that i can think of . thank you so much . and i think it looks good . [doctor] okay , awesome . all right . well , have a good rest of your day , and we'll see you soon . [doctor] for physical exam , constitutional elderly otherwise no acute distress . cardiovascular normal s1 and s2 is preserved with a normal rate and regular rhythm . there is a 4/6 systolic murmur at the right upper sternal border with , uhm , mild radiation to the carotids . neurologic gait is normal for age . [doctor] for assessment and plan , probably one cardiac murmur . diana has a 4/6 systolic murmur at the upper right sternal border with mild radiation to the carotids . this is most likely representative of aortic stenosis , for symptoms could be due to severe aortic , aortic stenosis . however , her s2 is relatively preserved , which would be more consistent with , consistent with moderate . some of her outside records do note diastolic dysfunction , so it is possible she , she did have an echocardiogram at some point in the past . she does not appear significantly volume overloaded today . [doctor] her next problem is pvcs . her referral mentioned tachycardia . uh , her ekg today shows sinus rhythm with frequent pvcs , as well as an anterior septum infarct pattern . she does not have any significant palpitations and we will check an echocardiogram to assess overa- overall cardiac structure and function . depending on results as well as the severity of her aortic stenosis , we will need to consider an ischemic evaluation , or further , possibly a heart mon- monitor to assess overall burden of the pvcs . at this point , she's asymptomatic , so we will start with the echocardiogram only . [doctor] her next problem , hypolipidemia , is managed by her pcp . due to bilateral leg pain over the last month , considered tavr evaluation following echocardiogram . statin could be indicated . [doctor] and next problem , lightheadedness , dizziness . she is on meclizine for this . it is possible that some of her lightheadedness and dizziness is related to the aorta stenosis , and we will do an echocardiogram as noted above . pvcs on her ekg could be contributing , but she does not feel palpitations . we will consider a monitor , but start with the echocardiogram first as noted above . follow up three to four weeks after her echocardiogram is done to discuss results and next steps . end of dictation .", "target": "ASSESSMENT\n\n\u2022 Cardiac murmur.\n \u2022 PVCs.\n \u2022 Hypertension.\n \u2022 Hyperlipidemia.\n \u2022 Hypothyroid.\n \u2022 Lightheadedness/dizziness.\n\nPLAN\n\nCardiac murmur\n Diana has a 4/6 systolic murmur at the RUSB with mild radiation to the carotids. This is most likely representative of aortic stenosis. She does have symptoms including a significant increase in fatigue over the last 6 months, shortness of breath, and some lightheadedness. This could be due to severe aortic stenosis, however, her S2 is relatively preserved which would be more consistent with moderate. She is unsure if she has had an echocardiogram, although some of her outside records do note diastolic dysfunction, so it is possible that she had one as some point in the past. We will order a repeat echocardiogram today to assess overall cardiac structure and function as well as valvular disease. If she does truly have severe aortic stenosis, I briefly discussed a TAVR procedure today as she is not a candidate for a surgical AVR given her age co-morbidities and frailty. She is unsure if she would be interested in this, but we will assess first with the echocardiogram and then discuss further at follow-up. She does not appear significantly volume overloaded today.\n \n PVCs\n Her referral mentions tachycardia. Her EKG today shows sinus rhythm with frequent PVCs as well as anterior septal infarct pattern. She does not have any significant palpitations. We will check an echocardiogram to assess overall cardiac structure and function. Depending on results as well as the severity of her aortic stenosis, we will need to consider an ischemic evaluation or possibly a heart monitor to assess the overall burden of PVCs. At this point, she is asymptomatic, so we will start with the echocardiogram only.\n \n Hypertension\n She is taking amlodipine and lisinopril. We will continue these as is.\n \n Hyperlipidemia\n This is managed by her PCP. She is on simvastatin 20 mg. She is having bilateral leg pain over the past month. This could be related to the simvastatin possibly and given her age, it would not be unreasonable to stop the simvastatin, but I will defer to her PCP. She has no known CAD but if we were to do a TAVR evaluation and this was discovered, a statin would be indicated.\n \n Hypothyroidism\n She takes levothyroxine for supplementation and will continue this as is.\n \n Lightheadedness/dizziness\n She is on meclizine for this. It is possible that some of her lightheadedness and dizziness are related to the aortic stenosis, and we will do an echocardiogram as noted above. She is also having some PVCs on her EKG, which could be contributing, but she does not feel palpitations. We will consider a monitor but start with the echocardiogram first as noted above."} {"idx": 122, "inputs": "[doctor] hey kyle it's nice to see you today can you tell me a little bit about what brought you in [patient] yeah i went to see my pcp for a cough which they diagnosed as bronchitis but then they did that chest x-ray to make sure i did n't have pneumonia and they found this lung nodule i went for a cat scan that confirmed it and they referred me here to you i'm really nervous document [doctor] okay well first of all i'm i'm sorry that you're nervous and what we're gon na do is we're gon na partner together okay and i'm gon na be right by your side the whole time to hopefully make you a little less nervous and and recognize the fact that we're you're gon na have a big support team around you okay [patient] okay [doctor] so let's talk a little bit about how long you've had that cough before you went to see your doctor [patient] i you know off and on i've had it for about three months i first noticed it when i was loading some pay i have horses and i i bought you know four hundred bills a day and when i spent a day loading it and then it's i just started coughing a lot more i think around that time and after that i i i just got a cold so that's what sent me to my pcp now i i i do exercise i i do a lot of biking and i typically do n't get sick and my cough has gone away [doctor] okay that's good to hear you mentioned exercise and biking i love to bike myself i've got a track seventy one hundred hybrid have you been on the the new trails they opened it was the old the old rail the old rail road right away they've opened that up it's like sixty miles of trails [patient] i love that that road i just i i do n't like riding on the road so i prefer to do those rails the trails type [doctor] yeah [patient] and it's just so phenomenal i do that a lot [doctor] yeah i love riding over there way we will we will get you all fixed up we will have to go for a bike ride [patient] absolutely i'd love it [doctor] that'd be great so i see here on your medical history that you also have a history of rheumatoid arthritis is that under control at this time and and and what do you do to to take care of your ra [patient] yeah it's it's it's fair you know arthritis never really goes away but i take methotrexate [doctor] okay [patient] i think it's seven and a half milligrams every week and as long as i'm keeping active my joints feel okay and if i do have any problems it's it's mostly with my hands but i have n't had any recent flares so i'm okay right now [doctor] okay that's good i also see here that you marked down that you were a previous smoker and and when when did you when did you stop smoking [patient] i stopped smoking probably about seven years ago [doctor] okay [patient] and i was young and should have stopped the way before that my kids were on me all the time but you know i i got a new start and finally was able to stop and i felt better after stopping [doctor] okay that's good and i'm glad to hear that you were able to to to stop and and stay tobacco free that that's great to hear do you have any pain or any shortness of breath or anything like that [patient] no not at all [doctor] okay and i would like to talk about your familial history here for just a second do you have any family history of lung cancer or any other type of malignancies [patient] no lung cancer my mom did have breast cancer but she is doing well now [doctor] okay alright and then things like lung infections or pneumonia do you have any previous history of that [patient] no no not not anything that i'm aware of [doctor] okay if it's okay with you i'm gon na do a quick physical exam your vital signs look good today blood pressure of one twenty four over seventy six heart rate of seventy respiration rate of sixteen o2 sat on room air of ninety eight percent and you are afebrile so you do n't have a fever today i'm gon na take a quick listen to your lungs here your lungs are clear and equal bilateral when i listen to them or when i auscultate your lungs now listening to your heart regular rate and rhythm no clicks rubs or murmurs and i do n't appreciate any extra beats doing a quick extremity exam your skin is pink warm and dry i do n't appreciate any edema to your lower extremities it looks like you do have a little bit of swelling to to your knuckles there on your third digit on each hand which can be normal for somebody who has ra however pulses are intact in all extremities and capillary refill is brisk so a quick review of your results now you had a chest ct before you came in to see me and the results of that chest ct do show a solitary two centimeter nodule in the lateral aspect of the right upper lobe now it appears the nodule is smooth in appearance and no evidence of any type of emphysematous disease is present which is good now for my assessment and plan for you so you do have an incidentally found right upper lobe lung nodule i'm going to order some pft which is pulmonary function test i just wan na get a check and and a baseline for your lung function i'm also going to schedule a pet ct this is gon na help to determine if that nodule is metabolically active meaning if it lights up it it can suggest that it's cancer or inflammatory i'm going to go ahead and suggest that we do remove this during or via video assisted thoracoscopy which means it's just gon na be three small incisions made on the side of your right chest i'm gon na go in with a camera and a scope and we'll remove that along with a very small portion of your lung you're gon na be under general anesthesia and it'll take about an hour and a half or so post procedure you're gon na be admitted and you will have a chest tube in until the following day and i'm gon na go ahead and take that out then at bedside most likely you're gon na be in the hospital for one night and go home the next day it could be a benign nodule but because your smoking history i really do think it's gon na be best that you have that removed now for your secondary concern of your rheumatoid arthritis i want you to continue to follow up with your rheumatologist and continue your medication therapy as has been previously outlined for you now do you have any questions comments or concerns before before we get the paperwork signed to start the the treatment process [patient] no i do n't think so i think i'll be okay i'm scared [doctor] i i know you're scared but we'll be right here with you the whole way [patient] okay [doctor] alright we'll get some paperwork and i'll see you again in a few minutes [patient] okay thank you", "target": "ASSESSMENT AND PLAN\n\n1. Right upper lobe lung nodule.\n - Medical Reasoning: The patient has incidentally found right upper lobe lung nodule visible on his chest CT. It could be a benign nodule, but because of his smoking history, I think it is best that he has it surgically removed.\n - Patient Education and Counseling: I had a thorough discussion with the patient concerning surgical treatment. Surgery will require general anesthesia and will take approximately 1.5 hours. I explained to the patient that his procedure will consist of 3 small incisions being made on the side of his right chest. I will then insert a camera and scope to assist in removing the nodule along with a very small portion of his lung. He was advised that he will be admitted for most likely an overnight stay. He will have a chest tube in until the following day when I remove it at his bedside. All questions were answered.\n - Medical Treatment: Pulmonary function test ordered today to obtain patient's baseline. PET CT will also be scheduled to determine if the nodule is metabolically active, which can suggest if it is cancerous or inflammatory. Nodule will be removed via video assisted thoracoscopy.\n \n 2. Rheumatoid arthritis.\n - Medical Reasoning: Stable.\n - Patient Education and Counseling: I encouraged the patient to continue to follow up with his rheumatologist.\n - Medical Treatment: Continue medication therapy and routine follow up with rheumatologist as previously outlined.\n \n "} {"idx": 90, "inputs": "[doctor] hi , albert . how are you ? [patient] hey , good to see you . [doctor] it's good to see you too . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] so , albert is a 62-year-old male , with a past medical history significant for depression , type 2 diabetes , and kidney transplant , who is here today for emergency room follow-up . [patient] mm-hmm . [doctor] so , i got a notification that you were in the emergency room , but , but what were you there for ? [patient] well , i , uh , i was n't really , uh , staying on top of my , uh , blood sugar readings , and i felt kinda woozy over the weekend . and i was little concerned , and my wife wanted to take me in and just have me checked out . [doctor] okay . and , and was it , in fact , high ? [patient] yeah , it was . [doctor] okay . did you ... were you admitted to the hospital ? [patient] uh , no . [doctor] okay . all right . and , uh , are you ... did they see a reason , as to why it was elevated ? [patient] uh , yeah . my mother was actually in the hospital the last week. she had a bit of a fall and had to do a hip replacement. she's feeling better now but we have been just grabbing meals at the cafeteria or picking up fast food on our way home and i just really was n't monitoring what i was eating . [doctor] okay . that's sorry to hear . and are you feeling better now ? [patient] uh , actually , when we got home from the , uh , f- from the visit , i felt a lot better . [doctor] okay . and since then , have you been following your diet pretty closely ? [patient] yes . [doctor] okay . 'cause we do n't wan na end up in the hospitaltoo [patient] no . [doctor] all right . um , okay . and , so , before that happened , how are you doing with your diet ? [patient] uh , during the week , i've been fine , 'cause i've been very busy . on the weekends , doing things . you're seeing people . you're having people over . it's , i- not , not as consistent on the weekend . [doctor] okay . all right . um , is there a way that you think that that can improve ? [patient] uh , s- stop eating . [doctor] okay . all right . well , let's talk about your , your kidney transplant . how are- [patient] mm-hmm . [doctor] . you doing ? you're taking immunotherapy meds ? [patient] yes . [doctor] okay . [patient] yeah . i've , i've been pretty diligent about it , following doctor's orders , so it's been , it's been pretty good so far . [doctor] okay . and , and y- the last time i saw that you saw dr. reyes , was about three weeks ago , and everything seemed to be fine . [patient] that's correct . [doctor] your kidney function is good . [patient] yes . [doctor] okay . all right . and in terms of your depression , how are you , how are you doing ? [patient] and it's been about a , a tough , ugh , year-and-a-half or so , but i've been pretty good with it . i , i have my moments , but i- as long as i find some time to relax , at least in the afternoon , then , then it seems to work out okay . [doctor] okay . so , i know that we've kind of talked about holding off on medical therapy- [patient] mm-hmm . [doctor] . 'cause you're on so many other meds . [patient] mm-hmm . [doctor] um , is that something that you wan na revisit , or do you wan na look into therapy , or do you think anything's needed right now ? [patient] uh , i think i probably wan na shy away from any therapy . my , my wife got me into meditation recently and , and , uh , i , i find that relaxing . so , i think i'd like to continue that , at least for a couple more months and see how it goes . [doctor] okay . all right . that sounds good . all right . well , i know the nurse did a quick review of systems with you , when you- [patient] mm-hmm . [doctor] . checked in . do you have any symptoms , any chest pain or shortness of breath ? [patient] none whatsoever . [doctor] lightheadedness ? dizziness ? [patient] no . [doctor] no ? okay . um , and i just wan na go ahead and do a quick physical exam . [patient] mm-hmm . [doctor] hey , dragon . show me the vital signs . [doctor] so , looking here right now , your vital signs look great . you know , your pulse ox is great . your h- your blood pressure and heart rate are right where they should be . [patient] mm-hmm . [doctor] so , i'm gon na just check you out , and i'm gon na let you know what i find . okay ? [patient] sure . [doctor] okay . so , on your physical exam , everything looks really good . um , you do n't appear in any distress at this time . i do n't appreciate any carotid bruits . your heart , on your heart exam , i do hear that slight 2/6 systolic ejection murmur , but we heard that in the past . [patient] mm-hmm . [doctor] your lungs sound nice and clear , but i notice , you know , 1+ , uh , edema in your lower extremities . okay ? [patient] mm-hmm . [doctor] um , so , let's go ahead . i wan na look at some of your results . okay ? [patient] sure . [doctor] hey , dragon . show me the glucose . [doctor] so , right now , your blood sugar is about 162 . have you eaten before you came in here ? [patient] i did not . [doctor] okay . all right . um , hey , dragon . show me the diabetes labs . [doctor] okay . i'm looking at your diabetes labs . you know , your hemoglobin a1c is about 8 , and that's a , that's a little high . [patient] mm-hmm . [doctor] so , not only , you know , have your blood sugars , were they high that one day , they were , they've been a little elevated . [patient] mm-hmm . [doctor] so , we'll talk about , you know , how to go ahead and , and fix that . okay ? [doctor] so , let me talk a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so , for your first problem , this hyperglycemia , you know , i wan na go ahead and increase your lantus to 20 units at night . okay ? i want you to continue your monitor your blood sugar and let me know how they're running 'cause we might have to adjust that further . [patient] mm-hmm . [doctor] okay ? um , and i wan na order another hemoglobin a1c in a couple months . hey , dragon . order a hemoglobin a1c . [doctor] for your next problem , your depression , i think you're doing a great job with your current strategies with the meditation . we will hold off on medication or therapy at this time , and you know to call me if you need anything , right ? [patient] mm-hmm . [doctor] okay . and for your third problem , your kidney transplant , your kidney function looks stable . uh , i'm gon na just have you go back to dr. reyes , to manage all of your immunosuppression medications . [patient] okay . [doctor] um , and then , he knows to reach out to me if he needs anything . okay ? [patient] you got it . [doctor] all right . well , the nurse will be in soon to check you out . okay ? [patient] perfect . [doctor] hey , dragon . finalize the note .", "target": "ASSESSMENT AND PLAN\n\nAlbert Powell is a 62-year-old male with a past medical history significant for depression, type 2 diabetes, and kidney transplant. He is here today for an emergency room follow-up.\n \n Hyperglycemia.\n \u2022 Medical Reasoning: He was recently seen in the emergency department with elevated blood glucose levels. He admits to dietary indiscretion prior to this, but has since improved his diet. His recent blood glucose level was 162, and his recent hemoglobin A1c was 8.\n \u2022 Additional Testing: Repeat hemoglobin A1c in a few months.\n \u2022 Medical Treatment: Increase Lantus to 20 units at night.\n \u2022 Patient Education and Counseling: I advised him to continue monitoring his blood glucose levels at home and report those to me, as we may need to make further adjustments to his medication.\n \n Depression.\n \u2022 Medical Reasoning: He reports personal stressors over the past year and a half but is doing well overall. He recently started meditating.\n \u2022 Medical Treatment: He should continue his current management strategies. We will hold off on medication and therapy at this time.\n \u2022 Patient Education and Counseling: The patient was encouraged to contact me if he needs anything.\n \n Status post renal transplant.\n \u2022 Medical Reasoning: His kidney function appears stable and he has been compliant with his immunotherapy medications.\n \u2022 Medical Treatment: Continue seeing Dr. Reyes for management of his immunosuppression medication.\n \u2022 Patient Education and Counseling: He knows to reach out to me if he needs anything.\n \n "} {"idx": 106, "inputs": "[doctor] hey charles i'm using this cool new recording device to help me with my documentation is that okay with you [patient] sure [doctor] awesome how are you doing today [patient] well i could be better you know i moved out in the city [doctor] about two years ago bought this big plot of land [patient] oh [doctor] i love it lots of deer round awesome [patient] you be hunter [doctor] huge hunter i love hunter yeah [patient] i have a refrigerator full of venison at home [doctor] do you [patient] mm-hmm [doctor] you want to carry share sure yeah we can switch [patient] nice but so the thing is i have noticed that for some reason my breathing [doctor] is n't what it used to be [patient] sure [doctor] yeah it's you know i i seem to catch my breath a lot more than i used to and i consider myself to be pretty healthy [patient] you look pretty healthy [doctor] thanks so do you thank you you you're feeling short of breath [patient] yes [doctor] okay is there you know is there any other symptoms that you have with that i get like you know mid shortness of breath suddenly for some reason i'm not quite sure why [patient] hmmm [doctor] eyes they're water does n't make very much sense to me [patient] mm-hmm [doctor] i always think it's allergies [patient] okay [doctor] mostly could be [patient] i have a dog that eyes water like that she always gets eyebugers [doctor] yeah i get eyebugers too [patient] uh [doctor] crazy uh the last time it happened i went to the urgent care and they gave me a nebulizer that helped [patient] they prescribed me an inhaler that i use now when i feel the symptoms coming on [doctor] okay great do you ever notice a rash with any of this [patient] no [doctor] do you have any nausea vomiting [patient] no [doctor] besides when you go out heavy drinking right [patient] i mean i diarrhea quite a bit once i go out [doctor] i understand that [patient] heavy drinking [doctor] yeah do you ever get lip or throat swelling [patient] no [doctor] have you ever had any issues with allergies in the past [patient] no [doctor] hmmm what situations do you notice the symptoms come on when is it when you're near your cat or outside the house [patient] i have noticed them in all three situations [doctor] hmmm [patient] in the house when the cat is n't around and outside as well [doctor] hmmm yeah i'm not a big cat person [patient] no neither [doctor] do you do you have any symptoms now well which is [patient] no [doctor] no no travels and no symptoms right now [patient] mm-hmm [doctor] okay [doctor] okay alright so i'm gon na do a physical exam for you right now your vital signs look good your pulse is okay and yeah your pulse ox is normal so that's good you do n't appear in any distress you may be might be a little bit nervous to come in and see me but looks pretty good i do not appreciate any rash on your body there is no angioedema which is just swelling of your lips like you mentioned no audible stridor which is a bad noise in your airway when it gets swollen so that's good news if you just want to take a deep breath listening to your lungs on your lungs exam i do appreciate some faint expiratory wheezing bilaterally in all lung fields so i know you had a chest x-ray when you came in i'm looking at that chest x-ray right now and your pulmonary function test and they were both normal so let's talk a little bit about what i think is going on for your first problem you have newly diagnosed allergic asthma so i want you to continue the albuterol inhaler i do n't want you to wait until your symptoms flare up or are bad take it as soon as you start to feel any symptoms at all i'm gon na prescribe something else called singulair ten milligrams you might have seen some commercials for it [patient] hmmm [doctor] you take that once daily and that's gon na help decrease the occurrences of your asthma [patient] hmmm [doctor] i also am gon na proceed with allergy testing have you ever had an allergy test before [patient] no [doctor] okay we'll start with skin testing and we'll see if we can target what the triggers in hopes in hopes that we can avoid any any other management and this can be successful if we ca n't figure out what it is from that we'll have to discuss more testing in your blood and do immunotherapy so i wan na see you next week to schedule the skin testing do you have any questions for me [patient] should i come my cats [doctor] yes", "target": "ASSESSMENT\n\nNewly diagnosed allergic asthma.\n\nPLAN\n\nAfter reviewing the patient's examination, radiographic findings, and pulmonary function test results today, I have had a lengthy discussion with him regarding his current symptoms. He will continue to use the albuterol inhaler; however, he should limit its use to when he is experiencing a severe flare-up of symptoms. I advised he should take it as soon as he starts to feel any symptoms at all. I have also prescribed the patient Singulair 10 mg to be taken once daily. This should help to decrease the occurrences of his asthma. I have also recommended we proceed with an allergy skin test to target what his triggers are in the hope that we can avoid any other management. If we unable to determine his allergens, then we may consider further testing or immunotherapy."} {"idx": 15, "inputs": "[doctor] thanks , rachel . nice , nice to meet you . [patient] yeah . [doctor] um , as my nurse told you , we're using dax . so i'm just gon na tell dax a little bit about you . [patient] mm-hmm . [doctor] so rachel is a 48-year-old female here for shortness of breath . she has a history of depression , smoking , and chronic back pain . so tell me about this shortness of breath . [patient] okay . so there are times when i'm either doing very , very mild exercises or just walking , even if i'm just walking up , you know , my driveway , i find myself palpitating a lot , and there's a little bit of shortness of breath . [doctor] mm-hmm . [patient] i do n't know if it's got to do with the back pain , you know , whether that gets triggered as well at the same time . [doctor] right . [patient] but definitely i feel it happens more often lately . [doctor] okay . and anything else change recently ? like , have you changed lifestyle , like you're exercising more than you used to , having any allergies , anything like that ? [patient] probably exercising more to get rid of the covid 15 . [doctor] the covid 15 . yeah . now last time i saw you , you were smoking two packs a day . how much are you smoking now ? [patient] um , it's gone down quite a bit because , yeah , we said we have to make some , you know , changes as you get older . [doctor] yeah . [patient] so i would say it's probably , um , maybe , maybe a couple ... probably a coup- i do n't know . probably once or day or something . [doctor] just couple cigarettes a day ? [patient] probably once a day , yeah . [doctor] we're getting close . [patient] yeah . [doctor] that's awesome . [patient] mm-hmm . [doctor] that's great news . um , and then how's your depression doing ? [patient] i have my moments . [doctor] yeah . [patient] there are some days when i feel , you know , i wake up and everything was great . [doctor] uh- . [patient] and then there are times , i do n't , i do n't know whether it's got to do with the weather or what else kind of triggers it . [doctor] yeah . [patient] there are some days when i feel extremely low . [doctor] okay . and you had been taking the effexor for your depression . are you still taking that ? [patient] yes , i am . [doctor] okay , great . and then , um the chronic back pain , we've been giving you the gabapentin neurontin for that . is that helping control the pain ? [patient] i think it is . [doctor] yeah . [patient] it is ... it's definitely , um , i feel better . [doctor] uh- . [patient] but it does come every now and then . [doctor] right . what do you do when it's really bad ? [patient] um , i try to just get as much rest as i can . [doctor] okay . and you had talked about doing yoga . are you doing yoga anymore ? [patient] i wish i said yes , but i have n't really made it a habit . [doctor] okay . okay . well , um , you know , said ... you said you were coming in with shortness of breath , so we sent you to get some pulmonary function tests . [patient] mm-hmm . [doctor] so let's just look at those . hey , dragon , show me the pulmonary function tests . okay , so it looks like ... , it's interesting . it says that you might be having a little bit of asthma or , uh , copd . and if you are , we'll talk about that . [patient] mm-hmm . [doctor] let's look at our x-ray . hey , dragon , show me the most recent x-ray . okay , i said it wrong . hey , dragon , show me the most recent chest x-ray . okay , this is interesting . your ... kind of your diaphragm is a little bit flatter , and we'll see that in some , uh , copd , which happens with smokers often . so let's just do a quick physical exam . i know my nurse did the review of systems with you . is there anything else bothering you that we need to talk about today ? [patient] no other issues . [doctor] okay . great . let's do the exam . all right , so your physical exam looks pretty normal other than you've got kind of these mild wheezes in all your lung fields . and so i think you do have copd from your pulmonary function tests , your x-ray , and that . so i'm gon na diagnose you with copd . chronic obstructive pulmonary disease . it means you're not able to exhale appropriately . [patient] mm-hmm . [doctor] so we're gon na put you on a medicine called combivent . okay , you're gon na do two puffs twice a day . it's gon na help open up your lungs . it's an inhaler . [patient] mm-hmm . [doctor] i'm also gon na prescribe albuterol , which you use when you get really short of breath . it's like a rescue thing . [patient] mm-hmm . [doctor] um , and then i'm gon na prescribe some steroids to help , also some prednisone . so let me just order those . [patient] okay . [doctor] hey , dragon , order combivent , uh , two puffs twice a day . order albuterol , two puffs as needed . and order , uh , prednisone uh taper pack . okay , so and then it sounds like your depression's stable , so we're not gon na change anything . you're gon na keep taking the effexor . um , do yoga for depression and your back pain , so for your back pain , stay on the neurontin , and we just wo n't do anything different . any questions for me . [patient] no , i think this is good . thank you . [doctor] perfect . hey , dragon , finalize the note . why do n't you ...", "target": "ASSESSMENT AND PLAN\n\nCOPD.\n \u2022 Medical Reasoning: The patient presents today with shortness of breath with exertion. Her pulmonary function tests suggest asthma or COPD and her most recent chest x-ray and physical examination today are also consistent with COPD.\n \u2022 Patient Education and Counseling: I counseled the patient on the importance of smoking cessation.\n \u2022 Medical Treatment: We will start the patient on Combivent, 2 puffs twice a day. I will also prescribe an albuterol inhaler, 2 puffs as needed, and a prednisone taper pack.\n \n Depression.\n \u2022 Medical Reasoning: It sounds like her depression is stable, so we will not change anything at this time.\n \u2022 Patient Education and Counseling: She will keep taking the Effexor. I encouraged her to practice yoga for depression relief as well as her back pain.\n \n Chronic back pain.\n \u2022 Medical Reasoning: The patient says she is doing well on Neurontin with only occasional exacerbation of the pain.\n \u2022 Medical Treatment: She can continue Neurontin as is. I also encouraged her to practice yoga for her back pain.\n \n "} {"idx": 53, "inputs": "[doctor] so barbara i i know you are here for some itchy scalp pain can you tell me a little bit about how you're doing [patient] yeah it's still quite a problem you know something i've been suffering with for so long now it's still quite itchy and it's really embarrassing too because i'll have dandruff so much like all over me but but i just ca n't stop itching [doctor] okay when did you first notice this [patient] i wan na say it's been a while but probably worsening in the past like six months or so [doctor] okay okay and have you seen ever noticed any rashes either when it first started or intermittently anywhere else [patient] on my body no not really [doctor] okay okay just mainly up underneath your on your scalp there uh and i can i can see that man that looks really itchy and scaly have you died your hair recently or used any other chemicals you you know like a new hair spray or gel [patient] nothing new i mean i do dye my hair but i've been doing that for years now but otherwise i do n't really use a lot of products in my hair [doctor] yeah i you know it's funny you say that because i keep saying i earned this gray hair and i'm gon na keep it so yeah have you tried any over the counter treatments i know there is a lot out of there something you know like a t gel or any of those other have those helped [patient] yeah i did that i did head and shoulders i even tried some castor oil and but none of them really seemed to be helping [doctor] okay okay let's talk about some other symptoms any joint pain fever weight loss [patient] not that i can recall i've been pretty good otherwise [doctor] okay good and going back you know to your grandparents has anybody else in the family had similar symptoms that you're aware of [patient] no well maybe my sister [doctor] maybe your sister okay [patient] yeah maybe my sister i mean i know she'll is no one has as bad as i do but she does report like just having a dry scalp [doctor] okay okay now you know a lot of times we can see this with you know high levels of stress has there been any new mental or emotional stressors at work or at home [patient] not really i mean it's basically the same things [doctor] okay yeah i yeah we have a lot of that yes so let me go ahead and and look at this a little closer here the first off i wan na tell you the the vital signs that the my assistant took when you came in your blood pressure is one thirty over sixty eight your heart rate was ninety eight and your respiratory rate was eighteen so those all look good and appear normal and your temperature was ninety seven . seven and that is all normal now when i look at your scalp here i do notice that you have demarcated scaly erythematous plaques and that's just kind of explaining technically what's going on those patches and they're they're in a patchy format they're diffusely present across the back of your skull and that's probably why you you see all that that that white dander you know on your on your your clothes as you go through the day now lem me talk a little bit about my impression and plan i think that you have a scalp psoriasis and let's and here is my thoughts on that what i would like you to use is to use clobetasol that's a zero . zero five percent solution and i want you to use that twice daily on the the affected areas of your scalp so you're just gon na put this on and just kinda gently rub it in now i know to do it twice daily is going to be difficult but if you can do it first thing in the morning when you get up and then before you go to bed you know get a shower and before you go to bed that will be great i want you to continue to use t-gel shampoo that you listed when you first came in that's a very good solution shampoo for that and that will help with controlling a lot of this now there is no cure for this unfortunately and flareups can be unpredictable but we see that you know not a we do n't have a great finger on what causes the flare ups but i'm gon na give you some steroids that will help and we're gon na have to manage that on a ongoing basis but when you get do get a flare up i want you to be using these flare steroid that i give you as we go through that and then i wan na see you back here in three months or sooner if it gets significantly worse do you have any questions for me [patient] no okay so i'll just use that steroid solution and then just as needed if it's really bad but then otherwise just use the t gel [doctor] yeah i want it's exactly what i want you to do i want you to use that that solution twice daily when you get that flare but then other than that just continue to use that t-gel shampoo [patient] alright [doctor] okay i'm gon na have my nurse come in and get you discharged but i the we will see you again in three months or and again please if it gets worse please do n't hesitate to call me and come in sooner [patient] alright perfect thank you [doctor] thank you [patient] okay bye", "target": "ASSESSMENT AND PLAN\n\n1. Scalp psoriasis.\n - Medical Reasoning: The patient presents today with symptoms similar to scalp psoriasis.\n - Patient Education and Counseling: Nature of the diagnosis was discussed as well as treatment options. Patient was advised there is no cure for this. Patient was counseled on how to apply clobetasol 0.05%.\n - Medical Treatment: Prescription for clobetasol 0.05% solution twice daily provided. Continuing using T/Gel shampoo. Prescription for steroids provided to be used for flare ups.\n \n "} {"idx": 30, "inputs": "[doctor] donna torres , date of birth , 08/01/1980 . [doctor] hi donna ! how are you ? [patient] i'm good . how about you ? [doctor] i'm doing well , thank you . and so , i saw that dr. brown put you on buspar . have you been on that before ? [patient] no , that's new . [doctor] okay . how is it working for you ? [patient] my anxiety is going good now , thankfully . i'm serious , it was brutal in november and december . finally , i was like , i can not do this . i have no idea why it happened . dr. ward did put me on singulair , and she did say we need to be careful because singulair can cause anxiety . so i'm not sure if that was the issue or what . [doctor] mm . okay . [patient] and it would , um , start usually during the day , at work . [doctor] i see . [patient] i mean , i'm fine now . [doctor] well , that's good , that things have settled . i do wonder if some of what you are dealing with is hormonal , and that's why i was asking . 'cause you were on the progesterone , and i feel like you were having some irritability back then too . [patient] i did . [doctor] and that was before we started the progesterone . [patient] yes . [doctor] so i know we started it for regulating your periods , but perhaps it helped with this also . [patient] yeah . and before , in november and december , i noticed that the week before my period , my anxiety would go through the roof . which then , i knew my period was coming . then it turned into my anxiety spiking just at random times . [doctor] hmm , okay . [patient] and it seemed like it was for no reason . [doctor] but november and december you were on the progesterone at that time . [patient] yes . [doctor] all right . so not really a link there , all right . [patient] yeah , i do n't know . [doctor] yeah , i do n't know either . um , sometimes with the aging process , that can happen too . [patient] i figured maybe that's what it was . [doctor] and we did go through the golive in november and december , so that can be pretty stressful also . [patient] yeah , and at work , that's when i first started to lead the process of delivering the results to patients with covid . in the beginning of the whole pandemic , patients would have to wait nine days before they'd get their results . and then we opened the evaluation centers and the covid clinic . so i think it just took a toll on me . [doctor] yeah , i can absolutely see that . [patient] yeah , and then i was feeling selfish because i was n't even on the front lines . i mean , i was supporting people , sure , but i was n't in the icu . so i felt selfish and guilty . i mean , hands down , the physicians and nurses were in the thick of it and there i was , having anxiety . and it felt ridiculous . [doctor] well , honestly , you feel how you feel and what you were doing was n't easy as well , so ... but let's see . i need to just put this dax back to work . all right , so no other issues whatsoever ? [patient] no . [doctor] have you lost weight ? [patient] no , but i stopped taking the camila birth control . my hunger level was at a new high . i mean , i was eating constantly . i felt like , what is going on ? [doctor] all right . [patient] and now i am feeling better . [doctor] okay , that's good . and your masked face , though , it does look thinner . [patient] well , the past six months i have lost some weight . [doctor] okay , good . um , anything else going on ? [patient] no . [doctor] all right . so your pap was in 2019 . i do n't think that we need to repeat that because it was negative/negative . um , have you ever had an abnormal pap ? [patient] not with you , but i did around 2009 , and then i had to be seen every six months for a while . and then i had a normal pap . [doctor] all right , well , let's just repeat it then . [patient] yeah , that's fine with me , to be safe . [doctor] okay . i know it sounds superstitious , but i feel like with all the immunocompromising , the pressure , the stress that people's bodies have been under , and the potential for getting covid or the vaccine ... i have actually seen some , um , an increase in abnormal paps in people who have been fine for a while . so that's why i figure let's just check . [patient] okay . i fight the vaccine fight every day at home because my husband is n't ready to get it . same with my daughter . she shares the same worries as her dad in how it'll impact her when she gets older . [doctor] have you had the vaccine ? [patient] yes , i have . and so has my son . he , um , has had his first already . [doctor] okay . well , you know , you can only do what you can do . [patient] yeah , i agree . [doctor] all right . well , let's complete your exam . [patient] all right . [doctor] so let's take a deep breath . and again . all right , you can breathe normally . all right , and take one more deep breath . okay , now i'm gon na touch your neck . go ahead and swallow . perfect . and just place your hand above your head . okay , i do feel some little bumps . [patient] yeah , but they're not as big as they were . [doctor] mm-hmm . okay , in this breast it does feel a little bit denser . does it hurt at all ? [patient] it does , where your left hand just was . [doctor] okay , right here ? [patient] yeah , down here . but whenever i breastfed , it was always sore there too . i had a clog and something else . the lumps do feel smaller , but they are still there , unfortunately . [doctor] yeah , they are . uh , well now i do n't know , because if it was the progesterone , they would've gone away . [patient] yeah . [doctor] all right , well just let your knees just op- relax and open . how's the itching or discomfort ? are you still using the cream ? [patient] yes , and i actually need to get that refilled for the first time ever . [doctor] okay . [patient] uh , but yeah , i use it once a week and it does help . [doctor] okay , great . all right , looks good . [patient] good . [doctor] you can go ahead and sit up . [patient] thank you . [doctor] all right , so typically the lumps would often just shrink up pretty quickly after you've had one or two cycles , and you've had two cycles so far . so i think let's just keep monitoring them for now . [patient] okay . and what could that mean ? [doctor] well , so just like people have an increased risk of breast cancer , there's also an increased risk for breast issues . you know what i mean ? so for example , cysts and lumps and fibroadenomas , those are all benign things . they're annoying and require some workup , but they're all benign . [patient] and i'm- i'm just worried because i'm almost 40 and my mom was almost 45 when she was diagnosed with breast cancer . so i mean , i know there's nothing i can do about it , but it's just i feel like , uh , we had it under control and now it is n't . [doctor] well , i would n't say that . i mean , i feel like we're at a point where we have a good cadence for you having surveillance on things , and i think you are more aware of your breasts than ever before , and things actually have n't changed . [patient] yeah . [doctor] so those are all good things . [patient] okay . [doctor] because , um , if it was cancer , we'd actually , we would see some change . [patient] we would ? okay , thank you for explaining that . [doctor] yeah . so i know it's annoying and distressing , but i think that's where we're at . it's annoying that you have the breast issue , and it's annoying that we have to follow them . [patient] yeah , i agree there . [doctor] um , but the only extra that i could po- , uh , potentially do , is we could get a breast specialist on the team and have you start to follow with them . and one of the advantages there is that they sometimes will do an ultrasound as an extension of their physical exam , in the office , to check out it- check it out on their own . uh , they also have a lot more experience and more willingness to sometimes perform procedures earlier , if they think it needs , um , if they think it needs to be done . and i think they tend to be much quicker than , you know , like radiology as to biopsy it . [patient] okay . i'll do whatever you think i should . [doctor] all right . well , i think since you're feeling worried , let's go ahead and we can get them on board . i'll send out a referral and they will call you within the next couple of business days to schedule . [patient] okay , i think that sounds great . [doctor] all right . i do too . all right , well any questions or anything else we can discuss today ? [patient] no , i think i'm all set . [doctor] all right , good . all right , well have a good rest of your day and just give us a call if you need anything else . [patient] all right , thank you . you have a good day too . [doctor] all right .", "target": "ASSESSMENT\n\n\u2022 Follow-up bilateral breast cysts.\n \u2022 Pap smear.\n\nPLAN\n\nFollow-up bilateral breast cysts\n Physical exam indicated stable breast density bilaterally. The patient is being seen regularly for monitoring. The plan is to continue close monitoring and the patient will be referred to breast specialist for additional review. The patient agreed to this plan.\n \n Pap smear\n Exam was normal. No additional treatment needed at this time."} {"idx": 76, "inputs": "[doctor] hello . [patient_guest] hi . [doctor] i'm dr. evelyn , one of the kidney doctors . it's good to meet you guys . [patient_guest] it's nice to meet you also . [doctor] yeah . so i was reading about this syndrome that i actually have never heard of . [patient_guest] yeah , me too . [doctor] i do n't think it's very common . [patient_guest] definitely not . it's c- pretty rare . [doctor] so- [doctor] can you start at the beginning ? i know she's a twin , so are these your first two babies ? [patient_guest] no , i have a son also who is nine . he also has autism . [doctor] okay . [patient_guest] and when the twins were born , katherine , she was about 4 pounds , 8 ounces . and her twin was a bit smaller , at 3 pounds , 13 ounces . [patient_guest] katherine , she was doing fine . she just had problems with eating , where she would stop breathing when she was eating . [doctor] like preemie type stuff ? [patient_guest] uh- . yeah . she just had a hard time regulating her temperature , but she did fine . she does have a gi doctor , because she has reflex really bad . she also had a dietician , who told us to take her off cow's milk . which we did . and then she has seen an allergist , and also a neurologist ... who diagnosed her with this syndrome , because she still does n't walk and she was n't sitting by herself a year old . [doctor] yeah . [patient_guest] but so now she is crawling and she is trying to take steps , so think she's doing pretty good . [doctor] good . is she in therapy ? [patient_guest] she is in therapy . she's in feeding therapy , occupational therapy , and also physical therapy . [doctor] awesome . okay . [patient_guest] and we also have speech therapy , who is going to be starting within the next couple of weeks . [doctor] that's great . [patient_guest] so , she has a lot of therapies . we have also seen an orthopedic and an ophthalmologist . i can never say that . we have seen everything , really . [doctor] and audiology too , right ? [patient_guest] yes . [doctor] yeah , wow. . [patient_guest] yeah , it has definitely been a whirlwind of stuff . when we saw the geneticist , she told us that sometimes people with this syndrome , they have trouble with their kidneys . that they might actually fuse into one . she also said sometimes they have problems with their legs , so that was why we saw ortho . [doctor] okay . okay . [patient_guest] so we have seen everybody , really . we are just here to make sure that her kidneys are looking good right now . [doctor] yeah , okay . so , um , tell me about how many wet diapers she has in a 24 hour period ? [patient_guest] she has a lot . [doctor] so like normal 8 to 10 , or like 20 ? [patient_guest] yeah , it's around 8 to 10 . [doctor] okay . great . [patient_guest] yeah , she seems to pee a lot , and it feels like she drinks a lot too . [doctor] that's perfect . [patient_guest] and she used to only drink milk , and then i took her off dairy milk . so when i say milk , i actually mean , you know , ripple pea protein milk . [doctor] sure , yeah . [patient_guest] so i give her that milk , water now that she's used to it , and sometimes water with just a little bit of juice . so i do feel like she's drinking a lot better now . [doctor] that's great . and she's how old now ? [patient_guest] she'll be two mo- two next month . [doctor] okay . is her twin a boy or a girl ? [patient_guest] she's a girl . [doctor] okay , and how's she doing ? [patient_guest] she's doing really good . she's running around , and she does n't have any problems . [doctor] all right . is she bigger than her or the same size ? [patient_guest] they're about the same size . they're able to wear the same clothes , so ... [doctor] okay . [patient_guest] i do n't even think she's a pound hav- heavier , actually . [doctor] yeah . yeah . [patient_guest] but she is a little bit taller than her ... um , katherine . she's just sh- a little shorter and chunkier , but i think that's a part of her syndrome . [doctor] yeah . yeah , i was reading all the things associated with the syndrome . it sounds like we're looking for continual- congenital anomalies wi- of the kidney and urinary tract . which is basically something is wrong with the plumbing . [patient_guest] okay . [doctor] so the only way to know that , is to do a kidney ultrasound . [patient_guest] okay , that sounds okay . [doctor] okay . let me put that into the system , and then downstairs they can do the ultrasound . [patient_guest] all right , thank you . [doctor] okay , yeah . where do you all live ? [patient_guest] uh , we live in dallas . [doctor] okay . anybody in the family with kidney failure , dialysis or transplant ? [patient_guest] no . [doctor] okay . so let's get your ultrasound done , and we'll see how it goes . [patient_guest] all right , that sounds good . [doctor] all right . let me take a quick look at her . [patient_guest] sure . [doctor] all right . please use my physical exam template . um , i wan na take a quick listen to her heart and lungs . i'll look in her ears too . and she can sit , she can just sit on your lap . [patient_guest] okay . [doctor] all right . that's it . [patient_guest] all right , that was n't too bad . [doctor] hmm . so , let's complete the ultrasound today . i'll call you with the results . if it's normal , you wo n't need to see me again , but if it's abnormal , you can see me in kennesaw . [patient_guest] okay , that sounds good . [doctor] okay . we'll determine what the next steps are if there are any , after we see her results . [patient_guest] all right , sounds good . thank you . [doctor] you're welcome . the nurse will be in to have you complete some paperwork , and give you instructions for the ultrasound . we'll talk soon . [patient_guest] all right . thank you , and have a good day . [doctor] you too . [doctor] all right . physical exams show the well-nourished female , who is slightly fussy when examined . eyes are small appearing . she has mild hypotonia of the lower extremities in her arms . normal external female genitalia . [doctor] assessment and plan . katherine is a 22-month-old former 34 and 3-week-old , twin with smith magenis syndrome . several organ systems can be affected by this chromosomal deletion syndrome . congenital anomalies of the kidney and urinary tract have been reported in the literature . [doctor] we will obtain the screening of the kidneys by ultrasound today . if there are abnormalities on the kidney ultrasound , we will determine next steps and future follow-up . the family lives in dallas , georgia , so her follow-up should be at the town center location . [doctor] end of recording .", "target": "ASSESSMENT\n\n\u2022 Smith-Magenis syndrome.\n Katherine is a 22-month-old former 34+3-week-old twin with Smith-Magenis syndrome.\n Several organ systems can be affected by this chromosomal deletion syndrome and congenital anomalies of the kidney and urinary tract have been reported in the literature.\n\nPLAN\n\nWe will obtain a kidney ultrasound screening today. If there are abnormalities on the kidney ultrasound, we will determine the next steps and future follow-up. The family lives in Dallas, Georgia, so her follow-up should be at the Town Center location."} {"idx": 100, "inputs": "[doctor] kayla ward , date of birth , 4/28/07 . mrn 3-8-4-9-2-0 . she's here for a new visit with her mother for acne located on the face , which started about two years ago and is present most every day . she has been using persa-gel and washing regularly , which is somewhat helpful . there are no associated symptoms including itching , bleeding , or pain . no additional past medical history . she lives with her parents and sister . they have a dog , bird , and bunnies . she is in 7th grade . she plays basketball and volleyball and tap . she wears sunscreen in the summer , spf 30 . no additional family history . hi kayla , i'm dr. juan price . i hear you are starting to get some acne on the face . how about the chest and back ? [patient] it's not too bad . [doctor] so , it's not bad on the chest or back . you've used some over the counter items like washes and persa-gel ? [patient] yeah . [doctor] do those seem to be helping ? [patient] yes , i think so , a little bit . [doctor] good . what's your skin care routine like now ? [patient] do you wan na know , like , the things i currently use ? [doctor] yes . what do you do for your acne in the morning ? and then what do you do at nighttime ? [patient] i wash my face , more like i wipe it down in the morning . then at night i use an elf facial cleanser called the super clarity cleanser . i finish with a toner and then the persa-gel . [doctor] when you say , wipe your face in the morning , do you use a product or just water ? [patient] mm , just water and a washcloth , really . if i feel really greasy , sometimes i'll use the elf cleanser in the morning , too . [doctor] okay . and is today a good day , bad day , or an average day for you ? [patient] mm , i would say it's probably a good day for me , of course , since i'm here , right ? [doctor] acne is always good when you come to see the doctor . do you find that your acne flares with your periods ? [patient] no , not really . [doctor] and do you get a regular period ? [patient] yup . [doctor] how long have you been getting a regular period ? [patient] mm , i think about two years . [doctor] okay . [patient_guest] the biggest flare , probably , was when she started school sports in the fall , just with all the sweating . [doctor] yup , that will do it . is there anything else that you've noticed , mrs. ward ? [patient_guest] no . kayla really has been doing a good job with the facial care regimen . it just does n't seem to help as much as we wanted . [doctor] got it . okay . well , let's take a look then . full exam is performed today , except for under the underwear and under the bra . multiple benign nevi on the trunk and extremities . scattered skin colored papules . open and closed comedones . and erythmateous papules on the face , primarily on the forehead and with also some on the central cheeks and chin . the chest and back are relatively spared . and the remainder of the examination is normal . so , what i'm seeing from your exam today is mild to moderate acne , mostly comodonal with small inflammatory component . [patient] okay , so is there anything we can do to help it ? [doctor] yes . i would like to start with a topical therapy first . every morning , you will wash your face with a mild cleanser then use a moisturizer labeled , noncomedogenic , with sunscreen spf 30 or higher . this means it wo n't clog your pores . now , in the evening , wash your face with the same cleanser and allow it to dry . apply adapalene , 0.1 % cream , in a thin layer to the areas you generally get acne . i want you to start off using this a few nights a week and slowly work up to using it every night . if it is ... excuse me , if it is very expensive or not covered by insurance , you can try different gel over the counter . you can follow that with clean and clear persa-gel in a thin layer , or where you generally get acne . and then a noncomedogenic moisturizer . you're atopic retinoid will cause some sensitivity , so you will need to wear sunscreen when you are outside . it may also cause some dryness or irritation . [patient] okay , i can do that . [doctor] you also have multiple benign moles on your arms , legs , back and abdomen . this means they all look normal with no worrisome features . we will see if you have any progress over the next six months and follow up at that time . [patient] okay , that sounds good . thank you . [doctor] do you have any questions for me ? [patient] no , i do n't think so . [doctor] okay . if you have questions or concerns before your next visit , please call the office . [patient] thank you , doctor , we will .", "target": "ASSESSMENT\n\n\u2022 Comedonal acne.\n \u2022 Multiple benign melanocytic nevi of upper and lower extremities and trunk.\n \n Kayla Ward is a 15-year-old female seen today for new acne evaluation. Full skin examination revealed mild to moderate comedonal acne with a small inflammatory component and multiple benign melanocytic nevi of upper and lower extremities and trunk.\n\nPLAN\n\nComedonal acne.\n We discussed the diagnosis, etiology, and treatment options. I recommend starting with topical therapy first. The patient was instructed to wash face every morning with a mild cleanser, then use a non-comedogenic moisturizer with sunscreen SPF 30 of higher. In the evening, wash face with same mild cleanser and allow to dry. Apply a thin layer of topical retinoid, Retin-A 0.1% gel, to acne prone areas. Start off using a few nights a week, slowly work up to using every night. If it is very expensive or not covered by insurance, you can try Differin gel over the counter. Your topical retinoid will cause sun sensitivity, so you will need to wear sunscreen when you are outside. It may also cause some dryness or irritation.\n \n Multiple benign melanocytic nevi of upper and lower extremities and trunk.\n Reassurance given moles are normal in appearance and have no concerning characteristics. Will continue to monitor for progression or changes in 6 months."} {"idx": 11, "inputs": "[doctor] hi , roger . how are you ? [patient] hey . good to see you . [doctor] good to see you . are you ready to get started ? [patient] yes , i am . [doctor] roger is a 62 year old male here for emergency room follow-up for some chest pain . so , roger , i heard you went to the er for some chest discomfort . [patient] yeah . we were doing a bunch of yard work and it was really hot over the weekend and i was short of breath and i felt a little chest pain for probably about an hour or so . so , i got a little nervous about that . [doctor] okay . and had you ever had that before ? [patient] no , i never have , actually . [doctor] okay . and- [patient] whose mic is on ? i'm in . [doctor] okay . and , um , how are you feeling since then ? [patient] um , after , uh , we were done , i felt fine ever since , but i thought it was worth looking into . [doctor] okay . and no other symptoms since then ? [patient] no . [doctor] okay . and any family history of any heart disease ? [patient] uh , no , actually . not , not on my , uh , uh , on my immediate family , but i have on my cousin's side of the family . [doctor] okay . all right . all right . and , um , you know , i know that you had had the , uh , knee surgery- [patient] mm-hmm . [doctor] a couple months ago . you've been feeling well since then ? [patient] yeah . no problem in , uh , rehab and recovery . [doctor] okay . and no chest pain while you were , you know , doing exercises in pt for your knee ? [patient] no . that's why last week's episode was so surprising . [doctor] okay . all right . and in terms of your high blood pressure , do you know when you had the chest pain if your blood pressure was very high ? did they say anything in the emergency room ? [patient] um , they were a little concerned about it , but , uh , they kept me there for a few hours and it seemed to regulate after effect . so , it , it did n't seem to be a problem when i , when i went home . [doctor] okay . and , and i see here that it was about 180 over 95 when you went into the emergency room . has it been running that high ? [patient] uh , usually no . that's why it was so surprising . [doctor] okay . all right . all right . well , let's go ahead and we'll do a quick physical exam . so , looking at you , you know , i'm feeling your neck . i do feel a little enlarged thyroid here that's not tender . you have a carotid bruit on the right hand side and , uh , your lungs are clear . your heart is in a regular rate and rhythm , but i do hear a three out of six systolic ejection murmur . your abdomen is nice and soft . uh , there is the healed scar on your right knee from your prior knee surgery , and there's no lower extremity edema . [doctor] so , let's look at some of your results , okay ? [patient] mm-hmm . [doctor] hey , dragon , show me the blood pressure . yeah . and here , your blood pressure's still high , so we'll have to talk about that . um , hey , dragon , show me the ekg . so , here you- that's good , your , your ekg- [patient] mm-hmm . [doctor] . here is normal , so that's , that's very encouraging . um , i know that they had the echocardiogram , so let's look at that . hey , dragon , show me the echocardiogram . okay . so , looking at this , you know , you do have a little bit of a , a low pumping function of your heart , which , you , you know , can happen and we'll have to look into that , okay ? [patient] mm-hmm . [doctor] so , you know , my impression is is that you have this episode of chest pain , um , that could be related to severe hypertension or it could be related to some heart disease . so , what i'd like to go ahead and do is , number one , we'll put you on , um ... we'll change your blood pressure regimen . we'll put you on carvedilol , 25 milligrams twice a day . that helps with coronary disease as well as your pumping function of your heart . um , i wan na go ahead and order a cardiac catheterization on you and make sure that we do n't have any blockages in your heart arteries responsible for the chest pain . [doctor] for the high blood pressure , we're gon na add the carvedilol and i want you to continue your lisinopril 10 milligrams a day and i wan na see , uh , how your blood pressure does on that regimen , okay ? [patient] okay . sounds good . [doctor] all right . so , the nurse will be in soon and i'll ... we'll schedule that cath for you , okay ? [patient] you got it . [doctor] hey , dragon , finalize the note .", "target": "ASSESSMENT AND PLAN\n\nThe patient is a 62-year-old male who presents for emergency room follow-up. He presented to the emergency room for chest pain and elevated blood pressure of 180/95. His EKG from the emergency room was normal, but ejection fraction on echocardiogram was abnormal. His blood pressure today was still elevated.\n \n Chest pain and hypertension.\n \u2022 Medical Reasoning: Given his recent episode of blood pressure elevation and chest pain, I suspect an element of coronary artery disease as well as pumping dysfunction.\n \u2022 Medical Treatment: We will change his blood pressure regimen to carvedilol 25 mg twice a day. He should also continue lisinopril 10 mg a day and I want to see how his blood pressure does on that regimen. I also recommended cardiac catheterization on him to make sure that he does not have any blockages in his heart.\n \n "} {"idx": 70, "inputs": "[doctor] hi logan . how are you ? [patient] hey , good to see you . [doctor] it's good to see you as well . [doctor] so i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] so logan is a 58 year old male , with a past medical history significant for diabetes type 2 , hypertension , osteoarthritis , who presents today with some back pain . [patient] mm-hmm . [doctor] so logan , what happened to your back ? [patient] uh , we were helping my daughter with some heavy equipment and lifted some boxes a little too quickly , and they were a little too heavy . [doctor] okay ... and did you strain your back , did something- [patient] i thought i heard a pop when i moved and i had to lie down for about an hour before it actually relieved the pain . and then it's been a little stiff ever since . and this was- what , so today's tuesday . this was saturday morning . [doctor] okay , all right . [doctor] and is it your lower back , your upper back ? [patient] my lower back . [doctor] your lower back , okay . and what- what have you taken for the pain ? [patient] i took some tylenol , i took some ibuprofen , i used a little bit of icy heat on the spot but it really did n't seem to help . [doctor] okay . and um ... do you have any numbing or tingling in your legs ? [patient] uh ... i felt some tingling in my toes on my right foot until about sunday afternoon . and then that seemed to go away . [doctor] okay , and is there a position that you feel better in ? [patient] uh ... it's really tough to find a comfortable spot sleeping at night . i would- i tend to lie on my right side and that seemed to help a little bit ? [doctor] okay , all right . [doctor] well , um ... so how are you doing otherwise ? i know that , you know , we have some issues to talk- [patient] mm-hmm . [doctor] . about today . were you able to take any vacations over the summer ? [patient] um ... some long weekends , which was great . just kind of- trying to mix it up through the summer . so lots of three day weekends . [doctor] okay , well i'm glad to hear that . [doctor] um ... so let's talk a little bit about your diabetes . how are you doing with that ? i know that- you know , i remember you have a sweet tooth . so ... [patient] yeah ... i-i love peanut butter cups . um ... and i have to say that when we were helping my daughter , we were on the fly and on the go and haven't had a home cooked meal in weeks, our diets were less than stellar . [patient] and uh ... i-i think i need to go clean for a couple of weeks . but other than that , it was been- it's been pretty good eating . [doctor] okay , all right . and how about your high blood pressure ? are you monitoring your blood pressure readings at home , like i recommended ? [patient] i'm good about it during the week while i am at home working, but on the weekends when i'm out of the house i tend to forget . uh , and so it's not as regimented , but it's been pretty good and-and under control for the most part . [doctor] okay , and you're you're taking your medication ? [patient] yes , i am . [doctor] okay . and then lastly , i know that you had had some early arthritis in your knee . how- how are you doing with that ? [patient] uh ... it gets aggravated every once in a while . if i- maybe if i run too much or if i've lift boxes that are a little too heavy , i start to feel the strain . but it's been okay . not great , but it's been okay . [doctor] okay . all right , well ... let me go ahead and- you know , i know that the nurse did a review of systems sheet with you when you- when you checked in . i know that you were endorsing the back pain . [doctor] have you had any other symptoms , chest pain , nausea or vomiting- [patient] no . [doctor] . fever , chills ? [patient] no . no none whatsoever . [doctor] no . okay . all right , well let me go ahead , i want to do a quick physical exam . [patient] mm-hmm . [doctor] hey dragon ? show me the blood pressure . [doctor] so it's a little elevated . your blood pressure's a little elevated here in the office , but you know you could be in some pain , which could make your- [patient] mm-hmm . [doctor] . blood pressure go up . let's look at the readings . [doctor] hey dragon ? show me the blood pressure readings . [doctor] yeah ... yeah you know they do run a little bit on the high side , so we'll have to address that as well . [patient] mm-hmm . [doctor] okay , well . let me- i'm just going to be listening your heart and your lungs and i'll check out your back and i'll let you know what i find , okay ? [patient] sure . [doctor] and kick against my hands . [doctor] okay , good . all right . [doctor] okay , so ... on physical examination , you know , i-i do hear a slight 2 out of 6 s- s- systolic heart murmur . [patient] mm-hmm . [doctor] on your heart exam . which you've had in the past . [patient] mm-hmm . [doctor] so that sounds stable to me . [doctor] on your back exam , you know , you do have some pain to palpation of the lumbar spine . and you have pain with flexion and extension of the back . and you have a negative straight leg raise , which is which is good . so , let's- let's just look at some of your results , okay ? [patient] mm-hmm . [doctor] hey dragon ? show me the diabetes labs . [doctor] okay , so ... in reviewing the results of your diabetes labs , your hemoglobin a1c is a little elevated at eight . i'd like to see it a little bit better , okay ? [patient] sure . [doctor] hey dragon ? show me the back x-ray . [doctor] so in reviewing the results of your back x-ray , this looks like a normal x-ray . there's good bony alignment , there's normal uh- there's no fracture present . uh , so this is a normal x-ray of your back , which is not surprising based on- [patient] mm-hmm . [doctor] . the history , okay ? [patient] mm-hmm . [doctor] so let's just go ahead and we'll- we're going to go over , you know , my assessment and my plan for you . [doctor] so for your first problem , your back pain . you know , i think you have a lumbar strain from the lifting . so , let's go ahead . we can prescribe you some meloxicam 15 mg once a day . [patient] mm-hmm . [doctor] i want you to continue to ice it , okay . i want you to try to avoid any strenuous activity and we can go ahead and- and refer you to physical therapy- [patient] mm-hmm . [doctor] . and see how you do , okay ? [patient] you got it . [doctor] for your next problem , your diabetes . y-you know , i think it's a little under- out of control . so i want to increase the metformin to 1000 mg twice a day . and i'm going to um ... um ... i'm going to repeat a hemoglobin a1c in about 6 months , okay ? [patient] mm-hmm . [doctor] hey dragon ? order a hemoglobin a1c . [doctor] so , for your third problem , your hypertension . uh ... i-i'd like to go ahead increase the lisinopril from 10 mg to 20 mg a day . [patient] mm-hmm . [doctor] does that sound okay ? i think we need to get it under better control . [patient] no that's fine . i agree . [doctor] hey dragon ? order lisinopril 20 mg daily . [doctor] and for your last problem , your osteoarthritis , i-i think that you were doing a really good job , in terms of you know what , monitoring your knee and uh ... [patient] mm-hmm . [doctor] i do n't think we need to do any- any further , you know , work up of that at this time , okay ? [patient] mm-hmm . [doctor] do you have any questions logan ? [patient] not at this point . [doctor] okay . all right . [doctor] so the nurse will come in to help you get checked out , okay ? [patient] you got it . [doctor] hey dragon ? finalize the note .", "target": "ASSESSMENT AND PLAN\n\nMr. Logan Walker is a 58-year-old male with a past medical history significant for diabetes type 2, hypertension, and osteoarthritis, who presents today with low back pain.\n \n Lumbar strain.\n \u2022 Medical Reasoning: He injured his lower back while moving heavy boxes. His recent x-ray was unremarkable.\n \u2022 Medical Treatment: Initiate meloxicam 15 mg once a day.\n \u2022 Specialist Referrals: Referral to physical therapy.\n \u2022 Patient Education and Counseling: He was encouraged to continue icing the area and avoid strenuous activity.\n \n Diabetes type 2.\n \u2022 Medical Reasoning: His recent hemoglobin A1c was elevated at 8. He does admit to some dietary indiscretion lately.\n \u2022 Additional Testing: Repeat hemoglobin A1c in 6 months.\n \u2022 Medical Treatment: Increase metformin to 1000 mg twice a day.\n \n Hypertension.\n \u2022 Medical Reasoning: His blood pressures have been slightly elevated based on home monitoring and in clinic today.\n \u2022 Medical Treatment: Increase lisinopril from 10 mg to 20 mg a day.\n \n Osteoarthritis.\n \u2022 Medical Reasoning: This is mostly well controlled.\n \u2022 Medical Treatment: Continue to monitor the knee. No further work up is needed at this time.\n \n "} {"idx": 4, "inputs": "[doctor] hi , james , how are you ? [patient] hey , good to see you . [doctor] it's good to see you , too . so , i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] james is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes who presents today with back pain . [patient] mm-hmm . [doctor] so , james , what happened to your back ? [patient] uh , i was golfing and i hurt my back when i went for my backswing . [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 . [doctor] okay . and how long ago did this happen ? [patient] this was saturday morning . [doctor] okay . so , about four days ago ? [patient] mm-hmm . [doctor] okay . um , and what have you taken for the pain ? [patient] uh , i took some tylenol . i took some ibuprofen . [doctor] mm-hmm . [patient] i tried ice . i tried heat , but nothing really worked . [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 . [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 . [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 . [doctor] uh- . [patient] not too fast . [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 . [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 . [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 . [doctor] okay . so , you're avoiding the salty foods like we had talked about ? [patient] yes . [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 . [doctor] okay . all right . and any problems laying flat while you go to bed ? [patient] no . [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 . [doctor] jelly beans ? [patient] i love jelly beans , yeah , yeah . that's been a struggle , but i'm getting through it . [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 . [doctor] okay . and you are still on your metformin ? [patient] yes . [doctor] okay . all right . all right . now , i know the nurse did a review of symptoms sheet when you checked in . [patient] mm-hmm . [doctor] i know that you were endorsing the back pain- [patient] mm-hmm . [doctor] . and maybe a little weakness in your right leg . um , any other symptoms ? i know we went through a lot . [patient] no . [doctor] okay . um , so , i wan na go ahead and move on to a physical exam , okay ? [patient] mm-hmm . [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 . [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 . [doctor] lean up . okay . all right . so , on your physical exam , everything seems fine . [patient] good . [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 . [doctor] . so that's stable . [patient] okay . [doctor] on your back exam , you do have some pain to palpation of the lumbar 5 or lumbar spine- [patient] mm-hmm . [doctor] at the level of l5 . [patient] okay . [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 . [doctor] 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 . [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 ? [doctor] 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 . [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 . [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 . [doctor] . just to make sure that you do n't have any disc herniation or anything like that , okay ? [patient] that's fine . [doctor] how does that sound ? [patient] no problem . [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 . [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 . [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- [doctor] of the lisinopril ? [patient] actually , i do . [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 . [doctor] um , any questions ? [patient] not at this point . [doctor] okay . hey , dragon , finalize the note .", "target": "ASSESSMENT AND PLAN\n\nJames Allen is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes, who presents today with back pain.\n \n Acute lumbar strain.\n \u2022 Medical Reasoning: The patient reports feeling a 'pop' and immediate pain while golfing approximately 4 days ago. He has tried Tylenol and ibuprofen without significant relief.\n \u2022 Additional Testing: If he continues to have pain, we will obtain an MRI for further evaluation.\n \u2022 Medical Treatment: Initiate meloxicam 15 mg once daily.\n \u2022 Specialist Referrals: We will refer him to physical therapy to work on strengthening the area.\n \n Diabetes type 2.\n \u2022 Medical Reasoning: He has been compliant with metformin and dietary modifications, but his recent hemoglobin A1c was 8.\n \u2022 Additional Testing: Repeat hemoglobin A1c in a couple of months.\n \u2022 Medical Treatment: Increase metformin to 1000 mg twice daily.\n \n Congestive heart failure.\n \u2022 Medical Reasoning: He is doing well from this standpoint. He has been compliant with his medications, dietary modifications, and regular physical activity.\n \u2022 Medical Treatment: Continue lisinopril 20 mg once daily and Lasix. Lisinopril was refilled today.\n \n "} {"idx": 17, "inputs": "[doctor] hello , mrs . peterson . [patient] hi , doctor taylor . good to see you . [doctor] you're here for your hip today , or your- your leg today ? [patient] yes . i hurt my- the- my- top part of my right leg here . [doctor] hey , dragon . i'm seeing mrs . peterson , here , she's a 43-year-old patient . she's here for left leg pain . right leg pain , right leg pain ? [patient] yes . [doctor] um so , what happened to you ? [patient] i was bowling and as i was running up to the lane , i had my bowling ball all the way back , and when i slung it forward , i hit it right into my leg instead of the lane and so then i fell but- yeah- [doctor] did you get a strike ? [patient] no . in fact , i actually dropped the ball and it jumped two lanes over and landed in the other people's gutter . [doctor] terrific , terrific . so , did it swell up on you ? [patient] it- not- did n't seem like it swelled that much . [doctor] what about bruising ? [patient] um , a little bit on the back- back end , that side . [doctor] have- have you been able to walk on it ? [patient] just a little bit . very carefully . [doctor] sore to walk on ? [patient] yes . it's very sore . [doctor] um , and going upstairs or downstairs , does that bother you at all ? [patient] yeah , well , i do n't have stairs , but um , i would avoid that at all costs . [doctor] okay . um , it looks like you had a history of atopic eczema in your past ? [patient] yes . yes , i have eczema . [doctor] okay . and you take uh- uh , fluocinonide for that ? [patient] yes , when it gets really itchy , i'll- i'll use that and it usually takes care of it . [doctor] okay . and , it looks like you have a pre- previous surgical history of a colectomy ? what happened there ? [patient] yes , i had a- um , some diverticulosis and then um , i actually went into diverticulitis and they ended up going in and having to remove a little bit of my colon . [doctor] okay , let me examine you . does it hurt when i push on your leg like that ? [patient] yes , it does . [doctor] okay . if i lift your leg up like this , does that hurt ? [patient] no . [doctor] so , on my exam , you have some significant tenderness to the lateral aspect of your um right upper leg . you do n't seem to have any pain or tenderness with flexion or extension of your um your lower leg . um , are you taking anything for it right now ? [patient] i've been going back and forth between taking ibuprofen and tylenol . [doctor] okay . well , my impression is that you- you probably have a contusion , but let's take a look at your x-ray first . hey , dragon . show me the x-ray . yeah , so if you look at this , this is a normal femur . um , really do n't see any evidence of a fracture or any swelling , so it's essentially , a normal x-ray . so , what we're going to do is , i'm going to start you on um an anti-inflammatory . it's going to be mobic 15 milligrams uh , once a day . i want you to use some ice for the pain , um , and it should , honestly , just being a contusion , get better in the next week or so . if it's not getting better , of course , come on back and- and see me . [patient] okay , sounds good . [doctor] hey , dragon . go ahead and um , pres- do the orders and um , procedures uh , as described . come with me , and uh , i'll get you checked out . dragon , go ahead and finish off the note .", "target": "PLAN\n\nAt this point, I discussed the diagnosis and treatment options with the patient. I have recommended Mobic 15 mg once a day. She will use ice for pain. She will follow up as needed.\n \""} {"idx": 24, "inputs": "[doctor] patient is pamela cook . medical record number is 123546 . she's a 36-year-old female post bilateral reduction mammoplasty on 10-10 20-20 . [doctor] hey , how are you ? [patient] good . how are you ? [doctor] i'm doing well . it's good to see you . how have you been ? [patient] i've been doing good . [doctor] great . how about your breasts , are they doing all right ? [patient] great . [doctor] are you having any chills , fever , nausea , or vomiting ? [patient] no . [doctor] good . all right . let's take a peek real quick . [patient] sure . [doctor] how's life otherwise ? pretty good ? nothing new ? [patient] no , just enjoying summertime . [doctor] okay . how's your family ? [patient] they're good . [doctor] good . all right . i'm going to take a look at your breast now . if you would just open up your gown for me . [doctor] everything looks good . [patient] yeah . [doctor] how's your back pain ? [patient] i'm not really having any more . [doctor] any hard spots , lumps , or bumps that you've noticed ? [patient] i did when i came in last time when i saw your pa , ruth sanchez in march . she said i , she said she found a lump right here under my left breast , but i have n't felt it since then . but i did the massages . [doctor] okay , well . that that's good . uh , it's probably just the scar tissue , but everything looks good and you're healing wonderful , so . [patient] i told her that the scars here was kind of bothering me and i got scar gel . i was using it everyday , but i do n't think i need it now . [doctor] yeah , that scar did widen a little bit . let me take a closer look , hang on . this one widened a little too , ? the incisions are well healed though with no signs of infection or any redness on either breast , so i'm not concerned . [patient] yeah , but this one just bothered me a little bit more . [doctor] i understand . um , you can close your gown now . [doctor] the only thing that is really going to help out that is to uh , to cut it out and re-close it . [patient] [doctor] and you do n't want that , ? [patient] i mean , not right now . [doctor] um , you want to come back and revisit um , maybe six months ? [patient] yeah , i will do that . i still have n't , i still have some more of the gel and i can try using that again . [doctor] okay . keep doing that twice a day . the gel is going to lighten the color a little bit , which is already pretty light . um , but , just in that area , and it's high tension , so it's going to rub a little bit . [patient] yeah , but it kind of bothers me a little bit . [doctor] uh , i do see that . like i said , the only way to really fix that is to cut it out . [patient] uh- . [doctor] um , let's take a look in six months and then we'll go from there . sound like a plan ? [patient] but we have n't hit a full year yet . [doctor] i know . um , i would n't do any revisions anyway for scar tissue until we're at least a year out anyway . [patient] okay . [doctor] so let's wait those six months . you can keep using uh , the mederma scar gel twice a day . massage and scar gel will help for the scars . um , you can put it on other scars too , if you need . [patient] okay . [doctor] um , so that's what i would do . let's just get some pictures today so we can keep up um , with them . and keep an eye on these scars and then we'll go from there . [patient] sounds good . [doctor] all right , well it's good to see you . i'm glad you're doing well . [patient] yeah , same here . [doctor] all right . well , i'm going to tell the front desk six months and we'll revisit those scars . [patient] all right . [doctor] thank you . they're gon na come get your photos now , okay ? [patient] okay .", "target": "ASSESSMENT\n\n\u2022 Status post bilateral reduction mammoplasty.\n \n Pamela Cook is a 36-year-old female who is status post bilateral reduction mammaplasty on 10/10/2020. There is some widening of the scar tissue bilaterally.\n\nPLAN\n\n- Obtain bilateral breast photos today to monitor scarring.\n - Continue Mederma scar gel and incisional scar massage twice daily."} {"idx": 86, "inputs": "[doctor] hey nicholas nice to see you today your pcp looks like he sent you over for a nonhealing foot ulcer on your right foot can you tell me about how long you've had that [patient] yeah i've had the boot for about six weeks i first noticed it when i put on a pair of shoes that were little bit too tight i felt some burning and some stinging and looked down and saw a blister i did n't think too much of it because it was on the pad of the bottom of my foot around my heel and i just had been walking on the front part of my foot i started to notice a foul smell and my wife mentioned something to me the other day and i noticed my dog was also smelling my socks a lot and so we looked and saw that the blister had become unroofed or the the top part of the skin of the blister became undone and then underneath it was just this really thick soft mushy skin that had a bad smell with some yellow drainage and so and barbara called the primary care doctor who then got me in to see you he started me on some antibiotics about six days ago and i never had any nausea or vomiting but my wife checked my temperature it was about ninety nine point seven and then at one point i had to put on an extra blanket in bed because i had some chills and when i started the antibiotics it started to feel pretty good but we've now noticed that it has turned black around the outside of the wound and i'm getting some cramping in my calf muscle as well and so there was a red streak also that was coming up the front part of my my ankle along the inside portion of my calf muscle and it's super super hot and so they wanted me to take a have have you look at it [doctor] okay thank you for sharing that history with me and did you complete that course of antibiotics [patient] i think he called in ten days' worth and i'm on day six or seven right now i know i've got about two or three days left [doctor] okay and you mentioned that it had some stinging and it was a bit uncomfortable are you experiencing any pain right now [patient] yeah it was it was stinging initially like i had just done something small but at this point it's it's really like throbbing it's almost like there is a fire poker in the bottom of my foot now and then the inside of my calf muscle is really hard and i've noticed that every time that i push that i feel it all the way up to my knee behind my kneecap and then noticed that i've been coughing a lot the last two days and then i've noticed that i've had like difficult time catching my breath when i'm walking around the house and so it's almost like two different things going on at this point [doctor] okay so now i see here in your record that you have some that you're diabetic and have some diabetic neuropathy as well how's your blood sugars been running i'm i'm assuming kind of all over the place over the last i'm gon na say probably three or four weeks can you tell me about that [patient] yeah my my a1c is six point seven it's pretty well controlled [doctor] okay [patient] i used to be on an insulin pump and i had an a1c that at one point was like thirteen but we worked with an endocrinologist to get it down to where it's at now i've been six point seven for probably two years now and i rarely have a blood sugar that goes over two hundred i check two or three times a day if i feel weird i'll check it again but i noticed my sugars have probably been trending in the three to four hundreds the last two weeks and then i had one spike at one point at like five or six hundred that got our attention and i think that's also what made my wife call the primary care doc [doctor] okay now i know this was caused by a new pair of shoes you had mentioned before to your pcp and he relayed this to me that you really like to go on hikes you and your wife have been hiking have you gone to the new trails that that were just opened up here behind the park [patient] yeah we actually hiked to charlie's bunion about a week before this i've had a new pair of diabetic shoes and inserts i get those every year i changed the inserts every three or four months i mean i've been in cruise control as far as that goes for some time i did get a new pair of shoes the prosthetist told me to check my feet every day for the first week or two which we did i did go hiking about the third or fourth day and i think that might be what caused it as i just went too far when we were hiking but yeah the trails are the trails are gorgeous they're open it's time to to be outside and i'm sorta stuck with this right now [doctor] absolutely yeah my wife and i like to go back there and and hike those trails as well so i'm gon na do a quick physical exam for your vital signs i do recognize a slight fever however your vitals themselves look good now on your foot exam i do recognize the necrotic wound on your heel as you mentioned it is present it's approximately two by two centimeters i i do recognize the sloughing of the of the tissue as well as what looks like cellulitis around the area as well as erythemia so now unfortunately i do also smell the odor you are correct it is it does it is odds but i do not appreciate any bony exposure now on vascular exam i do have bilateral palpable pulses femorally and popliteal pulses are present however i do n't recognize a palpable pulse dorsalis pedis or posterior tibial however i did use the doppler and they are present via doppler now i'm gon na press on the actual affected area of the wound do you have any pain there [patient] i do n't feel that right there [doctor] okay i'm gon na review the results of your right foot x-ray that we did when you came in today the good news is i do n't see any evidence of osteomyelitis meaning that there is no infection of the bone so let's talk a little bit about my assessment and plan for this nonhealing diabetic foot ulcer i'm going to order a test to check blood supply for this wound also i'm going to do a debridement today in the office we may have to look at we are going to do a culture and we may have to look at different antibiotic therapy i am concerned about the redness that's moving up your leg as well as this the the swelling and pain that you have in your calf so we're gon na monitor this very closely i wan na see you again in seven days and then as far as your diabetes is concerned i do want you to follow up with your endocrinologist and make sure that we do continue to keep your hemoglobin a1c below seven and we're gon na need to closely monitor your blood sugars since we're going to be doing some medication therapy with antibiotics and and potentially some other medications any other questions comments or concerns before i have the nurse come in we're gon na prep you for that procedure [patient] no not really so you're gon na continue the antibiotics that i'm on and possibly extend or call in a new antibiotic depending on the culture [doctor] correct [patient] if i heard [doctor] yep that's correct so what we're gon na do is you said you're six days in do a ten or twelve day course so we're gon na go ahead and continue your antibiotics therapy that your pcp put you on i do want to get the culture back and then we'll make the determination as far as additional or changing that antibiotic therapy [patient] okay sounds good [doctor] alright", "target": "ASSESSMENT\n\nRight non-healing diabetic foot ulcer.\n Diabetes.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that I do not see any evidence of osteomyelitis. I am concerned about the redness that is moving up his leg, as well as the swelling, and pain that he has in his calf. I have recommended that we obtain a venous ultrasound to check his blood supply for the wound. I have also recommended that we perform a debridement of the wound today. We may have to obtain a culture and look at different antibiotic therapy. I am recommending that he continue with antibiotics that his primary care physician prescribed.\n \n In regard to his diabetes, I have advised him to follow up with his endocrinologist to ensure that we do continue to keep his hemoglobin A1c below 7. We will need to closely monitor his blood sugar since we are going to be doing some medication therapy with antibiotics and potentially some other medications depending on the culture results."} {"idx": 89, "inputs": "[doctor] hi andrea , how are you ? [patient] i'm doing well . how are you ? [doctor] doing well . uh , so i know the nurse told you about dax . i'd like to tell dax a little bit about you . okay ? [patient] okay . [doctor] so , andrea is a 52-year-old female with a past medical history significant for rheumatoid arthritis , atrial fibrillation , and reflux who presents today for her annual exam . so andrea , it's been a year since i saw you . how are you doing ? [patient] i'm doing well . so , i've been walking like you told me to and , um , exercising and doing yoga , and that's actually helped with my arthritis a lot , just the- the constant movement . so , i have n't had any joint pain recently . [doctor] okay . good . so , no- no issues with any stiffness or pain or flare ups over the last year ? [patient] no . [doctor] okay . and i know that we have you on the methotrexate , are you still taking that once a week ? [patient] yes , i am . [doctor] okay . and any issues with that ? [patient] no . [doctor] no . okay . and then in terms of your a-fib , how are you doing with that ? are you having any palpitations ? or , i know that you've kind of been in and out of it over the past , you know , year or so . [patient] yeah . i've still been having palpitations . the- the last one i had was about a week ago . i've noticed that when i start to get stressed , um , they start to flare up again . so , i've been trying meditation , trying running with my dog to try and relieve the stress but it has n't really been working . [doctor] yeah . i- i know that you had called , um , last month and we- we did that event monitor for you , uh , which we'll take a look at in a few minutes . okay ? [patient] okay . [doctor] um , how about um , your reflux ? you know , we had placed you on the protonix , uh , has that helped ? and i know that you were gon na do some dietary modifications . [patient] yeah . i cut out soda and that- that's helped- seemed to help , and the medication's been helping too . i have n't had a flare up in over , i think , five months . [doctor] okay . all right . um , so , you know , i know that you did the review of systems sheet when you checked in and , you know , you had- you know , you endorsed the palpitations and you had some nasal congestion . any other symptoms ? you know , chest pain , shortness of breath , nausea or vomiting ? [patient] no , nothing like that . just the nasal- nasal congestion because of my allergies . [doctor] okay . all right . okay . well , i'd like to go ahead and do a quick physical exam , okay ? [patient] okay . [doctor] all right . hey dragon , show me the vital signs . okay . so , you're in- here in the office today , it looks like , you know , your heart rate's really good today . it's- it's nice and controlled so that's good . um , i'm just gon na take a look into your heart and lungs and- and i'll let you know what i find . okay ? [patient] okay . [doctor] okay . so , on physical examination , um , you know , everything looks really good . on your heart examination , i do appreciate a slight 2/6 systolic- systolic ejection murmur , um , which we've heard in the past so i'm not worried at that . you're in the- a nice regular rate and rhythm at this time . your lungs are nice and clear . on your right elbow , i do notice some edema and some erythema . does it hurt when i press it ? [patient] yeah , it does a bit . [doctor] okay . so , she has pain to palpation of the right elbow . um , and you have no lower extremity edema , okay ? um , so i wan na go ahead and just take a look at some of your results . okay ? [patient] okay . [doctor] hey dragon , show me the event- event monitor results . okay . so , you know , this is the results of your event monitor which shows that , you know , you're in and out of a-fib , you have what we call a conversion pause . you know , you're in a-fib , you pause , and then you go back to regular rhythm . so , we'll talk about that , okay ? [patient] okay . [doctor] hey dragon , show me the autoimmune panel . so , looking here at your autoimmune panel , everything looks good , it looks like you're- you know , everything is well controlled with your rheumatoid arthritis on the methotrexate . okay ? so , let me just go over a little bit about my assessment and my plan for you . okay ? [patient] okay . [doctor] so for your first problem , your rheumatoid arthritis , again , everything looks good . i wan na just continue you on the methotrexate 2.5 mg , once weekly . um , and uh , if you need a referral back to see the rheumatologist , let me know , but i think everything seems stable now . do you need a refill of the methotrexate ? [patient] yes , i do . [doctor] okay . hey dragon , order methotrexate , 2.5 mg once weekly . for your second problem , the atrial fibrillation . so , you're going in and out of a-fib and i'd like to just keep you in normal sinus rhythm . so , i wan na go ahead and refer you to cardiology for a cardiac ablation which just maps out where that rhythm is coming from and burns it so it does n't come back . okay ? you're young , we wan na keep you in a normal rhythm and , being that you're going in and out of a-fib , i think that's what we should do . okay ? [patient] okay . [doctor] hey dragon , order a referral to cardiology . and for your last problem , the reflux , you know , i wanna- i want you to just continue on the protonix , 40 mg a day . continue with your dietary modifications , you know , avoiding coffee and spicy foods , that type of thing . okay ? and then let me know if you have any other issues with that , okay ? [patient] will do . [doctor] any questions ? [patient] no , i do n't . [doctor] okay . all right . it was good to see you . [patient] good seeing you . [doctor] hey dragon , finalize the note .", "target": "ASSESSMENT AND PLAN\n\nAndrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen.\n \n Rheumatoid arthritis.\n \u2022 Medical Reasoning: The patient has remained active and has been compliant with methotrexate once weekly. Her recent autoimmune panel was normal.\n \u2022 Medical Treatment: She will continue on methotrexate 2.5 mg once weekly. This was refilled today.\n \u2022 Specialist Referrals: If she needs a referral back to the rheumatologist, she will let me know.\n \n Atrial fibrillation.\n \u2022 Medical Reasoning: She continues to experience episodes of palpitations. Her most recent episode was about 1 week ago. She is in normal sinus rhythm today, but her recent cardiac event monitor demonstrated a conversion pause.\n \u2022 Specialist Referrals: We will refer her to cardiology for a cardiac ablation.\n \n GERD.\n \u2022 Medical Reasoning: She has been compliant with dietary modifications and denies any episodes in approximately 5 months.\n \u2022 Medical Treatment: Continue on Protonix 40 mg daily.\n \u2022 Patient Education and Counseling: She could continue with dietary modifications and avoid known dietary triggers.\n \n "} {"idx": 26, "inputs": "[doctor] dictating on donald clark . date of birth , 03/04/1937 . chief complaint is left arm pain . hello , how are you ? [patient] good morning . [doctor] it's nice to meet you . i'm dr. miller . [patient] it's nice to meet you as well . [doctor] so , i hear you are having pain this arm . is that correct ? [patient] that's correct . [doctor] okay . and it seems like it's worse at night ? [patient] well , right now the hand is . [doctor] mm-hmm . [patient] and the thing started about two weeks ago . i woke up about two o'clock in the morning and it was just hurting something awful . [doctor] uh- . [patient] and then i laid some ice on it and it finally did ease up . [doctor] okay , that's good . [patient] so i got up , i sat on the side of the bed and held my arm down , thinking it would , like , help the circulation , but it did n't . [doctor] okay , i see . [patient] and so , after a while , when it eased off , maybe about four , five am , i laid back down and it did n't start up again . [doctor] mm-hmm , okay . [patient] um . i went back to sleep but for several nights this happened , like , over and over . so , i finally went to see the doctor , and i do n't really recall her name . [doctor] okay . yeah , i think i know who you're talking about , though . [patient] um , she's the one who sent me to you , so , i , i would , i would think so . but when i went to her after the third time it happened and she checked me out , she said it was most likely coming from a pinched nerve . [doctor] probably . uh , do you notice that moving your neck or turning your head seems to bother your arm ? [patient] uh , no . [doctor] okay . is moving your shoulder uncomfortable at all ? [patient] no . [doctor] and do you notice it at other times besides during the night ? [patient] um , some days . if it bothers me at night , then the day following , it usually will bother me some . [doctor] okay . and do you just notice it in the hand , or does it seem to be going down the whole arm ? [patient] well , it starts there and goes all the way down the arm . [doctor] okay . have you noticed any weakness in your hand at all ? [patient] uh , yes . [doctor] okay . like , in terms of gripping things ? [patient] yeah . [doctor] okay . [patient] uh , this finger , i hurt it some time ago as well . [doctor] really ? [patient] yeah . it does n't work properly . or , it works very rarely . [doctor] gotcha . and did i hear that she gave you some prednisone and some oral steroids , or ? [patient] uh , well , she gave me some numbing medicine . it helped a little bit . the other two were a neck pill and gabapentin . uh , you should have my full list in your notes , though . since then it has n't really bothered me at night . also , just so you know , i am a va and i'm one percent disabled from this leg , um , issues from my knees down to my feet . [doctor] okay . is it neuropathy ? [patient] uh , yep . [doctor] gotcha . that is good to know . all right , well , let's go ahead and take a look . [patient] okay . [doctor] all right . so , to start , i'm gon na have you do something for me . uh , just go ahead and tilt your chin as far as you can down to your chest . okay , good . and now , go the other way , tilting your chin up as far as you can . now , does that seem to bother you at all ? okay . and now , come back to normal , just look and turn your head as far as you can that way . great . and now , as far as you can towards that wall . uh , does that seem to bother you at all ? [patient] no . well , actually , i do feel a little strain . [doctor] okay . so , you feel it in the neck a little bit ? [patient] yeah , just a little strain . [doctor] okay . uh , now squeeze my fingers as hard as you can with both hands . great . now , hold your arms like this . [patient] okay . [doctor] and i'm going to try to strain your arms and try to keep them as stiff as you can . do n't let me strain it . okay , good . good . now , when i , i'm just touching your hands like this . does it seem to feel about the same in both hands ? [patient] uh , yes . [doctor] okay . all right . so , i do agree with betty . uh , more than likely , this seems like it would be coming from your neck . that's the most common reason that causes what , what you're experiencing . and i looked at an x-ray of your neck , and you do seem to have a lot of arthritis there , and there does seem to be potential for a disc to be pushing on a nerve . and now , what i do n't have is an mri , which would show me , uh , kind of exactly where the nerve roots are getting pinched off . [patient] i see . [doctor] so , gabapentin can help a little bit with the nerve pain , and what i would like to do is potentially set you up for an epidural . and what that is is it , it's a focused anti-inflammatory medicine , excuse me , that works behind the nerve roops that , nerve roots that we are thinking might be getting squished off . it can often help alleviate your symptoms , and i do need to get an mri of your neck . um , i know we have had one of your lower back , but i need one of your neck to see exactly where the roots are getting pinched off . so , what i can do is tentatively set you up for an epidural , but before you do that , we do need to get that mri so i can see right where i need to put the medicine for your epidural . uh , what do you think of that ? [patient] i think that sounds good to me . [doctor] okay , good . and just to confirm , do you take any blood thinners ? i do n't think i saw any on your medicine list . [patient] uh , no , i do n't . [doctor] okay , good . and what i would have you do is continue with the gabapentin . um , are you taking 300 or 100 ? [patient] um , not sure . my lady friend helps me handle this stuff . [doctor] okay . [patient] i am taking eliquis , though . [doctor] okay . um , so whatever you are doing you can just keep doing it , and i'm going to set you up for the epidural and imaging study , um , just so i know right where to put the medicine . and i will follow up with you after s- um , that's in . we can do the shot , just to make sure your arm is feeling better . sound good ? [patient] sounds good . for the last couple of nights , though , my neck has not been bothering me . [doctor] okay . s- um , so , presumably what's happening , then , is when you're sleeping your neck is kind of gets off-tilt , uh , kilter , and it compresses the nerve roots there . now , if you think you're doing fine , we could hold off , but at the very la- least , i'd like to update that mri of yours and see what's going on , because probably this is something that will likely flare up again . [patient] yeah , it , it has been for the last week , so , i understand . [doctor] okay . all right . well , do you want to do that work-up and do the epidural , or do you think you're doing fine and you want to wait ? [patient] well , my hand is still bothering me . [doctor] okay . so , you're saying your neck is not bothering you but the hand is . okay . so then , let's just stick with the plan . mri of the neck , so we can see where the nerve roots may be compressed , that's giving your hand the issue . and then , we're going to set you up with the epidural . [patient] okay . sounds good . [doctor] all right . so , keep going with the gabapentin . i will order the imaging of your neck , and the shot will hopefully help some with those symptoms in your hand , and then we'll follow up afterwards . [patient] all right . is the mri today ? [doctor] um , you probably ca n't do it today , but let me talk with roy and see how soon we can get it done . just give me a quick minute , and then roy will come in and get things scheduled as soon as we can . [patient] all right . [doctor] all right . well , it was nice meeting you , my friend . [patient] you as well . thank you . [doctor] physical exam , elderly white gentleman presents in a wheelchair . no apparent distress . per the template , down through neuro- neurologic . one plus bilateral biceps . triceps brachioradialis . reflexes bilateral all negative . follow up and take out the lower extremities . gait not assessed today . strength and sensation is per the template . uh , upper and lower extremities . musculoskeletal , he is non-tender over his cervical spine . he does have mildly restricted cervical exte- extension . right and left lateral rotation which is symmetric , which gives him mild lateral neck pain but no radi- radicular pain . spurling's maneuver is benign . [doctor] paragraph , diagnostics . cervical x-ray 6421 . cervical x-ray reveals significant disc degeneration at c56 , and to a lower extent c45 and c34 . significant lower lumbar facet arthropathy c67 and c7-t1 is difficult to visualize in the current x-rays . [doctor] paragraph , impression . number one , left upper extremity neuropathy suspicious for cervical radicularopathy . possible contribution of peripheral neuropathy . number two , neck pain in the setting of arthritis disc degeneration . [doctor] paragraph , plan . i suspect that this is a flare of cervical radicularopathy . i'm going to set him up for a cervical mri , and we'll tentatively plan for a left c7-t1 epidural afterwards , although the exact location will be pending the mri results . he'll continue his home exercise program as well as twice a day gabapentin . we'll follow up with him afterwards to determine his level of relief . he denies any blood thinners .", "target": "ASSESSMENT\n\n\u2022 Left upper extremity neuropathy, suspicious for cervical radiculopathy, possible contribution of peripheral neuropathy\n \u2022 Neck pain in the setting of arthritis and disc generation\n\nPLAN\n\nI suspect that this is a flare of cervical radiculopathy. I am going to set him up for a cervical MRI. We will tentatively plan for a left C7-T1 epidural afterwards, although the exact level will be pending the MRI results. He will continue his home exercise program as well as twice daily gabapentin. We will follow up with him afterwards to determine his level of relief. He denies any blood thinners.\n \n This plan was discussed in detail with the patient who is in agreement."} {"idx": 110, "inputs": "[doctor] okay hi wayne well i understand you're here for you've got a sore on your foot that's not healing is that right [patient] yes [doctor] so can you tell me about that how are you doing [patient] well i've been doing okay but i've had this wound on my right foot for a couple of weeks and it's not getting better i saw my pcp and they referred me to you i i used to see a podiatrist and a couple of years ago but they moved and i was n't able to get another one [doctor] okay and how long have you had the wound [patient] about two to three weeks [doctor] okay have you had any kind of trauma to that foot [patient] no i bought a new pair of shoes to travel with and the neuropathy i guess i did n't feel that they were too tight at first it was just a blister but it looked a lot worse now i've been putting a band-aid on it and [doctor] okay and so did your doctor put you on any antibiotics when they they saw your foot [patient] yes i finished the course yesterday the wound looked about the same though [doctor] okay now does it hurt [patient] no i ca n't feel it [doctor] okay now have you had any other symptoms like fever chills drainage from the wound or anything along those lines [patient] no but when i take my sock off sometimes it sticks to the wound even when i put a band-aid on [doctor] okay well are you still wearing those same shoes that cause the problem [patient] no i'm upset [doctor] i'm so upset too i love those shoes [patient] no i'm so upset i i love those shoes [doctor] okay so what kind of shoes are they [patient] they're hoka's [doctor] ah so where did you get them [patient] i got them at rei couple of years ago [doctor] they're pretty good about helping you to fit your fit you in a shoe are n't they [patient] yeah [doctor] so what do you like about them [patient] they are comfortable they are easy to take on and off and they provide good stability [doctor] that's good so you've had some issues with stability sometimes or [patient] yes [doctor] okay okay well another question i want to ask you is how is your diabetes doing [patient] i do n't think it's too bad my last hgb a1c was a little over eight [doctor] okay alright well let me just do a quick physical exam okay for vital signs your temperature is ninety eight . one your vital signs look good your heart rate is seventy two respirations sixteen blood pressure is one ten over sixty five okay so on your foot exam let's see there is a one by two inch circular wound on the dorsal aspect of the lateral right foot it is just proximal to the right fifth to the fifth mtp joint and there is some yellow slough present with minimal granulation tissue there's no surrounding erythema or cellulitis and there's no evidence of fluid collection there's no necrosis there is no odor i do not appreciate any bony exposure on on vascular exam there are palpable bilateral femoral and popliteal pulses there are no palpable dp or pt pulses but doppler signs are present okay so does this hurt when i touch it here [patient] no it's okay [doctor] okay alright so i've reviewed the results your right foot x-ray that we did before you i came in the room and this shows no evidence of osteomyelitis which means there is no evidence of bone infection so that's really good so let me tell you a little about my assessment and plan for you so for your first problem your diabetic foot ulcer so i want to order an ankle brachial index abi to determine the blood supply to your foot to see if you can heal this wound i'm also gon na perform a debridement here in the office to take off some of the dead tissue and then next i'm going to prescribe a collagenase ointment to be applied to the wound once daily and then cover with a dry sterile dressing now we will continue this until we see the wound shrinking and a nice pink tissue is present and i want you to wear a surgical shoe to take pressure off of the area okay so i do n't think any more antibiotics are needed at this time and i want to see you again in two weeks so we may need to refer you to a vascular specialist if the abi indicates your blood supply is not optimal for wound healing okay [patient] okay [doctor] okay so for your diabetes it's gon na be very important to get your diabetes under control in order to get the wound to heal so we might even go ahead and get a diabetic consult so that we can go over some some maybe some ways you can modify your diet without a being too much but maybe that can bring down your hemoglobin a1c into a little bit better level okay [patient] okay [doctor] alright do you have any other questions [patient] no [doctor] okay", "target": "ASSESSMENT\n\n1. Right foot diabetic ulcer.\n 2. Diabetes.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient regarding his current symptoms. I have explained to him that his x-rays did not reveal any evidence of osteomyelitis. At this time, I have recommended that we obtain an ankle brachial index ABI to determine the blood supply to his foot to see if he can heal this wound. I have also performed a debridement in the office to remove some of the dead tissue. I have prescribed a collagenase ointment to be applied to the wound 1 time daily and instructed him to cover with a dry sterile dressing. He will continue this until we see the wound shrinking and the nice pink tissue is present. I have also recommended that the patient be placed in a surgical shoe to take pressure off the area. I do not think that antibiotics are needed at this time. He may need to see a vascular specialist if the ABI indicates that his blood supply is not optimal for wound healing.\n \n Regarding his diabetes, I explained the need for controlling his diabetes and the effects this will have on wound healing. I have recommended a diabetic consultation to discuss diet modifications to bring his hemoglobin A1c to a better level."} {"idx": 44, "inputs": "[doctor] good morning julie how are you doing this morning [patient] i've been better my primary care doctor wanted me to see you because of this this knee pain that i've been having for about six months now [doctor] okay and do you remember what caused the pain initially [patient] honestly i do n't i ca n't think of anytime if i fell or like i i've really been trying to think and i ca n't really think of any specific event [doctor] okay now it it says here that it's in both knees is that correct [patient] yes both my knees [doctor] okay it kinda try let's let's try describing the pain for me please [patient] yeah it's kind of feels like it's like right behind my kneecaps [doctor] okay [patient] and it's like a deep achy pain [doctor] a deep achy pain okay what kind of activities makes the pain feel worse [patient] let's see so anytime so if i'm sitting at my desk and i get up i have a lot of pain so anytime from like standing up from sitting for a while or even going up and down the stairs [doctor] okay so you work from home [patient] i do [doctor] okay okay so there is a lot of desk setting at home is your office upstairs or is it i mean do you have to go up or downstairs to get to it [patient] no well first thing in the morning but otherwise it's downstairs [doctor] okay okay how do you like working from home [patient] you know it has it's plus and minuses [doctor] okay [patient] i like it though my i like my commute [doctor] yeah [patient] i love it [doctor] and the parking i'm sure the parking is [patient] and the parking is great [doctor] yeah i you know if i could do telehealth visits all day long i would be totally happy with that yeah and just set it home and do those so you mentioned is there anything that makes that pain feel better [patient] usually after like if i feel that pain and then i just it does get better [doctor] okay now you mentioned earlier that you tried some things in the past what have what are they and did they work at all [patient] yeah i've done some ibuprofen or aleve sometimes some tylenol and that does help [doctor] okay [patient] it takes the edge off [doctor] okay but you're never really pain free is that what i hear you saying [patient] not really unless i'm like really just resting which i hate to do but otherwise any type of movement especially from sitting it causes pain [doctor] okay so are you active other than going up and down the steps to your office [patient] very i'm a big runner i love to run i run about five to six miles a day but with this knee with with these knee pain that i've been having it's i barely can even do half a mile [doctor] yeah you know what that's that's i am a biker and i know that once you get that into your you know you have loved doing that activity it's so frustrating when you ca n't it's almost like a it's almost like a dry it almost becomes a drug when you get up [patient] exactly [doctor] yeah [patient] it's [doctor] okay so have you noticed any redness or swelling in your knees [patient] no [doctor] okay and have you ever injured your knees before [patient] you know despite how active i am i you know i've never [doctor] okay [patient] injured or broken a bone [doctor] okay great so let's go ahead and do a i just wan na take a look here i reviewed your vitals and overall they look good your blood pressure is one twenty over seventy your your heart rate is sixty and your respiratory rate is fourteen those are all phenomenal numbers as i listened to your heart it is at a regular and a slower rate but i do n't hear any extra sounds so there is no murmurs as we go through that now on musculoskeletal exam you have a normal gait i watched you you know kinda walk in here this morning your strength i just wan na check it when i go ahead and i want you to move your leg okay your muscle strength is is good you do have a three out of five for abduction of your legs bilaterally and that's you know kinda bringing your legs in the remainder of your muscle strength for your lower extremities is a five out of five now let me focus specifically on your knee examination i do n't see any redness or ecchymosis or warmth of the skin and those are big words you know i do n't see any bruising or or that redness there is no effusion that's just like a fluid underneath the knee i do n't appreciate that any at all you do seem to have some tenderness when i palpate and you do have a positive patellar grind test when you stood up i could feel that as we went through there you did say you had that knee pain with squatting but your lachman your anterior and posterior drawer and mcmurray test are all negative bilaterally neurologically and your your your lower extremities your patella and your achilles reflex are symmetrical and that's good so i did review the x-rays of both your knees which shows no fractures or osteoarthritis so based on what you told me and reviewing the mri that you had done before you came in your symptoms are consistent with patellofemoral pain syndrome and this is a really common condition that we see that causes knee knee pain especially in really active young people that's probably why i do n't get it when i'm riding my bike forever and ever now this condition has to do with the way your kneecap moves across along the groove of your thigh bone your femur so for pain i want you to continue to take the ibuprofen or any other anti-inflammatories you know aleve or any of those as you need it to help with the pain now i am going to recommend physical therapy well they will show you a number of lower extremity exercises this is probably one of the best things that you can do and this will help increase your lower extremity strength your mobility and correct any incorrect running mechanics that you might have do you have any questions for me [patient] so will i be able to run again [doctor] absolutely my goal is to get you out there and maybe we can cross pads on the the bike trail some day you are gon na have to take it a little bit easy for now but we are gon na get you back and once we do that i think you will be really pleased is there anything else [patient] no i think that's it [doctor] okay have a great day [patient] okay you too [doctor] thank you [patient] bye", "target": "ASSESSMENT AND PLAN\n\n1. Patellofemoral pain syndrome, bilateral.\n - Medical Reasoning: After reviewing her x-ray, previous MRI, and exam findings, her symptoms are consistent with patellofemoral pain syndrome.\n - Patient Education and Counseling: We discussed the nature of this condition in detail. I encouraged the patient to be conservative with her physical activity for now.\n - Medical Treatment: Continue with over-the-counter NSAIDs for pain relief We are going to refer her to physical therapy to help strengthen her lower extremities, increase mobility, and demonstrate proper running mechanics.\n \n "} {"idx": 5, "inputs": "[doctor] hey , ms. hill . nice to see you . [patient] hi , dr. james , good to see you . [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 . [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 . [patient] and i hit the ceiling of the car . [doctor] okay . when did this happen ? [patient] uh , it was saturday , so about four , five days ago . [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 . [doctor] how much damage to your car ? [patient] uh , not too much . the , the trunk crumpled up a little bit . [doctor] okay . and no other injuries ? just the finger ? [patient] just the middle finger . [doctor] so you would've escaped this accident without any injuries ? [patient] yes . uh , i'm not proud . [doctor] okay . um , so four days of right middle finger pain- [patient] yes . [doctor] . after a motor vehicle accident . [patient] yes . [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 . [doctor] very interesting . let me check it out . um , so does it hurt when i push right here ? [patient] yes . [doctor] and does that hurt ? [patient] very much so . [doctor] what about down here ? [patient] no . [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 . [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 ? [doctor] it will be okay . so you have atrial fibrillation . [patient] yes . [doctor] you take digoxin . all right . any other questions for me ? [patient] no , that's it . thank you . [doctor] you're welcome . hey , dragon , go ahead and finalize the recording , and , uh , come with me . we'll get you checked out .", "target": "PLAN\n\nAt this point, I discussed the diagnosis and treatment options with the patient. I recommend a prescription for Tramadol 50 mg every 6 hours as needed for pain, dispense 8. She is provided a finger splint and will return in 2 weeks for a follow-up x-ray. All questions were answered.\n \""} {"idx": 23, "inputs": "[doctor] next patient is paul edwards , date of birth is january 15th 1962 . so he's a 59 year old hiv positive gentleman here for hypogonadism . patient was last seen on november 24th 2020 . his notable things are number one , he is on 1 milliliter every 10 days , uh , his levels were less than 300 to begin with . he's on finasteride currently . he also takes cialis daily so he takes all his pills just from me . um , patient's other area of concern is gynecomastia which is ... which we will discuss with him today . his last psa was 0.66 and his last testosterone was greater than 1,500 . [doctor] hey , how are you today ? [patient] all right , how have you been ? [doctor] i'm good . [patient] good , good . [doctor] have you lost some weight or are you at least putting on some muscle ? you look trim . [patient] no , i think i'm pretty much the same as i've always been . [doctor] really ? okay , maybe it's just your black shirt . makes you look thin . [patient] yeah , i guess that's it . [doctor] so health wise , how is everything going ? [patient] good , the testosterone's going well . [doctor] that's great . [patient] uh , it helped me out . i feel good , more vigorous , sleeping well and i think it's having some positive effects . not so much physically because like i said i've- i've been this way my whole life , but i'm seeing some good improvements in my bloodwork . [doctor] okay , well that's good . [patient] so the finasteride i'm only taking half a pill , it's the 5 milligram one . [doctor] yeah , i remember you telling me that . [patient] and cialis , on the days i work out i take 5 milligrams otherwise i take two and a half milligram pills , but , uh , i have been out of it . [doctor] okay . [patient] but overall i'm doing well , i'm actually taking the correct steps to get my life together . [doctor] good . it's always great to hear . well let's take a look . uhm , i'm gon na listen to your heart and lungs . [patient] okay . [doctor] please use my general exam template , all right . just take a few breaths . [patient] okay . [doctor] in and out . [patient] okay . [doctor] all right , everything sounds good , no concerns there . [patient] great . so i wanted to show you something . [doctor] sure . [patient] look at this . [doctor] okay , this is your cholesterol ? [patient] yeah , my cholesterol and triglycerides . uh , i used to have high triglycerides , you see they were 265 milligrams per deciliter , and i took my first dose of the testosterone on the 28th . [doctor] right . [patient] now 5 months later look at my numbers . [doctor] wow , that's remarkable . [patient] is it the test ? it's the only change . [doctor] i do n't know , i have n't honestly seen many guys over the years that have cholesterol problems and this . i mean there's a big correlation between diabetic control and testosterone replacement , meaning those who get good levels of their test see their diabetic control improve . [patient] yeah . [doctor] but i have n't seen a lot of data on the impact on cholesterol . regardless , we will take it . [patient] i agree . i was very impressed with my triglycerides and was just wondering if the test may be what's helping . [doctor] yeah , that's an unbelievable difference . [patient] 145 milligrams per deciliter from 265 milligrams per deciliter is awesome . i also read that it- it's cardioprotective . [doctor] absolutely . [patient] my red blood cell count has increased . [doctor] yeah , i saw that . it's fine though . [patient] stable . [doctor] your psa today is also , uh , is good also . it's , uh , .6 i think . [patient] yeah . , is it ? [doctor] yeah , it was .5 last year and anything under 4 is good . [patient] nice , that's good news . [doctor] so it just needs to be checked every year or so . [patient] so in terms of , uh , estrogen control i've been hearing that indole-3-carbinol , or broccoli extract , supposedly can improve my estrogen levels . have you ever heard of it ? [doctor] yeah , i've heard of it but i have n't had anybody consistently use it . i mean , your levels are fine and we checked your estra- estradiol and it was not elevated , so . [patient] okay . [doctor] i would argue that we could test that in the fall if you want , but we do n't need to do , uh , do any more tests ... any more than test once a year , excuse me . [patient] okay , what about increasing my testosterone to 175 milligrams ? i'm at 140 now . [doctor] well , your levels are high . [patient] are they right now ? [doctor] well , i mean they were last time . [patient] yeah but i just- just injected though , or i had right before that was taken . [doctor] i know . i know you had then , uh , when did you inject this time ? [patient] i figure i'm on my eighth day today . [doctor] okay . [patient] so i'm due to dose on thursday or friday . [doctor] all right . [patient] i have a little med calendar and i put checks and ts on it . that helps me . [doctor] that's a great idea . so look , the biggest issue i've seen , even if your levels today are around 700 , is that your peaks are getting greater than 1,500 , putting you at a higher chance of needing to come off due to blood thickness . and your risk will only astronomically go up the higher the dose that we go on . [patient] okay . [doctor] you look well , your levels are good and you're feeling well . [patient] yeah , i'm feeling good . [doctor] i'm going to be blunt . unfortunately this happens often where you're feeling good but you want to feel really good . i mean , i get it and this is why people get into problems with this stuff , right ? it's like , back in the day when it was n't prescribed by doctors and people would get it at gyms and stuff and they would take huge doses . and then they would have a heart attack at 50 . [patient] yeah , they have to be taking a lot . [doctor] likely they are taking more than testosterone , but still . [patient] and they are taking stuff for a long time . [doctor] true . but right now i would not change your dose . [patient] okay . [doctor] make sense ? [patient] it does , i appreciate the discussion . [doctor] no problem . what pharmacy are you using ? have you changed it or anything ? [patient] no changes , i use walmart pharmacy . i do need more cialis and finasteride . [doctor] okay . [patient] i would prefer the paper prescription . [doctor] for all of them ? [patient] sure . [doctor] all right , will do . i'm gon na get your prescriptions . [patient] okay , thank you .", "target": "ASSESSMENT\n\n\u2022 Hypogonadism.\n\nPLAN\n\nI recommend maintaining current management. The patient\u2019s last testosterone levels were greater than 1500 ng/dL, although this level was likely related to his recent injection. He requested an increase to his testosterone cypionate from 140 mg to 175 mg, which I denied due to his already high testosterone levels. I counseled the patient on the risks associated with high testosterone levels and Indole-3-carbinol and it\u2019s lacking evidence to support his estrogen levels. The last time his estradiol levels were checked, they were normal; recommend annual screening.\n \n I provided paper prescription refills for Cialis and Finasteride.\n \""} {"idx": 3, "inputs": "[doctor] hi , john . how are you ? [patient] hey . well , relatively speaking , okay . good to see you . [doctor] good to see you as well . so i know the nurse told you about dax . i'm gon na tell dax a little bit about you . [patient] okay . [doctor] so john is a 61-year-old male with a past medical history significant for kidney stones , migraines and reflux , who presents with some back pain . so john , what's going on with your back ? [patient] uh , i'm feeling a lot of the same pain that i had when i had kidney stones about two years ago , so i'm a little concerned . [doctor] yeah . and so wh- what side of your back is it on ? [patient] uh , honestly , it shifts . it started from the right side and it kinda moved over , and now i feel it in the left side of my back . [doctor] okay . and , um , how many days has this been going on for ? [patient] the last four days . [doctor] okay . and is ... is the pain coming and going ? [patient] um , at first it was coming and going , and then for about the last 48 hours , it's been a constant , and it's ... it's been pretty bad . [doctor] okay . and what have you taken for the pain ? [patient] tylenol , but it really does n't seem to help . [doctor] yeah . okay . and do you have any blood in your urine ? [patient] um , uh , it ... i think i do . it's kind of hard to detect , but it does look a little off-color . [doctor] okay . all right . um , and have you had , uh , any other symptoms like nausea and vomiting ? [patient] um , if i'm doing something i'm ... i'm , uh , like exerting myself , like climbing the three flights of stairs to my apartment or running to catch the bus , i feel a little dizzy and a little light headed , and i ... i still feel a little bit more pain in my abdomen . [doctor] okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago . [patient] i've been pretty diligent about taking the meds . i ... i wan na make sure i stay on top of that , so i've been pretty good with that . [doctor] okay , so no issues with the migraine ? [patient] none whatsoever . [doctor] okay . and how about your ... your acid reflux ? how are you doing with ... i know you were making some diet changes . [patient] yeah , i've been pretty good with the diet , but with the pain i have been having, it has been easier to call and have something delivered. so i have been ordering a lot of take-out and fast food that can be delivered to my door so i don't have to go out and up and down the steps to get it myself. but other than that , it's been pretty good . [doctor] okay . are you staying hydrated ? [patient] yes . [doctor] okay . all right . okay , well , let's go ahead and , uh , i know the nurse did a review of systems , you know , with you , and i know that you're endorsing some back pain and a little bit of dizziness , um , and some blood in your urine . any other symptoms ? you know , muscle aches , chest pain ... uh , body aches , anything like that ? [patient] i have some body aches because i think i'm ... i'm favoring , um , my back when i'm walking because of the pain , like i kinda feel it in my muscles , but not out of the ordinary and not surprised 'cause i remember that from two years ago . [doctor] okay . all right . well , let's go ahead and ... and look at your vital signs today . hey , dragon ? show me the blood pressure . yeah , so your blood pressure's a little high today . that's probably because you're in some pain , um , but let ... let me just take a listen to your heart and lungs , and i'll let you know what i find , okay ? [patient] sure . [doctor] okay , so on ... on physical exam , you do have some , uh , cda tenderness on the right-hand side , meaning that you're tender when i ... when i pound on that . [patient] mm-hmm . [doctor] um , and your abdomen also feels a little tender . you have some tenderness of the palpation of the right lower quadrant , but other than that , your heart sounds nice and clear and your lungs are clear as well . so let's go ahead and take a look at some of your results , okay ? [patient] sure . [doctor] hey , dragon ? show me the creatinine . so we ... we drew a creatinine when you came in here because i was concerned about the kidney stones . it ... it is uh ... it is up slightly , which might suggest that you have a little bit of a obstruction there of one- [patient] mm-hmm . [doctor] . of the stones . okay ? hey , dragon . show me the abdominal x-rays . okay , and there might be a question of a ... uh , of a stone there lower down , uh , but we'll wait for the official read there . so the , uh , abdominal x-rays show a possible kidney stone , okay ? [patient] okay . [doctor] so let's talk a little bit about my assessment and plan for you . so , for your first problem , your back pain , i think you're having a recurrence of your kidney stones . so i wan na go ahead and order a ct scan without contrast of your abdomen and pelvis . okay ? [patient] mm-hmm . [doctor] and i'm also gon na order you some ultram 50 milligrams as needed every six hours for pain . does that sound okay ? [patient] okay . [doctor] hey , dragon ? order ultram 50 milligrams every six hours as needed for pain . and i want you to push fluids and strain your urine . i know that you're familiar with that . [patient] yes , i am . [doctor] for your next problem , for your migraines , let's continue you on the imitrex . and for your final problem , uh , for your reflux , uh , we have you on the protonix 40 milligrams a day . do you need a refill of that ? [patient] actually , i do need a refill . [doctor] okay . hey , dragon ? order a refill of protonix 40 milligrams daily . okay . so the nurse will be in soon , and she'll help you get the cat scan scheduled . and i'll be in touch with you in ... in a day or so . [patient] perfect . [doctor] if your symptoms worsen , just give me a call , okay ? [patient] you got it . [doctor] take care . [patient] thank you . [doctor] hey ... hey , dragon ? finalize the note .", "target": "ASSESSMENT AND PLAN\n\nMr. John Perry is a 61-year-old male with a past medical history significant for kidney stones, migraines, and gastroesophageal reflux, who presents with back pain.\n \n Kidney stones.\n \u2022 Medical Reasoning: He is experiencing pain in his back that is similar to his previous kidney stone pain. His recent abdominal x-ray demonstrates what appears to be a recurrent kidney stone.\n \u2022 Additional Testing: I have ordered a CT scan of the abdomen and pelvis without contrast.\n \u2022 Medical Treatment: We will start him on Ultram 50 mg as needed every 6 hours for pain.\n \u2022 Patient Education and Counseling: I advised the patient to stay well hydrated and to strain his urine.\n \n Migraines.\n \u2022 Medical Reasoning: He has been compliant with Imitrex and is doing well at this time.\n \u2022 Medical Treatment: Continue Imitrex.\n \n Reflux.\n \u2022 Medical Reasoning: This is typically well-controlled with dietary modifications.\n \u2022 Medical Treatment: Continue with Protonix 40 mg daily. A refill was provided.\n \n "} {"idx": 99, "inputs": "[doctor] next patient is randy gutierrez . date of birth , 8/10/2020 . please use review of symptoms . all text to write . physical exam , auto text uri . [doctor] hello , how are you doing today ? [patient_guest] we're okay , thank you . [doctor] that's good to hear . so , how many days has randy been feeling sick ? [patient_guest] well , i would say it started around supper time last night . [doctor] last night , okay , and what's been going on ? [patient_guest] well , he started to get a runny nose . [doctor] okay , and is he stuffy too ? [patient_guest] yeah . yeah . [doctor] okay , and have you noticed , is his mucous clear right now ? [patient_guest] it is , it is right now , yes . [doctor] okay . and , does he also have a cough ? [patient_guest] yes , but it's not barky . [doctor] and does he act like he has a sore throat or is he pulling on his ears ? [patient_guest] well , i know he's been pulling on his ears , yeah . [doctor] okay . [patient_guest] you know , he also , he's also been going crazy rubbing at his nose too . [doctor] okay . and , any fever you've noticed ? [patient_guest] i checked his rectal temperature and it was 100.3 . [doctor] okay . so , a little bit of a low-grade fever there , definitely . and , how was his appetite ? did he eat last night ? [patient_guest] yes , he did . yeah . [doctor] and how about this morning ? did he eat his breakfast ? [patient_guest] uh , this morning he ate about seven ounces from the bottle . [doctor] okay . [patient_guest] and then he got another bottle , and he barely ate that . um , i offered him cereal and he would n't eat that either . [doctor] okay . [patient_guest] so , he varies i guess . [doctor] how is his energy ? does he seem like he wants to take more naps , or does he have pretty good energy ? [patient_guest] mmm , it seems like he's irritable . [doctor] irritable because he is n't feeling good ? [patient_guest] yeah . he is energetic , but it seems like he ca n't go to sleep , like , he's fighting it really hard . [doctor] okay , and just for the chart , is there anyone , anybody else exposed to him who has been sick ? [patient_guest] yes , his older sister's been sick . [doctor] thank you . [patient_guest] we also had a play date with my nephew , who i learned later had a sinus infection . [doctor] and what medication have you tried for him ? anything at all ? [patient_guest] um , i've been doing the saline mist in his nose . [doctor] good , good . that's a good choice . [patient_guest] i did give him tylenol really early this morning because he was warm when i took the sleeper off of him , and we had the ac on in the house , but his whole body was sweating . [doctor] i see . and , any other medications ? [patient_guest] we did put some baby vick's on his feet last night to try and help him breathe . and , i also used the humidifier . [doctor] okay . that's good . [patient_guest] okay . okay . [doctor] so , there was another thing i wanted to bring up since we're here . it appears that his cradle cap has gotten a little worse . what are you using on it ? [patient_guest] i've been using the cradle cap brush , and then i use regular aveno shampoo . [doctor] is it a dandruff shampoo ? [patient_guest] no , i do n't think so . [doctor] okay , thank you . well , let's complete his exam and then we'll talk about the next steps . [patient_guest] okay , sounds good . [doctor] can you take a big breath randy . [patient_guest] where's mama ? [doctor] do n't forget to breathe little one . okay . let's try the front too . [patient_guest] yeah , it's okay buddy . [doctor] excellent . he's doing excellent . next let's- let's check out those ears . [patient_guest] okay . [doctor] let's try to make sure you do n't tip all the way over . [patient_guest] dino , you're doing so good . [doctor] all right . ears look okay . we're going to slide you forward so you do n't bump your head when i lay you down . [patient_guest] hey , you're- hey you're okay . you're okay . [doctor] okay , you can go ahead and sit him back up if you like . [patient_guest] all right . thank you . [doctor] all right . so , he's just kind of getting started with this , and i think we're seeing something viral right now . often sinus infections will start out as a virus and then will become bacterial infections if left alone and does n't go away . but , i do n't think he needs any antibiotics , at least not at this point in time . um , keep up with the fluids , rest , and i would watch him very carefully for a barking cough . if he does get a barky cough , then that tends to be a little bit more significant and a little more severe . so , if he develops a barky cough , i want you to give him a half a teaspoon of his sister's medicine . [doctor] you know , i'm almost tempted to give you some of the medicine because they're probably sharing the same virus . [patient_guest] okay . [doctor] actually , i will . i'll go ahead and just give you some as well . [patient_guest] okay . okay . [doctor] but , if he does n't become barky , you do n't have to use it . it only works for the barky cough . [patient_guest] mm-hmm , got it . [doctor] okay . we'll do the same thing with him , as long as nothing gets worse , and we'll see him back in one week . so , it wo n't get rid of a regular cough . he can use zarbee's , but use the dose for kids under a year of age . so , if you wan na get some of that , you can definitely try that for him , it can help out a little bit with the regular cough . [patient_guest] i do have a question . do you or do you not give honey to babies ? [doctor] yes , that's a great question . you do n't give honey to kids under a year , instead , you can give them agave , which is a different type of nectar . um , now you can give honey to his older sister , that is okay , but for him , it would not be very good because his stomach acid's not good enough to break down the botulism spores . so , it'd cause him harm . um , you should look at the package of say , honey nut cheerios . it says right on there to not give it to a baby . [patient_guest] okay . [doctor] now , whether that would really hurt a baby , i am unsure , but it has real honey in it . so , no honey for him , but agave is definitely fine . [patient_guest] okay . so , zarbee's for the stuffy nose . [doctor] yes , zarbee's . [patient_guest] and then you said , uh , which medicine to give him just in case ? [doctor] i'm gon na give him the same medicine as his sister , and just hang onto it , um , just to watch and see . if this was a monday and we had a whole week to watch , i would say to just call us if things got worse , um , but since , um , if it's gon na be the weekend , and things might worsen tonight or tomorrow night , i'd rather you have just what you need on hand . [patient_guest] okay . [doctor] right , does that make sense ? [patient_guest] yeah , yeah . that makes sense . [doctor] okay , great . and that way you do n't have to share , um , with his sister . [patient_guest] right , okay . [doctor] and since he's about half her size , we'll do half the dose , which is a half a teaspoon . [patient_guest] okay . will this information all be in the papers ? [doctor] yes . and so , if he ends up starting the medicine , just give him a half a teaspoon for five days . [patient_guest] okay . [doctor] yeah , that's the only thing it wo n't say is , as needed , or anything like that . [patient_guest] mm-hmm , understood , thank you . [doctor] you're welcome . [patient_guest] and the cradle cap ? [doctor] what i would do is use something like either head & shoulder's , or selsun blue , or nizoral ad . now , do n't get the extra strength stuff , just use the regular strength . um , cradle cap , it's just basically a fancy way of saying dandruff . so , those shampoos will help get rid of it . it's not an immediate thing 'cause they , um , they are all dead scales , and you still have to brush them off . so , continue to use the soft brush and some baby oil , or something that will help get the scales out , and those shampoos will actually help to prevent it as well . use it two times per week , not every day , but maybe twice a week . [doctor] so , two days between shampooing , use what you normally use any other time . and then , often , within six weeks or so , you'll notice that the-the cradle cap is just , um , not coming back anymore . but , he has to be careful because it's not ph balanced for eyes . so , just make sure when you're rinsing his hair you avoid his eyes . [patient_guest] okay . okay . [doctor] all right . and , if it keeps getting worse , definitely let us know . [patient_guest] okay . sounds good . [doctor] good . and , since they do n't have covid-19 , you can go right ahead and check out . [patient_guest] okay . and both appointments in the week ? [doctor] correct . we'll see you all then . bye randy , feel better . [patient_guest] all right , great . thank you so much . [doctor] you are welcome , and have a good rest of your day .", "target": "ASSESSMENT\n\n\u2022 Viral infection\n \u2022 Dandruff\n\nPLAN\n\nViral infection\n The patient presents with a viral infection and does not need antibiotics currently. I advised continuation of fluids, rest. Additionally, I suggested trying Zarbee\u2019s for children under 1 years old. If a croup cough develops, the patient will receive a 0.5 teaspoon.\n \n I also provided counseling to the mother to avoid giving honey to the patient for his first year of life due to botulism spores.\n \n Dandruff\n The patient is experiencing worsening symptoms of dandruff. I recommended Head and Shoulders shampoo, Selsun Blue, or Nizoral A-D 2 times per week, combined with his usual shampoo. I counseled the mother that she should be careful not to get the shampoo in the patient eyes and to not use the extra strength shampoos. Additionally, he may also use baby oil and a soft brush on the area."} {"idx": 85, "inputs": "[doctor] hi russell how are you what's been going on [patient] well i've been having this sharp pain on the right side of my abdomen below my ribs for the last several days [doctor] i saw my doctor and they ordered a cat scan and said i had a kidney stone and sent me to see a urologist okay well does the pain move or or or go anywhere or does it stay right in that same spot yeah it feels like it goes to my lower abdomen in into my groin okay and is the pain constant or does it come and go it comes and goes when it comes it's it's pretty it's pretty bad i feel like i ca n't find a comfortable position okay and do you notice any any pain when you urinate or when you pee [patient] yeah it kinda burns a little bit [doctor] okay do you notice any blood i do n't think there is any you know frank blood but the urine looks a little dark sometimes okay and what have you taken for the pain i have taken some tylenol but it has n't really helped okay and do you have any nausea vomiting any fever chills i feel nauseated but i'm not vomiting okay is anyone in your in your family had kidney stones yes my father had them and have you had kidney stones before yeah so i i've i've had them but i've been able to pass them but this is taking a lot longer okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay [patient] okay [doctor] okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over your over your right kidney and that just means that you might have some inflammation there so i i reviewed the results of the ct scan of your abdomen that the primary care doctor ordered and it does show a . five centimeter kidney stone located in the proximal right ureter so this the ureter is the duct in which urine passes between the kidney and the bladder there's no evidence of what we call hydronephrosis this means you know swelling of the kidney which is good means that things are still able to get through so let's talk a little bit about my assessment and my plan okay so for your first problem of this acute nephrolithiasis or kidney stone i i wan na go ahead and recommend that you push fluids to help facilitate urination and peeing to help pass the stone i'm going to prescribe oxycodone five milligrams every six to eight hours as needed for pain you can continue to alternate that with some tylenol i'm going to give you a strainer that you can use to strain your urine so that we can see it see the stone when it passes and we can send it for some some tests if that happens i'm also gon na order what we call a basic metabolic panel a urinalysis and a urine culture now i wan na see you again in one to two weeks and if you're still having symptoms we'll have to discuss further treatment such as lithotripsy which is essentially a shock wave procedure in which we sedate you and use shock waves to break up the stone to help it pass we could also do what we call a ureteroscopy which is a small telescope small camera used to go up to to the urethra and bladder and up into the ureter to retrieve the stone so let's see how you do over the next week and i want you to contact me if you're having worsening symptoms okay okay sounds good thank you", "target": "ASSESSMENT AND PLAN\n\n1. Acute nephrolithiasis.\n - Medical Reasoning: The patient presents with complaints of right-sided abdominal pain. His previous CT scan was reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter without evidence of hydronephrosis.\n - Medical Treatment: I have recommended that he push fluids in order to help facilitate urination to help pass the stone. He will be provided with a strainer to allow us to potentially test the stone if he is able to pass it. I have also prescribed oxycodone 5 mg every 6 to 8 hours as needed for pain. He can continue to alternate oxycodone with Tylenol. A basic metabolic panel, urinalysis, and urine culture will also be ordered."} {"idx": 45, "inputs": "[doctor] hi abigail how are you today [patient] hello hi nice to meet you i'm i'm doing okay [doctor] good i'm doctor sanchez and i'm gon na go ahead and take a look i saw with your notes that you've been having some knee pain yes that's that's true you know it's been going on for a while i like to run i do jogs i sign up for the 5k tack you know sometimes the marathon and i have n't been doing longer distances because [patient] when i'm running i my right knee here it just starts to ache and it's it's just to the point where i need your opinion [doctor] okay okay what have you done for it so far what makes it better what makes it worse [patient] well it used to be that when i run it ache and then i put ice on it and then it would be okay so i do ice and ibuprofen [doctor] okay okay and did you see anybody for this before coming into the office here [patient] yeah i doctor wood is my primary care provider and i talked to him about it actually over the years and this last visit he said he referred me to you [doctor] okay okay good so ice and rest makes it feel better running and and activity makes it hurt a little bit more is that correct [patient] yeah that's right [doctor] okay do you have any family history of arthritis or any of those type of immune diseases [patient] i'm trying to think no i do n't think so no [doctor] okay and do you get is it is this primarily worse in the morning or does it is it just there all the time when it comes on [patient] it actually is worse towards the end of the day [doctor] okay [patient] once i'm on my feet all day it starts to ache towards the afternoon [doctor] okay so let's go ahead and i want to do a quick examination here your blood pressure and was one twenty over sixty that's phenomenal your heart rate was fifty eight and you can tell that you're a runner with that that level of a heart rate and your respirations were fourteen so all of that looked very good there was no fever when you came in when i'm gon na just quickly listen to your heart and lungs okay those those sound good but let me get let's focus here on your lower extremities i'm i'm gon na look at your your left knee first when i move your left knee do you get any type of pain or is it just feel like normal and it's always your pain's always isolated to the right [patient] that feels that feels normal [doctor] okay okay so let me i just want you to back up here in the stretcher a little bit more and i'm just gon na do some movement of your knee any okay so i want you to push your leg out against my hand does that hurt [patient] no [doctor] okay and if you pull back does that hurt a little bit [patient] no [doctor] okay and i'm gon na move it around so when i look at the knee there is no redness there's no swelling i can appreciate a a small amount of effusion and that means that there's a little bit of fluid under the knee or in that knee's joint space and there is there is several reasons that could be now when i push on your knee does it hurt more on the inside or does it hurt more on the outside here [patient] the the right knee here hurts on the outside [doctor] okay okay and you've got a good pedal pulse so you know you can feel that and when i touch your feet you do n't have any numbness or tingling or anything like that [patient] no uh uh [doctor] okay well so what i want to tell you is that i think you have a knee sprain from overuse and we see that sometimes in runners now unfortunately you're gon na have to take some a little bit of time off of of active running but i do n't think it will be that long until we can get you up and running again now i reviewed the x-rays that we did when you first came into the office here this morning and the joint spaces of that right knee are are well maintained i do n't see any evidence of any fracture and when compared to the left knee everything looks good so i do n't even see any signs of any arthritis that i would've been suspecting i would like you to stay on two tylenol five hundred milligrams and two ibuprofen two hundred milligram tablets and i want you to take that three times a day and that's gon na help with both the pain and the inflammation i'm also gon na order some physical therapy for your your right knee and that physical therapy will help strengthen the lower extremities and make it give you a little bit of a balance and some they'll be able to recommend good running exercises for you i do wan na follow up with you in two weeks and see if we're getting better so let's no running for two weeks and if we're we're improving then we'll move on and probably start adding some additional activity does that sound like a plan [patient] yeah that does i i was curious so i will lay off the running for now can i you know lift weights and do like my squats and and those type of exercises at the gym [doctor] yeah absolutely and and those are good exercises but i'd like you to get that first physical therapy appointment in and they'll be able to talk with you on what the best exercises are for you to do [patient] okay got it [doctor] any questions [patient] hmmm no i do n't think so [doctor] okay thank you abigail and i'd like i said stop out at the desk and we'll make an appointment for two weeks [patient] okay thanks doctor [doctor] thank you", "target": "ASSESSMENT AND PLAN\n\n1. Right knee sprain.\n - Medical Reasoning: The patient is an avid runner and her symptoms appear to be the result of overuse.\n - Patient Education and Counseling: We discussed the nature of her diagnosis, as well as her x-ray results, in detail. I advised her that this is a common issue for runners and encouraged her to continue her strength training exercises.\n - Medical Treatment: She will take Tylenol 500 mg, 2 tablets, and ibuprofen 200 mg, 2 tablets, 3 times daily to reduce her pain and inflammation. We will also refer her to physical therapy to help strengthen her lower extremities, work on her balance, and demonstrate proper running exercises. She should avoid running for the next 2 weeks until her follow up visit, at which point we can consider adding some additional activity.\n \n "} {"idx": 51, "inputs": "[doctor] hi jeremy how are you [patient] i'm really good thank you how are you [doctor] i'm okay the the medical assistant told me that you had this ulcer on your foot that's been there for a couple of weeks [patient] yes [doctor] going away [patient] yeah it's been there gosh it's like six or so weeks right now and it's and it's on my right foot and it's just yeah it's just not going away i'm not sure if it maybe even gotten a little worse from when i first noticed it [doctor] okay and how long did you say it's going on for [patient] probably about [doctor] six eight weeks maybe [patient] okay and do you have any pain in your foot no no no pain at all okay now i know that you're a diabetic and you are on some insulin have your sugars been running okay yeah they have been running [doctor] okay [patient] you know on the most part they seem to be running a little higher than normal [doctor] your sugars are running higher than normal okay do you recall what your last hemoglobin a1c was was it above nine [patient] yes it it it definitely was higher than nine [doctor] okay alright now what do you think caused this ulcer were you wearing some tight fitting shoes or did you have some trauma to your foot or [patient] yeah i was you know i think initially i'm you know i was out in the backyard you know kind of you know doing some work and you know i know i you know i could've stepped on a nail or you know there was some other work but you know i'm always outside so i do n't know if that kind of led to anything or caused anything [doctor] okay alright and have you had any fever or chills [patient] no no no fever or chills you know i kinda you know get headaches pretty often i do n't know if that you know i do n't know if that's a stress or but you know always have like the tension headaches in the front [doctor] okay and do you have do you have neuropathy where you get like numbing and tingling in your feet [patient] occasionally yeah occasionally especially when it's like colder outside [doctor] mm-hmm kinda feels like it takes a little longer to [patient] warm up but yeah i kinda have some sensation in in all my extremities [doctor] okay alright and then are you are you a smoker or did you smoke [patient] i did back you know kind of years ago i did but yeah i have n't smoked anything in in good number of years [doctor] okay alright when did you stop smoking [patient] couple years ago maybe four or so years ago [doctor] okay alright and how many packs a day would you smoke [patient] gosh back then yeah was at least two [doctor] okay alright how many years did you smoke for like twenty [patient] yeah at least twenty yeah twenty plus years [doctor] okay alright now any other symptoms do you have any problems when you walk down the street do you get any pain in your calves at all when you walk [patient] no no no no pain you know just kind of you know it's just i know that it's there [doctor] okay and you said you're active you're out in the yard and things like that do you go on long walks at all or no [patient] no no you know it's you know i just kinda feel like i've been just trying to take it easy lately [doctor] mm-hmm [patient] but yeah most most of the stuff i've been doing is just kind of hanging around the house [doctor] okay alright so we talked a little bit about your diabetes let's talk about your heart disease now your heart disease you had a heart attack in twenty eighteen we put a stent into your right coronary artery you're still taking your medications for that you're still on your aspirin [patient] i am yes yeah i do the baby aspirin every day [doctor] okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything [patient] okay and do you have a podiatrist for your yearly foot exams [doctor] no i i i do n't okay alright alright well let's go ahead i wan na just do a quick physical exam i'm just gon na be calling out some of my exam findings so your vital signs here in the office you do n't have any fever so that's good your blood pressure is great it's like one twenty seven over eighty and your heart rate is nice and slow in the sixties on your neck exam i do n't appreciate any jugular venous distention or any carotid bruits on your lung exam your lungs are clear to auscultation bilaterally on your heart exam you do have a two out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do n't appreciate any palpable dorsalis pedis or posterior tibial pulses there is a two by three centimeter ulcerated lesion on the right lateral foot near the fifth metacarpal metatarsophalangeal joint there is no associated cellulitis does it hurt when i press here [patient] no [doctor] there is no pain to palpation of the right foot there is associated granulation tissue and some slight purulent discharge from the wound okay so what does all that mean that just means that you have this ulcer that's you know fairly sizable with i think we need to do some good wound care on it let's talk a little bit about my assessment and plan so you know i you have a nonhealing ulcer of your right foot so we need to do some studies on you to see if you have an adequate blood supply to heal this foot wound and since you since you probably do n't because of your diabetes you're here in a vascular surgeon's office we may have to go ahead and talk about being able to open up some of your arteries to improve the blood supply to your foot so that might mean getting a stent to one of your arteries in your legs to open up the blood supply it might mean mean that we might have to do some bypass surgery to to improve the blood supply to your foot in order to heal that that wound i do think that you'll be able to heal it i do n't think that we need to do anything drastic i want you to continue with your aspirin because that will help [patient] any questions [doctor] yeah i mean is this do we have to do any more tests or anything what are you we're gon na do an arterial ultrasound i'm going to go ahead and order an arterial ultrasound of your lower extremities to see what the blood supply is like and then i'm gon na go ahead and order a podiatry consult because i want them to see this wound and improve the wound care that you're doing and then for your next problem your diabetes i wan na go ahead and talk to your primary care physician we need to get your diabetes better controlled because that impacts your wound healing as well okay [patient] sure [doctor] sure understood alright and for your last issue your coronary artery disease continue with your statin and i will talk to your cardiologist in case you need a procedure to see if you're cleared from a medical standpoint okay [patient] okay perfect [doctor] alright [patient] perfect thank you so much [doctor] okay bye", "target": "ASSESSMENT\n\n1. Non-healing ulcer, right foot\n 2. Diabetes\n 3. Coronary artery disease\n\nPLAN\n\nAfter reviewing the patient's examination findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed that his right foot ulcer is fairly sizable and will require wound care. I advised him that the ulcer does not appear to be healing and that further studies will be needed to assess if he has adequate blood supply to heal his foot wound. He was advised that due to his diabetes it is possible surgical intervention such as stent placement or bypass surgery may be required to improve his blood supply. I also advised him that I believe we will be able to heal his wound. At this time, I have recommended continued wound care and for him to also continue taking aspirin 81 mg daily. We will order an arterial ultrasound of the lower extremities. He will also be referred to podiatry for a consult.\n \n Regarding his diabetes, this appears to be unstable as the patient reports his last hemoglobin a1c was greater than 9 and is now experiencing a non-healing right foot ulcer. We discussed the importance of blood sugar control as this will impact his wound healing. At this time, I have recommended that he follow-up with his primary care physician for further care.\n \n The patient's coronary artery disease is currently stable. It is recommended that he continue to take his statin as prescribed. I will contact his cardiologist for medical clearance should surgical intervention be required for his non-healing right foot ulcer.\""} {"idx": 111, "inputs": "[doctor] hey william so i see that you injured your knee could you tell me a bit about what happened [patient] yeah i thought it was a good idea to go to the trampoline park with my wife and heard a snap and instant pain when i was on the trampoline [doctor] okay alright and so do do you go to the trampoline park often [patient] i do n't and i think that's the issue [doctor] okay so this is the first time you'd ever done something like that [patient] yes [doctor] okay alright i just wan na get like a few more details do you like work out regularly was this for fun or for like an exercise class [patient] no it's just for fun [doctor] okay and do you have like a regular exercise regimen at all [patient] try to not consistent with it [doctor] okay no that's fine this is not a place of judgment i just i'm just trying to understand like if a little bit more of the background okay so we went to the trampoline park which knee where did you hurt [patient] my right [doctor] okay your right knee and so based on like your inside and outside which part hurts more [patient] it's kind of the outside of the knee [doctor] alright so the lateral aspect not a problem and you said that you heard a pop when you landed right [patient] yeah [doctor] okay have you taken anything for the pain [patient] just tylenol [doctor] alright so did the tylenol help [patient] not really [doctor] okay alright and so hmmm when does it have you tried anything else like did you ice it use heat anything like that [patient] no i just kinda elevated it and that was about it [doctor] okay that's fine and how long ago did this happen [patient] a week ago [doctor] okay alright so you put up with the pain for a week that's i'm proud of you for that [patient] i do n't like to come to the doctors [doctor] excuse me i feel rejected right now why why would you say something like that it's fine but you know i i like it when you're not here either because that means that you're doing a good job so let's see about like getting your knee fixed up but i want to talk about some of the other issues that you have first so we know that you have hypertension right and i discussed maybe you getting a blood pressure cuff because i needed you to measure those a bit more regularly did you get the cuff [patient] what no [doctor] no okay that's fine have you measured your blood pressure recently at all [patient] no [doctor] okay are you still taking your medication because i see you're on twenty milligrams of lisinopril [patient] yeah most days i remember [doctor] okay [patient] ra i'm not suspicious but we're just gon na go with that okay because looking at your vitals it it is of still a bit high i'm not really comfortable i see like a hundred and eighty over you know eighty and [doctor] that's not where we wan na be so i wonder if we might need to adjust your medication but let's talk about your diabetes how are your blood sugars [patient] i think they're little bit better [doctor] okay what makes you think that have you been taking them [patient] yeah i check it you know most days again kinda when i remember [doctor] okay how often are you checking it [patient] i would say four five times a week [doctor] okay you might wan na switch to maybe two or three times a day but you know that's something i'm glad that you are measuring are you taking your metformin [patient] yes [doctor] okay and then i think we have you on five hundred milligrams correct [patient] yes [doctor] alright how is your diet [patient] kinda the same as my exercise decent could be better [doctor] alright and okay not a problem so what is your do you are you measuring your calories at all looking at your macros are you just eating what you feel like [patient] yeah just trying to watch what i eat more than anything but nothing specific [doctor] okay and are you do you know if you're particularly focused on your salt like is it like a low salt diet [patient] no just trying to watch my carbs a little bit more but not counting or anything [doctor] alright so like is it a specific diet i just wan na make sure like are you on like the keto diet [patient] no [doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and do a quick physical exam as i mentioned before your blood pressure is a little high as i listen to your heart i do like it's got a nice regular rate and rhythm i do n't appreciate any murmur when i listen to your lungs they sound clear bilaterally i would like to look at your knee though so when i press here on the outside does it hurt [patient] little bit [doctor] okay and then when i press on the inside does it hurt [patient] no [doctor] alright can you bend your knee and straighten it [patient] i can i think that's all i can i can bend [doctor] mm-hmm alright so are you having problems walking can you bear weight [patient] i can but i have a little bit of a limp [doctor] okay so do you mind getting up and walking for me really quickly alright so i do notice that there is a slight gait like there is a small sorry you are correcting you do have a limp i i am a little worried about that but it's probably it's probably the superficial when i'm looking at your knee i do notice some like ecchymosis and edema that just means bruising and swelling along the lateral aspect of your knee i do n't notice any effusion and it looks like you have a decent range of motion but i do understand that you know you are experiencing pain with some movement okay i'm gon na go ahead and order an x-ray and when you come back we can have that discussion alright so i reviewed the results of your right knee x-ray which showed no evidence of fracture or bony abnormality so let's talk about my assessment and plan alright so for your first problem of right knee pain i think you have a lateral a lateral ligament strain i wan na prescribe some meloxicam which is gon na be fifteen milligrams daily for pain and swelling i'm gon na refer you to physical therapy to help strengthen the muscles around the area and to prevent further injury if you're still having pain we can do further imaging imaging but like this is a common injury that tends to heal on its own for your second problem with hypertension i wan na continue the lisinopril at twenty milligrams and order an echo i am concerned that we might not be getting your blood pressure to where we need it to be so we might have to do some medication modification for your third problem with diabetes i wan na order an a1c i know that you said you have been measuring your blood sugars but i think this would give us a better image of what's been happening long term and i also wan na order a lipid panel in case we need to make any adjustments to that medication as well do you have any questions [patient] sounds good [doctor] alright awesome", "target": "ASSESSMENT\n\n1. Right knee pain, lateral ligament strain.\n 2. Hypertension.\n 3. Diabetes type 2.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, his symptoms appear to be consistent with a lateral ligament strain of the right knee. I am going to prescribe meloxicam 15 mg once daily for pain and swelling. I also put in a referral for physical therapy so he can work on strengthening the muscles around the area and prevent any further injury. We can consider further imaging if he continues to have pain, but I explained that this is a common injury that typically heals on it's own.\n \n For his hypertension, I'm concerned that his blood pressure is not well controlled at this time, so we may need to modify his medication. I'm going to order an echocardiogram for further evaluation, but I want him to continue taking his lisinopril 20 mg for now.\n \n For his diabetes, he stated that he has been measuring his blood glucose levels 4 to 5 times per week, but I want him to start measuring them 2 to 3 times per day. His hemoglobin A1c levels should provide more detail as far as his long-term progress so we will order that today. I'm also going to order a lipid panel and we can determine if any adjustments need to be made to his medication. In the meantime, he should continue taking metformin 500 mg.\n \""} {"idx": 115, "inputs": "[doctor] alright so hey it's nice to see you jack i know you've been experiencing some neck pain could you tell me what happened [patient] yeah so i was in a a car accident [doctor] mm-hmm [patient] and i hit in the back and like my my neck went forward and my head went forward really quick and so i've been having some pain ever since [doctor] okay and so with this pain how long ago was the car accident [patient] that was about a week ago [doctor] okay with this pain like on a scale of one to ten how severe is it [patient] i would say it's about a seven [doctor] okay [patient] it's not a constant pain but like whenever i move my head which is like a lot i i feel it [doctor] alright so where exactly is it on the side on the back [patient] it's in the back of my neck [doctor] okay has anything made it better [patient] i mean i've tried some ibuprofen that helped a little bit but not too much [doctor] mm-hmm [patient] just about five out of ten [doctor] mm-hmm alright and did you say whether the pain was getting worse [patient] i mean it's been staying the same it just gets worse when i'm moving my neck [doctor] okay are you able to turn your neck from side to side [patient] mostly but there is there is pain with it [doctor] okay and then do you have headaches [patient] yeah i had i had a couple early on [doctor] uh uh [patient] i have had it lately [doctor] okay and so does the pain move anywhere like your upper back your shoulder [patient] no it just stays on monday [doctor] okay and then any kind of hearing any kind of hearing problems visual disturbances [patient] no [doctor] okay have you do have you ever like played sports before or had like a sports accident before [patient] yeah i played football [doctor] okay [patient] years ago but i i did n't have any issues with my neck though [doctor] okay and then when you got in the car accident did you end up going to the emergency room [patient] no i mean i i know that going to the emergency room that like the english rides like five hundred bucks so i did n't want to do that [doctor] i understand i understand okay was there any like swelling or bruising on your neck [patient] not that i know about no other mag of my neck i really ca n't see that [doctor] yeah okay no just checking okay so if you do n't mind i'm gon na go ahead and do my physical exam so when i press on here on the side of your neck does it hurt [patient] yeah a little bit [doctor] okay positive pain to palpation of the soft tissues of the neck what about when i press on your back or your shoulders [patient] no that's fine [doctor] okay so when you flex your neck when you're touching your chin to your chest does that hurt [patient] mm-hmm [doctor] alright positive pain with flexion what about when you move it back [patient] yeah that hurts worse [doctor] okay okay severe positive pain to extension okay so can you turn your head from side to side does that hurt [patient] yeah a little bit [doctor] okay positive pain with rotation and then can you touch your ear to your shoulders [patient] no [doctor] okay alright so positive pain on lateral bending wow this is pretty this is pretty serious not serious necessarily sorry about that so i reviewed the results of your x-ray but the results show no signs of fracture or bony abnormalities but let's go ahead and talk about my assessment and plan for you i believe what you have is something called neck strain for your neck pain i sorry treatments we are gon na go ahead and treat this a bit conservatively your i'm gon na put you on anti-inflammatories motrin six hundred milligrams and you're gon na take that every six to eight hours i also wan na give you a muscle relaxant called flexeril and it's gon na be ten milligrams and you'll take that every twelve hours as needed i'm gon na want you to try your best to to like relax your neck i'm sorry not to strain your neck anymore like to be conservative with how you move about and everything like that i also wan na order an mri just because you said you did n't go to the hospital or anything like that i just wan na make sure that you you're not suffering from like a concussion but this is something that's commonly referred to as like whiplash right your head just like it it just wiped essentially like back and forth to so severely and and that's probably what's causing your pain i think i wan na refer you to either physical rehab or a chiropractor once we get the results of the mri just to make sure that there is n't any impingement of like the nerves or anything like that do you have any questions [patient] i heard the chiropractors will shake they work [doctor] i do understand that some people have like reservations about going to the chiropractor but you know we do have some good ones that have like longstanding histories and patients that have had positive results from the experience but if you if you do n't like the idea of that we can consider other options like that rehab and physical therapy [patient] okay [doctor] alright any other questions [patient] no [doctor] alright thank you", "target": "ASSESSMENT\n\nNeck strain.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed his x-rays did not reveal any signs of a fracture or bony abnormalities. Treatment options were discussed and conservative treatment has been recommended. He will begin taking Motrin 600 mg every 6 to 8 hours. A prescription for Flexeril 10 mg every 12 hours as needed was also provided. He was advised to be mindful of how he moves his neck and to be conservative to avoid straining his neck. I have also recommended that we obtain an MRI for further evaluation as the patient did not go to the emergency room following his accident. He will also be referred to either physical rehab or a chiropractor pending his MRI results.\n \""} {"idx": 83, "inputs": "[doctor] hey lawrence how're you doing [patient] i'm doing alright aside from this elbow pain [doctor] so it looks like here that you came in to see us today for an evaluation of that right elbow pain can you tell me can you can you tell me well first of all what do you think has been causing that pain [patient] so i really during this pandemic i really got into ceramics and doing pottery so i've been doing a lot of pottery and over the past week i then started to develop this elbow pain [doctor] okay and then so tell me a little bit more about that elbow pain where does it hurt exactly [patient] you know it hurts a lot in the inside of my elbow [doctor] okay so the inside of your right elbow okay [patient] yeah [doctor] and then does the pain radiate down your arm or up into your shoulder or anything like that [patient] it does n't go into my shoulder it's it stays mostly at my elbow but it can go down a bit into my forearm [doctor] okay and then do you remember any trauma did you hit your arm or elbow or any on anything [patient] no nothing i i really was trying to think if there is anything else and i ca n't think of anything [doctor] okay and you've never injured that right elbow before [patient] no [doctor] alright so now let's talk a little bit about your pain and how bad it how bad is that pain on a scale from zero to ten ten being the worst pain you've ever felt in your life [patient] i would say probably a six [doctor] okay and does that pain keep you up at night [patient] it does [doctor] okay and when you have that kind of pain does it keep you from doing other type of activities [patient] yeah i mean i still try to like work through with using my arm but yeah it's it's it's difficult for me sometimes to lift and do things because of that pain [doctor] okay and then and how long has this pain been going on [patient] about four days now [doctor] alright and anything you've done to help relieve or alleviate that pain any anything that that's giving you relief [patient] i've tried ibuprofen that helps a little but not much [doctor] okay so if it's okay with you i would like to do a a quick physical exam your vitals look good and i'm gon na do a focused exam on that right elbow i'm gon na go ahead and and and press here do you do you have any pain when i press here [patient] yes i do [doctor] okay so you are positive for pain to palpation you do note that moderate tenderness of the medial epicondyle now i'm gon na have you turn your wrist as if you're turning a door knob do you have any pain when you do that [patient] not really [doctor] okay now turn your wrist in so do you have any pain when you do that [patient] yeah that hurts [doctor] okay so you do have pain you were positive for pain when you pronate that that that forearm okay i'm gon na go ahead and have you rest your arm on the table here palm side up now i want you to raise your hand by bending at the wrist and i'm gon na put some resistance against it do you have any pain when i press against your flexed wrist [patient] yes i do [doctor] alright so you are positive for pain with resistance against flexion of that left wrist so i let let's go ahead and review the x-ray that we did of your elbow the good news is i do n't see any fracture or bony abnormality of that right elbow which is good so let's talk a little bit about my assessment and plan for you so for the problem with elbow pain i do believe that this is consistent with medial epicondylitis which is caused by the overuse and potential damage of those tendons that bend [doctor] that that bend the wrist towards the palm now i want you to rest it i'm gon na order a sling and i want you to wear the sling while you're awake now we're also gon na have you apply ice to the elbow for twenty minutes three times a day and i want you to take ibuprofen that's gon na be six hundred milligrams q.6 h. with food and i want you to take that for a full week now you're not gon na like this part but i want you to hold off for the next couple of weeks on doing any type of pottery work okay alright now what i wan na do is i wan na see you again in a week and i wan na see how you're doing okay [patient] alrighty [doctor] alrighty so i'll have the nurse come in and get you set up with that sling and i will see you again in about a week [patient] alright thank you [doctor] thank you", "target": "ASSESSMENT\n\nRight medial epicondylitis.\n\nPLAN\n\nThe patient and I discussed his diagnosis in detail, and I explained that his symptoms are likely caused by overuse and potential damage of the tendons. We will provide him with sling to be worn during the day while he is awake. I want him to take ibuprofen 600 mg every 6 hours with food for a full week and ice the elbow for 20 minutes, 3 times daily. Finally, I advised the patient to rest his elbow and avoid doing any pottery for the next couple of weeks."} {"idx": 60, "inputs": "[doctor] hey jean how're you doing today [patient] i'm doing alright aside from this foot pain that i have [doctor] so i see here that you looks like you hurt your left foot here where you were playing soccer can you tell me a little bit more about what happened [patient] yeah so yeah i was playing in a soccer game yesterday and i was trying to steal the ball from another player and she ended up falling directly onto my right foot and i do n't know i i mean i was trying to get around her and my body ended up twisting around her and then i accidentally felt a pain in my foot [doctor] okay so have you ever hurt your left foot before [patient] no i've had a lot of injuries in soccer but never injured this foot [doctor] okay and then so after the fall and the entanglement with the other player were you able to continue playing [patient] no i had to stop playing right away and actually being helped off the field [doctor] wow okay and what have you been doing for the the pain since then [patient] so i've been keeping it elevated icing it the trainer wrapped it yesterday and taking ibuprofen as well [doctor] okay alright so without any ibuprofen can you tell me what your pain level is [patient] without ibuprofen i would say my pain is a three [doctor] okay and then with your ibuprofen can you tell me what your pain level is [patient] like a seven eight [doctor] okay so how long have you been playing soccer [patient] really since i was like four five i've been playing a long time [doctor] well that's cool yeah we our our youngest daughter she is almost sixteen and she plays the inner marrial soccer league they are down at the rex center did is that where you started playing or did you guys did you start playing somewhere else [patient] yeah just like this local town leak i started playing that way and then played all throughout school [doctor] that's [patient] high school teams [doctor] that's awesome so just out of curiosity with the left foot have you experienced anything like numbness or tingling or or any strange sensation [patient] no i have not [doctor] okay now if it's okay with you i would like to do a quick physical exam i reviewed your vitals and everything looks good blood pressure was one eighteen over seventy two heart rate was fifty eight respiratory rate was fourteen you are afebrile and you had an o2 saturation of ninety nine percent on room air on your heart exam your regular of rate and rhythm do n't appreciate any clicks rubs or murmurs no ectopic beats noted there on auscultation listening to your lungs lungs are clear and equal bilaterally so you're moving good air i'd like to do a focused foot exam on your left foot so i do see some bruising on the bottom of your foot and on the top of your foot as well now there is associated swelling and i do appreciate tenderness to palpation of your midfoot and you are positive for the piano key test on a neurovascular exam of your left foot you have a brisk capillary refill of less than three seconds dorsalis pedis pulse is intact and strong and you do have motor and sensation that it's intact to light touch now i would like to do a review of the diagnostic imaging that you had before you came in so i do notice a subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space so lem me talk to you a little bit about my assessment and plan now for for the first concern of right foot pain your right foot pain is due to a lisfranc fracture which is a fracture to one of your second metatarsal bones at the top of your foot where the metatarsals meet your cuboids now there are ligaments at the top of your foot so i'm gon na be ordering an mri to assess for injury to any of these ligaments now based on your exam and from what i'm seeing on your x-ray you're most likely going to need surgery of that foot now the surgery will place the bones back in their proper position and using plates and screws will hold them there while they heal and this is gon na allow those bones and ligaments to heal properly it is a day surgery and you will be able to go home the same day and then i'm going to have you follow up with me here in the clinic you'll be in a cast and you will need to use crutches and you will not be able to use that left foot for about six to eight weeks now after that six to eight weeks you will gradually start walking on your foot based on how you tolerate it and we'll see how you do at that point so i do believe you're gon na need surgery i i'm recommending this because there are significant complications to your foot if we do not do this poor bone and ligament healing can lead to losing the arch of your foot and you're becoming flat-footed you also have a high likelihood of developing arthritis in that foot so what i'm gon na do unfortunately you'll be out the rest of the season but we are gon na get you fixed up and ready for next season if you're okay with all of this i'm gon na have the nurse come in and get you started on your paperwork and then i will see you on monday morning and we will get your foot taken care of [patient] alright thank you [doctor] you're welcome", "target": "ASSESSMENT\n\nLisfranc fracture, left foot.\n\nPLAN\n\nI explained the nature of her injury in detail. Based on her exam and x-ray findings, she will most likely require surgery of the left foot, but I want to order an MRI to assess for any ligamentous injuries. We discussed the procedure and postoperative expectations, such as recovery time and restrictions, at length. We also discussed the complications associated with deferring surgical intervention including poor bone and ligament healing, pes planus deformation, and a high likelihood of developing arthritis in the foot. She will be unable to participate for the remainder of the soccer season, but should be able to play next season."} {"idx": 74, "inputs": "[doctor] patient , bruce ward . date of birth 5/21/1969 . please use my neuro consult template . this is a 52-year-old male with dia- newly diagnosed pituitary lesion . the patient is seen in consultation at the request of dr. henry howard for possible surgical intervention . mr . ward presented to his primary care provider , dr. howard , on 3/1/21 complaining of worsening headaches over the past few months . he denied any trouble with headaches in the past . his past clinical history is unremarkable . [doctor] worked out for worsening headaches was initiated with brain mri and serology where pituitary lesion was incidentally discovered . i personally reviewed the labs dated 3/3/21 including cbc , unes , uh , coagulation , and crp . all were normal . pituitary hormone profile demonstrates a low tsh , all other results were normal . um , i personally reviewed pertinent radiology studies including mri for the brain with contrast from 3/4/21 . the mri reveals a pituitary lesion with elevation and compression of the optic chiasm . the ventricles are normal in size and no other abnormalities are lo- are noted . [doctor] hello , mr . ward . nice to meet you . i'm dr. flores . [patient] hi , doc . nice to meet you . [doctor] i was just reviewing your records from dr. howard and he's referred you because the workup for headaches revealed a mass on your pituitary gland . i did review your mri images and you have a significant mass there . can you tell me about the issues you've been experiencing ? [patient] yeah sure . so i'm really getting fed up with these headaches . i've been trying my best to deal with them but they've been going on for months now and i'm really struggling . [doctor] where are the headaches located and how would you describe that pain ? [patient] located behind my eyes . it's like a dull nagging ache . [doctor] okay . was the onset gradual or sudden ? [patient] well it started about three months ago . and they've been getting worse over time . at first it was like three out of 10 severity , and it just gradually worsened . and now it's about six out of 10 severity . the headaches do tend to be worse in the morning and it feels like a dull ache behind the eyes . they last a few hours at a time , nothing makes them better or worse . [doctor] okay . can you tell me if the pain radiates , or if you have any other symptoms ? specifically feeling sick , fever , rashes , neck stiffness , numbness , weakness , passing out ? [patient] no . i have n't been sick or felt sick . ca n't recall a fever or any kind of rash . no- no neck issues , no numbness , no tingling . and i've never passed out in my life . but , um , for some reason recently i seem to be bumping into door frames . [doctor] okay . have you noticed any change in your vision or with your balance ? [patient] no i do n't think so . my eyes were checked in the fall . [doctor] okay . let's see , do you have any other medical problems that you take medicine for ? [patient] no i do n't have any medical problems and i do n't take any medicines . i tried tylenol a few times for the headaches but it did n't work , so i stopped . [doctor] i see . anyone in your family have any history of diseases ? [patient] i was adopted so i really have no idea . [doctor] okay . um , what kind of work do you do ? and are you married ? [patient] i work as a computer programmer and i've been married for 25 years . we just bought a small house . [doctor] that's nice . um , do you drink any alcohol , smoke , or use recreational drugs ? [patient] nope . i do n't do any of those and never have . [doctor] okay . um , well let me take a good look at you . um , now you'll hear me calling out some details as i perform the examination . these will be noted for me in your record and i'll be happy to answer any questions you have once we're done . [patient] sounds good , doc . [doctor] all right . the patient is alert , oriented to time , place , and person . affect is appropriate and speech is fluent . cranial nerve examination is grossly intact . no focal , motor , or sensory deficit in the upper or lower extremities . visual acuity and eye movements are normal . pupils are equal and reactive . visual field testing reveals bitemporal hemianopia . and color vision is normal . [doctor] all right , mr. ward . i'm going to review these pictures from the mri with you . um , now this appears to be a benign pituitary adenoma , but there's no way to be sure without sending the removed adenoma to pathology to make the diagnosis , which we will do . um , here you can see it's a well defined mass . and it's pressing right here on what we call the optic chiasm . and today when i was having you look at my fingers , you could n't see them off to the sides , that's what we call bitemporal hemianopia . and explains why you have been bumping into door frames . [patient] yeah i never noticed that i could n't see out of the side until you did that test , and you closed one eye with both eyes . i really could n't tell . [doctor] no because you're having this vision loss from the mass compressing the optic chiasm , the only option we have is to do surgery . [patient] okay , i understand . do you think i'll regain my vision ? [doctor] well there's no guarantees , but it is a possibility . i'm gon na refer you to the eye doctor for a full exam and they'll do what's called visual field test . this will map our your peripheral vision or side vision prior to surgery . and we can monitor after surgery to see if your vision is improving . [patient] all right . [doctor] and let's discuss the surgery a little more . um , we would do what's called a transsphenoidal approach to do the surgery . this is minimally invasive and we go through the sphenoid sinus . there are some risks i have to inform you of . uh , risk of anesthesia including but not limited to the risk of heart attack , stroke , and death . risk of surgery include infection , need for further surgery , wound issues such as spinal fluid leak or infection , uh , which may require long , prolonged hospitalization or additional procedure . uh , seizure , stroke , permanent numbness , weakness , difficulty speaking , or even death . [patient] well i guess we have to do it regardless . [doctor] okay . so i will have you see our surgery scheduler , deborah , on the way out to get you set up . we will get this scheduled fairly quickly so i do n't want you to be alarmed . um , she'll also get you set up today or tomorrow to have the visual field test and you may not be able to see the eye doctor until after surgery . but we have the pre-surgery visual field test for comparison after surgery . [patient] okay . i look forward to these headaches going away . i never thought it could be something like this going on . [doctor] yeah . come this way , we'll get your things lined up . please call if you think of any questions . [patient] thanks , doctor . [doctor] diagnosis will be pituitary adenoma . mr . ward is a very pleasant 52-year-old male who has benign appearing pituitary adenoma , incidentally discovered during workup for worsening headaches . he is symptomatic with clinical and radiographical evidence of optic chiasmal compression , therefor surgical intervention to excise and decompress the pituitary fossa is indicated . end of note .", "target": "ASSESSMENT\n\n\u2022 Pituitary adenoma\n \u2022 Bitemporal hemianopia\n \n Mr. Ward is a very pleasant 52-year-old male who has a benign appearing pituitary adenoma discovered on work up for worsening headaches. There is clinical and radiographical evidence of optic chiasmal compression, examination today revealed a bitemporal hemianopia. Radiographically this appears to be a benign pituitary adenoma but that there was no way to be sure without a pathological diagnosis. Surgical intervention to excise and decompress the pituitary fossa is indicated given optic chiasmal compression.\n\nPLAN\n\nPituitary adenoma.\n We discussed the general indications for surgical intervention. The risks, benefits to trans-sphenoidal resection were explained to the patient. The risks of anesthesia including but not limited to the risks of heart attack, stroke, and death. The risks of surgery including infection, need for further surgery, wound issues (such as spinal fluid leak or infection) which may require prolonged hospitalization or additional procedure, seizure, stroke, permanent numbness, weakness, difficulty speaking, or death. The patient voiced understanding and wishes to proceed with trans-sphenoidal resection of the adenoma.\n \n Bitemporal hemianopia.\n We will have the patient scheduled this week to have visual field testing with ophthalmology. The preoperative visual field will serve as baseline for comparison of postoperative visual field testing to monitor for improvement in the bitemporal hemianopia. Additionally, we discussed that unfortunately no guarantees could be given that his vision would return."} {"idx": 68, "inputs": "[doctor] hi , brian . how are you ? [patient] hi , good to see you . [doctor] it's good to see you too . so , i know the nurse told you a little bit about dax . [patient] mm-hmm . [doctor] i'd like to tell dax about you , okay ? [patient] sure . [doctor] so , brian is a 58 year old male with a past medical history significant for congestive heart failure and hypertension , who presents today for follow-up of his chronic problems . so , brian , it's been a little while i've seen you . [patient] mm-hmm . [doctor] whats , what's going on ? [patient] i , i just feel out of sorts lately . i do n't know if it's the change in the seasons or if we're just doing a lot of projects around the house and , and some , some construction on our own . i'm just feeling out of it . lack of , uh , energy . i'm just so tired and fatigued , and i feel kinda ... i feel lightheaded every once in a while . [doctor] okay . all right . um , how long has that been going on for ? [patient] uh , probably since labor day , so about five weeks or so . [doctor] okay . and , have you noticed any , like , symptoms of weight gain , like , like swollen legs , or , you know , your belly feels bloated and things like that ? [patient] i feel , i feel bloated every once in a while . [doctor] okay . all right . um , and , are you taking your , your medications ? [patient] uh , yes , i am . [doctor] okay . and , how about your diet ? are you watching your diet ? [patient] uh , it's been a little bit of a struggle . we began construction on our kitchen over labor day weekend , and it was ... hard to cook or prepare meals so we ate out a lot, and not always the best food out. it , it , it kind of reeked havoc , uh , so it's been maybe off a little bit . [doctor] okay . all right . and , how about , you know , other symptoms , like , have you had a fever or chills ? [patient] no . [doctor] okay , and any problems breathing ? do you feel short of breath ? [patient] uh , just when i'm doing doing the projects . again , not even lifting anything really heavy , it's just that if i'm ex- exerting any energy , i , i kinda feel it at that point . [doctor] okay . do you have any chest pain ? [patient] slight cramps . that seems to go away after about , maybe about an hour or so after i first feel it . [doctor] okay , and how about a cough ? [patient] a , a slight cough , and again , i'm not sure if it's just the change of seasons and i'm getting a cold . [doctor] mm-hmm . okay . all right . well , you know , for the most part , how , you know , before all of this- [patient] mm-hmm . [doctor] . how were you doing with your heart failure ? i know that we've kinda talked about you being able to watch your healthy food intake and that's been kind of a struggle in the past . [patient] i , i , i've actually been pretty good about that ever since . the , the , the last year , it's been a little chaotic , but i wanted to make sure i stayed on top of that . [doctor] okay . all right . are you excited for halloween ? [patient] uh , ca n't wait . [doctor] okay . [patient] our home renovations should be complete by then [doctor] all right , yeah , right . [patient] yeah . [doctor] and , so , lastly , for your high blood pressure , how are you doing with that ? have , are , did you buy the blood pressure cuff like i asked ? [patient] yeah , i , i did , and we do mon- , i , i monitor it regularly . my wife makes sure i stay on top of that , but it's been pretty good . [doctor] okay . all right . well , i know you did the review of systems sheet when you checked in , and you were endorsing this fatigue- [patient] mm-hmm . [doctor] . and a little dizziness and we just talked a lot about a lot of other symptoms . [patient] mm-hmm . [doctor] any other symptoms i might be missing ? nausea or vomiting , diarrhea ? [patient] no . [doctor] anything like that ? [patient] no . [doctor] okay . all right . well , i just want to go ahead and do a quick physical exam . [patient] mm-hmm . [doctor] hey , dragon ? show me the vital signs . so , looking at your vital signs here in the office , everything looks good . you know , your blood pressure and your heart rate and your oxygenation all look really good . [patient] mm-hmm . [doctor] so , i'm gon na just take a listen to a few things and check some things out , and i'll let you know what i find , okay ? [patient] perfect . [doctor] okay . so , on your physical examination , you know , i do appreciate some jugular venous distention to- [patient] mm-hmm . [doctor] to about eight centimeters . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which we've heard in the past . and , on your lung exam , i do appreciate some fine crackles at the bases bilaterally , and your lower extremities have , you know , 1+ pitting edema . so , what does all that mean ? that means i think you're retaining a little bit of fluid . [patient] mm-hmm . [doctor] okay ? i wan na just go ahead and look at some of your results , okay ? [patient] sure . [doctor] hey , dragon ? show me the chest x-ray . so , looking here at the results of your chest x-ray , it does look like you have a little bit of fluid in your lungs there , and that can be just from , um , your heart failure , okay ? hey , dragon ? show me the echocardiogram . so , this is the echocardiogram that we did about four months ago , and this shows that the pumping function of your heart is a little bit reduced at 45 % , and it also shows that leaky valve , the mitral regurgitation that , that you have , okay ? um , so , let me just go over and talk about , a little bit , my assessment and my plan for you . [patient] mm-hmm . [doctor] okay ? so , for your first problem , your congestive heart failure , i think you're retaining fluid , and i wan na go ahead and increase your lasix to 80 mg once a day . [patient] mm-hmm . [doctor] i want you to weigh yourself every day . i want you to call me if you're gaining more weight . [patient] mm-hmm . [doctor] and , i certainly want you to call me if you have any other symptoms of shortness of breath , and i wan na go ahead and order another echocardiogram , okay ? [patient] sure . [doctor] hey , dragon ? order an echocardiogram . lastly , for your high blood pressure , it looks like you're managing it well at this time , okay ? so , i wan na go ahead and continue with the lisinopril 20 mg a day . i want you to continue to record your blood pressures at home , and report them to me in the patient portal if you see they're getting elevated , okay ? [patient] mm-hmm . [doctor] does that sound like a plan ? [patient] that sounds fine . [doctor] okay . um , i'm gon na be in touch with you after we get your test results , and we'll go from there , okay ? [patient] sure . [doctor] all right . hey , dragon , finalize the note .", "target": "ASSESSMENT AND PLAN\n\nBrian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow up of his chronic problems.\n \n Congestive heart failure.\n \u2022 Medical Reasoning: The patient reports increased fatigue, dizziness, and chest discomfort on exertion. He also exhibits some jugular venous distention, lung base crackles, and lower extremity edema on exam today. He has been compliant with his current medications but admits to dietary indiscretion lately. His recent echocardiogram demonstrated a reduced ejection fraction of 45%, as well as mitral regurgitation.\n \u2022 Additional Testing: We will order a repeat echocardiogram.\n \u2022 Medical Treatment: Increase Lasix to 80 mg daily.\n \u2022 Patient Education and Counseling: I advised the patient to monitor and record his daily weight and report those to me via the patient portal. He will contact me should he continue to experience any dyspnea.\n \n Hypertension.\n \u2022 Medical Reasoning: This is well controlled based on home monitoring.\n \u2022 Medical Treatment: Continue lisinopril 20 mg daily.\n \u2022 Patient Education and Counseling: I advised him to monitor and record his blood pressures at home and report these to me via the patient portal.\n \n "} {"idx": 16, "inputs": "[doctor] hi , edward , how are you ? [patient] i'm doing well , yourself ? [doctor] i'm doing okay . [patient] good . [doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] absolutely . [doctor] edward is a 59 year old male with a past medical history significant for depression , hypertension and prior rotator cuff repair who presents for followup of his chronic problems . so , edward , it's been a little while since i saw you . [patient] mm-hmm . [doctor] how are you doing ? [patient] i'm doing pretty well , actually . it's been a good , uh , good six months . [doctor] good . okay . so , you know , the last time we spoke , you know , you were trying to think of some new strategies to manage your depression . you did n't wan na go on medication because you're already on a bunch of meds . [patient] absolutely . [doctor] so , how are you doing with that ? [patient] i'm doing well . i see a counselor , uh , once a week . uh , and i've been out swimming at the pool a lot this , this , uh , summer , and , uh , fall . so , things have been well , going well with my depression . [doctor] okay , so , you do n't wan na , you do n't feel the need to start any medications at this time ? [patient] no , no , no . but , i know i can call you if i do . [doctor] yeah , absolutely . [patient] okay . [doctor] yeah . all right . and then , in terms of your high blood pressure , how are you doing with that ? i know we , we were kind of struggling with it la- six months ago . how are you doing ? [patient] i still have my good days and my bad days . i do take my medicine daily . uh , but , you know that burger and wine , every once in a while , sneaks in there , and that salt be ... we know what that does . [doctor] yeah . so , i love burgers and wine too . [patient] okay . [doctor] so , i get it . um , okay , so , and you're taking the norvasc ? [patient] norvasc , yep . [doctor] okay . um , and , you're checking your blood pressures at home , it sounds like ? [patient] i , i do . well , i go to cvs pharmacy . they , they have a , uh , machine that i can sit down at quickly and get my , uh , blood pressure taken . and , i go there about once a week . [doctor] okay . all right . and then , i know that you had that rotator cuff repaired about eight months ago . how are you doing ? [patient] um , it's doing well . i , i'm , i'm , been stretching with a yoga ball . [doctor] uh- . [patient] and , uh , i'm getting stronger each time . and , i can continue that once a week also . [doctor] okay . are you still seeing the physical therapist in the center , or are you just doing exercises at home ? [patient] i'm just , i progressed to exercises at home . [doctor] okay . all right . great . all right . well , i know you did a review of systems sheet when you checked in . [patient] mm-hmm . [doctor] and , you know , it seems like you're doing well . any symptoms at all ? any nasal congestion or chest pain , shortness of breath , anything ? [patient] no . none of those . i do , do notice that i get a little bit of a de- , uh , swelling in my ankles . [doctor] okay . [patient] uh , mainly near the end of the day . [doctor] okay . [patient] um , it seems to go away by the next morning . [doctor] okay . all right . all right . maybe that has to do with some of the salt intake you're , you're eating . [patient] okay . [doctor] all right . well , i wan na go ahead and do a quick physical exam , okay ? [patient] mm-hmm . [doctor] hey , dragon ? show me the blood pressure . yeah , so , your blood pressure's a little elevated today , 156 over 94 . [patient] okay . [doctor] you know , you could be a little happy to see me . i do n't know . [doctor] um , but let's look at some of the readings . hey , dragon ? show me the blood pressure readings . yeah , so , they've been a , running a little high over the past couple months . [patient] okay . [doctor] so , we'll have to just kinda talk about that , okay ? [patient] okay . [doctor] i'm gon na go ahead and listen to your heart and lungs , and i'll let you know what i find , okay ? [patient] okay . [doctor] okay . all right . so , on physical exam , you know , everything looks good . on your heart exam , i do appreciate a slight three out of six systolic ejection murmur , but we've heard that in the past . [patient] okay . [doctor] so , that seems stable to me . um , on your lung exam , everything sounds nice and clear , and on your lower extremity exam , i do appreciate , you know , 1 to 2+ pitting edema in your legs , okay ? so , we'll have to just talk a little bit about your diet and decreasing the salt intake , okay ? [patient] okay . [doctor] so , let me just look at some of your results , okay ? hey , dragon ? show me the labs . so , looking here at your lab results , everything looks really good . you know , your creatinine , that's your kidney function , that looks stable . everything looks good from that standpoint . hey , dragon ? show me the ekg . and , looking here at your ekg , everything , you know , looks fine . there's no evidence of any coronary artery disease . it's a nice , normal ekg , which is good . [patient] okay . [doctor] okay ? [patient] good . [doctor] so , let me just talk a little bit about my assessment and my plan for you . okay ? so , from a depression standpoint , it's , you know , your first problem , i think that that sounds like you're doing really well managing it . you know , you have good strategies . it sounds like you have a good support system , um , and i agree . i do n't think you need to start on any medication at this time , but you said before , you know you can call me , okay ? [patient] yes . [doctor] for your second problem , your hypertension , i , i do n't believe it's well controlled at this time . so , i wan na go ahead and , you know , increase the norvasc up to 10 mg a day , and i wan na go ahead and order an echocardiogram and a lipid panel , okay ? [patient] okay . [doctor] hey , dragon ? order an echocardiogram . and , for your third problem , your rotator cuff repair , i , i think you're doing really well with that . i would just continue with the exercises and , uh , i do n't think we need to intervene upon that anymore . it sounds like that's pretty much resolved , okay ? [patient] good . good . [doctor] do you have any questions about anything ? [patient] no questions . [doctor] okay , great . hey , dragon ? finalize the note .", "target": "ASSESSMENT AND PLAN\n\nEdward Butler is a 59-year-old male with a past medical history significant for depression, hypertension, and prior rotator cuff repair. He presents for a follow-up of his chronic problems.\n \n Depression.\n \u2022 Medical Reasoning: He is doing well with therapy and physical activity. He continues to decline medication for this.\n \u2022 Medical Treatment: Continue current management strategies.\n \u2022 Patient Education and Counseling: I encouraged him to contact me should he want to try medication.\n \n Hypertension.\n \u2022 Medical Reasoning: This is uncontrolled at this time. He is compliant with Norvasc, but admits to occasional dietary indiscretion.\n \u2022 Additional Testing: We will order a lipid panel and an echocardiogram.\n \u2022 Medical Treatment: Increase Norvasc to 10 mg daily.\n \n 8 months status post rotator cuff repair.\n \u2022 Medical Reasoning: He is doing well postoperatively. He has progressed from formal physical therapy to solely home exercise.\n \u2022 Medical Treatment: Continue with home exercise.\n \n "} {"idx": 55, "inputs": "[doctor] karen nelson is a 3 -year-old female with no significant past medical history who comes in for evaluation of a new right eye twitch karen is accompanied by her father hi karen how are you [patient] i'm okay i guess [doctor] hey dad how are you doing [patient] hey doc i am okay yeah karen has been having this eye twitch i noticed a couple of weeks ago when i talked to her pediatrician and they told me to come see you [doctor] okay alright so karen have you felt the twitch [patient] yeah well i mean i feel my face sometimes [doctor] yeah and do you have any pain when it happens [patient] no it it does n't really hurt but i noticed that dad looks real nervous when it happens [doctor] yeah i i i can understand that's because he loves you do you feel the urge to move your face [patient] sometimes and then it moves and then i feel better [doctor] okay okay and so so dad how often are you seeing the twitch on karen [patient] i do n't know i mean it varies sometimes i see it several times an hour and there is other days we do n't see it at all until sometimes late afternoon but we definitely notice it you know everyday for the last several weeks [doctor] okay so karen how is how is how is soccer [patient] i like soccer [doctor] yeah [patient] yeah dad dad takes me to play every saturday [doctor] okay [patient] it's it's pretty fun but there's this girl named isabella she she plays rough [doctor] does she [patient] she yeah she tries to kick me and she pulls my hair and [doctor] oh [patient] sometimes she's not very nice [doctor] that is n't very nice you gon na have to show her that that's not very nice you're gon na have to teach her a lesson [patient] yeah and and then sometimes after soccer we we go and i get mcdugge's and it and it's it makes for a nice day with dad [doctor] is that your favorite at mcdonald's in the the mcnuggates [patient] not not really but they are cheap so [doctor] okay alright well you you made dad happy at least right [patient] yeah that's what he says because i'm expensive because i want dresses and dogs and stuff all the time [doctor] yeah well yeah who does n't well okay well hopefully we will get you you know squared away here so you can you know play your soccer and go shopping for dresses with dad so so dad tell me does the karen seem bothered or any other and have any other issues when this happens [patient] no i mean when it happens she just continues playing or doing whatever she was doing when it happens [doctor] okay alright has she has she otherwise been feeling okay since this started has she been acting normally [patient] i i'd say she seems fine i mean she has been eating well and playing with her friends and she goes about her normal activities really [doctor] okay good [patient] never even though anything was going on [doctor] okay alright good so has has karen had any seizures in the past [patient] no [doctor] no okay and then so tell me when the twitch occurs do you ever notice any you know parts of her like moving or twitching [patient] well no uh it's just her face [doctor] okay [patient] i mean the whole side of her face moves when it happens it seems like it several seconds and then it finally stops and she just seems to be blinking frequently and and and you know wait a minute i i did make a video so you can see just in case it does n't do it during the visit [doctor] okay okay yeah that would be great to see that because i wan na see what's going on so thank you for that tell me is there any family history of seizures or like tourette's syndrome [patient] well no history of seizures but i i i never heard of that tourette thing [doctor] yeah so so toret is that it's a nervous system disorder that you know involves like repetitive movements or like unwanted sounds and it typically begins in childhood and i do n't know have you noticed anything like that with her when she was younger [patient] really i had nobody in our family got anything like that [doctor] okay now tell me have you noticed any other symptoms how about like fever or chills [patient] no [doctor] okay coughing headache [patient] ma'am [doctor] okay how about any problems with karen's sleep [patient] nope [doctor] okay okay good let's go ahead and do physical exam on karen here alright karen i'm just gon na take a look at you and and ask you to follow some commands okay [patient] okay [doctor] alright can you follow my finger with your eyes good now can you do me a favor walk across the room for me great job okay now i want you to close your eyes and reach out your arms in front of you good now keep your eyes closed can you feel me touch you here how about okay how about there [patient] mm-hmm [doctor] does that feel the same [patient] yeah [doctor] okay alright so i'm just gon na check your reflexes okay alright now on your on the neurological exam the patient is awake alert and oriented times three speech is clear and fluent gait is steady heel toe walking is normal and the cranial nerves are intact without focal neurologic findings there is no pronator drift sensation is intact reflexes are two plus and symmetric at the biceps triceps knees and ankles so this means everything looks good karen [patient] that's great [doctor] good alright so i'm gon na go ahead and tell you what we're gon na do so i'm gon na tell you my assessment and plan here so dad so for the first problem i do believe that karen does have a tick eye tics are very common in children and as many as you know one in five children have a tick during their school years and tics can also include things like shoulder shrugging facial grimacing sniffling excessive throat clearing and uncontrolled vocalization i can say that essentially they're brief sudden and involuntary motor movements now we do n't have a full understanding of the cause of the tics but they typically occur around five to ten years of age but most ticks go away on their own and they disappear within a year so these are what we call transient tics and the best thing to do is ignore the tics so it does n't seem to be bothering karen and she seems to be doing well in school and activities so it may wax and wane over time but you might notice it more towards the end of the day when the child is tired so you may also you know see it if they're stressed so that's why it's important to just ignore it now when you draw attention to the tick it does make the child conscious so that can make the tic worse so we want to be careful again just to to kind of not to draw too much attention on it and do you have any questions for me [patient] so you mean you're telling me you do n't think he had a seizure or a bit or nothing [doctor] yeah i do n't think it's i do n't think so because it's it is the same part of her body that's moving every time that and she reports that it's somewhat of an there is an urge to blink her eye and some relief afterwards [patient] so you're not recommending any kind of treatment there is no pill or cream or nothing [doctor] not at this time because she seems to be doing well overall and the tic has n't impacted her school or her activities but if it worsens then we can consider some treatment okay [patient] alright alright sounds good [doctor] alright thank you you guys have a good day [patient] doctor [doctor] bye karen", "target": "ASSESSMENT AND PLAN\n\n1. Transient tics.\n - Medical Reasoning: The patient's father provided a video today as she did not have a twitch in office. It appears the patient is experiencing a tic.\n - Patient Education and Counseling: Nature of the diagnosis was discussed today with the patient and her father. I advised eye tics are very common in children and as many as 1 in 5 children have a tick during their school years. We discussed tics can also include things like shoulder shrugging, facial grimacing, sniffling, excessive throat clearing, and uncontrolled vocalization. I explained that essentially they are brief, sudden and involuntary motor movements and that we do not have a full understanding of the cause. We also discussed that they typically occur around 5 to 10 years of age and mostly resolve on their own within a year. Dad was advised that treatment is not recommended as they do not appear to be bothering Karen and she continues to do well in school and activities. Additionally, we discussed avoiding drawing attention to the tic as it may cause Karen to feel self-conscious and increase the severity of the tic.\n - Medical Treatment: None at this time.\n \n "} {"idx": 119, "inputs": "[doctor] hey betty how are you doing [patient] i'm doing okay i just been really frustrated because with my asthma and it just seems like i can never catch a break never get better i'm always it seems like i'm always coughing and wheezing [doctor] i'm sorry to hear that what normally triggers your asthma type symptoms [patient] i find that it's really really when i get sick if i get sick with a cold i almost always know that my asthma is going to flare i did notice one time though that when i went to my aunt's house i i had a flare afterwards and i think it's because of her cat so i try to avoid going there and i have n't really had an issue since [doctor] okay so now you mentioned that that happens somewhat a lot how frequently does this occur that you have these breathing type problems [patient] it seems like it happens really every month or every other month for the past six months i usually end up going to the urgent care a lot and get or my primary care doctor and so sometimes they'll give me antibiotics sometimes i'll get steroids one time it was so bad i actually ended up going to the emergency department [doctor] wow that that can be a little bit scary so you mentioned that your primary care provider or the urgent care provider gave you medications what medications are you using for your asthma right now [patient] i have two inhalers one but i really just use one of them it's a blue one that seems like the only inhaler that helps me the other one when i when i try to use it it does n't work [doctor] okay so do you think that's the albuterol inhaler is it do you remember the name like ventolin or [patient] yes yes that's the name of it [doctor] is that it okay alright and then how often do you feel like you need to use that [patient] i would say like almost everyday i feel like i'm using my inhaler because i'm always coughing and wheezing and a couple of times a night i'll wake up as a couple times a week i'll end up waking up needing to use my inhaler as well [doctor] okay and then when you use it at that time does it help [patient] it does [doctor] okay and how many walk me through how you use that you just wake up and you take one puff or is it two puffs [patient] yeah i take i usually take two puffs [doctor] okay but then you get enough relief that you can go back to sleep [patient] yeah for the most part [doctor] okay now have you ever needed to be hospitalized due to your asthma symptoms you mentioned you've had to go to the er [patient] yeah for only once i can think of when i was young i think like around eight years old i had to be hospitalized but nothing since then [doctor] okay i do wan na take a little bit of a a deeper dive here into your er and urgent care visits can you tell me a little bit more about those [patient] yeah i feel like i've had several i do n't remember the exact number but i've had several this past year they almost always have to start me on prednisone [doctor] okay like a prednisone taper pack that type of thing [patient] yeah yeah sometimes they'll just give me like like a like a large dose over five days [doctor] okay [patient] and then sometimes they make me take less and less and less so the over like nine or ten days [doctor] okay so both the dosepak and then also the high dose as well okay [patient] yeah [doctor] and then when was your last exacerbation [patient] probably about a month ago [doctor] okay so just out of curiosity you mentioned that you you have trouble when you go over to your aunt's house because of your cat now i see here that you really like to go outside and walk and do those type of things do you have any other type of issues whenever you you go outside any any seasonal allergies or anything like that [patient] no not really [doctor] okay so you do n't have any history of seasonal allergies which is good so it looks like here that you put down that you enjoyed hiking so you do n't have any trouble getting out and going hiking and and have you tried the new trails there behind behind the wreck center [patient] yeah i'm really excited to i mean i have to be careful because i you know with my coughing my wheezing but i'm really i'm looking forward to getting better so i can really start hiking again [doctor] okay now i really need you to be truthful when you answer these next questions this is important for taking a good history do you smoke any type of cigarette or tobacco product and have you ever smoked or do you smoke marijuana on a regular basis [patient] no i've never smoked and i do n't vape either or yeah i do n't smoke cigarettes or marijuana [doctor] okay and then you said you do n't vape so no vaping or e-cigarette use at all [patient] hmmm hmmm [doctor] okay and then are you routinely in an area where there is a lot of airborne particular like smoking in bars or around any type of of you know like race tracks or anything like that [patient] sometimes i go to the bars with some friends and yeah the smoking does irritate me [doctor] okay [patient] so i do n't try to go there often [doctor] okay thank you for sharing that with me so if it's okay with you i'd like to go ahead and do a quick physical exam [patient] okay [doctor] now i reviewed your vitals for today and your your blood pressure is good it's one twenty eight over eighty two your respiratory rate is sixteen and your oxygen saturation is ninety nine percent on room air which is a good thing i'm gon na take a listen to your heart here your heart is regular rate and rhythm and i do n't appreciate any ectopic beats or and i do n't hear anything like rubs murmurs or gallops which is good so i'm gon na go take and listen to your lungs here on your lung exam i do appreciate some diminished lung sounds throughout with the occasional slight expiratory wheeze and that's bilaterally so i hear that on both sides i'm gon na go do a quick neck exam here neck is supple trachea is midline i do n't appreciate any lymphadenopathy taking a listen here i do n't appreciate any carotid bruit now i'm also gon na take a look at your hands here i note strong bilateral pulses i do n't appreciate any clubbing on any of your fingertips which is which is important and i also note brisk capillary refill i'm gon na go ahead and review the results of your pulmonary function test that i had you do when you came into the office today and reviewing those results i do see that they are consistent with somebody who would be diagnosed with asthma so lem me go ahead and tell you a little bit about my assessment and plan so now for your first problem of asthma your symptoms are consistent with moderate to intermediate or i'm sorry moderate moderate intermittent asthma and it's gon na be really important for us to be consistent with your inhaled inhaled steroid inhaler so i'm gon na need you to take that as prescribed and that's really gon na help cut down on those daily symptoms and needing to use that rescue inhaler that albuterol inhaler as frequently so the more you take and more consistently you take your inhaled steroid inhaler the less you will use your albuterol now it's not a fast acting inhaler like your albuterol but what is important is as going to be what helps you long term now if you do have an acute exacerbation so if you're having an acute issue with your breathing i do want you to continue to use your albuterol inhaler one to two puffs and then i want you to wait and see how your breathing is before you would take an additional one to two puffs we hope you have less of those acute exacerbations as you continue to use your inhaled steroid i'm also going to put together an asthma action plan for you and that's gon na help us look at your symptoms see where your your pain points can be you know like those being having issues with with cats or dust that type of thing and we'll work on how to handle those symptoms through that asthma action plan so do you have any questions comments or concerns otherwise i will see you in thirty days [patient] alright thank you [doctor] you're welcome [doctor] so let me tell you a little bit about my assessment and plan for your first problem of asthma your symptoms are consistent with moderate intermittent asthma i'm gon na start you on flovent one hundred ten micrograms one puff twice per day that's gon na be important for you to be consistent with your inhaled steroid inhaler this is gon na help prevent those daily symptoms and from needing for you to use your albuterol inhaler or that rescue inhaler less frequently you can continue using your ventolin inhaler and that would be two puffs every four to six hours p.r.n . i'm also gon na put together an asthma action plan for you so we know what to do based on your symptoms i'd like to see you again in a month or sooner if you have any worsening symptoms does that sound okay [patient] it does thank you [doctor] you're welcome i'll see you in a month [patient] alright thanks", "target": "ASSESSMENT AND PLAN\n\n1. Moderate intermittent asthma.\n - Medical Reasoning: The patient's symptoms and results of her PFT are consistent with moderate intermittent asthma.\n - Patient Education and Counseling: I explained the importance of consistency with her daily inhaler as this will help prevent daily symptoms and the need to use the albuterol inhaler as frequently. My hope is that she has less acute exacerbations as she continues to use her inhaled steroid.\n - Medical Treatment: Prescribed provided for Flovent 110 mcg 1 puff twice per day. She can continue using her Ventolin inhaler 2 puffs every 4 to 6 hours as needed. I have recommended using her albuterol inhaler 1 to 2 puffs and then monitor her breathing prior to taking an additional 1 to 2 puffs. I am also going to put together an asthma action plan for her so we know what to do based on her symptoms.\n \n "} {"idx": 87, "inputs": "[doctor] hi richard how are you the medical assistant told me that you have a tick bite is that what happened [patient] i really do n't know where i got it but i i had i do get out in the woods and i do spend a lot of time out in the yard but yeah i've got a tick bite around my knee and and it's been it's been over a week and and just it just burns and just quite annoying [doctor] okay and have you had any fever or chills [patient] i have not at this point it just feels warm on that spot [doctor] okay alright and have you noticed any other joint pain like in your elbows or shoulders or anything like that that since this started [patient] nothing other than my typical arthritic pain [doctor] okay alright now you say that you like to go outside and and you're working in the yard now i i heard that you were a a hunter when was the last time you went hunting has hunting season started yet i do n't even know [patient] well i i did go hunting not long ago couple of weeks ago [doctor] okay did you did you [patient] windle season is open well it it's actually on a on a a got the right word for it but it it's where they train dogs and things like that [doctor] okay [patient] type thing [doctor] okay did you i did did did were you able to shoot anything did you bring anything home [patient] well actually i yeah i shut several i had some grandchildren with me so i let them have what they wanted [doctor] nice nice you know i i did hear i do n't know much about hunting but i did hear a hunting software joke the other day do you want to hear it [patient] sure [doctor] so what software do hunters use for designing and hunting their pray [patient] man i have no idea [doctor] the adobee illustrator get it [patient] do n't be [doctor] anyway i die grass let's just get back to our visit here so about your line or about your tick bite so do you notice that it's hard for you to move your knee at all [patient] not at this time no [doctor] no and do you have any problems walking [patient] no [doctor] no okay and have you ever had a tick bite before [patient] i have when i was younger i used to get a lot of them because i spent a lot of time out of the woods never get into anesthesia takes you can get several bites out of that but this was just one [doctor] okay alright and have you ever been diagnosed with what we call lyme disease before [patient] i have not [doctor] you have not [patient] i would n't know so i would n't know what symptoms are [doctor] okay [patient] what you just asked me i guess maybe [doctor] yeah so some of those symptoms like any flu like symptoms have you had like any body aches or chills or anything like that [patient] no just really just kind of a a headache just generally do n't feel well [doctor] generally do n't feel well okay and has that been since the tick bite [patient] it has [doctor] it has okay alright and any other symptoms like a cough or shortness of breath or dizziness or anything like that [patient] no [doctor] okay now since you are here let me just ask you a little bit about your high blood pressure did you buy the blood pressure cuff i asked you to have you been checking your blood pressure at home [patient] periodically yes [doctor] okay and do you think that they are running okay [patient] yeah blood pressure seems to be doing okay the lisinopril works well [doctor] good i was just gon na ask you if you were taking your lisinopril so that's good okay and any side effects from the lisinopril since we started it i think we started it about a year ago two years ago [patient] no no no side effects that i'm aware of [doctor] no side effects okay and then in terms of your diabetes are you watching your sugar intake [patient] yeah i usually watch it the form of high what i'm eating but [doctor] i am a big pie fan as well i know what's your favorite type of pie [patient] well you know it's favorite boy i just like pie you know apples cherry chocolate you know bicon [doctor] yeah [patient] i try to try to avoid the bicon because i think it's just all sugar but i do like it [doctor] okay [patient] less [doctor] i like it too alright are you taking the metformin twice a day [patient] not everyday but most of the time [doctor] okay alright and are you checking your blood sugars pretty regularly [patient] i try to [doctor] okay and do you do you know on average how they're running are they running below like one fifty or [patient] yeah it's definitely running below that [doctor] okay your blood sugars are running below [patient] it's it's probably with with with the metformin it seems to be you know one twenty [doctor] good [patient] pretty regular [doctor] good your blood sugars are running in the one twenties that's really good okay alright well i wan na just go ahead and do a quick physical exam okay so i'm looking here at your vital signs and your vital signs look really good i do think you're doing a good job with taking your lisinopril your blood pressure's about one twenty two over seventy right now which is right where we want it your heart rate is nice and slow at sixty seven again which is right where we want it and i do n't appreciate any fever today you you have a normal temperature at ninety eight . four which is really good so i'm just gon na be going ahead and calling out some physical exam findings and i'm gon na let you know what that means when i'm done okay so on your heart exam your heart is in a nice regular rate and rhythm i do n't appreciate any murmur rub or gallop on your lung exam your lungs are nice and clear to auscultation bilaterally on your right knee exam i do appreciate some erythema and edema as well as an area of fluctuance over your right patella now does it hurt when i press [patient] it's a little bit sore [doctor] okay there is pain to palpation of the right anterior knee and i'm just gon na bend your knee up and down does that hurt at all [patient] no no it's just more of the typical grinding that i would feel [doctor] okay there is full range of motion of the right knee and on skin examination there is evidence of a bull's-eye rash over the right knee okay so what does that mean richard so that means that you know you do have some area of some inflammation over the over the right knee where you where you have that tick bite and you do have what we call that bull's eye rash which is what we get concerned about with with lyme disease so let's just talk a little bit about you know my assessment and my plan for you okay so for this first problem of your of your tick bite my concern is that you might have lyme disease based on the presentation of your right knee so i'm gon na go ahead and start you on doxycycline one hundred milligrams twice a day [patient] we're gon na continue that for about three weeks i'm also gon na go ahead and send a lyme titer as well as a western blot to see if you do in fact have lyme lyme disease and we'll have to go ahead and just see how you do with this we you know i'd like to avoid intravenous antibiotics which i think we can avoid but i wanted to see how you do so [doctor] do you have any questions about that [patient] yeah i did n't know what those last two things or just [doctor] yeah so so we are gon na start you on some antibiotics to help help you with this [patient] you know possible lyme disease and i'm gon na just order some blood tests just to see exactly what's going on and then you know sometimes people need intravenous antibiotics because lyme disease can cause problems on other organs like your heart that type of thing [doctor] if not treated appropriately and sometimes we need to give antibiotics through the iv which i'd like to avoid i think that we got this early enough that we can just treat you with some oral antibiotics okay for your second problem of your hypertension you know i think you're doing a really good job let's go ahead and continue you on the lisinopril twenty milligrams once a day and i wan na just go ahead and order a lipid panel just to make sure that everything is okay with your cholesterol how does that sound [patient] that's fine [doctor] great and then for your third problem of your diabetes i wan na just go ahead and order a hemoglobin a1c and continue you on the metformin one thousand milligrams twice a day it sounds like you're doing a good job since your blood sugars are running in the one twenties i do n't think we need to make any adjustments but we'll see what the hemoglobin a1c shows that gives us a an idea of what your blood sugars are doing on a long-term basis how does that sound [patient] okay at what point time do you start kinda checking kidney function i've been told that metformin can possibly cause some kidney issues [doctor] so it can you know your kidney function we've you know i think you've been really lucky it's been normal i checked it about two months ago and it looks pretty good it looks pretty normal but since we're doing blood work on you i can go ahead and order a a basic metabolic panel just to make sure that your kidney function is stable [patient] okay that'd be good [doctor] okay anything else [patient] not that i can think of at this time as soon as i leave [doctor] well you know where to find me okay [patient] alright [doctor] take care bye", "target": "ASSESSMENT AND PLAN\n\n1. Tick bite.\n - Medical Reasoning: My concern is that he might have Lyme disease based on the presentation of his right knee.\n - Patient Education and Counseling: The patient and I discussed blood testing to determine if he does in fact have Lyme disease. I explained that Lyme disease can cause problems with other organs if not treated appropriately. We discussed that sometimes antibiotics need to be administered intravenously if oral antibiotics are not given early enough. We will see how he does with a course of oral antibiotics as I would like to avoid intravenous antibiotics.\n - Medical Treatment: Prescription for doxycycline 100 mg twice a day for 3 weeks provided. Lyme titer and Western blot will be obtained to determine if he has Lyme disease.\n \n 2. Hypertension.\n - Medical Reasoning: This is well-controlled at this time.\n - Patient Education and Counseling: The patient and I discussed that he is doing really well monitoring his blood pressure at home.\n - Medical Treatment: Continue lisinopril 20 mg once a day. Lipid panel ordered to assess his cholesterol levels.\n \n 3. Diabetes type 2.\n - Medical Reasoning: He is doing a good job managing his diabetes since his blood sugars are running in the 120s. I do not think we need to make any adjustments, but we will see what the hemoglobin A1c shows as that gives us an idea of what his blood sugars are doing on a long-term basis.\n - Patient Education and Counseling: We discussed that metformin can affect kidney function; however, his kidney function was last checked 2 months ago, and it has remained within normal limits.\n - Medical Treatment: Continue metformin 1000 mg twice a day. Hemoglobin A1c ordered. Basic metabolic panel ordered to assess kidney function. \n \n "} {"idx": 58, "inputs": "[doctor] russell ramirez is a 45 -year-old male with past medical history significant for cad status post prior status post prior rca stent in twenty eighteen hypertension and diabetes mellitus who presents for hospital follow-up after an anterior stemi now status post drug-eluting stent and lad and newly reduced ejection fraction ejection fraction thirty five percent and moderate mitral regurgitation alright russell hi how are you doing today [patient] hey document i i do n't know i'm doing alright i guess [doctor] just alright how's it [patient] well [doctor] how's it been since you've had your heart attack have you been have you been doing alright [patient] no i've been seeing you for years since i had my last heart attack in two thousand eighteen but i've been doing pretty good i ca n't believe this happened again i mean i'm doing okay i guess i just feel tired every now and then and but overall i mean i guess i feel pretty well [doctor] okay good were you able to enjoy the spring weather [patient] yeah some i mean i'm hoping now that i've had my little procedure that i'll feel better and feel like getting back out and and maybe doing some walking there is some new trails here behind the rex center and maybe get out and walk those trails [doctor] that will be fine i know you love walking the trails i know you like looking at the flowers because i think you you plant a lot of flowers as well do n't you especially around this time [patient] yeah i do some gardening around the house [doctor] yeah [patient] and you know i really like photography too being able to go out and take nature pictures [doctor] yeah [patient] so i'm hoping to be able to go out and do that [doctor] okay well we'll we'll do what we can here to get you out and going doing all those fun activities again now tell me have you had any chest pain or any shortness of breath [patient] no not really no chest pain or shortness of breath i've been doing some short walks right around the house so like around the block [doctor] okay [patient] but i stay pretty close to the house i've been doing some light housekeeping and i do n't know i seem to be doing okay i think [doctor] okay alright now tell me are you able to lay flat at night when you sleep or [patient] well i mean i i never have truly laid flat on my back i've always slept with two pillows which is normal for me [doctor] okay [patient] so i mean i guess i really do n't have any troubles with my sleeping [doctor] okay good how about are your legs swelling up [patient] nope i've always i always had skinny ankles like like i got dawn knots legs [doctor] well that's cute were you able to afford your medications and are you taking them as prescribed [patient] yeah i've been taking my medicine i got pretty good insurance there through the plant and and so the co-pay is n't too bad [doctor] okay [patient] and i've been taking them because i do n't want my sense to close up and they told me that that to take them this you know all the time and and i've been taking them since i got out of the hospital [doctor] okay well very good i'm glad you're doing that good for you russell and and then please keep that up now tell me are you watching your salt intake and trying to change your diet [patient] yeah so when i was in the hospital they said something about my way my heart pumps now [doctor] mm-hmm [patient] it it's it's a little low and i might keep fluid on my legs if i'm not careful [doctor] right [patient] and it's gon na be hard because you know i i really do like pizza and and they told me that i'm really gon na have to watch salt and they said that there is a lot of salt and pizza [doctor] there is a lot of salt and pizza and you know and you're gon na have to be able to avoid all the other salty foods as well so and i know that's hard but it's very important for your heart to be able to function at it's best right and you wan na be able to get out and walk you know walk take those walks again at the park and then you know do your photography so in order to do that we're gon na have to really cut back on those okay [patient] well [doctor] alright so why do n't we go ahead and do a quick physical exam on you here i just want to take a look at you your vital signs look good i'm glad to see you're tolerating the medication well i'm gon na go ahead and feel your neck here i do n't appreciate any jugular venous distention and there are no carotid bruits on your heart exam there is a three out of six six systolic ejection murmur it's heard at the left base but that's pretty much the same as last year so we'll continue to monitor that okay let me listen to your lungs here real quick russell your lungs are clear so good good and your extremities i do n't see any swelling or edema on your right radial artery the cath site there is clean and it's dry and intact and i do n't see any hematoma so that's good and there is a palpable rra pulse so russell i did review the results of your ekg which showed normal sinus rhythm good r wave progression and evolutionary changes which are anticipated so let's go ahead and talk about my assessment plan for you for your first diagnosis of coronary artery disease we are gon na have you continue your your aspirin eighty one milligrams daily and brilinta ninety milligrams twice daily and we're gon na have you continue on that high dose statin that atorvastatin you might call it lipitor eighty milligrams daily and then also continue on that toprol fifty milligrams daily okay and i'm also going to refer you to cardiac rehab so for you to get some education about your heart and also give you the confidence to get back exercising regularly now i know patients love the cardiac rehab program i think you will do well does that sound good to you [patient] that sounds good document [doctor] alright so for your second diagnosis here the newly reduced left ventricular dysfunction and moderate mitral regurgitation i think your pumping function will improve in time you know they got you to the lab quickly so i think that heart muscle is just stunned and you're very compliant you're very good with your medications and following through with those so i think it will recover so that said i want you to go ahead and continue continue your lisinopril twenty milligrams a day i do n't think you need a diuretic at this time but i do want to add aldactone twelve . five milligrams daily and then you'll need to get labs next week okay and then we're gon na repeat another echocardiogram echocardiocardiogram in about two months [patient] okay [doctor] okay and then for your hypertension your third diagnosis of hypertension i want your to take your blood pressure just like you would you know every so often and then because your blood pressures actually seem fine at this time so we will continue to monitor that and i think you will tolerate the aldactone well as well [patient] alright sounds good document [doctor] okay well you take care and you have a good evening [patient] yeah you too [doctor] bye", "target": "ASSESSMENT AND PLAN\n\n1. Coronary artery disease.\n - Medical Reasoning: The patient's exam is consistent with coronary artery disease.\n - Patient Education and Counseling: We discussed that he should continue to watch his diet and salt intake. We also discussed that the cardiac rehab should help with his confidence with exercising regularly and for his education.\n - Medical Treatment: Continue taking aspirin 81 mg daily Continue taking Brilinta 90 mg twice a day. Continue taking Lipitor 80 mg daily. Continue taking Toprol 50 mg daily. I will refer him to cardiac rehab.\n \n 2. Newly reduced left ventricular dysfunction and moderate mitral regurgitation.\n - Medical Reasoning: The patient's physical exam is consistent with this diagnosis.\n - Patient Education and Counseling: We discussed that his pumping function should improve in time. We also discussed that since he is compliant with his medications and presented to the cardiac cath lab quickly, he should recover. I advised the patient that he does not need to start a diuretic at this time.\n - Medical Treatment: Continue taking lisinopril 20 mg a day. Prescription for Aldactone 12.5 mg daily provided. Order for labs provided. Repeat echocardiogram ordered to be completed in 2 months.\n \n 3. Hypertension.\n - Medical Reasoning: This seems stable at this time.\n - Medical Treatment: Continue home blood pressure monitoring.\n \n "} {"idx": 49, "inputs": "[doctor] hey linda good to see you today so looking here in my notes looks like you you think you have a kidney stone think you've had them before and and you i guess you're having some pain and while we are here i see you i see you have a you have past medical history of hypertension diabetes and we will check up on those as well so with your kidney stone can you tell me what happened what's going on [patient] and i've been in a lot of pain it started about i would say probably about three days ago [doctor] okay [patient] started having pain on my left back [doctor] okay [patient] and since then i continued to have pain it is traveling a little lower it's gotten little low but i definitely have not passed it yet and i'm just in so much pain [doctor] okay so is the pain that you're having is it constant or does it come and go [patient] it's constant [doctor] okay [patient] all the time i ca n't get comfortable [doctor] alright are you able to urinate [patient] i am and this morning i actually started seeing some blood [doctor] okay yeah so and i know you said i see you've had some kidney stones in the past like how many times would you say you've had one of these episodes [patient] i've had it for probably this might be my third time [doctor] third time alright [patient] yeah i have n't had one in a while but yeah this is my third time [doctor] okay so have you noticed any nausea chills fever [patient] no fever some chills and i i just in so much pain i i ca n't eat and i do feel a little nauseous [doctor] okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain [patient] yeah i've been taking tylenol i have had to try some ibuprofen i know you said to be careful with my blood pressure but i have been trying to do that because i'm just in so much pain and it's not really working [doctor] okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved [patient] yeah usually usually about about three four days to pass it yeah [doctor] right so this is this is the looks like this is the third day [patient] yeah [doctor] so we are getting close there [patient] okay [doctor] yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today your blood pressure was a was a little bit high and i know that's probably because you are in a bunch of pain so that definitely makes sense but i think last time we talked a little bit about you getting a blood pressure cuff and taking your blood pressures regularly so those readings first off were you able to get the blood pressure cuff [patient] i was i have n't been great about taking it but i did get the blood pressure cuff [doctor] so the time that you did take it and i think that's something we got to work on is you've taken them i think at least three times a week i would like you to what have those been running [patient] like the top numbers they're usually the one thirties sometimes i get i do go into one forties and once it went to like one fifty [doctor] okay [patient] and then the bottom number has been between seventy and eighty okay that i mean that's not too bad i think when you were first diagnosed you were up there in the [doctor] the one eighties which was really high [patient] right [doctor] so let me talk a little bit also about you trying to lower your salt intake to like like twenty three hundred milligrams a a day so have you been able to do that [patient] trying my best but doc i really like my french fries [doctor] yeah [patient] like [doctor] we we all like we all like the french fries you know but you know we we we we also do n't like strokes so we do n't want to have a scope and all the all the french fries so that's something definitely i would like you to work on and do you think you'd be able to to curb that french fry habit or that bad this bad food habits by yourself or do you think you need help [patient] yeah some help could be helpful okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright [doctor] so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday [patient] i have and those those have been pretty good they are like in the low one hundreds [doctor] okay that that that's definitely good because when you came in i think we did a glucose test on you couple of months ago and you were around three hundred which is which is pretty up there so i'm glad that you know those levels are down and have you been taking that metformin everyday [patient] i do [doctor] okay [patient] i do take it [doctor] that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain [patient] no chest pain [doctor] no chest pain are you having any belly pain [patient] the back pain is starting to kind of go down into my groin but i would n't say any back pain i mean abdominal pain [doctor] no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt [patient] yes [doctor] okay i'm gon na press here on your back is that painful [patient] yes [doctor] alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tinnitus on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflammation around your kidney that's what that that's that tenderness around your cva is is telling me so let's go talk a little bit about my assessment and plan for you so you know right now because of your history of of having kidney stones you you do have a kidney stone so what we're gon na do is first off i'm gon na get you some pain medication kinda you're in a ton of pain right now i'm gon na prescribe you some oxycodone five milligrams you can take that every six to eight hours as needed for pain and so hopefully that can help you feeling better and you can continue to take that tylenol for any breakthrough pain that you're having i do wan na make sure that you're pushing fluids right now because we need to try to push that stone out that you're having just kinda clear your kidneys and that that would definitely help i also want to give you a strainer so you can strain your urine to see if you do actually pass that stone and then i'm going to refer you to urology and we're actually i'm gon na have you you even if you pass a stone in the next couple of days i want you to go anyway because it seems like you're having recurrent kidney stones and so hopefully they can help do something to to help this from happening in the future for your hypertension i'm gon na keep you on that two . five norvasc your your blood pressures look good so i'm not gon na make any changes there and then for your diabetes we'll keep you on the five hundred of metformin and i also want to give you a referral to nutrition to a dietitian and they will be able to help you with your your diet i know you said you have a few issues so you know they can possibly write a diet for you and if you follow it you know hopefully in the future we can get you off of both of these medications and get you back to normal so how does that all sound [patient] that sounds good and i i just i just want this pain to go away so thank you [doctor] okay no problem", "target": "ASSESSMENT AND PLAN\n\n1. Kidney stone.\n - Medical Reasoning: Patient presents today with symptoms consistent with kidney stones. She does have a history of kidney stones with this being her third episode.\n - Patient Education and Counseling: We discussed the importance of pushing fluids to help facilitate passing the kidney stone.\n - Medical Treatment: Prescription for oxycodone 5 mg every 6 to 8 hours as needed for pain was provided today. Tylenol is recommended for breakthrough pain. She will push fluids and has been provided with a urine strainer. Referral to urology was also provided due to her recurrent episodes.\n \n 2. Hypertension.\n - Medical Reasoning: Patient is currently stable and has not had any elevated readings. Her blood pressure was slightly elevated today, however, this is due to her current pain level.\n - Patient Education and Counseling: We discussed the importance of home blood pressure monitoring with the goal of at least 3 times per week. She was also advised on the importance of diet modification with limiting salt to 2300 mg daily.\n - Medical Treatment: Continue Norvasc 2.5 mg. Continue with home blood pressure monitoring 3 times per week. Limit salt intake to 2300 mg daily.\n \n 3. Diabetes.\n - Medical Reasoning: Patient is currently stable and has not had any elevated glucose readings.\n - Patient Education and Counseling: We discussed the importance of diet modification.\n - Medical treatment: Continue metformin 500 mg daily. Continue with home glucose monitoring before meals. Referral to a dietitian was provided.\n \n "} {"idx": 38, "inputs": "[patient] hey bruce so see here my my notes here is you here he had positive lab work for hep c so how're you doing today [doctor] i'm doing okay but i'm a little bit anxious about having hep c i've really surprised because i've been feeling fine they had done it as you know a screen as just part of my physical so i'm really surprised that that came back positive [patient] okay so in the past have any doctors ever told you that you had hep c [doctor] no never that's why i'm i'm so surprised [patient] okay so just you know i need to ask do you have a history of iv drug use or you know have known any hep c partners [doctor] i mean i used to party a lot and even did use iv drugs but i have been clean for over fifteen years now [patient] okay that that's good i mean i'm i'm happy that you were able to to kick that habit i know a lot of my patients that i see you know they're still dealing with with those dements so i'm i'm i'm happy that you're able to do that so hopefully we can get you better okay [doctor] thank you [patient] so what about alcohol use is that something that you used to do a lot [doctor] i did i did i mean i i still have a beer here and there everyday but not as much as i used to [patient] okay and have you ever smoked before [doctor] i do smoke i smoke about one to two cigarettes per day i've cut down a lot but i'm just having a hard time kicking those less too [patient] yeah yeah and that that's something i've got to work on too because hep c along with smoking you know both of those are n't are n't good so hopefully we can help you out you know if your pcp has n't prescribe something for you already and possibly we can we can do that for you as well [doctor] okay [patient] so do you have any other medical conditions [doctor] no i'm actually other than that i just had my physical and i'm not taking any medications no i'm i'm pretty good otherwise [patient] okay and what conditions would you say run in your family [doctor] i have high blood pressure diabetes and depression [patient] okay [doctor] alright so let me go ahead and do a quick physical exam on you so i reviewed your vitals and everything looks good and on general appearance you appear to be in no distress no jaundice on the skin on your heart exam you have a nice regular rhythm rate [patient] regular rate and rhythm with a grade two out of six systolic ejection murmur is appreciated on your lung exam your lungs are clear without wheezes rales or rhonchi on your abdominal exam bowel sounds are present your abdomen is soft with no hepatosplenomegaly [doctor] hepatosplenomegaly yes let me i will change that one [patient] splenomegaly and on your muscle exam there is no gait disturbance or edema so i did we i was able to review your your results of your recent lab work and your hcv antibody test was positive so your your liver panel we did one of those and it showed an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so that's pretty good so let's talk a little bit about my assessment and plan for you so you do have hepatitis c so your initial labs were consistent with that hep c diagnosis and so you know i do n't know if you read much about hep c but hepatitis c is a viral infection that does affect your liver and you've most likely had it for several years now it it it most patients do n't see symptoms until years later so the next step that i would like to do is just confirm the diagnosis with some additional blood work so that includes checking your hep c rna and your hcv genotype and i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and we will do that by ordering an ultrasound elasto elastography with this information we will we we will be able to know how we can proceed as far as treatment right so how does that sound [doctor] i hmmm so i do have a wife and kids so should i be worried about them [patient] okay yeah so we can start with the same screening that you had for august first so we'll just let's do that hep c antibody test and i'll actually help you set up those appointments with your your family doctor and then we can just see you back in three weeks and based on the results you know we will take action as needed okay [doctor] okay that sounds good [patient] alright [doctor] alright [patient] my nurse will be in with those those orders [doctor] alright thank you [patient] alright thanks [doctor] bye", "target": "ASSESSMENT\n\nHepatitis C.\n\nPLAN\n\nAfter reviewing the patient's laboratory findings today, I have had a lengthy discussion with him in regard to his current symptoms. His initial labs were consistent with a hepatitis C diagnosis. I have recommended that we confirm the diagnosis with additional blood work including checking his hepatitis C RNA and HCV genotype. I have also recommended that we obtain an ultrasound elastography to evaluate for fibrosis of the liver.\n \n The patient is married with children and is concerned about their hepatitis C status. I advised the patient that his family should be screened and we will assist him with setting appointments with their primary care physician."} {"idx": 48, "inputs": "[doctor] alright brittany so i see that you are experiencing some right foot pain could you tell me what happened [patient] yeah well i was playing tennis and i was trying to you know volley the ball [doctor] mm-hmm [patient] it was like a double game and i was trying to volley the ball and i got in front of another player and actually ended up falling on top of my foot [doctor] alright [patient] and then yeah it kinda hurt i quickly then twisted my myself around her because i was trying to catch myself but then i started to feel some pain in my foot [doctor] mm-hmm okay have you ever injured that foot before [patient] yeah no sorry i injured my other foot before not this foot [doctor] okay so right now you're experiencing right leg pain but you have injured your your left leg before is that what i'm hearing [patient] yeah that's fine [doctor] alright were you able to continue playing [patient] no i had to stop i actually it was like i had to be held from the field because i could n't put weight on my foot [doctor] i'm sorry okay so what have you been doing for the pain since then [patient] i wrapped it after a the game they had some ace wraps in their clubhouse and so i wrapped it up and then i iced it last night and i just kept it up on a pillow and then i took some ibuprofen [doctor] okay could you one more time when did this injury happen [patient] this happened about couple days ago [doctor] okay so did you say whether does the ibuprofen help at all [patient] yeah it helps a little bit but then you know it it you know after a while it wears out [doctor] okay and then have you experienced any numb numbness or tingling [patient] no no numbness [doctor] okay alright any loss in sensation [patient] no i mean i i can still feel like i can still feel my foot [doctor] okay alright that's good to hear so you were playing tennis is that what you normally do to work out [patient] i do i'm trying to learn but i can not afford tennis less lessons so me and my friends just hit the balls back and forth i do sleep [doctor] i love it absolutely yeah my dad one time took me to play racquet ball and i learned the very bruisy way that that was n't for me yeah [patient] that scares me [doctor] it's it they they move pretty fast i'm not gon na lie alright so if you do n't mind i'm gon na go ahead and do my my physical exam i'm gon na be calling out some of my findings but if you have any questions go ahead stop me let me know but i will be explaining along the way okay [patient] okay [doctor] alright so i've looked at your vitals and honestly they look great you know your blood pressure i see is one twenty five over seventy that's almost textbook respiratory rate we are seeing you at a smooth eighteen excuse me your temperature you're running normal ninety seven . one you're you're satting at a hundred percent so and then your pulse so that's interesting like you're you're going at like about sixty beats a minute so i think they're i think we're doing pretty well i'm gon na go ahead and listen to your heart on your heart exam i do n't appreciate any like murmur rub or gallop we have a nice regular rate and rhythm for your lung exam i do appreciate a little bit of stridor that's really interesting but i do n't hear any wheezes or rales so that's great for your i know this sounds weird but for your abdominal exam i do n't appreciate any rebound no guarding on your skin exam i do n't sorry like on your your head everything looks symmetrical your your mucosal membranes are normal you do n't feel hot to touch so that's great but i'm gon na do my foot exam okay so on the right foot there is some bruising of the plantar and dorsal aspects of the foot there is associated swelling when i touch on your midfoot here does it hurt [patient] no uh uh [doctor] okay alright tenderness to palpation of the midfoot and positive piano key test of the first and second metatarsals alright it's also warm to touch alright so on your neurovascular exam of your right foot your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch your left foot exam is normal capillary refill is appropriate pedal pulses are strong and sensation is intact so i know that before here we before i came in that we got an x-ray so i've reviewed the results of your x-ray of your right foot and it showed subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space alright i know those were a bunch of fancy words so now i'm gon na explain to you what that all means for my impression and plan your first problem is right foot pain consistent with a lisfranc fracture which is a fracture to one of your second metatarsal bones near the top of your foot right so the big part of your toe is the first metatarsal the second part where you can kinda like bend it right that's the that's the metatarsal that we're talking about based on your exam and what i'm seeing on your x-ray i am gon na recommend surgery for your foot the surgery will help place the bones in their proper positions using plates and screws to help prevent further complications there are also many ligaments at the top of your foot so i will be ordering an mri to further assess the fracture and any injury to the ligaments i know this is a lot do you have any questions [patient] yeah do i have to do the surgery [doctor] so i'm recommending it as there can be significant complications to your foot if you do n't it can lead to poor bone alignment or poor ligament healing which can lead to you losing the arch of your foot and becoming flat-footed you can also develop arthritis in that foot so yes i i i highly recommend it if you want to be able to walk and move about in a way that you are familiar with [patient] i just hate that word surgery doc [doctor] i know [patient] you know it scares me every time i mean especially with my foot i want to be able to walk again and so i just get really worried i mean how long is the procedure usually too [doctor] so it's actually [patient] have to be in the hospital [doctor] no no no no no it's actually a day surgery and you'll be able to go home the same day and then you will follow up with me here in the clinic in about a week you'll be in a cast and you will use crutches as you will not be able to use that foot for six to eight weeks after that you'll start gradually walking on your foot based on how you do so the procedure itself is not very long you will and so like since you will be able to go home that's great but you wo n't be able to drive especially since you're saying are you left handed or right handed [patient] i'm right handed [doctor] yeah so your your right foot is probably your dominant one and the also the one you're supposed to drive with so no you're gon na you're gon na need somebody to take you home but what [patient] i mean [doctor] uh uh [patient] does that mean i'm out for the rest of the season i mean i wan na be able to get back and play again i really am i'm getting a little better so i [doctor] mm-hmm [patient] i really wan na keep on playing my tennis with my friends but [doctor] yeah so unfortunately yes it does mean that you're out for the rest of the season but hopefully we can get you a great get you to a set up well for next season and in the meantime i think i'm gon na recommend after surgery that we get you to physical therapy i think that that's gon na be a really great way to like kinda strengthen the muscles and make sure that you're at peak performance before we put you back out there [patient] i suppose so [doctor] yeah [patient] okay [doctor] alright [patient] thank you [doctor] no problem so i do wan na let you know that there are some risks associated with any kind of surgical procedure i'm gon na bring you some paperwork and that my ma is gon na go over with you such as like risks of bleeding loss of sensation nerve damage all those things will be discussed with you and if you have any questions leading up to and even after your procedure go ahead and ask them and we'll be more than happy to help with that okay [patient] okay [doctor] alright [patient] good [doctor] thank you [patient] thank you", "target": "ASSESSMENT\n\nRight foot pain, consistent with a Lisfranc fracture.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have explained to her that her x-rays revealed a Lisfranc fracture. We discussed treatment options for this and I have recommended that we proceed with surgical intervention. The plan is to proceed with a right foot ORIF and all indicated procedures. We went over the risk, benefits, and alternatives of the surgery. The risk include but not limited to continued pain, swelling, damage to surrounding tissue including nerves and blood vessels, numbness that could be permanent, infection, nonunion, malunion, failure of hardware, and need for further surgery. There is always a risk of amputation, heart attack, stroke, blood clots, pulmonary embolism, and death. There is a possibility of chronic pain and the inability to get back to the previous level of function. The patient wishes to proceed with the operation and she will follow up with me on the day of surgery. In the meantime, I have recommended that the patient attend formal physical therapy to strengthen her right foot.\n \""} {"idx": 123, "inputs": "[doctor] so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened [patient] hey doctor michael yeah so my son sean i think you met in the past he he started playing basketball and there we do multiple seasons and so we're kinda getting ready for the next season that starts in in april and we were at the courts plan and i went up for a shot and he's far more aggressive than with me than he is with you know his peers i guess he could say and so he he found me while i was going for a lap and then when i came down i kind of landed awkwardly and i kind of like rolled and twisted my my ankle so now it's it's hurting a bit like kind of on the outside you can you can even see it's it's bruised up and a bit swollen [doctor] yeah [patient] and yeah i've been having trouble walking and it just does n't feel solid really stable which is a problem i i recently got back into working out and i had been in a really good rhythm going to the gym [doctor] okay [patient] and i do n't want to disrupt that moments on because it took a lot for me to get back to a good place so [doctor] absolutely okay totally understand that glad to hear that you're back out on the court playing with your son how is he doing by the way [patient] he is doing great he is doing great i mean you know he is a big step kurry fan so he likes to keep up shots from from way out past the three point line and he is only ten and tiny so it's it's not a good idea for him to do that but he is doing really well and i'm just happy he's tried every sport and basketball's really what took so i'm just really happy that he has a sport and loves and couple of his buddies playing to lead with him so it's just makes me happy that he's found something he really enjoys [doctor] good good to hear alright well let's take a look at that ankle it looks like it's pretty swollen so let me just do a quick exam on that right now alright so looks like the outside of your ankle if i push on that does that hurt pretty bad [patient] yeah yes [doctor] okay so exquisite tenderness tenderness laterally and then if i push here does that hurt too [patient] yeah a little bit [doctor] okay so some tenderness over the medial deltoid region so swelling on the lateral side of the ankle no epidermolysis skin is intact looks like you have brisk capillary refill no horrible malalignment so alright can you can you stand on it did you say that you're having trouble walking at all [patient] yeah i mean i can stand on it and i ca n't walk on it it just it hurts and it feels like i'm going to possibly injure it more just because it does n't feel particularly solid [doctor] sure so it does n't quite feel stable [patient] yeah [doctor] okay okay i gotcha so i know you had an x-ray as you came in today and so i'm just looking at this x-ray here i'll show you on the screen right here i can turn my monitor towards you this is an ap lateral oblique and this is your right ankle so what we're looking at is a displaced lateral malleolus at the weber c level there's no evidence of medial or posterior malleolar fractures but this is a fracture on the lateral side of your ankle now based on the position it's a bit unstable that's why you're feeling some of that that instability when you're walking so for your diagnosis what i'm gon na put down is a lateral malleolar fracture and what i would recommend for that since it is in the location that it is is you're probably unfortunately gon na need surgery we're gon na wan na get that healed what that includes is putting some plate and some screws in and you're gon na be out for a little bit so i know you've been trying to work out and and you wan na get back on the court but but you may have to have to sit out for a little bit we'll get you some crutches [patient] how long it's a little bit because i'm also i i forgot to say i'm also i did volunteer to coach [doctor] great [patient] starting in april so [doctor] alright well [patient] how long [doctor] yeah you you're probably gon na be out for about three months but continue the coaching go ahead and and let's get you back out there we'll get you some crutches and and hopefully you can kinda you know get back on the court start coaching and then within that three months we'll we'll get you back out doing some exercise again [patient] okay [doctor] alright in the meantime i'm gon na prescribe some medication for now let's try meloxicam and try to get some of the swelling down i want you to ice it and also keep that that ankle elevated do you have a job where you can elevate your ankle regularly [patient] yeah i i work from home so that that should n't be a problem it's just everything else i do n't know who is gon na walk my dogs and and do all this stuff that's rest of my family refuses to walk my dog so we'll figure it out [doctor] yeah i i'm a dog walker as well so alright sorry for the bad news but let's get you healed up so that we can get you back out doing everything you need to do [patient] alright thank you doctor [doctor] alright thanks", "target": "ASSESSMENT\n\nRight lateral malleolar fracture.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding treatment options. Recommendation was made for an open reduction internal fixation of the right ankle. We discussed the risks and benefits of the procedure as well as the postoperative recovery period following surgery. I advised that it will be 3 months before he can resume his exercise routine. In the meantime, I will prescribe meloxicam to reduce swelling. I recommended he ice and elevate the ankle as well. He will be given crutches to assist with ambulation.\n \n The patient understands and agrees with the recommended medical treatment plan.\""} {"idx": 14, "inputs": "[doctor] hi , louis . how are you ? [patient] hi . good to see you . [doctor] it's good to see you as well . are you ready to get started ? [patient] yes , i am . [doctor] louis is a 58-year-old male here for follow up from an emergency room visit . so , louis , what happened ? [patient] yeah . i was playing tennis on saturday . it was really , really hot that day , very humid . and about after about a half an hour i was very short of breath , i was struggling breathing . i thought i was having a heart attack , got really nervous . so , my wife took me to the er and , uh , everything checked out , but i was just very upset about it . [doctor] okay . all right . and how have you been feeling since that time ? [patient] uh , foof , probably , probably about six hours after we got home , i felt very light-head and very dizzy and then , sunday , i felt fine . i just thought it was worth checking up with you though . [doctor] okay . and have you been taking all of your meds for your heart failure ? [patient] i have . i have . i've been , uh , very diligent with it . and , uh , i'm in touch with the doctor and so far , so good , other than this episode on saturday . [doctor] okay . and , and you're watching your diet , you're avoiding salt . have you had anything salty ? [patient] i cheat every now and then . you know , i try and stay away from the junk food and the salty foods . but , for the most part , i've been doing a good job of that . [doctor] okay . all right . um , and i know that they removed a cataract from your eye- [patient] mm-hmm . [doctor] . a couple of , like couple months ago . that's been fine ? [patient] that was three months ago , thursday , and everything's been fine ever since . [doctor] okay . so , no vision problems . [patient] no . [doctor] okay . and you had a skin cancer removed about five months ago as well . you've had a lot going on . [patient] yeah . it's been a really busy year . an- and again , so far , so good . that healed up nicely , no problems ever since . [doctor] okay . all right . um , so , why do n't we go ahead and we'll do a quick physical- [patient] mm-hmm . [doctor] . exam . hey , dragon , show me the blood pressure . so , here , your blood pressure is a little high . [patient] mm-hmm . [doctor] um , so , you know , i did see a report in the emergency room that your blood pressure was high there as well . [patient] mm-hmm . [doctor] so , we'll have to just kind of talk about that . uh , but let's go ahead and we'll examine you . [patient] sure . [doctor] okay ? [patient] mm-hmm . [doctor] okay . so , you know , looking at you , your neck is very supple . i do n't appreciate any fibular venous distention . your heart is a regular rate and rhythm , no murmur . your lungs have some fine crackles in them , bilaterally . and you have trace lower extremity edema in both legs . so , what that means , essentially , is that you may have some extra fluid on board , um , from eating salty foods- [patient] mm-hmm . [doctor] . along with this history of your congestive heart failure . but , let's go ahead and look at some of your results . hey , dragon , show me the ecg . so , this is , uh , a s- a stable ecg for you . this basically shows that you have some left ventricular hypertrophy which caused your congestive heart failure . um , let's go ahead and review your echocardiogram . hey , dragon , show me the echocardiogram . so , in reviewing the results of your echocardiogram , it shows that your pumping function of your heart is a little low , uh , but it's stable . and , you know , i think that we know this and we have you on the appropriate- [patient] mm-hmm . [doctor] medication therapy . and then , i just wan na be reminded about , um , the results of your skin biopsy . hey , dragon , show me the skin biopsy results . okay . and in reviewing the pathology report for your skin cancer- [patient] mm-hmm . [doctor] . you know , it looks like they got all of that and everything's fine . [patient] yep . [doctor] so , you know , my impression of you at this time , for the shortness of breath that you had in the emergency department , i think it was an exacerbation of your heart failure . and you probably had some , what we call , dietary indiscretion , you ate some salty food which made you retain some fluid . [patient] mm-hmm . [doctor] so , for that , i'm going to prescribe you , you know , an extra dose of lasix 80 milligrams , once a day . and , um , we're going to , uh , put you on some carvedilol 25 milligrams , twice a day . okay ? [patient] okay . perfect . [doctor] um , and i think from a , a cataract surgery standpoint and your skin cancer removal , everything seems to be fine and you're doing well , so i do n't think we need to adjust any of those medications . [patient] good to hear . [doctor] okay ? hey , dragon , order lasix 80 milligrams , once a day . hey , dragon , order carvedilol 25 milligrams , twice a day . okay . and the nurse will come in and she'll see you soon . okay ? [patient] great . [doctor] hey , dragon , finalize the note .", "target": "ASSESSMENT AND PLAN\n\nThe patient is a 58-year-old male who presents for follow-up after emergency room visit.\n \n ED follow-up and congestive heart failure.\n \u2022 Medical Reasoning: I believe his symptoms which led to his ED visit were due to an exacerbation of his heart failure. He admits to some dietary indiscretion, which likely resulted in fluid retention.\n \u2022 Medical Treatment: I will prescribe Lasix 80 mg once a day. I will also place him on carvedilol 25 mg twice a day.\n \n Status post basal cell carcinoma removal.\n \u2022 Medical Reasoning: He seems to be doing well and the removal site is well-healed. No change in treatment is necessary at this time.\n \n Status post cataract surgery.\n \u2022 Medical Reasoning: He seems to be doing well. We will continue to observe, but no treatment changes are needed today.\n \n "} {"idx": 59, "inputs": "[doctor] okay [patient] good morning [doctor] good morning thanks doctor doctor cooper i'm i'm you know i'm a little i'm sad to be in here but you know thanks for taking me in i appreciate it [patient] sure absolutely what can i help you with today [doctor] so you know i've been dealing with my asthma and like i tried to join sports but it's really kind of it's getting hard you know and i i i just wonder if there's something that can be done because i really do like playing water polo [patient] but i'm having difficulty breathing sometimes i've had to like you know stop matches and sit on the side just to kind of like catch my breath and use my inhaler so i was wondering if there was something we could do about it [doctor] and then like i'm kind of a little bit worried i think my mood is getting a little a little worrisome and i i wanted to explore like what my options were [patient] okay let's talk about the asthma first so what inhaler are you using now [doctor] i have an albuterol inhaler [patient] okay and when when you're having trouble it's usually just around sports that is it keeping you up at night [doctor] so i do n't really like wake up at night a lot typically like it's sports like you know if i'm doing anything like crazy aerobic or like running or anything i do notice that if any if i'm around smoke i do start coughing a little bit but most of the time it's sports [patient] okay and can you describe a little bit for me what happens [doctor] i start to yeah no so i start to feel like there is like some phlegm building up in my in my throat and i start coughing like my chest gets tight i start wheezing and i just have to sit down or else i'm gon na get like lightheaded too [patient] okay and then when you use your inhaler [doctor] mm-hmm [patient] does it does it alleviate the problem [doctor] so yeah it helps with that like phlegm feeling you know but i still i still have to sit down you know and like breathe and then the thing that i hate about that inhaler is i start getting like shaky is that supposed to be happening [patient] yes that is unfortunately normal and a side effect with the inhaler [doctor] okay [patient] so you use you're using two puffs of the inhaler [doctor] mm-hmm [patient] for the symptoms [doctor] yes [patient] and then you sit down and does it does it get better within about fifteen minutes or so [doctor] yeah yeah it does but you know i had to like step out of the the pool to make that happen i'm hoping that there is something else we can do okay have you ever taken any daily medications for your asthma an inhaler or singulair or anything like that no i i just use my inhaler whenever i have an attack [patient] okay so that's something we might wan na consider but how often is it happening [doctor] pretty much every time i do any kind of aerobic workout [patient] okay and outside of physical activity you're not having any problems [doctor] yeah there's that part where like if i'm around somebody who has been smoking a lot or is currently smoking but i usually just step away i do n't even like to be around them you know that makes sense [patient] alright well we will look at that tell me about the mood issues you are having [doctor] yeah so one of the reasons i got into like trying to get into sports is like i feel like you know you you feel a lot more energized and a lot you know happier but like lately i've just been kinda stressed out you know like i have i have like sats that i need to study for i've got like all these ap classes you know there's just it i feel like there's a lot of pressure and you know like i get it but there are times where i'm just like really down and i i do n't really know what else i can do [patient] okay that makes sense any any difficulty with focusing or you're having difficulty retaining information or is it more feeling sad not having motivation [doctor] so i think it's like a lot of sadness a lot of like you know i do n't really i kinda feel like you know i do n't really like want to do anything you know my friends will go out and i'll just be like i'd rather be at home i am really tired a lot too [patient] okay alright well let me let me go ahead and check you out [doctor] mm-hmm [patient] and then we can talk a little bit more [doctor] okay [patient] i'm gon na take a listen to your heart and lungs [doctor] mm-hmm [patient] and everything sounds good [doctor] let me take a look at your eyes [patient] mm-hmm and in your ears everything looks okay have you had any problems with allergies you have seasonal allergies or anything like that [doctor] yeah i think so yeah [patient] i do see just a little bit of fluid in the ears [doctor] mm-hmm [patient] and i'm gon na look in your mouth too [doctor] okay [patient] and throat looks fine no tonsils [doctor] mm-hmm [patient] lem me go ahead and have you lay back on the table and i'll take a listen to your stomach [doctor] okay [patient] everything sounds okay i'm gon na feel around just to make sure everything feels normal [doctor] mm-hmm [patient] everything feels fine and i'm gon na check reflexes and they're all normal [doctor] awesome [patient] it's really hard to do with actual patient so in terms of the asthma i think we could try a daily medication since it looks like you might be having a little bit of allergies maybe we can try some singulair [doctor] mm-hmm [patient] and start with that once you are on that daily and you can continue to use the albuterol inhaler those side effects unfortunately you're right it's it's just one of the expected side effects with an albuterol inhaler i would recommend just what you're doing just sit down for a little bit after you take it [doctor] and we will get you started on the singulair probably within about a month you should see a difference so i will have you come back in about six weeks and follow up and see how you're doing with that [patient] in terms of the mood is this new for you [doctor] yeah i think so like when i started this year [patient] and it sounds like related to school expectations and the stress with saps and all of that [doctor] yeah [patient] okay let's consider having you start seeing a therapist i think that would be a good place to start [doctor] mm-hmm [patient] and we will do some screening questionnaires and and then follow up in a couple weeks on that too [doctor] okay alright sounds like a plan okay [patient] thank you", "target": "ASSESSMENT AND PLAN\n\n1. Asthma.\n - Medical Reasoning: The patient has experienced an increased need to use her albuterol inhaler. She is not currently utilizing a daily medication. At this time, we will try a daily medication since it looks like she might be having some allergies.\n - Patient Education and Counseling: I explained the side effects of albuterol to the patient. We also discussed Singulair and that she should start to see a difference in her breathing within approximately 1 month.\n - Medical Treatment: We will start her on a daily asthma medication. She can continue to use the albuterol inhaler. We will start her on Singulair in about a month.\n \n 2. Mood.\n - Medical Reasoning: The patient reports being under a lot of stress with school. I believe this may be attributing to her mood.\n - Medical Treatment: I would like for the patient to be seen by a therapist. She will also complete our screening questionnaire.\n \n "} {"idx": 22, "inputs": "[doctor] this is philip gutierrez , date of birth 1/12/71 . he is a 50-year-old male here for a second opinion regarding the index finger on the right hand . he had a hyperextension injury of that index finger during a motor vehicle accident in march of this year . he was offered an injection of the a1 polyregion , but did not want any steroid because of the reaction to dexamethasone , which causes his heart to race . he was scheduled to see dr. alice davis , which it does n't appear he did . he had an mri of that finger , because there was concern about a capsular strain plus or minus rupture of , quote , fds tendon , end quote . he has been seen at point may orthopedics largely by the physical therapy staff and a pr , pa at that institution . [doctor] at that practice , an mri was obtained on 4/24/2021 , which showed just focal soft tissue swelling over the right index mcp joint , partial-thickness tear of the right fds , and fluid consistent with tenosynovitis around the fdp and fds tendons . radial and ulnar collateral ligaments of the index mcp joint were intact , as the mcp joint capsule . extensor tendons also deemed intact . [doctor] his x-rays , four views of the right hand today , show no bony abnormalities , joint congruency throughout all lesser digits on the right hand , no soft tissue shadows of concern , no arthritis . hi , how are you , mr . gutierrez ? [patient] i'm good , how about you ? [doctor] well , how can i help you today ? [patient] so i was a passenger in , uh , a car that was rear-ended , and we were hit multiple times . i felt two bumps , which slung me forward and caused me to stretch out my right index finger . [doctor] so hitting the car in front of you all made that finger go backwards ? [patient] um , i do n't really know . i just felt , like , it felt like i laid on my finger , and so , i felt like it went back , and it's been hurting since about march . and it's been like that ever , ever since the wreck happened . so i , and i ca n't make a fist , but sometimes the pain's unbearable . and , like , even driving hurts . [doctor] okay , so this was march of this year , so maybe about three months ago ? [patient] yeah , and it's still swollen . so i was seeing , uh , an orthopedist , and they sent me to an occupational therapist . and i've been doing therapy with them , and then they sent me to go back and get an mri . so i went and got the mri . uh , then they told me that the mri came back , and it said i had a tear in my finger , but he was n't gon na give me an injection , because the injection was going to make the tear worse . [doctor] mm-hmm . [patient] and then , after he got the mri , he said that i have , uh , a tear in my finger , and that he did n't wan na do surgery , but he would do an injection . then i'm thinking that you told me you would n't do an injection in there , and then the oper- , occupational therapy says it's because of the tear . and then , they do n't want me to keep rubbing the thing , and doing things with my hand . so i feel like i'm not getting medical care , really . [doctor] yeah , i see that . [patient] so i came to see if you could do anything for this hand , because i am right-handed , and i kinda need that hand . [doctor] what do you do for a living ? [patient] uh , i'm an x-ray tech . [doctor] well , um , so do you have any diabetes or rheumatoid arthritis ? [patient] nope . [doctor] uh , do you take any chronic medications of su- , significance ? [patient] uh , i do take a blood pressure pill , and that's it . [doctor] okay , and it looks like you suffer from itching with the methylprednisolone ? [patient] uh , that's correct . [doctor] all right , well , i'm gon na scoot up closer and just take a quick look at your hand . all right , so , lean over here . all right , so on this exam today , we have a very pleasant , cooperative , healthy male , no distress . his heart rate is regular rate , rhythm , 2+ radial pulse , no swelling or bruise , bruising in the palm over the volar surface of his index finger , normal creases , slightly diminished over the pip of the index finger compared to the middle finger . [doctor] his index finger rests in a 10-degree pip-flexed , uh , position . all right , is that uncomfortable to correct that , and is it uncomfortable now here ? [patient] yeah , uh , when you push on it , yeah . [doctor] all right , how about here ? [patient] um , there , it's not . [doctor] okay , not as bad ? [patient] yeah , it feels , uh , a little numb . [doctor] gotcha , all right . bend , bend the tip of this finger . bend it as hard as you can . keep bending . keep bending . all right , straighten it out . all right , and now , bend it for me as best you can . [patient] my goodness . it feels like it's , it's tearing in there . [doctor] okay , okay . well , bend the tip of this finger , and bend it as hard as you can . keep bending . all right , straighten that out , and now , bend it for me as best you can . all right , good . now , bend that finger , and i'm going to pull , put it down like this . and then bend that finger for me . okay , sorry , can you bend it for me ? all right . now , make a fist . great , so relax the finger . all right , so just keep it , keep , when i bend the finger , we're just going to bend that finger where it meets the hand . is that okay there ? [patient] ow , . [doctor] okay , okay . so all the hurt , it seems , is stretching , because you have n't been doing this for so long . so , you know what i mean ? so , um , you're going to have to start really doing that . [patient] well , i've tried . i even bought myself a splint . [doctor] well , but a splint does n't help move you . it actually immobilizes you . [patient] okay . i thought it would straighten it out . [doctor] no , no . so , so you really need to start bending the finger right here for me , as hard as you can , and keep going , going . all right , so , so you're okay . all right , so i would say the following , that there is a partial tear in one of the two flexor tendons . there is the fdp and the fds , and the fds is the least important of the two . so the mri shows that it's the fds , the flexor digitorum superficialis , which is the least important of the two . [patient] okay . [doctor] uh , now , there's two halves of it . so it's a partial tear of one half of a whole tendon . that's not that important , and the other one is just fine . [patient] so the good one is good ? [doctor] yes , correct . so the one that goes all the way to the tip is good . [patient] okay , good . [doctor] yeah , so you know , i think what you have got so much scar tissue and inflammation around the fds tendon blocking excursion of these other tendons , that they ca n't get through to the pulley . [patient] okay , all right . [doctor] so what i would recommend what we try is a cortisone injection , and i would avoid the dexamethasone , because i saw you have a little reaction to that . but we could use the betamethasone , which is a celestone . [patient] i've gotten another , uh , methylprednisolone , and that itched me like crazy . [doctor] did it ? yeah , this one is water-soluble , and i think it's fairly low toxicity , but high benefit , and i think decreasing the pain will encourage you to move that finger . [patient] all right , we'll give it a try . [doctor] good . so , you do the shot , and it's going to take about three to five days before it starts feeling better . and then probably over the next couple of weeks , it'll start feeling even better . [patient] perfect . [doctor] all right , so take advantage of that . you've got ta start moving the finger . you're not going to tear anything or break a bone , uh , because your intensors , extensors are intact . but your collateral ligaments are intact , so you've got a stiff , sore finger . i'm going to try to help as much as i can with this soreness part , and then you have to do all the stiff part . [patient] the lady in occupational therapy tried some maneuvers to straighten the finger out , but it even hurt after i left . the whole thing just swelled up . [doctor] hmm . okay , so it was injured , and you had scar tissue . and then , you had post-traumatic inflammation . and so , this will help some with all of that . it's not going to make it to where your finger is like , , my finger does n't hurt at all , but it will make it to where at least tolerable , to where you can make some gains . and we actually might need to repeat this as well . [patient] will i be able to drive ? i drove myself here today , so ... [doctor] yeah , it may feel a little weird , but it's totally safe for you to drive . [patient] okay , good . [doctor] so for mr . gutierrez , just put that he has a post-traumatic rather severe stenosing tenosynovitis of his right index finger , and the plan is steroid injection today , do a trigger injection , but i'm using a cc of betamethasone . so , mr . gutierrez , do you have , um , therapy scheduled or set up ? [patient] uh , not at the moment . [doctor] all right , well , i mean , you know that you need to move that finger , and i think to the degree that they can help you do that . so i want you to move that finger , finger , but i think it would be , uh , beneficial for you to have an accountability , um , so at least you know to check in with them once a week with somebody . [patient] um , okay . that's kinda why i'm here , for you to tell me what needs to be done , you know ? [doctor] yeah , so i'll write you out , um , an outpatient prescription . i think if you go back to the same people where you were before , i'm hoping that after this injection , you're going to be able to do a whole lot more with them . so let's do outpatient once a week for six weeks , um , and then full active and passive range of motion is the goal with no restrictions . [patient] all right , sounds like a plan . [doctor] all right , well , i will have the nurse set up the injection procedure , and we'll , and i'll be back shortly . [patient] thanks , doc . [doctor] right trigger finger injection template . attempted to inject one cc of celestone with f- , a half a cc of lidocaine . however , the patient had a dramatic and violent painful reaction to the introduction of the needle , with contortions of the hand , and with dangerously withdrawing the hand with concerns for secondary needle stick . needle was withdrawn . the patient was counseled as to the importance of attempting to get some therapeutic steroid in the flexor tendon sheath . we attempted a second time for a similar injection using the same technique with one cc of celestone and half a cc of lidocaine . a small parma- , uh , palmar vein bled a scant amount , which was cleaned up and band-aid applied . reassured on multiple occasions that no harm was done to his finger . recommended icing in it this evening , and taking ibuprofen .", "target": "ASSESSMENT\n\n\u2022 Stenosing tenosynovitis of right index finger.\n \n Ms. Philip Gutierrez is a pleasant 50-year-old right-hand-dominant male here today for a 2nd opinion of his right index finger hyperextension injury sustained during a motor vehicle accident in March of this year. The findings of his examination are consistent with rather severe post-traumatic stenosing tenosynovitis.\n\nPLAN\n\nThe patient and I had a lengthy discussion regarding his history, symptoms, and radiographic findings. We discussed the pathophysiology and natural history of stenosing tenosynovitis and the anatomy of the flexor tendons and pulley system in the hand. I explained to the patient that the flexor digitorum superficialis tendon was clearly intact and that He is suffering from post-traumatic inflammation around the flexor digitorum superficialis tendon blocking excursion of the flexor tendons to the A1 pulley.\n \n Treatment options were discussed including conservative management with corticosteroid injections and their statistical effectiveness. Surgical correction was also briefly discussed, although I recommend exhausting non-operative measures with a minimum of 2 injections before proceeding with surgery. I recommended a right index trigger finger cortisone injection today, and the patient elected to proceed. I also recommend that the patient report to occupational therapy once a week for the next 6 weeks to work on full active and passive right index finger range of motion with no restrictions.\n \n The patient verbalizes understanding with the treatment plan and agrees. All questions were answered to the patient's satisfaction today."} {"idx": 125, "inputs": "[doctor] hi michelle what's been going on the medical assistant told me that you injured your knee [patient] yeah i'm gon na have to keep this my favorite story is that i had a sandra who injured her knee cold dancing so that would immediately came up to mine but let's try skiing so i was skiing in vermont last weekend and i caught my ski when i was coming off the lift and i fell and my knee popped and it's hurt ever since [doctor] okay and were you able to ski down the hill or did you have to be taken down by the ski patrol [patient] i had to be taken down by the ski patrol i was unable to bear weight [doctor] okay is n't that slightly terrifying they had to do the same thing for me and you're just kind of sitting there watching all of the trees go by so anyway so what part of your knee is bothering you the most is it the inside the outside [patient] it hurts on the outside but it also feels like it wo n't hold my weight [doctor] okay so it feels like it's gon na buckle [patient] hmmm yes [doctor] okay alright and are you able to bend it [patient] i was immediately after the injury but not really now [doctor] okay and how about straightening it are you able to straighten it at all [patient] somewhat but it really hurts when i try to straighten all the way [doctor] okay alright now do you have any numbing or tingling in your toes [patient] no [doctor] okay and can you feel your toes okay [patient] i think so [doctor] okay alright now are you a pretty active person you said you were skiing do you do what kind of other activities do you do [patient] i chase my two four -year-old [doctor] okay do you have twins [patient] i do [doctor] nice that's great [patient] yeah [doctor] so okay and what's your support like at home who is who is able to help out are you still doing that kind of hobbling around on crutches or [patient] yeah now my husband is home with me but he also works a job where he is gone quite a bit so it's just me and the kids [doctor] okay alright and did the ski patrol give you crutches i i see you have them here with you okay alright great and are you otherwise generally healthy [patient] yes [doctor] okay and no high blood pressure diabetes anything like that [patient] mm-hmm [doctor] no okay alright and well i i wan na go ahead let me just do a quick physical exam i'm gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay alright so on your heart exam your heart sounds in a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are nice and clear to auscultation and remind me what knee did you injure again [patient] my right knee [doctor] your right knee okay so on your right knee examination i do appreciate some edema and an effusion over the right knee does it hurt when i press [patient] yes [doctor] okay there is pain to palpation of the right lateral knee there is decreased flexion and extension there is a positive lachman sign there is a palpable palpable dorsalis pedis and posterior tibial pulse there is no leg edema in the ankle okay well let's just talk a little bit about you know my assessment and you know my plan for you so you know i know that you had the x-ray done of your of your right knee that did n't show any bony abnormality but i i'm concerned that you have ruptured your your acl or your anterior cruciate ligament that's like a major ligament that helps connect and helps your knee move back and forth so i wan na go ahead and order a knee mri just so that we can get a a a good look and just you know confirm that physical exam okay now some people can have a normal physical exam and their acl can still be torn but you do have a lot of pain on the lateral aspect of your knee so i wan na make sure if there make sure that there is not any other structures that have been damaged by this accident okay i wan na go ahead and you know are you what are you taking for the pain [patient] ibuprofen [doctor] is that helping [patient] somewhat yes [doctor] okay alright do you want something stronger [patient] no i'm okay [doctor] alright so let's just continue with ibuprofen you can take you know six hundred to eight hundred milligrams every eight hours as needed i wan na go ahead and put you in a brace that's gon na help your knee feel a bit more supported okay and let's go ahead and i'm hoping that we can get this mri done in you know the next couple days and then we can have a conversation about what needs to be done now you said that you are are are you know obviously a very active active mom any other exercise or anything else that that i should be aware of that you do just wondering in terms of which kind of graft we would use to fix this with your with your acl being injured [patient] hmmm no i not i i would like to get back to the running but currently not that active [doctor] okay alright alright do you have any questions about anything [patient] i think you've explained it well [doctor] okay alright so i'll see you again soon okay [patient] okay thank you [doctor] alright take care bye", "target": "ASSESSMENT\n\nRight knee pain, possible ACL tear.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have recommended that we obtain an MRI of the right knee to evaluate for a possible ACL tear. In the meantime, I have advised her to continue taking ibuprofen 600 to 800 mg every 8 hours as needed for pain. She will also be placed into a brace for increased knee support."} {"idx": 77, "inputs": "[doctor] hey diana it's good to see you in here so i see that you injured your wrist could you tell me a bit about what happened [patient] yeah i was walking up and down the stairs i was doing my laundry and i slipped and i tried to catch myself and i put my arms out to catch myself and then all of a sudden i just my wrist started to hurt real bad and it got real swollen [doctor] wow okay so which wrist are we talking about left or right [patient] it's my right one of course [doctor] okay and then have you ever injured this arm before [patient] no i have not [doctor] okay alright so on a scale of one to ten how severe is the pain [patient] gosh it's like a nine [doctor] wow okay have you done anything to ease it [patient] yeah i did the ice thing i put ice on it and then i you know i even i have a ace wrap at home i try to do that [doctor] mm-hmm [patient] and then i took some ibuprofen but it helps a little bit but it's just it's it's just not right [doctor] okay [patient] really [doctor] yeah okay have you sorry i'm trying to think how long ago did this injury happen [patient] this happened yesterday morning [doctor] okay [patient] maybe just you know i just bumped it but [doctor] okay [patient] it's just not it's really bad [doctor] okay no i understand okay so i'm going so you said you were doing laundry [patient] yes i had my back hit my basket and for some reason this cold started to kinda fall out a little bit i was trying to catch it i missed a step and i just totally [doctor] okay alright any does the pain extend anywhere [patient] no not really [doctor] okay [patient] it's just really along my wrist [doctor] okay any numbness any tingling [patient] a little one and one ca n't tell if it's just because of the swelling in my wrist but just i can like i can feel it my fingers still [doctor] mm-hmm [patient] but just maybe a little bit of tingling [doctor] okay alright and are you so so okay i'm gon na think on this but in the meantime i'm gon na do my physical exam alright [patient] okay [doctor] okay so you know looking at your looking at your head and your neck i do n't appreciate any like adenopathy no thyromegaly no no carotid bruit looking at your listening to your heart i do n't appreciate any murmur no rub no gallop your lungs are clear to auscultation bilaterally your lower legs you have palpable pulses no lower edema your shoulders every like your upper extremities i see normal range of movement with your right wrist let's go ahead and focus on it so when i push on the inside here does it hurt [patient] yes [doctor] okay [patient] it does [doctor] and what about the outside does that hurt as well [patient] yeah it does [doctor] are you able to move your wrist towards your arm like [patient] not without extreme pain [doctor] okay so pain on flexion what about extension when you pick your wrist up [patient] yeah i have a hard time doing that actually [doctor] alright what about we're gon na go ahead and hold your arm like straight like flat and then try and move it sideways does radial deviation hurt [patient] yeah [doctor] alright and then lateral as well [patient] yeah it's really hard to move any direction of this hand for some reason [doctor] alright so wrist abduction adduction positive for pain on movement are you able to make a fist [patient] hmmm yeah a little bit but i ca n't do it really tight [doctor] okay alright okay so i'm just gon na go ahead and feel on your fingers really quickly alright metacarpals intact noticed some obvious swelling ecchymosis obvious swelling and bruising tenderness on palpation throughout there is evidence of potential fracture feeling some bony crepitus alright so this pain is it like chronic i wanted to ask you [patient] yeah i would say it kinda goes away when i take that ibuprofen but for the most part i feel it i feel it there and it it's just really really bad when i move it all [doctor] okay so when you like is there a position either hurts less or hurts more like say if your arm is raised and elevated over your head does it hurt more or is it just best to keep it like down [patient] it's good if i keep it a little bit above my like a little i guess a little bit like around my like just a regular level like if you're typing or something and then i just put it on a pillow and i just let it stay straight like i feel better [doctor] okay yeah no i do n't think i understand completely okay so i took a look at your vitals and your blood pressure is a little elevated but honestly that's probably to do with the pain right our body can respond to pain in that way we are looking at like a hundred and forty over over seventy it's not anything crazy but something to mention i see that your heart rate is also a little elevated at like about like eighty beats a minute you are not running a fever so that's great look at ninety ninety seven . two your respiratory rate is pretty normal at like twenty so before we came in i i know that we had you do an x-ray and i'm sure that that was a bit more painful because we had to do so many manipulations but i do wan na note that you are positive for what we call a colles' fracture what that means is that the joints between your wrist like the bones between your wrist that there there is evidence of a a fracture and we are gon na have to treat it a little conservatively at first and then consider some of the options options that are available to us so for your primary diagnosis of a colles' fracture we are going to give you a thumb spica for today and that's going to [patient] i'm sorry [doctor] pardon what [patient] a what [doctor] we're gon na brace you we're gon na give you a brace [patient] okay thank you [doctor] sorry no problem sorry yeah not a thumb spica we're gon na brace your arm and you're gon na have that we we have a couple of options but i think the best course of action is gon na be for surgery we will in the meantime give you pain medication i wan na put you on fifty milligrams of ultram every six hours and then i also wan na get you on get you into physical therapy a few weeks after surgery this is gon na be just a normal procedure you will be in for an overnight stay but after that once we assess and make sure that everything is good you'll be able to go home okay [patient] when do i have to have the surgery [doctor] we would like it to happen as quickly as possible you know your body is a wonderful miracle and it's going to start trying to heal on it's own what we need to do is get your wrist straight and then like put screws in to make sure that we hold it in place or else it could like heal and malform [patient] okay [doctor] alright so what [patient] how how long do i have to wear that brace [doctor] you're gon na be wearing the brace for about six weeks [patient] six weeks [doctor] yeah so you're gon na you're gon na come in for your surgery we're gon na perform it you're gon na stay overnight and then you'll be bracing it for six weeks in the meantime you'll also then go to physical therapy i want you there like we're gon na they're gon na do an assessment and determine how much but i'm thinking probably three times a week just to make sure that you can get your wrist as strong as possible to prevent like future injury now the cool thing about getting any kind of a bone break is that your your body comes out even stronger so this should n't happen again but unfortunately like it's these situations that oof that just kind of [patient] oof [doctor] these these deform these deformities that really that really kind of hurt is the short version alright no problem any other questions [patient] no well i am going on vacation do i need to cancel it like can i still go even with the i mean after the surgery [doctor] yeah [patient] do it as soon as possible i'm going a vacation in a month so [doctor] okay how long is the vacation [patient] it's only for like a couple weeks [doctor] okay well so you might have to postpone it just because depending on what physical therapy says right if they feel that you can sustain if you can like sustain the exercises while you're gone that if there's something that you can do by yourself then you should be fine but we do wan na give it you said that it's gon na happen in a couple of weeks [patient] no vacation in a month [doctor] okay okay yeah so how about in a month we come you come back let's do a checkup again see where we are at and then we can assess whether or not this is something that i would recommend you do [patient] that sounds good thank you [doctor] no problem bye [patient] bye [doctor] the fracture appears extra-articular and usually proximal to the radial ulnar joint dorsal angulation of the distal fracture fragment is present to a variable degree if dorsal angulation is severe presenting with a dinner fork deformity ulnar styloid fracture is present", "target": "ASSESSMENT\n\nRight wrist Colles fracture.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have discussed with the patient that her x-rays revealed a right wrist Colles fracture. We discussed treatment options and I have recommended that we proceed with a right wrist ORIF and all indicated procedures. We reviewed the risks, benefits, and alternatives of the surgery. I explained that we should schedule the operation for as soon as possible to ensure adequate healing and to limit malformation of the wrist. I advised that this procedure will require her to be admitted to the hospital for an overnight stay.\n \n In the meantime, the patient will be placed in a thumb spica brace and receive instructions on its proper usage. I have prescribed the patient Ultram 50 mg every 6 hours to treat her pain. We also discussed that her postoperative course will include wearing a brace for 6 weeks. A few weeks after surgery, the patient will initiate formal physical therapy and will attend 3 times per week to strengthen her right wrist. The patient has a 2-week vacation planned in 1 month. I recommended that we consult with her physical therapist to determine if there are exercises she can perform on her own instead of postponing her vacation."} {"idx": 93, "inputs": "[doctor] hey lawrence . how are you ? [patient] hey , good to see you . [doctor] it's good to see you too . so , i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] so , lawrence is a 62-year-old male , with a past medical history significant for type i diabetes , congestive heart failure , depression , and reflux , who presents with complaints of shortness of breath . so lawrence , what's been going on ? wh- what's wrong with your breathing ? [patient] uh , i , i've noticed that i've been swelling up a little bit . i think a lot of it has to do with going to some house parties , eating some salty foods . i feel really lethargic . [doctor] okay . all right . and when you get short of breath , are you short of breath when you're just sitting here ? do you feel short of breath when you're walking ? [patient] it's something like walking up a flight of stairs i'll actually feel it . [doctor] okay . all right . now , um , how long has this been going on for ? [patient] probably about 10 days . [doctor] okay . all right . and you said you're noticed some swelling in your legs ? [patient] a little bit . [doctor] okay . do you have problems lying flat in bed ? [patient] um , i'm a little uncomfortable when i wake up in the morning and i feel pretty stiff . and , and , like , it takes me a little while to adjust to walking when i get up . [doctor] okay . all right . do you ever wake up acutely short of breath at night ? [patient] um , it happened once , probably about a week ago , but it has n't happened since . so i have n't been that concerned about it . [doctor] okay . all right . in terms of your , your diabetes , how are you doing with that ? i know you're on the insulin pump . [patient] mm-hmm . [doctor] um , are your blood sugars okay ? have you noticed a spike in them recently ? [patient] um , i have n't . i've been pretty good about monitoring it so i ... during the working week , i stay on top of that . but on saturdays or sundays we're so busy i forget to monitor it . but i have n't seen anything spike . [doctor] okay . and i remember your affinity for chocolate bars , so ... [patient] guilty as charged . i love chocolate bars . [doctor] okay . all right . so , in terms of your depression , how are you doing with that ? [patient] uh , it's been a crazy year and a half . um , i've tried some natural solutions . in the summer i did stretches outdoors every morning , which was great , but now the weather changed and , uh , you know , i've got ta find some alternatives . i'm not ready to try any medications just yet , so- [doctor] okay . [patient] . i'm open to some suggestions . [doctor] okay . we'll talk about that . [patient] sure . [doctor] and then in terms of your reflux , how are you doing ? i know we had you on the omeprazole . [patient] mm-hmm . [doctor] you were making some lifestyle modifications , cutting back on your red bull and caffeine . [patient] yeah . [doctor] alcohol intake has been ... how's that been ? [patient] tough during the holiday season , but i'm , i'm better . [doctor] okay . all right . and no issues with your depression ? you do n't want to hurt yourself or anyone else ? [patient] no . no . absolutely not . [doctor] okay , all right . well , let's go ahead . i know you did a review of system sheet when you checked in and you endorsed the shortness of breath . [patient] mm-hmm . [doctor] any other symptoms ? chest pain , fever , chills , cough ? [patient] no . [doctor] um , belly pain ? [patient] no . [doctor] okay . let's go ahead . i want to move on to a physical exam . [patient] mm-hmm . [doctor] hey , dragon ? show me the vital signs . so here in the office , you know , your vital signs look good . your , your pulse ox ... that's your oxygenation level ... looks good . so i'm encouraged by that with you just sitting here , okay ? i'm gon na go ahead and do another , uh , just check you over . i'll let you know what i find . [patient] mm-hmm . [doctor] okay . all right . so , on your exam things look okay . so , i do n't appreciate any jugular venous distension or any carotid bruits on your neck exam . on your heart exam , i do appreciate a slight 3 out of 6 systolic ejection murmur . on your lung exam , i do appreciate some crackles , bilaterally , at the bases . and on your lower extremity exam i do appreciate 1+ pitting edema . so what does all that mean ? so , i do think that you're retaining some fluid . it's probably from some of the dietary indiscretion . [patient] mm-hmm . [doctor] but i wan na go ahead and look at some of the results , okay ? i had the nurse do a chest x-ray on you before we came in , okay ? hey , dragon ? show me the test x-ray . so i reviewed the results of your chest x-ray and it looks good . there's no e- evidence of any airspace disease , but that does n't mean that you still ca n't be retaining some fluid , okay ? [patient] okay . [doctor] hey , dragon ? show me the labs . and your labs look okay . you know , you do n't have an elevated white blood cell count so i'm not really concerned about infection . we saw the chest x-ray , there's no pneumonia , so that's good . [patient] mm-hmm . [doctor] so , let's talk a little bit about , you know , my assessment and my plan for you . okay ? so , for your first problem of your shortness of breath i think that you are in an acute heart failure exacerbation . i want to go ahead and , uh , put you on some lasix , 40 milligrams a day . i want you to weigh yourself every day . [patient] mm-hmm . [doctor] if your weight is n't going down , uh , or if it's going up i want you to call me . certainly , if you get more short of breath at rest i want you to go ahead and call me or call 911- [patient] mm-hmm . [doctor] . and go into the emergency room . you might need some intravenous diuretics . [patient] mm-hmm . [doctor] okay ? for your second problem of your type i diabetes , um , let's go ahead ... i wan na order a hemoglobin a1c for , um , uh , just in a , like a month or so , just to see if we have to make any adjustments . and i want you to follow up with your endocrinologist . okay ? and i also want to make sure that you have a recent eye exam . all right ? uh , for your third problem of your depression , let's go ahead and refer you to psychiatry , just for some , um , like , talk therapy to help you through that . okay ? [patient] sure . [doctor] no medications . and for your fourth problem of your reflux , let's go ahead and continue you on the omeprazole , 20 milligrams a day . do you have any questions , lawrence ? [patient] not at this point . [doctor] okay . um , uh , again , i want you to call me if you have any problems with your breathing , okay ? [patient] you got it . [doctor] hey , dragon ? finalize the notes ...", "target": "ASSESSMENT\n\nLawrence Walker is a 62-year-old male with a past medical history significant for type 1 diabetes, congestive heart failure, depression, and reflux, who presents with complaints of shortness of breath.\n\nPLAN\n\nAcute heart failure exacerbation.\n \u2022 Medical Reasoning: The patient is retaining fluid. He has noticed increased fluid retention following dietary indiscretion. He has experienced dyspnea on exertion for the past 10 days.\n \u2022 Medical Treatment: Initiate Lasix 40 mg a day.\n \u2022 Patient Education and Counseling: I advised the patient to monitor and log his daily weights. He will contact me if these continue to increase. He was instructed to call me or 911 if he experiences dyspnea at rest.\n \n Type 1 diabetes.\n \u2022 Medical Treatment: This is currently stable with use of an insulin pump.\n \u2022 Additional Testing: I will order a hemoglobin A1c in 1 month.\n \u2022 Medical Treatment: He will continue the insulin pump. The patient will follow up with his endocrinologist.\n \u2022 Patient Education and Counseling: I encouraged the patient to have an eye exam.\n \n Depression.\n \u2022 Medical Reasoning: The patient has been doing well with outdoor stretching. He continues to decline the use of medications for this issue.\n \u2022 Medical Treatment: I will refer him to psychiatry as his current management strategy is unsustainable due to the change in season.\n \u2022 Patient Education and Counseling: We will defer initiating medication at this time.\n \n Acid reflux.\n \u2022 Medical Reasoning: His symptoms are stable with medication.\n \u2022 Medical Treatment: Continue omeprazole 20 mg a day.\n \n "} {"idx": 124, "inputs": "[patient] miss edwards is here for evaluation of facial pain this is a 54 -year-old male [doctor] how're you doing doctor cruz nice to see you today [patient] good to see you mister edwards i'm doctor [doctor] tell me what's been going on yeah so i've got this stabbing shooting pain i've had for a while you know and it it especially right here in my right face right in that cheek bone area it's sometimes it gets super hot i've had it for i think a couple of months now and i went to my family doctor and they said i should come see you [patient] okay great i would like to ask you a little bit more about that [doctor] had in your face do you remember how long that you had it probably for about two or three months just just came on slowly i started noticing it but now it's i have episodes where just shooting stabbing kind of a pain in my right cheek bone right face area [patient] mm-hmm do you have any sensory loss meaning like numbness or tingling in that part of your face [doctor] not that i've noticed no okay do you have any symptoms like this anywhere else on your face including the other side of your face [patient] no it's just on the right side mostly not on the left side just on the right side of my face [doctor] have you noticed any weakness on that side of the face like when you smile or while you're doing other things any weakness there not really i mean i've i've i've tried to you know when i smile my smile seems equal on both sides my eyes i do n't have any weakness there my vision seems to be unchanged but just this stabbing severe pain it's just like excruciating pain that i get sometimes does it happen on its own or there are certain things that trigger it [patient] sometimes if i'm if certain temperatures seem to trigger it sometimes or if it's super where it's cold i get a trigger sometimes [doctor] sometimes certain kind of sensory outside of the wind sometimes that seems to trigger it but that's about it [patient] okay and anything that you've done to to that helps for a little bit when you [doctor] pain excess [patient] you know i've tried ibuprofen and motrin that had really has n't helped it just comes on suddenly and then it's kinda stabbing excruciating pain i've tried rubbing some you know some tiger balm on it that did n't work [doctor] but that's you know so i i went to my family doctor and he said you know i really need to see a neurosurgeon [patient] got it how long do these episodes last these pain [doctor] you know it can last for anywhere from a few minutes to sometimes about an hour but generally generally a few minutes [patient] any history of something like multiple sclerosis or any brain tumors that you know [doctor] no nothing like that alright any other kinda headache symptoms that have anything like you had migraines or anything related to the headaches i mean i get occasional headaches but not really i do n't have a history of migraines but i occasionally get headaches like everybody else i take some tylenol that usually goes away but this is different [patient] how severe is the pain on a scale of one to ten [doctor] when it comes on it's like a ten it's like somebody is stabbing you with an ice pick and but usually you know after a few minutes usually it goes away but sometimes it can last up to an hour great so mister i would like to do a physical exam if that's okay with you [patient] sure [doctor] i would like you to follow my finger here and i see that you're following my finger in in both directions can you show me your teeth [patient] that looks nice and symmetric i'm gon na rub my fingers next to your ear can you hear that [doctor] yep [patient] you can hear it on the other side as well [doctor] yep [patient] okay [doctor] i'm gon na take this cotton tape and run it along the side of your face can you feel that okay [patient] yeah it's a little bit numb on my right side not so much on my left side [doctor] okay alright i'm gon na use this little needle here and i'm gon na poke here and i wan na see if you feel like it's being sharp or dull on that part of your face does that feel different or normal [patient] it feels a little bit dull on my left on my right side my left side it feels sharp [doctor] alright good well i had a chance to look at your mri [patient] okay [doctor] and i looked at your mri and it appears to have small blood vessel that is abutting and perhaps even pinching the trigeminal nerve the trigeminal nerve is nerve that comes from the brainstem that goes out to the face and provides the sensory inflammation from the face and you may have a condition called trigeminal neuralgia [patient] okay [doctor] where the nerve compression causes this kind of shooting electrical pain in the face how do we treat it [patient] well the first line would be to try some medications usually we start with medications that are called gabapentin [doctor] or tegretol these are medications that really help reduce the excitability of the nerve [patient] okay [doctor] most people can get the pain control with that but there are some people where the medications are n't gon na be enough and in that situation we would consider surgery i would n't i would n't recommend that now we usually try the medications first [patient] for considering a surgery to decompress the nerve the root cause of the problem is the compression of the blood vessel against the nerve [doctor] okay so we should be tried which one would you recommend the tegretol or yeah i think we could start with the tegretol to start with i just want to make sure that you understand some of the potential side effects that you can have with this [patient] sure [doctor] it's always a little bit of trial and error to figure out what the right dosing that would work for you but some common side effects can include you know memory loss tingling imbalance some people can actually have like dermatologic [patient] skin reaction to this medication and particularly people who have eustachian descent so that we may do some genetic testing just to make sure that it will be safe for you [doctor] okay sounds good let's do it [patient] okay so i will prescribe that for you and then we will see how that goes and if your pain continues we can talk about different surgical options to treat the pain [doctor] yeah i think i would like to try the tegretol first and if that does n't work then i can come back and so once should i come back and just to kinda check back with you and see if you know if it's had enough time for a fact or not [patient] i think one month would be a great time to follow up [doctor] okay sounds good so if you want to send that prescription over to my pharmacy that would be fine and then why do n't i come back in about a month and we'll go from there [patient] great i'll see you then [doctor] alright", "target": "ASSESSMENT AND PLAN\n\n1. Trigeminal neuralgia.\n - Medical Reasoning: The patient has been experiencing facial pain for 2 to 3 months. A recent MRI revealed a small blood vessel abutting, or perhaps even pinching, the right trigeminal nerve. The root cause of his facial pain is the compression of the blood vessel against this nerve.\n - Patient Education and Counseling: The patient and I discussed treatment options including medicating with gabapentin or Tegretol. I explained the common side effects associated with these medications can include memory loss, tingling, and imbalance. We discussed the need for genetic testing due to the possible side effect of dermatologic reactions in people of East Asian descent. We also briefly discussed surgical treatment to decompress the nerve, but this is not recommended at this time.\n - Medical Treatment: A prescription for Tegretol will be sent to the patient\u2019s pharmacy.\n \n "} {"idx": 36, "inputs": "[doctor] hey george how are you today i understand you're here for some numbness and tingling in your fingers and some pain in your wrist [patient] right my right wrist and hand has been bothering me probably for a few months now with pain and numbness [doctor] okay and you said that's been ongoing for several months do you know what caused this type of pain or is it just something that started slowly or [patient] it just kinda started on it's own it i notice it mostly at night [doctor] okay [patient] sometimes it will i'll wake up and my hands asleep and i got ta shake it out [doctor] shake it out and okay [patient] and then some [doctor] what kind of work do you do [patient] i do yard work [doctor] yard work [patient] landscaping landscaping [doctor] landscaping okay so a lot of raking a lot of digging so a lot of repetitive type movements [patient] yeah it's pretty heavy labor but it's yeah the same thing day in and day out [doctor] okay okay just a couple questions for you you did say that you have the pain at night in that and you have to you get that numbness into the hand is it in all the fingers [patient] yeah it seems to happen to all my fingers but i notice it more in my thumb and pointer finger [doctor] okay okay and anything into that little into your fifth finger your little finger any numbness there at times no [patient] sometimes yeah it seems like it's numb too [doctor] okay what about your right hand any problems with that hand [patient] no i do n't seem to have any problems with my right hand so far it's just mostly my left [doctor] okay okay good and just a couple you know do you how do you have many or do you drink often do you have you know many any alcohol consumption [patient] i drink usually a a beer or two on fridays and saturdays on the weekends [doctor] okay and do you have any evidence of any anybody ever said that you had some rheumatoid arthritis in your hand or wrist anything like that [patient] no nobody say anything like that so i mean [doctor] okay okay good so let me go ahead and do a physical exam here real quick and you know i'm gon na quickly just listen to your heart and lungs okay that's good i'd like you to squeeze i'm gon na hold your hands here and i'd like you to squeeze both hands [patient] okay [doctor] you seem a little bit weaker on that left hand is that what you've noticed [patient] yeah i i i experienced some weakness in my left hand [doctor] okay do you you find that you're dropping things when you're picking it up is it to that level or [patient] yeah i drop things mostly because i have a hard time feeling it [doctor] okay okay good and so you you do have a a grip strength is less on the left and i just wan na touch your fingers here on the on the right side you can feel me touching all the fingers on the right [patient] yeah i can i can say you touch me but it feels a little more weird on the thumb side than my pointer finger side [doctor] okay okay and i wan na turn your wrist over here and turn your hand over and i'm gon na go ahead and tap on the right wrist on the back here does that do anything when i do that [patient] i still i feel a little jolt or a zing in my finger tips [doctor] okay and then when i do that on the left side [patient] yeah same thing [doctor] same thing okay so you do have a bilateral positive tinel's sign so so here's here's where i'm at i think your your diagnosis is beginning to have some bilateral carpal tunnel syndrome usually we see that with repetitive actions such as the landscaping the heavy labor and you you know your your clinical exam and and history sound like it's a carpal tunnel syndrome i do want to order so where are we gon na go from here i would like to order a a study it's called an emg where it it measures some of that electrical impulses down into your fingers we will follow up with that but as far as your treatment so the treatment for carpal tunnel syndrome is really some activity modification now i know you are a landscaper is there any way that you could be work to have some lighter work during the time [patient] i suppose i could try to pass it off to some of my other employes and delegate [doctor] okay that would be good so that's i i just want you to kinda eliminate that the active repetitive motions that you're doing all the time just for a couple weeks i'm also gon na give you a wrist splint to wear and that should help and i'd like you to take ibuprofen six hundred milligrams every six hours and then i wan na see you back here in the office in two weeks and in that two week period i think we're gon na see if there's need for any other intervention if i need to do more diagnostic testing or if there is a possibly looking at a surgical intervention to release that pressure that's on the nerves in that hand does that sound like a a good plan for you [patient] yeah it sounds like a good first start [doctor] okay okay so i i just just off off the record here what kind of what do what do you specialize in landscaping is your company do [patient] mostly like yard work and maintenance flower beds not really designing just up keep [doctor] okay yeah i'm looking for a landscape designer i need somebody to put in some elaborate walkways back through the backyard so yeah we can do stuff like that i mean if you have an idea what you want i think that's easy [patient] okay [doctor] you know if you're looking for like some [patient] backyard elasis rehab remodel that's i mean i suppose we could do we have n't done things like that in a while because we're busy enough with just the up key but it's something to explore [doctor] okay yeah i may have to keep that in mind because i do wan na do some of that so let's listen i'm gon na get my my nurse in here to discharge you do you have any other questions for me before we end this [patient] no i think it's all clear i appreciate it [doctor] okay take care and i'll look forward to see you in two weeks [patient] very good appreciate your time", "target": "ASSESSMENT\n\nBilateral carpal tunnel syndrome.\n\nPLAN\n\nAfter reviewing the patient's clinical history and examination today, I have had a lengthy discussion with him regarding treatment options for his current symptoms. I discussed the importance of activity modification and encouraged the patient to limit active repetitive motions while working for the next 2 weeks. I also recommended that he wear a wrist splint to provide increased support. I advised him to take ibuprofen 600 mg every 6 hours. Additionally, I recommended we obtain an EMG of the bilateral upper extremities to evaluate for carpal tunnel syndrome. The patient will follow up with me in 2 weeks when the EMG results are available for review. If at that time his symptoms have not improved with these conservative measures, we will discuss further treatment options including additional diagnostic testing or possible surgical intervention.\n \n The patient states he understands and is in agreement with the plan. All questions were answered to the patient's satisfaction."} {"idx": 20, "inputs": "[doctor] hi , vincent . how are you ? [patient] i'm good . how about you ? [doctor] i'm good . so le- are you ready to get started ? [patient] i am . [doctor] okay . vincent is a 56-year-old male here with abnormal lab findings . so , i've heard you were in the er , vincent , and they found that you had a low hemoglobin . [patient] yup . [doctor] were you having some dizziness and some lightheadedness ? [patient] i was very lightheaded . i- i do n't know . very lightheaded . [doctor] okay . and have you noticed bleeding from anywhere ? [patient] i have not . i have n't hurt myself in quite a while . maybe a slight nick from a knife while chopping some onions , but nothing more than that . [doctor] but no blood in your stools or- [patient] no . [doctor] . anything like that ? [patient] no . [doctor] okay . and any type of weight loss or decreased appetite or night sweats ? coughs ? [patient] uh , s- slightly decreased appetite , but i wish i had some weight loss . [doctor] um , okay . and how about any abdominal pain ? fever , chills ? [patient] uh , none of that . [doctor] okay . all right . um , any nausea or vomiting ? [patient] not really . yeah . maybe a bit of nausea . [doctor] okay . [patient] i- sitting at the back of a car , that makes me nauseous at times . [doctor] okay . all right . um , well , how are you doing in terms of your knee replacement . i know you had that done last year . that's going okay ? [patient] mm , it seems okay . yeah . [doctor] okay . you're walking around without a problem ? [patient] yup , yup . just not good enough to run yet , but everything else works just fine . [doctor] all right . um , and i know a few years ago , you had , had that scare with the possible lung cancer , but then they did the biopsy and , and you've been fine . [patient] yup , yup . all good . [doctor] turned out to be benign . [patient] yup . [doctor] okay . great . all right . well , let's go ahead and do a quick physical exam . so looking at you , you do n't appear in any distress . your heart is regular . your lungs sound nice and clear . you have some tenderness to the right lower quadrant to palpation of your abdomen . your lower extremities have no edema . [doctor] um , all right . well , let's go ahead and look at your labs , okay ? [patient] yup . [doctor] hey , dragon , show me the hemoglobin . yeah , so your hemoglobin is 8.2 , which is quite low for somebody of your height and weight , so we'll have to look into that a , a little bit further . i know that they did the endoscopy in the emergency room . hey , dragon , show me the endoscope results . [doctor] good . so it looks like you had some gastritis , which is just inflammation of your stomach and they also found a slight polyp , which i know that they biopsied and the results are pending at this time . um , so , you may have had some bleeding from the gastritis . it's not usual for people to have bleeding from that . [doctor] um , okay , well , hey , dragon , show me the anemia panel . okay . [doctor] anyway , okay . well , vincent , i think , you know , in terms of , my impression of you is that you've had this newfound anemia and for that , i think that we should go ahead and put you on protonix , 40 milligrams , once a day to help with the gastritis . does that sound okay to you ? [patient] it does . you're the doctor . i do n't know what it is . [doctor] so that's just , uh , what we call a proton pump inhibitor which , uh , helps decrease the amount of acid secreted within your stomach . [patient] got it . makes sense . [doctor] hey , hey , dragon , order protonix , 40 milligrams , once a day . [doctor] and i'd like you to try to cut down on your caffeine 'cause that can also irritate your stomach . try not to take any ibuprofen and try to cut down on any alcohol intake , okay ? [patient] yup , yup . the coffee's the hard part . [doctor] yeah . it always is . how about one , one , one eight-ounce cup a day ? okay ? [patient] sure . [doctor] um , and we'll go ahead and we'll see you in a couple weeks , okay ? [patient] sure thing . [doctor] i'm going through , uh , i'll also order another , uh , cbc on you . hey , dragon , order a complete blood count . [doctor] all right . the nurse will be in soon . it's , you know , settle all that . i'll see you soon . [patient] see you . [doctor] hey , dragon , finalize the note . ", "target": "ASSESSMENT AND PLAN\n\nVincent Young is a 56-year-old male who presents today for lab review.\n \n New found anemia.\n \u2022 Medical Reasoning: His hemoglobin was 8.2, which is low for his height and weight. Endoscopy from the hospital showed gastritis which could be the source of bleeding. The endoscopy also showed a polyp and a polypectomy was performed. The pathology is still pending.\n \u2022 Patient Education and Counseling: I encouraged the patient to reduce his caffeine consumption avoid NSAIDs and alcohol.\n \u2022 Additional Testing: Repeat CBC was ordered.\n \u2022 Medical Treatment: I prescribed Protonix 40 mg once a day for gastritis.\n \n "} {"idx": 7, "inputs": "[doctor] and why is she here ? annual exam . okay . all right . hi , sarah . how are you ? [patient] good . how are you ? [doctor] i'm good . are you ready to get started ? [patient] yes , i am . [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 . [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 . [doctor] are , are you taking that ? [patient] i am taking it . i think it's just a lot has been weighing on me lately . [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 . [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 . [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 . [doctor] okay , and does the , um , do those symptoms improve when you stand up or change position ? [patient] yeah , it does . [doctor] okay . all right . and any weakness in , in your legs ? [patient] no , no weakness , just , just the weird numbing . like , it's , like , almost like it's falling asleep on me . [doctor] okay . and are you able to , um , do your activities of daily living ? do you exercise , go to the store , that type of thing ? [patient] yeah , i am . it bothers me when i'm on my feet for too long and sitting too long , just the extremes of each end . [doctor] okay . and i know that you've had a coronary artery bypass grafting at the young age of 27 , so how's that going ? [patient] yeah , i had con- i had a congenital ... you know , i had a congenital artery when i was a baby , so , um , they had to do a cabg on me , um , fairly young in life , but i've been ... my heart's been doing , doing well , and arteries have been looking good . [doctor] okay . all right , well , let's go ahead and do a quick physical exam . um , so looking at you , you do n't appear in any distress . um , your neck , there's no thyroid enlargement . uh , your heart i hear a three out of six , systolic ejection murmur , uh , that's stable . your lungs otherwise sound clear . your abdomen is soft , and you do have some pain to palpation of your lumbar spine . uh , and you've had decreased flexion of your back . uh , your lower extremity strength is good , and there's no edema . so let's go ahead and look at some of your results . hey , dragon , show me the ecg . okay , so that looks basically unchanged from last year , which is really good . hey , dragon , show me the lumbar spine x-ray . hey , dragon , show me the back x-ray . great . so this looks good . that's also stable from last year . okay . so let's go ahead and , you know , my , my plan for you at this time , you know , from a chronic back pain standpoint , if you need , um , you know , some more physical therapy , and i can refer you to physical therapy to help with those symptoms that are kind of lingering . [patient] mm-hmm . [doctor] um , and we can always give you some pain medication if you , if you get some pain periodically with activity . how do you feel about that ? do you need some pain medication ? [patient] no , i think physical therapy is the right way to , way to start out on this . [doctor] okay . hey , dragon , order physical therapy referral . and then in terms of your depression , we talked about increasing your prozac , so we'll increase it from 20 milligrams to 40 milligrams . it's just one tablet once a day . [patient] okay . [doctor] um , and i'll send those to your pharmacy . does that sound okay ? [patient] that sounds great . [doctor] hey , dragon , order prozac , 40 milligrams , once a day . and then in terms of your ... the heart bypass that you've had ... let's go ahead and just order another echocardiogram for you , and i wan na continue you on the aspirin for now , okay ? [patient] okay . [doctor] hey , dragon , order an echocardiogram . hey , dragon , order aspirin 81 milligrams daily . okay , so the nurse will come in . she'll help you schedule those things , and we'll go from there , okay ? [patient] okay . [doctor] all right , take care . [patient] thank you . [doctor] hey , dragon , finalize the note . ", "target": "ASSESSMENT\n\nThe patient is a 27-year-old female who presents today for an annual followup of chronic conditions.\n \n Chronic back pain.\n \u2022 Medical Reasoning: She is experiencing worsened pain with sitting for extended periods of time.\n \u2022 Medical Treatment: Physical therapy referral ordered. Patient would like to defer pain medication at this time.\n \n Depression\n \u2022 Medical Reasoning: The patient was previously doing well on Prozac 20 mg once daily but feels as though she needs a higher dose at this time.\n \u2022 Medical Treatment: Increase Prozac to 40 mg once daily. Prescription submitted.\n \n History of coronary artery bypass graft.\n \u2022 Medical Reasoning: She is doing well at this time. We will continue to monitor this.\n \u2022 Medical Treatment: Echocardiogram ordered. Continue aspirin 81 mg daily.\n \""} {"idx": 116, "inputs": "[doctor] hey hi bobby how are you doing [patient] i'm doing good how are you [doctor] i'm doing fine so i understand you're here having some left or some right shoulder pain that you've had for a few weeks now [patient] yeah it was i was doing some work in my backyard and a lot of different projects going on and you know i was obviously sore all over the next couple of days but my my right shoulder just keeps on bothering me and it keeps it's just really sore and it just has n't been going away [doctor] okay so have you had ever had any pain in that shoulder before [patient] a little bit i you know i i hurt that same shoulder because it's my my dominant hand my right hand i hurt it playing baseball when i was younger [doctor] mm-hmm [patient] so i've always had a little bit issues but this is it's does n't feel like it's in the rotator cuff it's it's kinda more on the outside and it's kinda like it's more tender on the outside when i raise my arm up so [doctor] okay yeah are you able to move your arm very well or not [patient] yeah there is no restriction with my arm it just i definitely feel some pain on the outside of it [doctor] okay and are you having pain all the time or just or does it come and go [patient] just whenever i move it if i'm sitting still i really do n't notice anything but whenever i move it then i can definitely feel some pain [doctor] okay how about at night is it bothering you at night also [patient] a little bit because i sleep on that side so [doctor] okay [patient] of course [doctor] okay and i may miss did you say what have you been taking for pain for that [patient] i just been taking some advil and then icing as much as i can so that's about it [doctor] okay and does that seem to help or [patient] a little bit yeah a little bit i mean it's it's still like you know sore to touch but it definitely dulls it a little bit [doctor] well sounds like you have quite a few projects going on what all what all are you doing for for your yard and [patient] i well let's see i've been putting an outdoor shower in we're extending our patio putting making some flower boxes putting down some you know for stone and all the flower beds so my wife's really put me to work i got a laundry lift [doctor] wow it sounds like a variety of projects but if you're putting down stone you're probably lifting those as well and then [patient] yeah [doctor] yeah i bet that is sore now tell me this have you experienced any numbness in your arm or your hands or [patient] no not really no numbness that i can think of [doctor] okay alright so see i'm gon na i'd like to do just a quick physical exam and i've reviewed your vitals those look good your no fever so that's good you're ninety seven . eight and your heart rate looks good at sixty two respirations sixteen your blood pressures one sixteen over eighty four that looks fine your oxygen saturation is real good at ninety nine percent so that all looks good so let's take a look at your left at your right shoulder so you have limited active and passive range of motion and there is some tenderness at the great tuberosity of the humerus there is no tenderness at the sternoclavicular or acro acromioclavicular joints you do have a good hand grip okay and on neurovascular exam of your right arm your capillary refill is less than three seconds and your sensation to touch is intact so i've reviewed the results of your shoulder x-ray and there is no fracture so that's good so let me tell you a little bit about my assessment and plan so for your first problem the left shoulder pain your symptoms are most likely due to this rotator cuff rotator cuff tendinopathy that means you that you injured injured the tendons of the muscles that help make your shoulder muscles i think we had to go ahead and order just an mri since you have had some problems before as well to make sure there's nothing else going on with it and i also want to refer you to physical therapy for approximately six to eight weeks and so during that time continue the tylenol and if your symptoms do n't improve we can go ahead and consider a steroid injection of your shoulder which could provide some relief do you have any questions about your plan [patient] no that sounds good [doctor] okay alright yeah a lot of patients it's very successful with the physical therapy so i really hope that will do it and so we'll just start there okay [patient] sounds great [doctor] okay thanks [patient] thanks [doctor] did you have any other any other problems any other injuries that that went along with this or [patient] my both my my feet are actually really sore too i obviously have been doing a lot of other yard work so you know it's kinda it's really stiff and stuff and they you know my ankle joints as well my wife seems to think that i do n't drink enough water so it could be something along that lines but i do n't know they're kinda this they just they're really sore and stuff so i've been trying to put them up and kinda put ice on them keep them elevated and it seems to be helping out a little bit but [doctor] yeah so if you do n't feel that you did anything to injure it we might start just maybe do some epsom salts have you tried soaking your feet in epsom salts that will tend to kinda pull out what's going on in there and just help your those muscles to relax and the soreness to to go away you might try that [patient] okay that sounds like a plan that sounds good", "target": "ASSESSMENT\n\n1. Right shoulder rotator cuff tendinopathy.\n 2. Bilateral foot pain.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any signs of a fracture. I have recommended that we obtain an MRI of the right shoulder to evaluate for a possible rotator cuff tear. I have also recommended that the patient attend formal physical therapy for 6 to 8 weeks. He can continue taking Tylenol as needed for pain. If his symptoms do not improve with physical therapy, I will recommend a cortisone injection.\n \n In regards to his bilateral feet pain, I have recommended that we treat the patient conservatively. I am recommending the patient soak his feet in an Epsom salt soak as well as elevate as needed.\n \""} {"idx": 102, "inputs": "[doctor] kelly wood . date of birth , february 15th , 1979 . established patient here for renal ultrasound because of hematuria . urine dipstick today . negative for leukocytes , nitrates , protein , ketone , bilirubin and glucose . color yellow and clear , urobilinogen 0.2 , ph 5.5 and specific gravity 1.020 . there is a trace amount of blood in the urine and intact . renal ultrasound impression . right kidney is 10 cm in length by five centimeter wide . there are no stones , masses or hydronephrosis . the left kidney is 10.8 centimeters in length and five centimeters wide . there is a six millimeter left renal stone non-obstructing . 533 milliliters pre-void and 0 milliliters post-void . hi , mrs. wood . i see you're just finished your ultrasound . [patient] yes , ma'am . [doctor] well , it looks like you have one stone in the left kidney but it's not obstructing anything . [patient] i knew it had to be a kidney stone . i passed what looked like two small stones last week after i scheduled this appointment . and then for the past six weeks , i've had a few episodes of bright red urine the color of , like , cherry kool-aid . and last week , i was constantly having to pee and it hurt something terrible . [doctor] how bad was your pain on a scale of zero to 10 ? zero being no pain and 10 being worse , as you can imagine . [patient] um , at the time , i'd say an eight . [doctor] are you having any flank pain now or tenderness in your lower back ? [patient] no , after passing those stones , things have felt a lot better . [doctor] that's good to hear . now , it looks like you're only taking alavert 10 milligrams a day and have no drug allergies . is that correct ? [patient] that's right . [doctor] all right , let's take a look at you today . let's use my default pe . well , mrs. wood , we know that the blood in your urine was due to the kidney stones . fortunately , you passed two last week and the blood has nearly subsided . you do still have one stone in the left kidney . since it's not obstructing or causing pain , i do n't recommend any surgical intervention at this time . [patient] i'd like to know what i can do to stop getting these stones . [doctor] as we discussed last time , the formation of kidney stones can not be attributed to a particular cause . but several factors increase the risk , such as dehydration , family history , certain foods , digestive tract disease and certain medical conditions . [patient] yeah , i know i do n't drink near the amount of water that i should . i drink more mountain dew than anything . [doctor] you should drink about half of your body weight in ounces of water a day . [patient] so , if i weight 250 pounds , i should drink ? [doctor] that would be 125 ounces of water a day and you should avoid drinking sugary drinks like mountain dew . [patient] okay . is there any food i should n't eat ? [doctor] great question . you should avoid food rich in sodium oxalate and animal protein . so that would be salty , processed food because they're high in sodium . ideally , you should consume less than 1,000 milligrams of sodium a day and reduce the amount of beef , poultry , fish , and pork . [patient] what's oxalate ? [doctor] it's an organic acid found in plants , that when digested , it binds to minerals that stones are formed from . foods like spinach , chocolate , beets , rhubarb and soy products . [patient] well , i'll do whatever it takes to try to avoid getting these stones again . [doctor] great . and here's a handout that you can look over . it goes over the dietary recommendations and what to avoid . [patient] okay , good . i like to have things in writing to help me remember . [doctor] perfect . well , if you have any more questions . if you do n't have any more questions , you're all set . i wo n't need to see you back until next year , as long as you do n't have any more issues like bleeding or pain . if you do have any issues , you can always call the office sooner . and if you experience any severe pain or bright red blood in your urine , you should go to the emergency room . [patient] all right . well , let's hope we do n't have to do either of those and i see you next year . [doctor] yes , let's hope . come right this way and i'll walk you to check out . update pe abdomen . no flank pain . anti gu . normal vaginal exam . primary diagnosis is hematuria . secondary diagnosis is chronic urol ... urolithiasis . thank you . this completes mrs. wood encounter .", "target": "ASSESSMENT\n\n\u2022 Hematuria.\n \u2022 Chronic urolithiasis.\n \n Mrs. Wood presents today for renal ultrasound. The patient has had recurrent episodes of hematuria over the past few months secondary to chronic urolithiasis. Mrs. Wood reports passing two small stone like structures last week. Urinalysis today was notable for only a trace amount of blood and the renal ultrasound revealed a 6 mm non-obstructing renal stone in the left kidney.\n\nPLAN\n\nNo surgical intervention is recommended, and the patient would like to discuss urolithiasis prevention. We had a very lengthy discussion with regards to urolithiasis formation and treating the underlying cause to prevent reoccurrence and associated potential dietary factors that could be involved with urolithiasis formation.\n \n It is recommended that the patient maintain a healthy diet; limit salt, and animal protein. she should increase fluid consumption; adequate intake is half of her body weight in ounces of water daily and avoid sugary drinks. A copy of the dietary recommendations and avoidances was provided to the patient for reference. We will continue to monitor annually with renal ultrasound unless new symptoms develop. The patient voiced understanding and agreed with the recommended medical treatment plan."} {"idx": 21, "inputs": "[doctor] next patient is christine hernandez , uh , date of birth is january 13th , 1982 . [doctor] hey , miss christine , how are you doing today ? [patient] i'm good , thanks . how are you ? [doctor] i'm pretty good . so it looks like you've completed the covid vaccine , that's great . [patient] yes , i did . [doctor] anything new since your last visit ? [patient] no , i did all the tests that you had recommended me to take . i have n't been able to take the thyroid medicine , the one that you prescribed , as i'm still taking my old one . um , the price was a little high on the new one . [doctor] okay , so did ... did you try the coupon that i gave you ? [patient] i did not try the coupon , uh , there was a charge of $ 75 . [doctor] okay , well , next time that ... that coupon should help , and it should only be about $ 3 . [patient] okay , um ... i do n't have it , do you happen to have another one you can give me ? [doctor] yep , right here . [patient] wonderful , thank you so much , and ... and then the gel , they are charging me $ 100 for it . so , i do n't know if this is because it's a ... it's wal-mart , or if i should try somewhere else , or ... maybe you know how or where i can get it cheaper . [doctor] yeah , let's try something else , um ... sometimes it can be cheaper if we just prescribe you the individual ingredients of a medication , rather than the , the combined medication itself . [patient] that would be great . [doctor] so , that's clindamycin gel and benzoyl peroxide , uh , maybe by doing them separately , they could be a lot cheaper . so , that we can do . the unithroid , with the discount code , should only be about $ 9 for 90 days . [patient] okay , that would be great . yeah , they were charging me $ 75 , and i just could n't pay that . [doctor] maybe we'll try different pharmacy , as well . [patient] okay . so , do you think that my weight gain could have been the birth control that i was taking before that caused it ? [doctor] maybe . i do n't really see an endocrine cause for it , at least , so i would need to see the , the hyperandrogynism or high testosterone . or , a high dhea , to cause acne , or hair growth , or any of that stuff . but , the numbers are n't showing up out of range . [patient] okay . [doctor] i really do n't see any endocrine cause for it , like i said . your growth hormone was fine , but we definitely want to and need to treat it . um , i do n't know if we talked about maybe a little weight loss study . [patient] you mentioned the weight loss study , and you mentioned that i have some meal plans , um , that you had given me . i still have those , too . [doctor] have you tried to make any changes in the diet since the last time we spoke ? [patient] i've been trying to get better . i will start back at the gym in july , because of my contract , i had to put a hold on it until then . [doctor] okay . [patient] so , i do want to start doing that . i will be a little freer since , um , i'll be on vacation after july 8th . [doctor] okay , good . [patient] and then my cousin was telling me to ask you about cla , because it's supposed to help your metabolism . is that okay to take ? [doctor] um , i'm not sure . what is c , cla ? [patient] i'm not sure what it is , either . [doctor] okay , well , i'm unfamiliar with it , so ... [patient] okay . i also have a coworker who has a thyroid issue too , and she suggested to try chromium for weight loss . [doctor] so , that likely will not help too much . you can try either , if you really want to , but then ... it will not accept you into the weight loss study if you try those two . [patient] okay . [doctor] chromium is just a supplement and it wo n't help that much . [patient] it wo n't , okay , thank you . [doctor] it wo n't hurt ... okay , i should n't say that it wo n't hurt , but , it also wo n't help that much . so , it's up to you . [patient] okay . and so , my cousin also suggested amino acids , and that i might find them in certain foods , i guess , for my workout . [doctor] yeah . amino acids are fine , they wo n't , wo n't really help with weight loss either , but it might help , uh , you replenish , and just kind of , feel hydrated . [patient] okay . are they proteins ? um , my cousin said she had lost some weight , and has been working out every day , but she does n't work , so ... i do n't know . [doctor] yes , amino acids are what make up the protein , which is in any food you eat , with any protein . so , meats , dairy , nuts , any of that sort of thing . [patient] okay , thank you . got it . [doctor] all right . um , are you allergic to any medications ? [patient] no , not that i know of . [doctor] okay . is your s- skin pretty sensitive ? [patient] yes . [doctor] all right . [patient] um , yeah , my size , i will start getting rashes , with different products . [doctor] and have you ever tried clindamycin topical , as an antibiotic for your acne ? [patient] no , i've never tried anything for it . [doctor] okay . we might give you some of that . [patient] okay . and i also want to mention that my feet do swell up a lot . [doctor] okay . i'm ... let me take a look at that for just a moment . um , any constipation ? [patient] yes , i also do have that problem . [doctor] all right . mira- miralax will definitely help with that . [patient] okay , yes , my doctor did also recommend that . [doctor] great . all right , let's do an exam real quick . please have a seat on this table and i'll listen to your lungs and heart . [patient] okay . [doctor] all right , deep breath . all right , again . [patient] okay . [doctor] all right , sounds good . [patient] great . [doctor] let me take a look at your feet and ankles . [patient] okay . [doctor] all right , they look okay right now , certainly let your doctor know about this if it gets any worse or reoccurs . [patient] okay , i will do that . [doctor] now , let's go over your lab work . so , when you took that pill , the dexamethasone test , you passed , which means you do n't have cushing's syndrome . on that test , at least . the salivary cortisol , though , unless you did one wrong ... two of them were completely normal and one was abnormal , so , we might need to repeat that in the future . [patient] okay , that's okay . [doctor] all right , so , your cholesterol was quite high . the total cholesterol was 222 . the good cholesterol was about 44 . the bad was 153 , and it should be less than 100 . the non-hdl was about 178 , and it should be less than 130 . the good cholesterol should be over 50 , and it was 44 . so , your screen for diabetes is ... was fine . you do have a vitamin d deficiency , and , i do n't know if we started the vitamin d yet , or not . [patient] yes , we did . i- i do need to take one today , though . [doctor] okay . so , i also checked a lot of other pituitary hormones , iron levels ... everything else seemed to be pretty good , and in decent range . [patient] okay , that sounds great . so , i wanted to also show you my liver enzymes , um , because i have n't come back since then ... but i was also happy , because one of them was back to normal . [doctor] okay , great . let's see them . [patient] okay . so , the one that's 30 , that was almost 200 not so long ago . [doctor] yeah , your alt was about 128 . [patient] okay , and , and back in october was 254 . [doctor] yeah , this is much better . [patient] okay , great . and then it dropped in january , and then it dropped a little more in march , since i stopped taking the medicine in december . [doctor] okay , that's good . so ... i'm proud of you with the course of your labs , so before i forget , i'm going to , uh , just put your labs into the computer today , and i wo n't be checking your vitamin d level for some time . [patient] okay . so , with the thyroid , and the low vitamin d , does that always happen together ? [doctor] um , i do have a lot of people that have thyroid , thyroid issues and they have vitamin d deficiency . [patient] okay . [doctor] this is what i'm , um , i'm going to do . i'm going to put , print out your prescriptions , so you can shop around at the pharmacies and see if you can find better prices . [patient] okay , that way i can go ask them and try cvs . [doctor] yeah , that sounds like a plan . [patient] okay , good . so , the weight loss study that you mentioned , when does that start ? or , how does that work ? [doctor] so , we are about to start , as we just got approval last week , and we are just waiting on our paperwork so we can get started . [patient] okay , and what's involved with that ? [doctor] so , it'll involve you receiving a medication which has been used for diabetes treatment , and it works mostly in the gut on satiety , or satiety hormones . um , the most common side effects are going to be nausea , vomiting , diarrhea and constipation . they are s- uh , six arms , to the study . one is a placebo , the other ones are a , various as ... various dosages of the medication , excuse me . um , you would receive an injection once a week . also , keep in mind that most of the weight loss medications are not covered by insurance . [patient] okay . [doctor] so , it's a way of getting them , but , the odds of getting one of the arms with the medication that are in your favor , right , might be only one out of five of our hundred patients that we have on the list for the study that will receive the placebo . [patient] okay . [doctor] does that make sense ? [patient] yes , it does . [doctor] so , we do expect pretty big weight loss , because of what we learn in diabetes study . so , it's a year long , uh , process , and it's an injection once a week . you come in weekly for the first four , five weeks , i believe . and then , after that , it's once a month . you do get a stipend for partici- for participating in the study , and parking is validated , and whatever else that you need for the study . [patient] okay , do you know how much the stipend is ? [doctor] um , i will have to double check for you , and , you do n't have to be my patient , you just have to meet the criteria . so the criteria is a bmi greater than 30 , if you do n't have any other medical condition . or , a bmi greater than 27 , if you do have another medical condition , like your cholesterol . um , a bmi greater than 27 would quali- uh , qualify you . [patient] i have a friend who might be interested , and she does have diabetes . [doctor] if she has d- diabetes , then she wo n't qualify . [patient] okay , you ca n't if you ... if you have diabetes , got it . [doctor] correct . yeah , the only thing that , um , they can not have , really , is diabetes . so , either a psychiatric disease , or schizophrenia , bipolar , things like that . [patient] okay . [doctor] but , if they have hypertension , high cholesterol , things like that ... they can definitely sign up . [patient] and they can , okay . thank you for explaining that . [doctor] of course . so , do you want me to try to get you into that study ? or , would you just like to try , me to prescribe something ? it's kind of up to you . [patient] i think i'll just wait for a little bit now . [doctor] all right , sounds good . i'll give you the information for the research , it's just in my office . um , it is a different phone number , though . so then , if you're interested , just call us within a month , because i do n't know how long , uh , the , the wait will be . [patient] okay , will do . [doctor] perfect . so , let me go grab your discount card for the unithroid . um , when you go in to activate it , the instructions are on this card , and then you use your insurance ... then , show them this , and ask how much it'll cost . if it's too expensive , just let me know . [patient] i will . thank you so much for your help on that . [doctor] you're welcome . then , what i did is , i gave you a topical antibiotic , plus i gave you the benzoyl peroxide . so , the peroxide may bleach your sheets , but , you want to make sure to take it and apply it at night , so you do n't have a reaction from the sun during the day . [patient] okay , i can do that . [doctor] but , you do also want to make sure that you do n't mess up your sheets . [patient] okay , sounds good . [doctor] um , so , that's that . and then , let's see how you do on the other medications . i think this will , this will get better . in the meantime , a low-carb diet , avoid alcohol and fatty foods , and low chole- cholesterol foods . [patient] okay . [doctor] and again , once you finish your dose of vitamin d , for the vitamin d deficiency , you're gon na start with the 2000iu daily , so that you're able to maintain those levels . sound good ? [patient] yes , that sounds great . [doctor] i really think your liver enzymes are going to get better once you lose the weight , though . [patient] okay , that would be great . [doctor] since we stopped your birth control , we can try once called phexxi , which is kind of like a spermicide , basically . [patient] okay . [doctor] and you just apply it before intercourse . [patient] okay . [doctor] if you need some , uh , just let me know . [patient] okay , i will . i'll let you know . [doctor] okay , perfect . so , stay put for me now . i'm going to go see if they have discount samples , and bring you that prescription . and then , i'm going to order the labs for next time . [patient] okay , great , thank you so much . [doctor] you're welcome . [doctor] so , under the plan , under abnormal liver enzymes , they have improved since discontinuation of her birth control . under abnormal weight gain , her dexamethasone suppression test was normal . two out of three salivary cortisol tests were normal , not consistent with cushing's , and therefore we're ruling out cushing's . under her hirsutism , her androgen levels were normal . for the acne vulgaris , the epiduo was not covered , so we'll try benzoyl peroxide with clindamycin , and remove the previous information . on the hyperthyroidism , we'll print out her prescriptions . unithroid should be better priced with the discount card , and we'll repeat levels of everything before next visit . thanks .", "target": "ASSESSMENT\n\n\u2022 Hypothyroidism.\n \u2022 Abnormal liver enzymes.\n \u2022 Abnormal weight gain.\n \u2022 Acne vulgaris\n \u2022 Vitamin D deficiency.\n \u2022 Hirsutism\n\nPLAN\n\nHypothyroidism\n The patient will again attempt to initiate Unithroid. I have printed out the prescription and a discount card, which should result in a reduced price. She will contact my office if she encounters additional issues.\n \n Abnormal liver enzymes\n We have seen improvement since the discontinuation of Microgestin. I recommended the spermicide Phexxi for alternative birth control. The patient will also continue working on weight loss, which should additionally improve her liver enzymes.\n \n Abnormal weight gain\n Cushing\u2019s Syndrome has been ruled out. I reviewed the weight loss study with the patient, she will call within a month if she is interested in participating. I advised her to follow a low carbohydrate, low cholesterol, abstain from alcohol, and reduce fatty foods diet.\n \n Acne vulgaris\n Epiduo was not covered and too expensive. The patient will try benzoyl peroxide and Clindamycin separately to see if the price improves.\n \n Vitamin D deficiency\n The patient will complete the high dose vitamin D and then should start vitamin D 2000 IU per day to maintain her levels.\n \n Hirsutism\n Her androgen levels were normal."} {"idx": 103, "inputs": "[doctor] next patient is melissa sanchez . date of birth , 9/23/1962 . mrn : 5484367 . she is being seen in office today for status post mitral valve repair done on 8/3/2020 . at her previous follow-up on 9/17 , we felt that she was doing quite well from a cardiac standpoint , and so we recommended she continue with the same medication . ecg taken on 12/26/2020 reveals atrial fibrillation with a controlled ventricular response . t-wave inversion anteriorly . compared to the previous study , there are no significant changes , and please add in the history , patient has a history of mitral regurgitation and atrial fibrillation , history of diabetes , asthma , and recurrent chest discomfort with negative cardiac workup for coronary artery disease . [doctor] ms. sanchez , it's good to see you again . [patient] yeah , it's good seeing you too dr. hughes . you look like you're doing well . [doctor] i am , thank you . you too . you're looking great . how have you been feeling ? [patient] pretty good . i'm definitely feeling better , thank goodness . i was having a rough time before surgery , um , but i think i'm overall pretty good now though . [doctor] okay . well , that's really good to hear . i'm glad . are you having any new symptoms right now ? [patient] no , not really . but , you know , i'm still getting some chest pains sometimes , and my breathing gets shallow . but , i guess i'm learning what i can and ca n't do . uh , so if i feel like that , if i'm , like , exerting myself , i slow down a bit which helps , and then when i go back to it later , i can usually finish whatever i was doing . [doctor] okay . so , it does go away though ? how long does an episode seem to last ? [patient] uh , only a few minutes i guess . then it disappears for a while . it's weird . [doctor] what is a while ? [patient] it goes away for a couple weeks . um , so when it happens , i just take the day nice and slow , i do n't push myself . [doctor] okay . so , maybe it's a couple times a month you feel this way ? [patient] yeah , just often enough for me to notice . [doctor] understood . okay . are you taking your medications regularly ? [patient] uh- . i've been trying to keep up with that . there's a lot of extra pills now , but i have a reminder app , so i do pretty well . [doctor] okay . that's great . and so , you're taking coumadin , right ? [patient] yeah , also lasix and the atenolol . [doctor] are you having any side effects from the medications at all ? [patient] not really . uh , i notice that the atenolol is making me irritable in the beginning , but i guess i've gotten used to it , does n't seem to bother me as much now . [doctor] okay . well , that sounds good . sounds like you're well on the mend . so , why do n't i start out , um , with the physical exam , and just check you out . [patient] okay . [doctor] you're going to hear me describe things in detail or repeat things as i go to reference later for my notes . [patient] okay . [doctor] okay then . i'm going to be using my status post template , ms. sanchez , please lie down on the table here and we'll get started . all right . can you turn your head to the left . head and neck no jvd detected . you can turn back now and just take a couple of deep breaths for me please . okay , that's good . and lungs have reduced breath , but auscultation and percussion are clear . okay . breath normally , i'm just going to listen to your heart . rhythm is irregularly irregular . [patient] that's a funny statement . what does that mean ? [doctor] yeah , it does sounds kind of weird , right ? it's when your heart does n't beat with the correct rhythm , and whatever rhythm it does n't have a pattern to it . so , it's part of the atrial fibrillation . [patient] wow , that sounds like a mess . [doctor] yeah , it's not ideal . but , many people have a-fib are able to keep it under control with medicine and lifestyle changes . [patient] agh , i see . that's good to know . [doctor] okay . so , s1 slightly accentuated , no s3 . i'm going to touch your belly , and does any of that hurt . [patient] nope . [doctor] how about there ? and your feet ? [patient] no , not really . [doctor] okay , great . and trace peripheral edema on extremities . all right ms. sanchez , you can sit up now . so , it looks like your heart valves are working well and you are recovering from the surgery nicely . [patient] good . [doctor] yes . we are , we looked at your ecg taken earlier today , and we are seeing the a-fib , but it's being well controlled with the medicine , and you're taking coumadin , four milligrams , lasix at four milligrams a day , and the atenolol , you're taking that every day as well , right ? [patient] yes . the 50 milligrams every day . [doctor] great . it sounds like you're well on your way to recovery . [patient] great . [doctor] so , let's continue on your current meds . i'm glad that you're figuring out what your body can handle . definitely try to keep active as that will certainly help . [patient] i'll do my best . [doctor] and that's about it . do you have any questions for me ? [patient] um , i do . when do i need to come back and get checked out ? [doctor] well , i do n't think you need to come back soon . everything from a cardio perspective is fine . so , i think let's do a followup in about six to nine months . [patient] all right , thank you . it was good to see you again dr. hughes . [doctor] you as well ms. sanchez , do take care . [patient] you too .", "target": "ASSESSMENT\n\n\u2022 Status post mitral valve repair\n \n Mrs. Melissa Sanchez is a 58-year-old female being seen today for a status post mitral valve repair, completed on 08/03/2020.\n\nPLAN\n\nContinue with current medications. Coumadin 4 mg daily, Lasix 40 mg daily, and Atenolol 50 mg daily."} {"idx": 121, "inputs": "[patient] hi kenneth how are you the medical assistant told me that you had some knee pain yeah i was getting ready for the holiday weekend and i was out on my boat skiing and i i did a jump and kinda twisted when i landed and my knee has been hurting me ever since [doctor] okay so that was about five days ago then [patient] yeah yeah that was last weekend [doctor] last weekend okay now which knee is it [patient] it's my right knee [doctor] your right knee okay and i know that it sounds like you were on a motor boat as you were you know water skiing but did you hear anything pop or feel anything pop when it happened [patient] no it just felt like something stretched and then it swelled up some afterwards [doctor] okay and were you i assume that you were were you able to get out of the water by yourself or did you need some assistance [patient] i was able to get out but it was very sore to climb up and you know any kind of squatting or bending is really pretty sore [doctor] yeah okay and have you ever injured this knee before [patient] no that was the first time [doctor] that was the first time okay where do you have a boat what lake do you have it on lake [patient] lake martin [doctor] okay nice and so you're a frequent water skier [patient] yeah i try to go every weekend when we can [doctor] that's nice very very good are you looking forward to spring are you a baseball fan are you excited by opening day [patient] no i'm not a baseball fan but i love spring and chicken time of year launds of outdoor activities nice nice i'm i'm not really a baseball fan either but my husband makes me watch the the meds all the time and they lose all the time so he is always upset so so anyway [doctor] yeah right so how about your high blood pressure how are you doing with that are you taking your blood pressure medication like i asked [patient] i'm taking it everyday and i check my blood pressure at home and it's been about one twenty five over eighty most of the days [doctor] nice okay so i believe we have you on lisinopril about twenty milligrams a day any side effects from that that you're noticing [patient] not that i know of it's been a good medicine for me and i do n't have any trouble with it [doctor] okay great alright and since you had this knee pain any numbing or tingling in your foot at all [patient] no just the swelling and the pain [doctor] okay and what have you taken for the pain [patient] i i took some aleve twice a day some over the counter aleve twice a day [doctor] okay and [patient] putting a cold pack on it [doctor] okay and has that helped at all [patient] yeah that's helped a fair amount it's still pretty sore though [doctor] okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here [patient] i had my tonsils out [doctor] okay you had your tonsils out okay alright well let me go ahead i wan na do a just a quick physical exam i'm gon na go ahead and be calling out some of my clinical exam findings and i'll let you know what that means when i'm done okay so looking at your vital signs here in the office it does look like you're doing a really good job managing your blood pressure your blood pressure is up is about one twenty over seventy seven today here in the office and that's with you probably in a little bit of pain so that's good and on your neck exam i do n't appreciate any lymphadenopathy on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are clear to auscultation bilaterally on your musculoskeletal exam on your right knee i do appreciate some ecchymosis some edema there is an effusion present does it hurt when i press [patient] yeah that's sore [doctor] okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt [patient] yeah do n't do that anymore [doctor] alright the patient has decreased range of motion there is a negative varus and valgus test there is a negative lachman sign there is a palpable dorsalis pedis and posterior tibial pulse there is otherwise no lower extremity edema so what does that what does that mean kenneth so that so that means that you essentially i agree with you you had quite quite an injury to your knee and you do have a little bit of fluid in your knee there and just some inflammation which i think we need to talk about okay so i wan na go ahead and just talk a little bit about you know my assessment and my plan for you so for your first problem of your right knee pain i do believe you have what we call a a medial collateral ligament strain you know i wan na go ahead and just order an x-ray of your right knee just to make sure that we're not missing any broken bones which i do n't think we are but what's good about this particular injury is that people typically heal quite well from this and they typically do n't need surgery we can just go ahead and refer you to physical therapy to to strengthen those muscles around your knee so that you do n't have another injury and i wan na go ahead and just prescribe meloxicam fifteen milligrams once a day and that will help take down the swelling and help with some of the pain and you only have to take it once a day and it wo n't really cause any upset stomach or anything like that do you have any questions about that [patient] yeah if i start that medicine today am i going to be able to ski tomorrow because we got a a big weekend plan [doctor] i would say i would like you to rest your knee i i think that my concern is that if you go skiing again and you fall that you might injure your knee even more so i think you'll recover from this injury right now but i do n't want you to injure it anymore so i would rest it for a little while at least until we have the results of the x-ray and that type of thing okay for your second problem of your hypertension i wan na just go ahead and continue on lisinopril twenty milligrams a day i wan na just go ahead and order an a lipid panel just to make sure everything is okay from that standpoint and then i'm just looking through your health record and it looks like you're due for a tetanus shot so we'll go ahead and just give you a a tetanus shot for a from a health maintenance perspective any other questions [patient] i think so sounds like a good plan to me [doctor] okay sounds good alright so i'll see you later we'll get those ordered and i'll be in touch okay take care bye [patient] thank you", "target": "ASSESSMENT AND PLAN\n\n1. Right knee pain.\n - Medical Reasoning: Based on the patient's symptoms and exam, I believe he has a medial collateral ligament strain.\n - Patient Education and Counseling: We discussed the nature of this injury as well as the expected recovery outcome. He was advised surgery is typically not needed and that physical therapy will be beneficial for strengthening to prevent future injuries. He was also counseled to rest his knee until we at least receive his x-ray results in order to prevent further injury and to allow for a quicker recovery.\n - Medical Treatment: X-ray of the right knee was ordered for further evaluation. Referral to physical therapy was provided for strengthening. A prescription for meloxicam 15 mg once a day for pain and swelling was also provided.\n \n 2. Hypertension.\n - Medical Reasoning: The patient is doing well on his current medication regimen. He is monitoring his blood pressure at home and has not had any elevated readings.\n - Medical Treatment: He will continue taking lisinopril 20 mg a day. Lipid panel was ordered today.\n \n 3. Health Maintenance.\n - Patient Education and Counseling: I advised the patient that his records indicate that he is due for a tetanus vaccine.\n - Medical Treatment: The patient will receive his tetanus vaccine in office today.\n \n "} {"idx": 126, "inputs": "[doctor] hey brandon you know glad to see you in here today i see on your chart that you're experiencing some neck pain could you tell me a bit about what happened [patient] yeah i was in a car crash [doctor] wow okay when was that [patient] well which car crash [doctor] okay so multiple car crashes alright so let's see if we can how many let's start [patient] my therapist said well my well actually my mother said i should go see the therapist and the therapist said i should see the lawyer but my neck's hurting [doctor] okay so i'm glad that you know you're getting some advice and so let's let's talk about this neck pain how many car crashes have we had recently [patient] well the ones that are my fault or all of them [doctor] all of them [patient] i was fine after the second crash although i was in therapy for a few months and then after the third crash i had surgery but i was fine until this crash [doctor] okay the most recent crash when was that [patient] that's when i was coming home from the pain clinic because my neck hurt and my back hurt but that was in february [doctor] okay alright so we had a car crash in february [patient] what year it was which february it was [doctor] okay so let's let's try with this one see what happens hopefully you remember i need you to start writing down these car crashes that this is becoming a thing but you know it's okay so let's let's say maybe you had a [patient] you're not judging me are you [doctor] no there's no judgment here whatsoever i want to make sure that i'm giving you the best advise possible and in order to do that i need the most information that you can provide me makes sense [patient] yes [doctor] alright so we're gon na say hope maybe that you had a car crash and we can verify this in february of this year and you've been experiencing some neck pain since then right [patient] yes [doctor] okay alright on a scale of one to ten what ten is your arm is being cut off by a chainsaw severe how bad is your pain [patient] twelve [doctor] okay terrible pain now i know you mentioned you had previous car crashes and you've been to therapy has anyone prescribed you any medication it's you said you went to a pain clinic yes [patient] well they had prescribed it recently i was i was on fentanyl [doctor] oh [patient] i have n't gotten a prescription for several weeks [doctor] okay alright and so we will be able to check on that when you take your medication so before you take your medication rather like are you able to move like are you experiencing any stiffness [patient] yes but it hurts [doctor] okay it hurts what kind of pain is it sharp is it dull is it throbbing [patient] it's the sharp incapacitating pain i ca n't work [doctor] wow okay are you having any headaches [patient] of course [doctor] any dizziness [patient] just sometimes [doctor] any visual disturbances is it hard to like are you [patient] not recently no [doctor] okay alright any numbness [patient] yes [doctor] where [patient] my left arm and my right leg [doctor] okay any spasms [patient] of course [doctor] okay where [patient] my body hurts i told you my neck hurts [doctor] okay so i no i'm absolutely i wan na make sure that we are gon na give you the medication that works like the best for you so i'm sorry if these questions seem like frustrating i would just wan na make sure that i understand what the problem is so [patient] i saw pamela and doctor collins's office she's much nicer than you know [doctor] i mean okay so you know what like maybe maybe pamela would be better like we could maybe talk talk about a referral if that would make you more comfortable [patient] my lawyer told me to come here [doctor] then you're stuck with me okay i'm so sorry but here it's we're gon na try and make it as good as possible alright so last thing i do wan na do my physical exam alright and i need you to let me know as as much as you as much as you can verbalize right so when i push here in the middle of your neck on top of the bone does it hurt [patient] yes yes [doctor] okay alright sorry what about on the side does that hurt [patient] yes [doctor] okay so pain on palpation both on the bony process and on the muscle can you move your neck from side to side can you move your neck can you swive it side to side no no alright so i'm i'm seeing i'm seeing some range of movement moderate range of movement that's fine okay i so when can you bend your neck forward that that's your whole body just just the neck are you capable of bending up [patient] really hurts it really hurts [doctor] okay it really hurts to bend forward and backwards okay alright so i'm just gon na make a little note here i do n't i do n't see any bruising i'm not noticing any swelling there is i i do n't see any laceration what [patient] just sometimes it bruises [doctor] okay sometimes alright that's fine i i just i'm not seeing one here today so that's okay alright so with that being said i do wan na ask have you been experiencing any fatigue are you tired [patient] well since the accident yes [doctor] okay alright just making sure okay so this is what this is my assessment and plan this is what we are gon na do i want to be able to like we had you do an x-ray before you came in here and looking at it i'm not noticing any fracture that's a really good sign considering how many car accidents we've been in lately [patient] it hurts it hurts [doctor] absolutely no i we're gon na address the pain so for my first so looking at your imaging results though i'm not seeing a fracture that's a great sign so for your first diagnosis i'm gon na say that you have what is called a neck sprain that [patient] thinking are are you saying i'm thinking [doctor] no not by any means i am saying [patient] pain i have a lot of pain [doctor] yes and your pain can be explained by multiple things but thankfully it's not a broken neck is that okay [patient] yes [doctor] alright so what we are gon na do when we are gon na like try and treat this as conservatively as possible [patient] said it might be broken [doctor] what [patient] pamela said it might be broken [doctor] if pamela said it's broken then you know what this is what we're gon na do we're gon na order something called a ct that's gon na give us even nope you know what let's upgrade to an mri it's gon na give us the most thorough image of everything that's going on the heart and the soft tissues is that gon na is that so that way we can really get a good image of what's happening inside right [patient] okay because what the lawyer said i needed was an mri [doctor] not a problem we're we're gon na make your lawyer happy next step we are going to try working like from the outside in so i do need you to work on getting like you're you're saying you've seen some bruising and some swelling yourself so i want you to put ice on that whenever you're experiencing that in the moment when you wake up i want you to do your best to just like i'm gon na give you some exercises on the sheet and i want you to roll through these exercises every morning right to just get some like movement and like free frenosive movement back into your neck i also wan na put you on a couple medications now i know that you said you were on fentanyl before that's a bit extreme and i i want i i i wan na like monitor this a little more conservatively so what we're gon na start with is something called robaxin [patient] hurts a lot if i do n't get more fentanyl [doctor] you know we can refer you to pain medicine if it really is getting that complicated but for this current period we're gon na put you on some robaxin it's gon na be fifteen hundred milligrams and you're gon na take that six to eight hours every six to eight hours and that really should help kinda relax the muscles in the area take off some of that tension and really help with that pain if you're noticing that the robaxin still is n't helping maybe then we can start we can like start using like a heat pad or maybe some icyhot the biofreeze is a really good one to kinda help with that and then we will refer you to physical therapy i think with the mri we can start evaluating maybe some additional steps so rather than you having to like take that fentanyl because i do n't want you to be in danger right like people i do n't want you to get rubbed so what we could explore are local injections right and we can refer you to pain medication and see about like locally injecting the area and that should be able to help you out hopefully with this [patient] i ca n't go to work like this [doctor] okay so if it's if it's that bad let's wait for the mri result we're gon na give you off for work because you know you ca n't move and we'll see what the mri says about what whether or not we can get you like true local injections in the moment is that alright for now [patient] yeah [doctor] okay okay any other questions [patient] not right now [doctor] alright", "target": "ASSESSMENT\n\nNeck sprain.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any signs of a fracture. I recommended an MRI for further evaluation. I have also prescribed the patient Robaxin 1500 mg every 6 to 8 hours to treat his pain. I have also advised him to utilize ice, a heating pad, IcyHot, or Biofreeze on his neck as needed. I have also provided him with a home exercise program to work on his range of motion. I advised the patient that he will not be able to work until we have the MRI results."} {"idx": 35, "inputs": "[doctor] well hello christina so how are you doing i was notified you were in the hospital for some heart failure what happened [patient] well i'm doing better now but i just started having problems that my ankles were swelling and could n't get them to go down even when i went to bed and could n't breathe very good had to get propped up in bed so i could breathe at night and so i just really got to feeling bad i called my friend diane and she said i probably ought to call nine one one since i was having a hard time talking and so i called nine one one and they sent out an ambulance and they took me into the er on the it was quite an experience [doctor] yeah [patient] having an ambulance ride and and i've never done that before so not an experience i wan na do again either [doctor] i'm sure you do n't yeah i see that your blood pressure was high also it was two hundred over ninety have you been [patient] yeah i guess is that really high [doctor] yeah that's [patient] i feel really bad [doctor] yeah that's pretty high are you taking your medications or you missing some doses [patient] i do n't know i might miss one now but i try to take them all time [doctor] yeah yeah you really need to take them very consistently now you also said you were watching your diet did you did you have some slips with that you said your ankles were swelling [patient] no i yeah i do i like to i like to eat [doctor] are you eating a lot of salty foods and pizza or [patient] i like potato chips [doctor] yeah [patient] i like the salt and vinegar potato chips they're really good so [doctor] well so do you do you go out to eat a lot or do you where you where where are you eating those potato chips or is that just the home snacking or [patient] that's home snacking i buy the the the the brand name salt and vinitive because brand wo n't taste real good but the the brand names really tastes good [doctor] oh [patient] so i eat those probably everyday [doctor] goodness well you know you we need to probably stop eating those now [patient] yeah well i hate to hate to give those up but i guess i might have to [doctor] well since you've been in the hospital and and they've helped you out with some with all that how are you feeling now [patient] well i'm i'm doing better [doctor] mm-hmm and they [patient] i do n't do n't have quite as much shortness of breath i think maybe getting up and walking a little more is helping [doctor] and they gave you a water pill and is that is that helping is that making you pee a lot [patient] yeah yeah i have almost incontinence so [doctor] goodness [patient] yes that's not very pleasant at all [doctor] and so they added another blood pressure medication also how are you doing with that are you feeling a little bit better [patient] yeah i think so [doctor] okay [patient] if i can remember to take the pills [doctor] yeah [patient] that seems to be a sticky point [doctor] well a a pill box or maybe setting an alarm on your phone might really help [patient] okay i'll i'll give that a try anything that will help [doctor] yeah okay well that's good to hear so now have you bought a blood pressure cuff to have at home now [patient] yes i already had one but i very failed if i ever used it [doctor] okay [patient] but [doctor] got it [patient] i'll i'll try to use it everyday now [doctor] okay and you might even just keep a log of what your blood pressures are and when it's up think about you know what you've eaten if you've done something different because that may help you to figure out what you need to cut back on or how you might need to change your your eating habits a little bit so [patient] okay okay [doctor] have you been short of breath or any problems sleeping since you've been home [patient] no i've been sleeping like a log [doctor] okay good alright have you had any chest pain [patient] no no chest pain [doctor] okay alright well let's do a quick physical exam here so your vital signs your blood pressure looks pretty good today at one twenty eight over seventy two your temperature is ninety eight . seven and your heart rate is seventy two your respirations are eighteen your oxygen saturation looks pretty good at at ninety six percent okay now on your neck exam there is no jugular venous distention on your heart exam i appreciate a two over six systolic ejection murmur which i've heard before and so it's stable and your lungs are clear bilaterally and your lower extremities show just trace edema now now we since we did the echocardiogram i reviewed those results and it does show a preserved ef of fifty five percent abnormal diastolic filling and mild-to-moderate mitral regurgitation so let me tell you a little bit about my assessment and plan so for your first problem for your congestive heart failure it sounds like this was caused by dietary indiscretion and some uncontrolled hypertension so i want you to continue on your bumex two milligrams once daily continue to watch your diet and avoid salty foods might try keeping that log we talked about with your blood pressures and what you've eaten if if your blood pressure seems a little high also weigh yourself daily and call me if you gain three pounds in two days okay [patient] okay [doctor] and i also want you to see a nutritionist to give you some education about what foods you can eat okay now for your second problem for i know this sounds like this is just for you and so for your second problem for your hypertension i want you to continue on the cozaar one hundred milligrams daily continue on the norvasc five milligrams once daily also and i'm going to order a renal artery ultrasound just to be sure we're not missing anything and then like maybe you know some renal artery stenosis or something and so so for your third problem for your kidney disease i wan na get some more labs to make sure you tolerate this the new medications and then i'll see you again in three months do you have any questions [patient] no i do n't think so not today [doctor] alright it's good to see you and i hope we'll just keep getting you feeling better [patient] okay", "target": "ASSESSMENT AND PLAN\n\n1. Congestive heart failure.\n - Medical Reasoning: This appears to have been caused by dietary indiscretion and uncontrolled hypertension.\n - Patient Education and Counseling: I encouraged the patient to continue making dietary modifications, including limiting her sodium intake. She could try keeping a food diary, as previously discussed, to log her diet and associated blood pressure readings. I also advised her to monitor her weight daily and contact me if she gains 3 pounds in 2 days.\n - Medical Treatment: Continue with Bumex 2 mg once daily. Referral placed for consult with a nutritionist for education and recommendations regarding her diet.\n \n 2. Hypertension.\n - Medical Reasoning: This has been poorly controlled due to inconsistent compliance with medication and dietary indiscretion.\n - Patient Education and Counseling: We discussed dietary modifications as noted above.\n - Medical Treatment: She can continue on Cozaar 100 mg daily and Norvasc 5 mg once daily. Renal artery ultrasound ordered to rule out any issues such as renal artery stenosis.\n \n 3. Kidney disease.\n - Medical Treatment: Labs will be ordered to assess her response to new medications.\n \n "} {"idx": 118, "inputs": "[doctor] alright so how're you doing today angela [patient] i'm doing pretty well [doctor] alright so looking here at your appointment notes it says you're you're here you think you have a kidney stone you had some in the past so we're gon na take a look at that and then you also have a past medical history of hypertension and diabetes we want to take a look at those as well so first thing what's going on with your kidneys you as what how long ago have you been feeling pain and and how's all that [patient] pain's been up and down i went to the emergency room last week but now i think i'm doing a little bit better [doctor] okay so the case of kidney stones so have you had you said you've had them in the past and how often would you say [patient] i do n't know i this is probably like my seventh or eighth kidney stone [doctor] seven or eight kidney stones so do you think you passed it yet or is it still in the [patient] i think this one passed yeah [doctor] this one passed how long would you say it took to [patient] well i went last week and then i think it passed about three days ago [doctor] okay so are you still noticing any blood in your urine [patient] no no more blood [doctor] alright are you still having pain [patient] nope [doctor] yeah [patient] the pain's gone [doctor] okay that that's that's that's really good did they do anything for you at the hospital giving you any medications [patient] they gave me some pain medicine [doctor] okay do you remember what it was [patient] i think it was percocet [doctor] okay well that's good i'm very glad to see that you were able to pass that stone have you seen a urologist before about this [patient] i have n't seen one in a while but yes i saw someone maybe a year ago [doctor] okay so yeah i know you keep having these recurrent kidney stones so i definitely think we can get you a referral to urology just to check up on that and also wan na do some labs as well [patient] okay [doctor] so i also see you're here for you have a past medical history of of hypertension and when you came in today your blood pressure was a little bit high it was a one fifty over ninety i'm reading here in your chart you're on two point five of norvasc [patient] hmmm [doctor] now have you been taking that regularly [patient] i have but at home my blood pressure is always great [doctor] okay maybe you have a little white coat syndrome some of my patients do have it i have it myself and i'm a provider so i definitely understand yeah i know we we talked about last time you getting a blood pressure cuff and taking those about two to three times a week so what have those readings been i'm usually like one thirty to one forty over sixty to seventy [patient] okay [doctor] that's that's that's not too bad i think when you first came in you were around like one eighty so it seems to be that that norvasc is is working for you how about your diet i know you were having a little issue eating some fast food and and cakes and cookies and have you been able to get that under control [patient] yeah it's hard to give up the fast food altogether because it's a lot of on the go you know [doctor] okay so do you think you would be able to get that under control by yourself or would you do you think you would need help with that maybe a dietitian be able to help you out [patient] yeah i do n't know i do n't know if i can make another appointment i just add to the extra [doctor] okay [patient] less time to make food so [doctor] yeah yeah definitely understand [patient] mm-hmm [doctor] alright yeah so i mean that's one thing we just got ta work one is your diet we try to keep you at least just twenty three hundred milligrams or less of sodium per day i know that's hard for a lot of salads and stuff i know it's hard for lot of people especially with all like the the prepackage foods we have around today so that's definitely something we we should work on [patient] mm-hmm [doctor] so let's also look here you have a history of diabetes and so you're on that five hundred milligrams of metformin daily now have you been taking that as well [patient] yeah i take my metformin [doctor] okay [patient] yeah [doctor] so what have your blood sugars been running daily [patient] well i do n't check it very often [doctor] okay [patient] but i think they've been pretty good [doctor] okay so i'm looking here i think last after your last visit you got a1c now was six . seven so it's a little bit high it's gone down a little bit since you were first diagnosed with the type two diabetes a year ago so i'm glad we're making progress with that as well alright so i'm just gon na do a quick physical exam on you before i do just wan na make sure are you having any chest pain today [patient] no [doctor] alright any any belly pain [patient] no [doctor] alright so i'm gon na listen to your lungs your lungs are clear bilaterally i do n't hear any crackles listen to your heart so on your heart exam i do hear that grade two out of six systolic ejection murmur and we already knew about that previously so it has n't gotten any worse so that's good so i'm gon na just press here in your abdomen because that you did have those kidney stones does that hurt [patient] no [doctor] alright i'm gon na press here on your back [patient] no pain [doctor] okay so on your abdomen exam of your abdomen i'm showing no tenderness to palpation of the abdomen or tenderness of the the cva either on the right side so that that's good i think that's pretty much cleared up so let's we'll talk a little bit about my assessment and plan for you and so my assessment you you did have the those kidney stones but i i think they are passed this time but i do want to get a couple of labs so we'll get a urinalysis [patient] okay [doctor] alright we'll get a urine culture just to make sure everything is is cleared up i also want to give you a referral to referral referral to urology [patient] okay [doctor] because you do keep having these all the time and so maybe there's something else going wrong and so they can help get that under control [patient] can i see doctor harris [doctor] of course yeah we can we can get you that road to doctor harris and [patient] he's not like [doctor] he's great he's he's he he he's great i've heard he does really good work so that'll be good so for the hypertension you seem to be doing well on the two . five of norvasc so we are not gon na make any changes to that do you need any refills right now [patient] no usually the pharmacy just sends them through when i call [doctor] okay great so we we wo n't we gave you refills with that i do wan na give you a consult to nutrition [patient] okay [doctor] just to help you with that diet [patient] okay [doctor] because i think that's a major factor of us eventually getting you off of all medications [patient] hmmm [doctor] and then for your diabetes i'm just keep you on that on that five hundred of metformin okay i think you're doing well with that as well also but i do want you to start taking your blood sugars if you can take them before every meal [patient] okay [doctor] just to gauge where you are so you can tell how much food you should actually be be eating [patient] okay [doctor] alright [patient] i can try that [doctor] so how does that that sound [patient] that sounds like a plan when should i come back and see you [doctor] so you can you can come back in three months and we'll check up again i forgot you did tell me last time that you were having some issues with insomnia [patient] hmmm [doctor] how is that going for you is it still happening [patient] i mean sometimes i stay awake just kinda worrying about things but but i've tried some meditation apps and that helps [doctor] okay alright and i know we talked a little bit before about practicing proper sleep hygiene you know just making sure that all of your electronics are off you know dark room [patient] yeah [doctor] cool room have you been doing that [patient] well i do like to sleep with the tv on and my phone is right by my bed because i never know if someone's gon na call me you know [doctor] yeah i i know i'm like apple i do n't know if you have an iphone or not but i know apple has this the the sleep mode now do that disturbance so you put that on [patient] it's a good idea [doctor] interrupt you [patient] yeah [doctor] okay have you tried taking melatonin to sleep [patient] i used it a couple times but but it did n't seem to help that much [doctor] okay how about i do n't think i've prescribed you anything yet do you think you would need anything [patient] hmmm i do n't really wan na take any sleeping pills [doctor] okay that's understandable alright so for the last issue for the insomnia i'm just gon na have you take ten milligrams of melatonin as needed [patient] okay [doctor] and just try i guess the best as possible to practice the proper sleep hygiene so you can get to sleep at night and and feel pretty rested [patient] okay [doctor] alright [patient] mm-hmm [doctor] so do you have anything any other questions for me [patient] no that's all [doctor] alright so we will see you in three months [patient] okay sounds good [doctor] alright [patient] like", "target": "ASSESSMENT AND PLAN\n\n1. Kidney stones.\n - Medical Reasoning: Patient recently experience an episode of kidney stones which is her 7th or 8th episode. Based on the patient's symptoms and exam today, I think she has likely passed her kidney stones.\n - Patient Education and Counseling: I advised the patient that we will obtain further testing, however, based on her recurrent episodes a referral to urology is necessary.\n - Medical Treatment: Urine culture and urinalysis were ordered. She will be referred to Dr. Harris in urology.\n \n 2. Hypertension.\n - Medical Reasoning: Patient is currently stable and doing well on Norvasc 2.5 mg.\n - Medical Treatment: Continue Norvasc 2.5 mg. Referral to nutrition provided.\n \n 3. Diabetes.\n - Medical Reasoning: Patient is currently stable and compliant with her metformin.\n - Patient Education and Counseling: She was advised to start checking her blood sugar prior to every meal.\n - Medical Treatment: Continue metformin 500 mg daily. Start daily blood sugar monitoring before each meal.\n \n 4. Insomnia.\n - Medical Reasoning: The patient has a history of insomnia.\n - Patient Education and Counseling: We discussed proper sleep hygiene.\n - Medical Treatment: I have recommended she take 10 mg of melatonin as needed.\n \n "} {"idx": 95, "inputs": "[doctor] hi , cheryl . how are you ? [patient] i'm doing well . how are you ? [doctor] i'm doing well . so i know the nurse told you a little bit about dax . i'd like to tell dax about you . [patient] okay . [doctor] cheryl is a 34-year-old female with a past medical history significant for hypertension , who presents today with back pain . cheryl , what happened to your back ? [patient] so i've been walking a lot lately . i've been walking to ... 30 minutes to an hour or so a day . and all of a sudden , um , when i was walking , my , um , back just kind of seized up on me . and i do n't really know what it was . maybe i was going a little bit faster . but it just all kind of clenched . [doctor] okay . so you felt like , maybe like a spasm or something like that ? [patient] yeah . [doctor] okay . and how many days ago was that ? [patient] that was about six days ago now . [doctor] okay . and what have you taken for the pain ? [patient] i've been taking ibuprofen . um , and then i've been putting some heat on it . but it's still pretty stiff . [doctor] okay . all right . um , and did you have any trauma before that happened ? were you doing anything strenuous like crossfit or lifting boxes or anything like that before you went for , for the walk ? [patient] i have been lifting more , um , probably around three times a week . so i do n't know if it was because i was doing deadlifts that day and then walked . [doctor] okay . [patient] um , maybe i was using my back more than my legs . [doctor] okay . all right . and was it any particular area in your back ? was it the lower back ? [patient] yeah , it was . [doctor] okay . on one side versus the other ? [patient] um , kind of both equally . [doctor] okay . all right . and any numbing or tingling in your legs or your feet ? [patient] no , i have n't felt anything like that . [doctor] okay . any weakness in your lower extremities ? [patient] no . [doctor] okay . all right . and then in terms of your blood pressure , how are you doing ? [patient] so i got that cuff that you suggested the ... our ... the last visit , and i've been doing readings at home . and that's been looking great , too . i've been watching my diet . again , my boyfriend's been great and dieting with me so i do n't have to do it alone . and everything's been good . [doctor] okay . excellent . and you're taking the lisinopril ? [patient] yes . [doctor] okay . wonderful . okay . so i know you did a review of systems sheet with the nurse , and i know you endorse , you know , this back pain . um , do you have any other symptoms ? fever , chills , congestion , cough , chest pain , shortness of breath ? [patient] i have a little bit of nasal congestion , but that's just from my seasonal allergies . [doctor] okay . all right . well , let's go ahead . i want to do a quick physical exam on you . [patient] okay . [doctor] okay ? hey , dragon , show me the vital signs . so good- you know , here in the office , your vital signs look great . your blood pressure's really well controlled , which is good . so that's a good job . so i'm going to take a listen to your heart and lungs . i'm going to examine your back , and i'm going to let you know what i find . okay ? [patient] okay . [doctor] okay . all right . so on physical examination , you know , everything looks good . you know , on your heart exam , i do hear that slight two out of six systolic ejection murmur , but you've had that before . that seems stable to me . on your back exam , you do have some pain to palpation on the right lateral aspect of your lumbar spine , and you do have pain with flexion and extension as well , and you have a negative straight leg raise . so what does that mean ? so we're going to go over that . okay ? let's ... let me look at some of your results , though , first . okay ? [patient] okay . [doctor] we did an x-ray before you saw me , so let's look at that . hey , dragon , show me the back x-ray . so looking here at this x-ray of the lumbar spine , everything looks good . there's good boney alignment . there's no obvious fracture , you know , which is not surprising based on your history . okay ? [patient] hmm . [doctor] hey , dragon , show me the labs . and your labs that we did before you came in all look great . there's no elevated white blood cell count . there's no signs of infection . again , those are all really good . okay ? so let me go over with you about my assessment and my plan for you . so for your first problem , this back pain , i think you have a lumbar strain , and , you know , that might've happened , you know , lifting something or exercising . and so what i want to do is prescribe meloxicam , 15 milligrams once a day . uh , i want you ... you can ice the area , and you can also apply heat sometimes as well . um , you know , i'm going to refer you to physical therapy just to do some strengthening exercises of your back , um , because i do want you to continue to be able to work out and exercise . okay ? [patient] okay . [doctor] and for your last problem , your high blood pressure , again , everything looks great here . um , you know , i think you're doing a really good job with that as well . i want you to continue on the lisinopril , 10 milligrams a day . and then , uh , let me know if you notice any increases in your blood pressure readings . okay ? [patient] okay . [doctor] do you need a refill of the lisinopril ? [patient] yes , i do , actually . [doctor] okay . hey , dragon ? order lisinopril 10 milligrams po daily . okay . uh , so the nurse will be in soon , and she'll get you checked out . okay ? [patient] okay . [doctor] all right . hey , dragon ? finalize the note .", "target": "ASSESSMENT AND PLAN\n\nMs. Ramirez is a 34-year-old female with a past medical history significant for hypertension, who presents today with back pain.\n \n Back pain.\n \u2022 Medical Reasoning: She experienced a spasm-like pain in her back while walking approximately 6 days ago. She has also been lifting weights recently. Her lumbar spine x-ray was unremarkable and her recent labs were normal. I believe she has a lumbar strain.\n \u2022 Medical Treatment: We will initiate meloxicam 15 mg once daily.\n \u2022 Specialist Referrals: We will refer her to physical therapy to work on strengthening exercises.\n \u2022 Patient Education and Counseling: She may apply ice and heat to the area.\n \n Hypertension.\n \u2022 Medical Reasoning: This is well controlled with lisinopril and dietary modifications based on home monitoring.\n \u2022 Medical Treatment: She will continue lisinopril 10 mg daily. This was refilled today.\n \u2022 Patient Education and Counseling: I encouraged her to continue with home monitoring and report any elevated blood pressures to me.\n \n "} {"idx": 81, "inputs": "[doctor] so beverly is a 53 -year-old female with a recent diagnosis of stage three nonsmile cell lung cancer who presents for follow-up during neo agit chemotherapy she was diagnosed with a four . four centimeter left upper lobe nodule biopsy was positive for adenocarcinoma molecular testing is pending at this time alright hello beverly how are you [patient] i'm good today [doctor] you're good today yeah you've been going through a lot lately i know you just had your treatment how how are your symptoms [patient] my symptoms are pretty good today i just kind of have a minimal cough and a sore throat [doctor] okay [patient] but that's all i'm feeling today [doctor] okay and how about fatigue have you been feeling more tired [patient] yes a little bit [doctor] okay and how about any nausea or vomiting [patient] no not as of today [doctor] okay and i know you were mentioning a cough before how is it as far as walking are you having any shortness of breath [patient] i have n't noticed any shortness of breath it just kind of seems to be a lingering kind of light dry cough [doctor] cough okay is it any mucus with it or is it a dry cough [patient] more dry [doctor] a dry cough okay and tell me more about this sore throat [patient] this kind of seems to be persistent comes and goes it will be worse sometimes and then others it feels better trying to drink lots of fluids [doctor] okay [patient] to see if it can it you know the dry coughing if it's part of that or what i can do [doctor] okay and when you mention drinking and eating is do you feel like anything is getting stuck there [patient] no i do n't feel like anything is getting stuck right now and i have n't been i have been eating but not as much as i normally would [doctor] okay okay alright and how are you doing as far as like just emotionally and mentally how are you doing i'm just talking a little bit about your support systems [patient] the nursing staff and the office has been very good to help you know with anything that i need as far as support so just since we are just getting started so far on the journey i do feel like i have support and mentally you know still feel strong [doctor] okay and how about with family or friends have you been able to turn to anyone [patient] i do have good family members that have been supportive and they have come to my treatment with me [doctor] okay excellent excellent and so right now you're on a combination of two different chemotherapies the cisplestan as well as the eupside and you had your last treatment just a few days ago but you're saying right now you've been able to tolerate the nausea and the fatigue [patient] yes i have n't had any nausea but you know just slight fatigue it does n't seem to be overwhelming [doctor] okay okay so we are gon na go ahead if it's okay with you and start your physical exam reviewing your vitals so vitals look good especially your oxygen especially with the chemotherapy you've been getting and the cough so your oxygen looks good so i'm happy with that so now i'm just examining your neck especially with your sore throat and i do n't appreciate any cervical lymphadenopathy and also no supraclavicular adenopathy listening to your heart you have a nice regular rate and rhythm with no murmurs that i appreciate now on your lung exam when you're taking some deep breaths i do notice some crackles in your lungs bilaterally and what that means is there is there is some faint sounds that i'm hearing which could represent some fluid there so on looking at your skin exam on your chest you do have some erythema on the anterior side of the chest on the left side and this could be related to the radiation so on your lower extremities i appreciate no edema and everything else looks good and thank you i know you did a chest x-ray before coming in so on your results for the chest x-ray it does look like you have some mild radiation pneumonitis which basically means some inflammation of the lungs most likely due to the radiation so what does this all mean so for your assessment and plan so for the first diagnosis the first problem of the lung cancer so what we're gon na do is we're gon na continue with the current regimen of your chemotherapy of the cisplacin and the etoside and we're gon na continue with your current dose of radiation at forty five grade and when that's complete we will repeat some imaging and hopefully you know the tumor will shrink down enough that we can remove it surgically okay for problem number two so the radiation pneumonitis so that's what causing that cough as well as some of the shortness of breath i know you're not experiencing it much now so what i'm gon na do for that is actually gon na prescribe you a low dose of prednisone and so that's an will help with the inflammation i'm gon na give you forty milligrams daily for five days and so hopefully that will help reduce the inflammation and so that you can continue with the radiation okay how does that sound so far [patient] that sounds great thank you [doctor] okay and then lastly for the painful swallowing that you're having so the inflammation you're having it not only in your lungs but it also in your esophagus as well so what i'm gon na do is prescribe you you're taking the the prednisone i'm also gon na give you a lidocaine swish and swallow and you can do that four times a day and so that will be able to help you so you can eat immediately after taking it and it can also help so that you can continue to take food and fluids prevent dehydration and any further weight loss [patient] great [doctor] okay any questions for me [patient] i do n't believe so at this time [doctor] okay alright so i'll see you at your next visit [patient] great thank you [doctor] you're welcome and so now just", "target": "ASSESSMENT AND PLAN\n\n1. Stage III non-small cell lung cancer.\n - Medical Reasoning: The patient has a recent diagnosis of stage III non-small cell lung cancer. Biopsy was positive for adenocarcinoma. Molecular testing is pending at this time.\n - Medical Treatment: We are going to continue with the current regimen of combination chemotherapy consisting of Cisplatin and etoposide. We are also going to continue with her current dose of radiation at 45 Gy. Once this is complete, we will obtain repeat imaging in hopes that the tumor will decrease in size enough for surgical removal.\n \n 2. Radiation pneumonitis.\n - Medical Reasoning: The patient is experiencing a persistent dry cough. Recent x-rays are reviewed and demonstrated evidence of mild radiation pneumonitis.\n - Patient Education and Counseling: We discussed the etiology of her dry cough is from her mild radiation pneumonitis.\n - Medical Treatment: A prescription of prednisone 40 mg daily for 5 days is provided to help with her inflammation.\n \n 3. Painful swallowing.\n - Medical Reasoning: The patient is experiencing painful swallowing secondary to inflammation of the esophagus.\n - Patient Education and Counseling: We discussed the etiology of her painful swallowing and that a lidocaine viscous solution will be beneficial in preventing dehydration and any further weight loss.\n - Medical Treatment: A lidocaine viscous solution was provided to be performed 4 times daily.\n \n "} {"idx": 73, "inputs": "[doctor] today i'm seeing christina cooper . her date of birth is 07/01/1954 . uh , ms. cooper is a new patient who was referred by diane nelson for a long-standing iron deficiency anemia . [doctor] hello , how are you ? [patient] i'm good , thank you . [doctor] so tell me what brings you in today . [patient] recently i tried to donate blood , around december i think , and they told me i was anemic , which is something i've been dealing with for a while , so it's not the first time i've been told i'm anemic . [doctor] or how have you been feeling in general with this ? [patient] not great . i have been feeling fatigued often during the day , and even feverish with chills at times . when i try to be active i like i ca n't catch my breath and i feel like i'm wheezing . i've had some headaches too , which is not like me . [doctor] okay . are there any other symptoms ? [patient] i've been noting some chilling sensations . i also get cold so easily . it's annoying . i feel like i have to really bundle up . i do n't know if this is related but my anxiety and depression feel like it has been getting worse lately . i feel like a mess . [doctor] sounds like you're not feeling great , obviously . and i'm glad you came to see us . um , we're certainly going to try to figure this out and figure out what's going on , uh , but it sounds like you've been dealing with this anemia for a long time ? [patient] yeah , i've been anemic since i was 13 years old . [doctor] right . so why do your doctors think you're anemic ? do you have a history of heavy periods ? [patient] well i did have heavy periods until i had a hysterectomy in 1996 . but no , they have not told me why they think i'm anemic , which is frustrating honestly . [doctor] yeah . i can imagine that is . um , let's see if we can help though . since you had your hysterectomy your periods , of course , are no longer the issue . um , when was your last colonoscopy ? [patient] about five to six years ago . [doctor] and was it relatively a normal exam ? did you have any polyps ? [patient] no . they said they'd see me in 10 years . [doctor] well that's good news . [patient] yeah , i agree . [doctor] um , do you have a pacemaker or defibrillator , or have sleep apnea , or use oxygen at night ? [patient] no . [doctor] all right . do you ever drink alcohol ? [patient] yeah , but only once or twice a year . [doctor] okay . are you taking any supplements such as iron or vitamin b12 ? [patient] i already started taking my iron pills which i have not taken in about a year . [doctor] all right . and what are you taking ? [patient] i'm taking 25 milligram tablets , twice daily . [doctor] okay , and that's the , the ferrous sulfate ? [patient] yeah , that's it . i take one in the morning and one in the evening . [doctor] okay . anything else ? [patient] yeah , i take vitamin b12 , just the over the counter stuff . [doctor] okay , very good . all right , well let's go ahead and take a look and see what's going on . [patient] sounds good . thank you . [doctor] of course . you'll hear me , uh , talk through your exam so that i get all the information documented . [patient] okay . [doctor] all right . so use my general physical exam template . i will start by listening to your heart and lungs . [patient] okay . [doctor] all right . next , i'd like you to lay back so i can examine your abdomen . [patient] okay . [doctor] is there any tenderness where i'm pressing ? [patient] no . [doctor] okay . you can sit up . so your physical exam is normal without any significant findings . all right ms. cooper , often when we initially see anemia and your host of symptoms , we suspect internal bleeding . [patient] is that why they want me to have another upper endoscopy ? [doctor] actually it would be an upper endoscopy and a colonoscopy , but yes , likely that's the reason why . [patient] lovely . [doctor] yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system . [patient] okay . [doctor] we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better . [patient] all right . [doctor] so let's go ahead , get your upper endoscopy and colonoscopy scheduled . [patient] okay . [doctor] um , have you ever had any issue with sedation in the past ? [patient] no , i was just sleepy afterwards . [doctor] okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy . [patient] okay . sounds like a plan . [doctor] all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work . [patient] okay , that sounds great . [doctor] all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if you have any questions or worsening symptoms . we'll be happy to help you . [patient] thank you . [doctor] you're welcome . have a great day , have a great day ms. cooper . [patient] you too . [doctor] all right . this is christina cooper , pleasant 65 year old female who was diagnosed with iron deficiency anemia in 12-2019 , and w- and was unable to donate blood . um , her followup blood work on 01/20/20 was revealed a low hemoglobin , stable hematocrit and normal iron labs , although ferritin was low . um , she was taking ferrous sulfate , three hundred , twenty phil- 25 milligrams by mouth . i've asked her to continue each dose with vitamin c found in orange juice , for the next 12 weeks , then recheck to the cbc , iron , ferritin , b12 , and folate . um , a referral was sent to her hematologist . we will plan for an egd and a colonoscopy to assess for potential sources of anemia or gi bleed . if this is inconclusive , capsule endoscopy will be considered . thanks .", "target": "ASSESSMENT\n\n\u2022 Iron deficiency anemia\n \n Mrs. Cooper is a 65-year-old female who was diagnosed with iron deficiency anemia in 12/2019 and was unable to donate blood. Her follow-up blood work in 01/2020 revealed a low hemoglobin, stable hematocrit, and normal iron labs, although, ferritin was low. She has been taking ferrous sulfate 325 mg by mouth.\n\nPLAN\n\nI have asked her to continue each ferrous sulfate dose with vitamin C found in orange juice for the next 12 weeks then recheck CBC, iron\u202fferritin, B-12, and folate. A referral was sent for her to see a hematologist. We will plan for EGD and colonoscopy to assess for potential sources of anemia or GI bleed. If this is inconclusive, capsule endoscopy can be considered."} {"idx": 31, "inputs": "[doctor] sophia brown . date of birth , 3/17/1946 . this is a new patient visit . she's here to establish care for a history of dcis . we'll go over the history with the patient . [doctor] hello , ms. brown . [patient] hi . yes , that's me . [doctor] wonderful . i'm doctor stewart . it's lovely to meet you . [patient] you as well . [doctor] so , you've come to see me today because you had a right breast lumpectomy last year . is that right ? [patient] yes . on january 20th , 2020 . [doctor] okay . and how have you been since then ? any problems or concerns ? [patient] no , i'm feeling good . i do my self breast exams religiously now and have n't felt anything since . [doctor] perfect . i want to back up and go over your history so i can make sure everything in your chart is correct and i do n't miss anything . so , i'll tell you what we have in your chart from your other providers and you tell me if anything is wrong or missing . sound good ? [patient] sounds good . [doctor] great . so , i have that you were found to have a calcification in your right breast during a mammogram in october 2019 . was that just a normal screening mammogram , or was it done because you felt a lump ? [patient] it was just a normal one you're supposed to get every so often . [doctor] i see . and then it looks like you had an ultrasound of your right breast on november 3rd , 2019 , which revealed a mass at the two o'clock position , 11 centimeters from the nipple in the retroareolar region . the report states the mass was point four by two by three centimeters . [patient] yes , that sounds right . hard to remember now , though . [doctor] yep , definitely . [doctor] based on those results , they decided to do an ultrasound-guided core needle biopsy on december 5th , 2019 . pathology results during that biopsy came back as grade two , er positive , pr positive , dcis , or ductal carcinoma in situ . [patient] yes . unfortunately . [doctor] i know . scary stuff . but you had a lumpectomy on january 20th , 2020 , which removed the eight millimeter tumor and margins were negative . the pathology confirmed dcis . looks like they also removed 5 lymph nodes , which , thankfully , were negative for malignancy . that's great ! [patient] yeah , i was definitely very relieved . [doctor] and your last mammogram was in january 2021 ? and that was normal . [patient] yes . [doctor] okay . so , i feel like i have a good grasp of what's been going on with you now . and you're here today to establish care with me so i can continue to follow you and make sure you're doing well , right ? [patient] yes . fingers crossed . [doctor] definitely . we'll keep a close eye on you and take good care of you . [patient] okay , sounds good . [doctor] i have a few more questions for you . when was your last colonoscopy ? [patient] i had one in 2018 and , if i remember correctly , i had one polyp and that was removed and it was n't cancerous . [doctor] okay , yes , i see that report now . one polyp in the sigmoid colon which had a benign tubular adenoma . okay . and when was your last menstrual period ? [patient] gosh . it was probably around 30 years ago . [doctor] okay . do you have children ? [patient] i do . i have five . [doctor] ah , big family then . that's nice . [patient] yes . and they're all having kids of their own now , so it's getting even bigger . [doctor] i bet . sounds like fun . [patient] it is . [doctor] did you have any other pregnancies that were miscarriages or terminations ? [patient] really , i did not . [doctor] okay . so for the record , that's g5 p5 . and now that you're post-menopausal , are you currently or have you ever been on hormone replacement therapy ? [patient] my primary care doctor gave me the option years ago but i decided against it . [doctor] okay . and on your review systems form , you indicated that you've not had any recent weight loss or gain , headaches , bone pain , urinary symptoms , or blood in the stools . but you did indicate that you have some back pain , joint pain , and high cholesterol . tell me some more about those . [patient] okay . so i've seen doctors for all of those . they've said , excuse me , the back and knee pain are age-related . and the cholesterol is a fairly new diagnosis , but i am working on exercise and cutting back on fatty foods to see if i can get it lower without any medication . [doctor] okay . and your primary care doctor is following you for that , right ? [patient] that's correct . [doctor] okay . for medications , i have that you take coq10 , vitamin d , vitamin c , fish oil , and elderberry fruit . is that all right ? [patient] yes , and that's all . [doctor] okay . so for your medical history , it's high cholesterol and stage 0 er/pr positive invasive ductal carcinoma of the right breast . any surgeries other than the lumpectomy ? [patient] i did have my tubes tied after my last baby , but that's all . [doctor] okay . and how about family history ? [patient] my mom had non-hodgkin's lymphoma and my dad had prostate cancer and heart disease , but i think that's it . [doctor] all right . any family history of breast cancer ? [patient] none . [doctor] did any of your children have medical issues or siblings with medical problems ? [patient] i do not have any siblings and , thankfully , my children are all healthy . [doctor] wonderful . do you have any history of smoking , illicit drug use , heavy alcohol consumption ? [patient] no drugs . i do drink socially , but never more than that . and i used to smoke , but really , everybody did back then and i probably quit about 30 years ago . [doctor] excellent . i have that you're allergic to penicillin . any other allergies ? [patient] nope , just penicillin . [doctor] okay . i think that covers it . hop up here and let me take a look at you . [doctor] okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes . [doctor] in the result section , note that her ecog performance status today is zero . [doctor] do you have ... did you have radiation after the lumpectomy ? [patient] i did . we also talked about endocrine therapy , but i decided against that . [doctor] okay . so your exam looks good , no masses , just some skin changes from that radiation . now , let's go over the plan for you . [patient] okay , sounds good . [doctor] as you know , you've had dcis which we'll list in my note as stage zero , er/pr positive , invasive ductal carcinoma of the right breast . your status post-lumpectomy with removal of five lymph nodes that were benign . you also had , um , radiation therapy but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy and your mammogram in january , 2021 was also negative for recurrence and malignancy . [doctor] so , based on all of that , we can just continue to observe you . [patient] okay . that sounds great . and when do i come back in to see you ? [doctor] in a year , but you should have another mammogram in april of 2022 before you come back to see me . [patient] okay , i can do that . [doctor] wonderful . i'm glad to see you doing so well . do you have any questions or concerns i can address for you today ? [patient] i do n't think so . [doctor] okay , great . my nurse will be in shortly to discharge you . take care ! [patient] you as well .", "target": "ASSESSMENT\n\nStage 0 ER/PR-positive invasive ductal carcinoma of the right breast.\n The patient is status post lumpectomy with removal of 5 lymph nodes which were benign. She also underwent adjuvant radiation therapy but declined endocrine therapy. Today\u2019s clinical examination shows no evidence of recurrent disease or other malignancy. She also had a negative mammogram in 01/2021.\n\nPLAN\n\n1. We will continue to observe the patient.\n 2. She is due for a mammogram in 04/2022.\n 3. She should follow up with me in 1 year after the mammogram.\""} {"idx": 29, "inputs": "[doctor] next patient is sophia jackson , mrnr472348 . she's a 57 year old female who is here for a surgical consult . her dermatologist referred her . she biopsied a 0.7 millimeter lesion which was located on right inferior back . pathology came back as melanoma . [doctor] mrs. jackson , it's good to meet you . [patient] likewise , wish it were under better circumstances . [doctor] yeah , i hear your dermatologist sent you to me 'cause she found a melanoma ? [patient] yes , that's what the biopsy said . [doctor] okay and when did you first notice the spot ? [patient] my mom noticed it when i was visiting her last month . [doctor] i see . and so you went to the dermatologist on april 10th to get it checked out , right ? [patient] yes , i wanted to be extra cautious because skin cancer does run in my family . [doctor] well i'm really glad you took it seriously and got it checked . who in your family has had skin cancer , and do you know if it was melanoma or was it basal cell or squamous cell ? [patient] my mom and her sister , i think they both had melanoma . [doctor] okay . do you have any other types of cancer in the family , like breast or ovarian ? [patient] my grandfather had pancreatic cancer . [doctor] okay , and was that your mom or dad's father ? [patient] mother's . [doctor] okay . and , um , have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ? [patient] no , this was the first time i've been to a dermatologist . um , but my primary care doctor looks over all of my moles every year at my physical and has n't said , um , he's concerned about any of 'em before . [doctor] good- good . uh , let's go over your medical history from your chart . i have that you're not taking any medications and do n't have any health problems listed , but that you're allergic to augmentin , is that right ? [patient] yes , that's correct . [doctor] okay , and for social history can you tell me what you do for work ? [patient] i own an auto repair shop . [doctor] okay and have you ever been a smoker ? [patient] yeah , i still smoke from time to time . i started that awful habit in my teens and it's hard to break , but i'm trying . [doctor] i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ? [patient] i had gall bladder and appendix . [doctor] okay , great , we can get your chart up to date now , thank you . and other than the melanoma , how has your health been , any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ? [patient] no , i've been feelin' great . [doctor] good . well let me take a look at your back here where they did the biopsy if you do n't mind . [patient] sure . [doctor] okay , i'm gon na describe it in medical jargon what i'm seeing here , so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ? [patient] okay , that's fine . [doctor] all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam . [doctor] okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further . [patient] okay , i should n't worry too much then ? [doctor] no , i have a low suspicion that it will show anything . [patient] okay , good . [doctor] so assuming that the ultrasound is normal , the treatment for you melanoma is to cut out the area where the lesion was . with lesions that are 0.7 millimeters or less , um , and that's what we recommend , and yours was exactly 0.7 millimeters . if it were any bigger , we would have had to do a more complex surgery . but what i recommend for you is what we call a wide local incision , excuse me , excision , meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision . [patient] okay , that is fine with me , i ca n't see back there anyways . [doctor] yeah , your wife can tell you what it looks like and she may need to help care for the incision at it , as it heals . um , but since we're , we are n't doing the more complex surgery , i actually do n't need to see you back unless you want to check in with me or have any problems . however , it is very important that you continue to follow up with your dermatologist regularly so she can monitor you . uh , your dermatologist will check that this one does n't come back , but she'll also check for other lesions that look suspicious . uh , unfortunately , since you've had one melanoma , you're at a higher risk of developing another one somewhere else . [patient] yeah , she did say she wants to see me back . [doctor] good , and i'm sure she's already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight . [patient] yeah , she definitely went over that , um , several times with me . [doctor] good . other than that , i think that's all for me . um , we'll get you set up for the ultrasound , the procedure . do you have any questions for me ? [patient] um , no i ca n't think of any at this time . [doctor] okay , my nurse will be in to get you scheduled , so sit tight . it was very good to meet you . [patient] thank you , nice to meet you as well . [doctor] please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border . [doctor] for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin . [doctor] primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance . [doctor] after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .", "target": "ASSESSMENT AND PLAN\n\nThe patient presents today with newly diagnosed melanoma. The biopsy revealed an intermediate thickness melanoma. On examination today, there is a right inguinal lymph node with slightly atypical consistency. I recommended an ultrasound to rule out metastatic disease. If the ultrasound is normal, the patient is a candidate for a wide local excision with a 1-2 cm margin. Primary closure should be possible, but skin graft closure may be needed. The relationship between tumor histology and prognosis and treatment was carefully reviewed. The need for follow up according to the National Comprehensive Cancer Network (NCCN) guidelines was reviewed. We also reviewed the principles of sun avoidance, skin self-examination, and the ABCDE\u2019s of mole surveillance. After discussing the procedure, risks, expected outcomes and possible complications, questions were answered, and the patient expressed understanding and did choose to proceed.\""} {"idx": 25, "inputs": "[doctor] next patient is nicole miller . date of birth is 09/18/1949 . patient was called for a follow-up with me for chronic congestive heart failure with diastolic dysfunction . bmp's been , uh , 3,000 in march , and is about six- was up to 6,000 in april . she was increasingly dyspneic . we changed her furosemide and torsemide 20 milligrams by mouth daily . uh to note , the patient is not currently on potassium supplement . her lisinopril had- has also been increased up to 10 milligrams daily in march . also did when i saw her last april . she reported being interested in having her right knee replaced this summer at east metro . it was recommended that we work to control her cardiovascular status before surgery . [doctor] hey , miss miller , how are you today ? [patient] i'm doing okay , thank you . [doctor] i asked you to come in today because we want to keep- we want you to have this knee surgery this summer but we want to keep a close eye on you to make sure a week before your surgery you do n't suddenly go into congestive heart failure and it gets postponed . [patient] yeah , that would not be good . [doctor] i see you're scheduled on the 24th for surgery . [patient] yeah , that's right . [doctor] okay , good . well it looks like you have lost about 3 , 3 and a half pounds since i saw you last in april . some of that might be water weight , but still , this is positive . [patient] yeah , i noticed that too . i think the oxyglutinine is helping as well . my urgency to use the bathroom is much better . [doctor] well that's great . [patient] yeah , i , i'm pleased about it too . [doctor] you ever get leg or finger cramps or anything like that ? [patient] yeah , i had leg cramps the other day , but i thought it might , was maybe just because i was cold as i had my ceiling fan on and fell asleep . i had cramps when i woke up in both legs right here . um i drank pickle juice and it went right away . [doctor] well do n't , do n't get crazy with the pickle juice because all of the salt in it . [patient] haha , i know , i only drink about 4 ounces or so . [doctor] okay good . [patient] um it went away so i did n't drink anymore . i find it works a lot better than trying to put some cream on my leg . [doctor] sure just , just keep it in moderation . [patient] okay . [doctor] and then are you still on an iron supplement ? and are you using the bathroom okay ? [patient] uh yes , everything is good . [doctor] good . how is your heart burn doing ? any problems with that ? [patient] no , it did get bad for a while so i tried to take some prilosec and then stopped that other one . [doctor] okay . [patient] um i did that for like , gosh , i think it was two weeks back in january and have n't had any problems since . [doctor] great . [patient] um and after i stopped taking that um i went back to the stomach one , so i'm doing good now . [doctor] okay and you're still due for a colonoscopy , correct ? [patient] uh yeah , that's right . [doctor] all right , let's review your blood work real quick . i checked your hemoglobin level because you have had some anemia in the past but that is still doing great . [patient] good , that's a relief to hear . [doctor] your potassium is 3.9 so it's holding steady on the torsemide . your creatinine was .7 not .8 so you're doing well with kidney numbers . your bun may be a tiny bit elevated at 23 which is the number we look for for dehydration sometimes the kidneys , but it's not terrible . um so when i look at your numbers as a whole i think you're tolerating the torsemide okay at the current dose . i also sent out to look at the heart failure number- i sent to look at your heart failure number . there is a test called a bmp that i was monitoring and in march it was up to 3,000 and then went up to 6,000 in april before i made the change . i'm still waiting for those results . [patient] okay . [doctor] all in all i think you're doing good on paper though . [patient] what about , um what's it called , a1c ? does that show up ? [doctor] um i do n't think i ordered it but i could . your last a1c was 5.5 in march . [patient] all righty . [doctor] so your blood sugar is a little bit high , it was 169 today but that kind of depends on what you ate and you were n't fasting for the blood check so i might have to repeat that test for pre-op , but i do n't think we need to do it today . [patient] all righty that sounds good . [doctor] i checked your magnesium level because sometimes you uh urinate out magnesium with the water pills but it was normal at 1.7 and your blood pressure is also looking good . [patient] okay great . that all sounds awesome . [doctor] all right let's take a quick listen . [doctor] use my general physical exam template . [doctor] and take a couple of deep breaths for me . [doctor] your lungs sound pretty good to me so keep doing what you're doing . um uh , like i said , i think you're doing good overall but let's just talk about a few things . [patient] all righty . [doctor] so we often like to keep people with heart problems on magnesium and get their levels up to around the 2-ish range . yours is a little bit less than 2 and we want that 2-ish range because it can help stabilize the heart muscle . so i might recommend putting you on magnesium supplement . it's supposed to be twice a day so that's kind of annoying , but i know you're on other medicines twice a day too , so i think you'll do fine . [patient] yeah , that'll be okay . [doctor] great . now before surgery we'll have to get you off your clopidogrel for a week beforehand . [patient] yes , okay , i have everything written down on my phone , and i have a letter taped to the side of my bed to remind me . [doctor] perfect ! we will give you a reminder as well . we will also need to complete a pre-op check within two weeks of your surgery during the first or second week of june . [patient] okay , i'll put that down . [doctor] you might also have to repeat an ekg before surgery which we could do today . i know i'm sure it feels like you're doing , you're always doing ekgs . um we do n't need to any x-rays of your chest because you had one recently , and we do n't need any more blood work because we did that today . [patient] yeah , i do a lot of ekgs . i'm basically a regular . but i'm happy to do one today , no problem . [doctor] lastly , once we get your knee surgery , um we , we should think about getting you a colonoscopy . we can do it here locally because you have medicare . do you have private insurance also ? [patient] yeah , i have both . [doctor] okay so yes , you can get it , your colonoscopy , wherever you'd like . [patient] okay , well my husband's insurance may be running out . might we be able to get the procedure done sooner ? maybe in the next 30 days ? is that okay ? [doctor] um i can put it in right now for , uh , for county for the next 30 days , and they might be able to get you in within the next few weeks . it should not take , it should not make you ineligible for the surgery . in other words completing a colonoscopy would not delay your surgery . [patient] okay , good . [doctor] so let me see . i've been doing one of two things at every one , and everyone is great so it depends more on timing availability of their or for the colonoscopy . we can send you to dr. martin for the surgery who is at county surgical services down here or the other option is valley medical , and they do it at springfield . [patient] okay , that sounds good . [doctor] i think either direction they're good technicians of the colon . [patient] okay , yeah whatever you can get me in , that works great . [doctor] so i'll call around . now if you get that done and they tell you 10 years then you'll be good to go . [patient] great , thank you . [doctor] you're welcome . have a great day . let us know if you need anything else , okay ? [patient] sounds good . [doctor] all right , assessment and plan . [doctor] chronic chf . mixed presentation . had a exacerbation of cf , chf earlier in the spring . we switched her from a furosemide to torsemide and symptomatically she is doing a lot better . she's about 3 , 3 and a half pounds down in weight . breathing is non-labored . going to repeat ekg today but otherwise continue with her current regimen . labs checked and creatinine is appropriate . [doctor] uh number 2 , pre-op examination . she is , she's having a right knee replacement end of june . also , she would like to have a colonoscopy performed which we'll try to have done at uh bartley regional , rightley regional hospital in the next month , uh , prior to a change in her insurance . this is just a screening colonoscopy that she is overdue for . no family history of colon cancer . [doctor] uh the next one is diabetes . a1c is 5.1 on the last check so no need for further a1c today . she may need another one prior to her surgery next month though . thanks .", "target": "ASSESSMENT\n\n\u2022 Chronic congestive heart failure with mixed presentation.\n \u2022 Preop examination.\n \u2022 Diabetes mellitus.\n \u2022 Colonoscopy\n\nPLAN\n\nChronic congestive heart failure with mixed presentation.\n She had an exacerbation of CHF earlier in the spring. We switched her from furosemide to torsemide and symptomatically, she is doing a lot better. She is about 1.5 kg down in weight. Her breathing is nonlabored. We are going to repeat an EKG today. Otherwise, continue her current regimen. Labs were checked and creatinine is appropriate. Her magnesium is below the preferred 2 at 1.7, with some occurrence of bilateral leg cramping, therefore we will start her on magnesium supplement.\n \n Preop examination.\n She is going to be having a right knee replacement at the end of 06/2021. We will schedule a preop check the first week or two of June prior to the surgery. She will discontinue clopidogrel for one week prior to knee replacement surgery; we will provide a reminder to patient of this as well.\n \n Diabetes mellitus.\n A1c is 5.5 on last check, so there is no need for a further A1c today. She may need another one prior to her surgery next month.\n \n Colonoscopy.\n The patient is overdue for a colonoscopy, which we will try to have done at County Hospital in the next month, prior to a change in her insurance. This is just a screening colonoscopy that she is overdue for. No family history of colon cancer.\n \n The patient understands and agrees with the recommended medical treatment plan."} {"idx": 9, "inputs": "[doctor] hi , bryan . how are you ? [patient] i'm doing well . i'm a little sore . [doctor] yeah ? [patient] yeah . [doctor] all right , well , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? [patient] that's fine . [doctor] so bryan is a 55-year-old male with a past medical history significant for prior discectomy , who presents with back pain . so , bryan , what happened to your back ? [patient] you ... my wife made me push a , uh , refrigerator out through the other room , and when i was helping to move it , i felt something in my back on the lower right side . [doctor] okay , on the lower right side of this back ? [patient] yes . [doctor] okay . those wives , always making you do stuff . [patient] yes . [doctor] and what day did this happen on ? how long ago ? [patient] uh , this was about five days ago . [doctor] five days ago . [patient] and , you know , i have that history of discectomy . [doctor] yeah . [patient] and i'm just worried that something happened . [doctor] okay . all right . and , and what have you taken for the pain ? [patient] um , i have , uh , been taking ibuprofen . uh , and i tried once tylenol and ibuprofen at the same time , and that gave me some relief . [doctor] okay . all right . and have you had any symptoms like pain in your legs or numbing or tingling ? [patient] um , no , nothing significant like that . [doctor] okay , just the pain in your back . [patient] just the pain in the back . it hurts to bend over . [doctor] okay , and any problems with your bladder or your bowels ? [patient] no , no . [doctor] i know the nurse said to review a symptom sheet when you checked in . [patient] mm-hmm . [doctor] and i know that you were endorsing the back pain . any other symptoms ? chest pain ? shortness of breath ? abdominal pain ? [patient] no . [doctor] nausea ? vomiting ? [patient] no other symptoms . [doctor] okay . all right . well , let's go ahead and do a quick physical exam . hey , dragon , show me the vital signs . so your vital signs here in the office look really good . you do n't have a fever . your blood pressure's nice and controlled . so that ... that's good . i'm just gon na check out your back and your heart and your lungs , okay ? [patient] okay . [doctor] okay , so on physical examination , you know , your heart sounds great . there's ... it's a regular rate and rhythm . your lungs are nice and clear . on your back exam , you do have some pain to palpation of the right lumbar spine , uh , in the paraspinal muscles along with decreased flexion and extension of the back , and you have a positive straight leg on the right . or positive straight leg raise on the right , uh , but your strength is good bilaterally in your lower extremities . so that means that i think that you've injured your back . [patient] okay . [doctor] uh , but , you know , i think it's something that we can , we can fix , okay ? [patient] okay , you do n't think there's anything wrong with the ... where i had the surgery before . [doctor] i do n't think so . [patient] okay . [doctor] let's took at some of your results . hey , dragon , show me the back x-ray . so this is an x-ray of your lumbar spine . you know , there's good bony , bony alignment . i do n't see any fracture or anything like that . so that's a good sign . um , hey , dragon . show me the labs . and your labs here all look good , so i'm , i'm happy to see that . uh , so let's talk a little bit about my assessment and my plan for you , okay ? [patient] okay . [doctor] so i ... my assessment for your first problem , your back pain . i think you have a lumbar strain . i do n't think that anything else is going on , but i wan na go ahead and order an mri- [patient] okay . [doctor] just to be sure . [patient] okay . [doctor] okay ? and then i'm gon na prescribe you some meloxicam 15 milligrams once a day along with some ultram , 50 milligrams every four hours as needed , okay ? [patient] okay . [doctor] um , and then we'll go ahead and refer you to some physical therapy once we get the mri results back , okay ? [patient] should i continue to take the tylenol and the ibuprofen ? [doctor] you can stop the ibuprofen . [patient] okay . [doctor] you can take tylenol if you want . [patient] okay . [doctor] you know to call me if , if you need anything . [patient] okay . [doctor] okay ? [patient] okay . [doctor] any questions , uh , bryan ? [patient] no , no questions . [doctor] okay . hey , dragon , finalize the note .", "target": "ASSESSMENT AND PLAN\n\nBryan Smith is a 55-year-old male with a past medical history significant for prior discectomy, who presents with back pain.\n \n Lumbar strain.\n \u2022 Medical Reasoning: He reports right-sided low back after moving a refrigerator approximately 5 days ago. X-ray of his lumbar spine is unremarkable. I do not believe this is related to his previous discectomy.\n \u2022 Additional Testing: We will order a MRI of the lumbar spine for further evaluation.\n \u2022 Medical Treatment: Initiate meloxicam 15 mg once daily, as well as Ultram 50 mg every 4 hours as needed.\n \u2022 Specialist Referrals: We will refer him to physical therapy to be started after we get his MRI results back.\n \u2022 Patient Education and Counseling: I advised the patient to discontinue the use of ibuprofen, but he may continue using Tylenol if he wishes.\n \n "} {"idx": 42, "inputs": "[doctor] good morning carolyn how are you [patient] i'm doing alright other than this ankle pain i've been having [doctor] so i see here that you hurt your right ankle can you tell me what happened [patient] yeah so yesterday i was going to take out the trash and it was quite icy i thought i was doing okay job and i just slipped and and fell and i'm pretty sure i heard a pop [doctor] okay and you said this happened yesterday correct [patient] yeah [doctor] okay and have you been able to walk on it at all [patient] no i was so initially when i first fell i was unable to walk at on it at all i had a friend that was visiting and so she heard me fall so she helped me inside now today i have been able to put a little bit more weight on it but i'm still limping [doctor] okay and then what have you been doing for your foot or ankle pain since that happened [patient] so i like iced it last night and kept it elevated and i also took some ibuprofen last night and this morning before coming in today [doctor] okay and can you rate your pain for me [patient] i would say right now it's like a four out of ten [doctor] okay and does the ibuprofen help with that pain [patient] it does it does help with the pain [doctor] okay and when you take your ibuprofen what can you what's your pain level then [patient] so this so what did i just say four [doctor] yes ma'am [patient] four out of ten so four out of ten is with ibuprofen [doctor] it's with ibuprofen okay what's your pain level without then [patient] i would say probably a six [doctor] okay [patient] i'm sorry it's a six out of ten without ibuprofen and it goes down to like a one with ibuprofen [doctor] okay alright that that sounds good have you ever injured that foot and ankle before [patient] you know i've had a lot of injuries to my ankle but i've never hurt this ankle before i just realized an error [doctor] okay you know and i see here that you have a history of playing sports looks like you played soccer in college and then played a little bit of a inner marrow soccer now [patient] yeah [doctor] i'm i'm guessing you probably have n't been able to do that since you hurt your ankle [patient] no i have not been [doctor] so did you hear about the new major league soccer stadium and team that's coming to town they opened in the this year actually they built the stadium have you been down there yet [patient] no i have to get there [doctor] yeah we are all excited it's going to be a good time well have you experienced any numbness or tingling in that right foot [patient] no [doctor] okay so if it's okay with you i would like to do a quick physical exam your vitals look good and everything there looks okay now i'm gon na do a focused exam on your right ankle i do appreciate some ecchymosis or bruising over the lateral malleolus malleolus associated with some edema or swelling of that area you are positive for tenderness to palpation of the anterior lateral soft tissue and now i do n't appreciate any laxity on anterior drawer and inversion stress there is no bony tenderness on palpation to that foot or ankle area now on neurovascular exam of your right foot you have brisk capillary refill of less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch and all of that is consistent with what's present on your left side as well so i did review the results of your of your x-ray the x-ray of your right ankle showed no fracture which is a good thing so now let me talk to you a little bit about my assessment and plan so for the first problem of right ankle pain your symptoms are consistent with a right ankle sprain or i'm sorry right ankle sprain of your lateral ligament complex more specifically your anterior talofibular ligament now this ligament's on the outside of your ankle ankle which got stretched when you fell the best treatment at this time for your sprain is to keep your leg elevated when you're seated and let's continue to ice okay you're gon na be given an air cast which is gon na help stabilize that ankle and i'm also going to prescribe some crutches because i want you to stay off that leg and start walking on it stay off your leg for now and then in a couple of days start walking on it as tolerated do you have any questions or concerns for me [patient] so how long do you think it'll take to heal [doctor] so your symptoms should significantly improve over a few weeks but i'd like to follow up with you and see how you're doing let's say i'll see you again in fourteen days now i do want you to go ahead and continue to take nsaids or ibuprofen as needed to help with any pain and that's also gon na help reduce that inflammation and swelling okay [patient] okay [doctor] alright i will see you again in two weeks carolyn [patient] great thank you [doctor] you're welcome", "target": "ASSESSMENT\n\nLateral ligament complex sprain, Right ankle.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, her symptoms are consistent with a right ankle sprain of the lateral ligament complex, more specifically the anterior talofibular ligament. We had a lengthy discussion regarding the nature of this injury and the course of treatment. I advised her to keep her leg elevated when she is seated and continue to ice her ankle. She should also continue taking ibuprofen as-needed for pain and inflammation management. She will be placed in an Aircast to help stabilize her ankle, and I am going to order crutches so she can remain non-weight-bearing for the next couple of days. At that point, she can start bearing weight on the ankle as tolerated."} {"idx": 32, "inputs": "[doctor] good morning ms. reyes ! [patient] good morning . [doctor] how are you doing ma'am ? [patient] i'm doing well doctor , how are you ? [doctor] i am fine thank you . so you've been having some problems with your right hip ? [patient] yeah . [doctor] okay , and where are you hurting ? can you show me ? [patient] right in the groin area . [doctor] okay , and this has been going on since february 2020 ? [patient] yeah . [doctor] okay . and is it worse with movement ? [patient] well when it catches and i almost fall , yeah . [doctor] okay . so it kinda grabs you ? [patient] yeah . [doctor] okay , and this all started when you were walking ? [patient] well , walking around the infusion room . [doctor] okay . [patient] so it started if i took a step back or , you know , stuff like that . now it happens anywhere . [doctor] okay , so now it hurts whenever you move ? [patient] it hurts when i pivot . [doctor] okay . so if you pivot then it hurts , got it . um ... [patient] anything can sometimes do it . sometimes it wo n't though , and sometimes it'll do it several times in a row . [doctor] several times in a row , okay . [patient] and sometimes i fall . [doctor] okay . and you rate the pain to range from two through seven out of 10 ? [patient] yeah , that's correct . [doctor] okay . and are you experiencing fever or chills ? [patient] no . [doctor] okay . and any tingling or numbness ? [patient] no . [doctor] and have you had any problems with your bowel or bladder ? [patient] no . [doctor] okay . and if you stay still , do you feel better ? [patient] yes , but i do n't want to stay still . [doctor] i understand , no problem . and for past medical history , do you have anything going on ? [patient] i've had a lot of surgeries . i've had pcl , i had infertility , a gall bladder removed , but that's it . [doctor] okay . and for family history , it looks like there's high blood pressure , diabetes , thyroid disease , heart disease , kidney disease and gastric ulcers . for your current medications , it does n't look like you're taking anything at this time . and you're allergic to percocet , vicodin and regulin . and it looks like you've had intentional weight loss ? [patient] yes , i've lost 110 pounds . [doctor] that is awesome . and how did you do that ? [patient] with weight watchers . [doctor] that's great . [patient] mm-hmm . [doctor] and how many months have you been participating in weight watchers ? [patient] i started in 2018 , and i've been at my current weight for a little over a year . [doctor] that is awesome . [patient] yeah , thank you . [doctor] yeah , very good , and congratulations . and so , for social history , it looks like you work at an infusion center ? [patient] yes , over at . [doctor] okay . and you live with your roommate , no history of tobacco and you limit alcohol intake to less than five drinks per month . [patient] that's correct . [doctor] all right . well let's go ahead and take a look at your hip . [patient] okay . [doctor] please use my general physical exam template . physical exam . ms. reyes is a pleasant 56-year-old woman who is five feet , six inches in height , weighing 169 pounds . blood pressure is 115 over 75 . pulse rate is 67 . ankles , no ankle edema is noted , no calf tenderness . okay , ms. reyes , can you go ahead and stand up for me please and take a couple of steps ? great . [patient] okay . [doctor] and can you walk on your tippy toes ? good , okay . and can you walk on your heels ? kind of a heel walk and toe walk are intact . um , go ahead and turn around please . [patient] okay . [doctor] examination of the cervical spine , any pain here now ? [patient] no . [doctor] okay , no tenderness . look at your right and your left and then over to the right , then go ahead and look up , then look down , and look straight ahead . range of motion is full in the neck without pain . spurling's test is negative . exam of the low back . any pain here ? [patient] no . [doctor] okay . skin is intact , no midline tenderness to palpitation . go ahead and lean back . and lean to your right , to your left . does that hurt at all ? [patient] no . [doctor] okay , great . and go ahead and bend forward and then come back up . and that does n't bother you ? [patient] no . i did or do have several bulging discs . [doctor] okay . but you're not hurting right now ? [patient] no , the weight loss has really decreased all the pain . [doctor] okay . range of motion is decreased in exertion . lateral flection without pain . any pain when i push ? [patient] no . [doctor] okay . you can go ahead and , um , sit down please . no pain ? [patient] no . [doctor] okay . sacroiliac signs are negative . examination of the hips . trochanteric is non tender . go ahead and lift your knee up , does that bother you ? [patient] um , just a little bit . [doctor] okay , little bit . and then back one , probably bothers you ? [patient] right there , like there , yeah . [doctor] okay . how about this way ? not too bad ? [patient] no . [doctor] okay . range of motion is decreased in right hip with pain in the groin and internal and external rotation . okay , go ahead and keep it up , do n't let me push it down . does that hurt ? [patient] right there . [doctor] okay . resisted right hip flection causes pain in the right groin region . no tenderness is noted . do you feel me touching you all the way down ? [patient] yeah . [doctor] okay . motor control is normal in the lower extremities . go ahead and lift your knee up . [patient] okay . [doctor] okay , lift it up . any pain ? [patient] no . [doctor] okay . and this one ? [patient] yeah . [doctor] and squeeze your knees together , push it out and kick your leg out straight . now go ahead and bring it back and kick it out straight again . and go ahead and lean back , keep it loose . okay , all set . you can go ahead and sit up now . [patient] okay , thank you . [doctor] you're welcome . so what i think we're dealing with is right hip degenerative joint disease . [patient] okay . [doctor] and we do have some options . so first is to start some low impact exercises . i can provide you with a hand out with what exercises you can do . you should take nsaids as needed to help with the pain and discomfort , as well as use of a cane to help offload the right side . a cane will help support your painful side to help reduce the pain . [patient] hmm , i do n't love that idea but i'll give it a try . [doctor] okay , that would be great . and we can also try a cortisone injection into the right hip joint to see if that offers any relief . [patient] i would like to definitely get the injection . [doctor] okay . we can take care of that today while you're here and then schedule a follow up appointment in three months to see how you're doing , and then receive another injection if needed . [patient] okay , that sounds good . [doctor] okay . and here are the risks associated with getting the inje- injection . um , please just take a moment to review it and consent to the shot . [patient] i'm good . [doctor] great . we'll get that set up for ya . all right , well i hope things , um , feel better , and we will see you back here in three months . [patient] see you . have a nice day . [doctor] thank you so much , you as well . deep tendon reflex is one plus throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list ? next radiographs , mr arthrogram of the right hip done june 3rd 2021 show high grade condromalacia involving the interosuperior right acetabulum with subchondral marrow edema and cyst formation . next paragraph plan . options include low impact exercise program , use of an nsaid and use of a cane to offload the right . we discussed that she'd like to proceed with the cortisone injection in right hip joint . i explained the risks of injection , including needles , sterile and covid . she understood and decided to proceed with the injection . she will follow up with me in three months for another injection if needed . end of dictation .", "target": "ASSESSMENT\n\n\u2022 Right hip degenerative joint disease.\n\nPLAN\n\nI discussed the clinical and radiological findings with the patient. Treatment options discussed are low impact exercises, use of analgesics as needed, and use of a cane to offload the right hip. She would like to proceed with a cortisone injection into her right hip joint. We will administer the injection today. I reviewed the procedure in detail, including the risks of the injection related to the use of steroid in the COVID setting. She understands the risks and would like to proceed with the injection."} {"idx": 92, "inputs": "[doctor] hello , mrs . martinez . good to see you today . [patient] hey , dr . gomez . [doctor] hey , dragon , i'm here seeing mrs . martinez . she's a 43-year-old female . why are we seeing you today ? [patient] um , my arm hurts right here . kind of toward my wrist . this part of my arm . [doctor] so you have pain in your distal radius ? [patient] yes . [doctor] how did that happen ? [patient] um , i was playing tennis , and when i went to hit , um , i was given a , a backhand , and when i did , i m- totally missed the ball , hit the top of the net but the pole part . and , and it just jarred my arm . [doctor] okay . and did it swell up at all ? or- [patient] it did . it got a ... it had a little bit of swelling . not a lot . [doctor] okay . and , um , did , uh , do you have any numbness in your hand at all ? or any pain when you move your wrist ? [patient] a little bit when i move my wrist . um , no numbness in my hand . [doctor] okay . do you have any past medical history of anything ? [patient] um , yes . allergic , um , l- i have allergies . and so i take flonase . [doctor] okay . and any surgeries in the past ? [patient] yes . i actually had a trauma of , um , a stabbing of , um ... i actually fell doing lawn work- [doctor] okay . [patient] on my rake . [doctor] okay . [patient] yeah . [doctor] i was wondering where you were going to go with that . [patient] yeah . [doctor] okay . great . so , let's take a look at , uh , the x-ray of your arm . hey dragon , let's see the x-ray . okay , looking at your x-ray , i do n't see any fractures , uh , do n't really see any abnormalities at all . it looks essentially normal . great . let me examine you . [patient] okay . [doctor] does it hurt when i press on your arm here ? [patient] yes . [doctor] okay . how about when i bend your arm ? [patient] yes . [doctor] okay . that's pretty tender , ? [patient] mm-hmm . [doctor] how about when i go backwards like that ? [patient] not as much . [doctor] and how about when i flex like this ? [patient] a little . [doctor] but mostly when i do that type of motion ? [patient] yes . [doctor] okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again . [patient] okay . [doctor] okay , great . hey dragon , go ahead and order the procedures , and the medications as discussed . why do n't you come with me . dragon you can finalize the note . [patient] thank you .", "target": "PLAN\n\nAt this point, I discussed the diagnosis and treatment options with the patient. I have recommended ice and anti-inflammatory medications. I am prescribing Motrin, 800 mg to take 3 times a day with food. She will follow up with me in 1 week or as needed.\n \""} {"idx": 64, "inputs": "[doctor] hey matthew how're you doing [patient] hey doc i'm doing pretty good how are you [doctor] i'm doing pretty good hey i see here in the nurse's notes it looks like you hurt your left ankle can you tell me a little bit more about that [patient] yeah i did my wife and i were on a walk yesterday and i was just talking to her and and stepped off the curb and landed on it wrong it's kind of embarrassing but yeah it's been killing me for a couple days now [doctor] okay now when you fell did you feel or hear a pop or anything like that [patient] i would n't say i really heard a pop it was just kind of really kind of felt extended and stretched and it it's just been really bothering me ever since kind of on the outside of it [doctor] okay and then were you able to walk on it after the incident [patient] i was able to get back to the house because i did n't wan na you know make my wife carry me but it was it was painful [doctor] okay and then have you done any or had any injuries to that ankle before [patient] nothing substantial that i would say in the past [doctor] okay and then what have you been doing for that left ankle since then have you done anything to help make it make the pain less [patient] i have taken some ibuprofen and then i just tried to elevate it and ice it a little bit and keep my weight off of it [doctor] okay so let's talk real quick about your pain level zero being none ten being the worst pain you've been in in your life without any medication on board can you rate your pain for me [patient] i would say it's about an eight [doctor] okay and then when you do take that ibuprofen or tylenol what what's your relief level what's your pain look like then [patient] maybe a seven it it's a little [doctor] okay now you mentioned going for a walk my wife and i've been on on back behind the new rex center where the new trails are have you guys been back there [patient] we have n't yet but i'm sure we'll check it out ever since i feel like working at home during covid we we we take walks all the time [doctor] yeah i [patient] no i have n't been there yet [doctor] yeah those those trails are great there's like five miles of regular flat trails and then there's a bunch of hiking trails that they've opened up as well it's a really great place man you guys need to get out there we'll get you fixed up and we'll get you back out there okay [patient] awesome [doctor] so let's let's talk a little bit about my physical exam if it's okay with you i'm gon na do a quick physical exam on you your vitals look stable by the way a little elevated i know you're in pain on a focused exam of your left ankle now i do appreciate that there is ecchymosis or bruising over the lateral malleolus and there is some swelling i do i do appreciate some edema now you are positive for tenderness to palpation on the lateral side and the the soft tissue is swollen here the good news is i do not appreciate any laxity in the joint okay and i do n't feel any any type of bony tenderness to palpation of your foot now on the neurovascular exam of your left foot capillary refill is brisk less than three seconds and i do appreciate strong dorsalis pedis pulses and you do have motor and sensation intact which is good now it's important that they were compared bilaterally and they are yeah your your exam is the same bilaterally so that that's an important thing now we did do an x-ray of that left ankle when you came in so i'm gon na review those x-ray results with you now the good news is i do not appreciate a fracture or any bony abnormalities so that's a good thing right so let me talk to you a little bit about my assessment and plan so for your first problem of your left ankle pain your symptoms are consistent with an ankle sprain of the lateral ligament complex and the ligament on the outside of your ankle is what got stretched when you fell now the best treatment for this sprain is what you've kind of already been doing doing the elevation and compression and ice so we're gon na continue the rice protocol and i am gon na go ahead and give you an air cast just to stabilize that ankle i'm gon na prescribe you some crutches i want you to stay off that leg but i do want you to start walking as tolerated but it may be a few days before you feel like doing that now your symptoms are going to get better significantly over the first you know four five six seven days but i am gon na wan na follow up with you just to make sure you're doing okay so what i do is i would like to see you in two weeks and i'm gon na have you continue taking those nsaids as well to help reduce that pain and swelling any other questions comments or concerns before i have the nurse come in and get you fixed up [patient] no i think that sounds like a plan [doctor] okay sounds good like i said i will see you in two weeks if you have any questions or if you have a lot of pain come back in we'll reevaluate otherwise i think you're headed in the right direction and i'll see you again in two weeks [patient] awesome thanks document [doctor] alright thanks bye-bye", "target": "ASSESSMENT\n\nLeft ankle sprain of the lateral ligament complex.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed that his symptoms are consistent with an ankle sprain of the lateral ligament complex. The nature of the diagnosis and treatment options were discussed. At this time he will continue to follow the RICE protocol. He will continue to take NSAIDs as needed for pain and swelling. He will also be placed into an Aircast for ankle stabilization and will be provided crutches in order to remain non-weight-bearing. We discussed that it may be a few days before he feels able to tolerate walking. I also advised him that his symptoms will likely start to improve significantly over the next 4 to 6 days."} {"idx": 1, "inputs": "[doctor] hi , martha . how are you ? [patient] i'm doing okay . how are you ? [doctor] i'm doing okay . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? [patient] okay . [doctor] martha is a 50-year-old female with a past medical history significant for congestive heart failure , depression and hypertension who presents for her annual exam . so , martha , it's been a year since i've seen you . how are you doing ? [patient] i'm doing well . i've been traveling a lot recently since things have , have gotten a bit lighter . and i got my , my vaccine , so i feel safer about traveling . i've been doing a lot of hiking . uh , went to washington last weekend to hike in northern cascades, like around the mount baker area . [doctor] nice . that's great . i'm glad to hear that you're staying active , you know . i , i just love this weather . i'm so happy the summer is over . i'm definitely more of a fall person . [patient] yes , fall foliage is the best . [doctor] yeah . um , so tell me , how are you doing with the congestive heart failure ? how are you doing watching your diet ? i know we've talked about watching a low sodium diet . are you doing okay with that ? [patient] i've been doing well with that . i resisted , as much , as i could , from the tater tots , you know , the soft pretzels , the salty foods that i , i love to eat . and i've been doing a really good job . [doctor] okay , all right . well , i'm glad to hear that . and you're taking your medication ? [patient] yes . [doctor] okay , good . and any symptoms like chest pains , shortness of breath , any swelling in your legs ? [patient] no , not that i've noticed . [doctor] okay , all right . and then in terms of your depression , i know that we tried to stay off of medication in the past because you're on medications for your other problems . how are you doing ? and i know that you enrolled into therapy . is that helping ? or- [patient] yeah , it's been helping a lot . i've been going every week , um , for the past year since my last annual exam . and that's been really helpful for me . [doctor] okay . so , no , no issues , no feelings of wanting to harm yourself or hurt others ? [patient] no , nothing like that . [doctor] okay , all right . and then in terms of your high blood pressure , i know that you and i have kind of battled in the past with you remembering to take some of your blood pressure medications . how are you doing with that ? [patient] i'm still forgetting to take my blood pressure medication . and i've noticed when work gets more stressful , my blood pressure goes up . [doctor] okay . and , and so how has work going for you ? [patient] it's been okay . it's been a lot of long hours , late nights . a lot of , um , you know , fiscal year end data that i've been having to pull . so , a lot of responsibility , which is good . but with the responsibility comes the stress . [doctor] yeah , okay , all right . i understand . um , all right . well , i know that you did a review of system sheet when you checked in with the nurse . i know that you were endorsing some nasal congestion from some of the fall pollen and allergies . any other symptoms , nausea or vomiting , abdominal pain , anything like that ? [patient] no , nothing like that . [doctor] no , okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ? [patient] okay . [doctor] hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it is a little elevated . you know , it could just , you could just be nervous . uh , let's look at some of the past readings . hey , dragon , show me the blood pressure readings . hey , dragon , show me the blood pressure readings . here we go . uh , so they are running on the higher side . um , y- you know , i , i do think that , you know , i'd like to see you take your medication a little bit more , so that we can get that under control a little bit better , okay ? [patient] okay . [doctor] so , i'm just gon na check out your heart and your lungs . and you know , let you know what i find , okay ? [patient] okay . [doctor] okay . so , on your physical examination , you know , everything looks good . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which i've heard in the past , okay ? and on your lower extremities , i do appreciate one plus pitting edema , so you do have a little bit of fluid in your legs , okay ? [patient] okay . [doctor] let's go ahead , i wan na look at some of your results , okay ? hey , dragon , show me the echocardiogram . so , this is the result of the echocardiogram that we did last year . it showed that you have that low-ish pumping function of your heart at about 45 % . and it also sh- shows some mitral regurgitation , that's that heart murmur that i heard , okay ? [doctor] um , hey , dragon , show me the lipid panel . so , looking at your lipid panel from last year , you know , everything , your cholesterol was like , a tiny bit high . but it was n't too , too bad , so i know you're trying to watch your diet . so , we'll repeat another one this year , okay ? [patient] okay . [doctor] um , so i wan na just go over a little bit about my assessment and my plan for you , okay ? so , for your first problem your congestive heart failure , um , i wan na continue you on your current medications . but i do wan na increase your lisinopril to 40 milligrams a day , just because your blood pressure's high . and you know , you are retaining a little bit of fluid . i also wan na start you on some lasix , you know , 20 milligrams a day . and have you continue to watch your , your diet , okay ? [patient] okay . [doctor] i also wan na repeat another echocardiogram , okay ? [patient] all right . [doctor] hey , dragon , order an echocardiogram . from a depression standpoint , it sounds like you're doing really well with that . so , i'm , i'm really happy for you . i'm , i'm glad to see that you're in therapy and you're doing really well . i do n't feel the need to start you on any medications this year , unless you feel differently . [patient] no , i feel the same way . [doctor] okay , all right . and then for your last problem your hypertension , you know , again i , i , i think it's out of control . but we'll see , i think , you know , i'd like to see you take the lisinopril as directed , okay ? uh , i want you to record your blood pressures within the patient , you know , take your blood pressure every day . record them to me for like , about a week , so i have to see if we have to add another agent , okay ? 'cause we need to get that under better control for your heart failure to be more successful , okay ? [patient] okay . [doctor] do you have any questions ? , and i forgot . for your annual exam , you're due for a mammogram , so we have to schedule for that , as well , okay ? [patient] okay . [doctor] okay . do you have any questions ? [patient] can i take all my pills at the same time ? [doctor] yeah . [patient] 'cause i've been trying to take them at different times of the day , 'cause i did n't know if it was bad to take them all at once or i should separate them . i do n't know . [doctor] yeah . you can certainly take them , you know , all at the same time , as long , as yeah , they're all one scale . you can take them all at the same time . just set an alarm- [patient] okay . [doctor] . some time during the day to take them , okay ? [patient] that might help me remember better . [doctor] all right . that sounds good . all right , well , it's good to see you . [patient] good seeing you too . [doctor] hey , dragon , finalize the note .", "target": "ASSESSMENT AND PLAN\n\nMartha Collins is a 50-year-old female with a past medical history significant for congestive heart failure, depression, and hypertension who presents for her annual exam.\n \n Congestive heart failure.\n \u2022 Medical Reasoning: She has been compliant with her medication and dietary modifications. Her previous year's echocardiogram demonstrated a reduced ejection fraction of 45%, as well as some mitral regurgitation. Her cholesterol levels were slightly elevated on her lipid panel from last year.\n \u2022 Additional Testing: We will order a repeat echocardiogram. We will also repeat a lipid panel this year.\n \u2022 Medical Treatment: She will continue with her current medications. We will increase her lisinopril to 40 mg daily and initiate Lasix 20 mg daily.\n \u2022 Patient Education and Counseling: I encouraged her to continue with dietary modifications.\n \n Depression.\n \u2022 Medical Reasoning: She is doing well with weekly therapy.\n \n Hypertension.\n \u2022 Medical Reasoning: She has been compliant with dietary modifications but has been inconsistent with the use of her medication. She attributes elevations in her blood pressure to increased stress.\n \u2022 Medical Treatment: We will increase her lisinopril to 40 mg daily as noted above.\n \u2022 Patient Education and Counseling: I encouraged the patient to take her lisinopril as directed. I advised her to monitor her blood pressures at home for the next week and report them to me.\n \n Healthcare maintenance.\n \u2022 Medical Reasoning: The patient is due for her routine mammogram.\n \u2022 Additional Testing: We will order a mammogram and have this scheduled for her.\n \n "} {"idx": 117, "inputs": "[doctor] mister jackson is a 45 -year-old male who has a history of diabetes type two and mild intermittent asthma and he is here today with right elbow pain so hey there mark nice to see you again listen sorry you're having some elbow pain let's talk about it but i would like to record this conversation with this cool app that i'm using that's gon na help me focus on you a bit more would that be alright with you [patient] yeah that sounds great [doctor] okay great so mark tell me about your right elbow pain what's been happening [patient] so yeah i've been playing a lot of tennis recently buddy of mine you know you're always telling me to get off the couch and be more active so a buddy of mine asked me if i wanted to go play tennis he just joined a country club i've been hitting hitting the cord a lot more and it's just been killing me for the last three weeks or so [doctor] okay alright and where in your elbow is it hurting [patient] outside part [doctor] hmmm okay does the pain radiate anywhere like down to your arm up to your shoulder or anywhere else [patient] no it does n't [doctor] okay and what would you say the pain is you know on a scale of zero to ten [patient] it's probably an eight when i'm just when i'm using it even if it's to get something out of the cupboard and it's a three when i'm just kinda resting [doctor] hmmm okay and do you would you say it's a sharp pain stabbing pain aching throbbing how would you describe it [patient] all of the above shooting stabbing very sharp [doctor] okay alright and you let's see other than the the tennis you know increase in tennis activity you have n't had any trauma recently falling on it or you know felt a pop anywhere or anything like that have you [patient] not that i can recall [doctor] okay and and you said it's it's worse with movement better with rest is there anything else that makes it makes it worse or makes it better [patient] i've taken some tylenol and ibuprofen but as soon as those wear off it it comes right back so they do n't really help [doctor] okay [patient] and i did try a little ice i probably should ice it more but i did n't notice it helping much [doctor] okay okay alright yeah well i definitely i'm glad you're getting some exercise now that's good for your diabetes and all that and out there playing tennis kinda back back to the back to the old days for you right did do i recall that were n't you a big tennis player back in the day like state champ in high school or something [patient] yeah yeah that was a hundred years ago i ca n't i i try to play like that and i ca n't i ca n't do that anymore but yeah a good memory that's a that's a good memory [doctor] now [patient] kind of a tennis guy too right did you see the the australia open [doctor] i did i did yeah that was that was crazy that was a great tournament what a what a finish unbelievable [patient] yeah hey did you see the masters i know you're a golfer [doctor] yeah yeah yeah i do n't get out as often as i as as i like to but but the masters yeah that was that was amazing that was lot of fun to lot of fun did you catch it too [patient] i did [doctor] yeah [patient] yeah [doctor] yeah [patient] but that's it was i i could n't believe tiger went out there of course he did [doctor] right [patient] it was cool to see nothing [doctor] yep yep agreed agreed and so well listen we'll we'll hopefully get you feeling better here and get you back out on the court and out on the course and we'll talk about that but let's let me ask you about your diabetes a little bit a little bit here so how have your blood sugars been running mark have they been what in the low one hundreds two hundreds where are they [patient] they are like one fifty one sixty you know we just had easter and my kids got a whole bunch of candies so i keep eating that [doctor] hmmm okay yeah yeah understood so those cadboy eggs they'll get you every time too right [patient] yes [doctor] boy my gosh yeah those are the best so those are those are deadly do n't tell my cardiologist so okay so listen you know i see that we have you on metformin five hundred milligrams once a day no actually last visit we increased it so i've got you on metformin five hundred milligrams twice a day correct you're still taking that [patient] yes twice a day [doctor] okay and but your blood sugars are a bit off you know maybe those the cadberry eggs so how about your asthma how has that been doing you know have you had any asthma attacks you're still taking flovent twice a day and the albuterol as needed [patient] yeah knock on wood i my asthma is pretty much under control [doctor] okay excellent excellent alright and i recall you know just kinda review a few things i i think you've got an allergy to penicillin is that correct [patient] that's correct yes [doctor] okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct [patient] yes that's right [doctor] okay and then let's go ahead and examine you alright so mark your exam is pretty much you know for the most part normal with a few exceptions on your heart exam you still have a grade three out of six systolic ejection murmur and that's unchanged from prior exam we're watching that and so that just means i hear some some heart sounds as your heart is beating there i'm not too concerned about it as as that's not changed otherwise normal cardiovascular exam and your physical exam otherwise on your musculoskeletal exam on your right elbow you do have moderate lateral epicondylar tenderness of the right elbow and how about when i move this when i move your elbow like this does that hurt you [patient] kills [doctor] okay sorry about that so you've got moderate pain with passive range of motion of the right elbow there is no palpable joint effusion and now what if i press against your wrist like so does that hurt you [patient] yeah it hurts a little bit [doctor] okay alright sorry so that's you have mild pain with resisted extension of the right wrist as well okay otherwise normal unremarkable exam and let's talk about your results now so your right elbow x-ray today shows no acute fracture or other bony abnormality so that's good there's no malalignment or sign of joint effusion and otherwise it's a normal right elbow x-ray so that's reassuring okay and hey you know i meant to ask you you know and do you have any history of fever recently you know along with the elbow pain you had noticed a fever [patient] no i do n't think so [doctor] okay great excellent alright so tell you what let's let's talk about my assessment and your plan here so for your first problem my assessment is is that you have acute lateral epicondylitis of your right elbow and this is also known as tennis elbow go figure right so this is due to overuse likely the increase in your your tennis activity which normally would be good but maybe we're overdoing it a little bit so i have a few recommendations i'd like you to rest your right arm as much as you can i want you to stop tennis for the next four to six weeks and please avoid repetitive stress in that right arm as well i want you to ice that right elbow for twenty minutes at least three times per day and this should reduce the pain and inflammation and then i'm also going to give you a brace for your right forearm and my nurse will give this to you before you leave that should help with the discomfort okay in that right elbow i will also write you a prescription for ultram and this should help with the pain i'll write you a prescription ultram fifty milligrams once per day that should help with your elbow pain so then i wan na see you in follow-up in four weeks and so we'll reevaluate your elbow at that time and if you we'll consider some additional imaging if needed possibly a physical therapy referral depending on how you're doing mkay now for your second problem of diabetes type two my assessment is is that your blood sugar is a little bit out of control mkay so we need to make some adjustments i'm going to increase your metformin to one thousand milligrams twice per day and i want you to check your blood sugar twice daily for the next two weeks and then let me know how your blood sugar is running and we can make some additional adjustments if needed but i will increase your metformin to one thousand milligrams twice a day now i'm going to also order a hemoglobin a1c level and and a cbc blood test today and and so we'll check those results the hemoglobin a1c and the cbc and then i'm going to also check a chem-12 blood test as well and now for your third problem of the mild acute intermittent asthma you my assessment is that it really remains under good control so let's keep you on that flovent and the albuterol no changes there and you can use those as tolerated it does look like you need a refill on your albuterol so i'm gon na write you a prescription for a refill of the albuterol and you can pick that up at your pharmacy as well so how does that all sound any questions for me [patient] it sounds pretty good i ca n't believe it's just tennis elbow feel like a looser coming in here but it's okay i get it [doctor] yeah yeah well [patient] i'm not i'm not young anymore [doctor] yeah well let's let's keep you active but take a break for a bit and let's ease back into it okay so it's great to see you and i'll see you back in four weeks let me know if you have other problems in the meantime [patient] okay", "target": "ASSESSMENT AND PLAN\n\n1. Acute lateral epicondylitis of right elbow.\n - Medical Reasoning: Patient presents today with symptoms consistent with lateral epicondylitis secondary to overuse.\n - Patient Education and Counseling: The nature of the diagnosis was discussed. He was advised that this is like due to increased tennis activity and was encouraged to rest as much as possible. - Medical Treatment: Patient will discontinue playing tennis for the next 4 to 6 weeks, as well as avoid repetitive stress with the right arm. He will apply ice to the elbow for at least 20 minutes 3 times per day to reduce pain and inflammation. Right forearm brace was provided today to help with discomfort. Prescription for Ultram 50 mg once per day was also provided for pain.\n \n 2. Diabetes type 2.\n - Medical Reasoning: His blood sugar today is not controlled.\n - Patient Education and Counseling: We discussed that I would like him to take his blood sugars twice a day for the next 2 weeks and to let me know how they are running so we can make additional adjustments if needed.\n - Medical Treatment: He will increase his metformin to 1000 mg twice a day. He will begin home blood sugar monitoring twice a day for the next 2 weeks. Hemoglobin A1c, CBC, and a Chem-12 test were ordered today.\n \n 3. Mild acute intermittent asthma.\n - Medical Reasoning: This remains well-controlled.\n - Medical Treatment: The patient will continue his Flovent twice a day. Refill of albuterol provided today to be used as needed.\n \n "} {"idx": 12, "inputs": "[doctor] hi , joseph . how are you ? [patient] hey , i'm okay . good to see you . [doctor] good to see you . are you ready to get started ? [patient] yes , i am . [doctor] okay . joseph is a 59 year old male here for routine follow-up of his chronic problems . so , joseph , how have you been doing ? [patient] yeah , i've been kind of managing through my depression , and , uh , my asthma's been acting up 'cause we had a really bad pollen season , and i am at least keeping my diabetes under control , but just , uh , it's just persistent issues all around . [doctor] okay . all right . well , let's start with your diabetes . so , your diet's been good ? [patient] um , for the most part , but we have been traveling all over to different sports tournaments for the kids , so it was , uh , a weekend of , uh , eating on the go , crumby junk food , pizza , and did n't really stick to the diet , so that was a bit of an adjustment . [doctor] okay . all right . um , but , ha- ha- have you ... let's just talk about your review of systems . have you had any dizziness , lightheadedness , fever , chills ? [patient] running up and down the stairs , it was pretty warm , so i did feel a little bit lightheaded , and i did get a little dizzy , but i thought it was just the heat and the fatigue . [doctor] okay . any chest pain , shortness of breath , or belly pain ? [patient] shortness of breath . no belly pain though . [doctor] okay . all right . and , how about any joint pain or muscle aches ? [patient] uh , my knees hurt a little bit from running up and down , and maybe picking up the boxes , but nothing out of the ordinary . [doctor] okay . all right . um , and , in terms of your asthma , you just said that you were short of breath running up and down the stairs , so , um , do , how often have you been using your inhaler over the past year ? [patient] only when it seems to go over about 85 degrees out . that's when i really feel it , so that's when i've been using it . if it's a nice , cool , dry day , i really do n't use the inhaler . [doctor] okay . and , um- [doctor] and , in terms of your activities of daily living , are you able to exercise or anything like- [patient] yes , i do exercise in the morning . i , i ride , uh , our bike for probably about 45 minutes or so . [doctor] okay . all right . and then , your depression , you said it's ... how's that going ? i know we have you on the , on the prozac 20mg a day . are you taking that ? are you having a lot of side effects from that ? [patient] i was taking it regularly , but i've kind of weened myself off of it . i thought i felt a little bit better , but i think , uh , i , i kinda go through battles with depression every so often . [doctor] okay . all right . are you interested in resuming the medication , or would you like to try a different one ? [patient] i , maybe adjusting what i'm currently taking , maybe l- less of a dose so i do n't feel the side effects as much , but i , i'm willing to try something different . [doctor] okay . all right . okay , well , let's , let's go ahead and we'll do a quick physical exam . so , looking at you , you're in , in no apparent distress . i'm feeling your neck . there's no cervical lymphadenopathy . your thyroid seems not enlarged . and , listening to your lungs , you do have some bilateral expiratory wheezing that's very faint , and your heart is a regular rate and rhythm . your abdomen is soft , and uh , your lower extremities have no edema . so , let's go ahead and look at some of your results . hey , dragon , show me the pfts . [doctor] okay , so your , your pfts , that , those are your breathing studies , and those look quite good , so i know that you're wheezing right now , but , um , you know , i think that we can add , add , um , a regimen to that to help , to help you with your , um , exacerbations during the , the summer months , okay ? [patient] okay . [doctor] and then , let's look at your ... hey , dragon ? show me the hemoglobin a1c . okay , so your a1c , you're right , you know , over the past couple months is , you know , your blood sugar's probably been running a little high , so , you know , i know that you're gon na get back on your diet regimen , but , um , for right now , let's go ahead and we'll increase your metformin , okay ? [patient] okay . [doctor] um , and then , hey , dragon ? show me the chest x-ray . okay , good , and your chest x-ray looks fine , so we know that there's no pneumonia there . [patient] mm-hmm . [doctor] and , it's just is all just from your asthma . so , you know , my impression of you at this time , you know , from a diabetes standpoint , let's , let's increase the metformin to 1,000 mg twice a day . um , and , we will get a repeat hemoglobin a1c in three months , and i want you to continue to monitor your blood sugars at home . [doctor] from an asthma standpoint , let's continue you on the albuterol , two puffs , uh , every four to six hours as needed , and we'll add symbicort , two puffs twice a day during the summer , to kind of help prevent those exacerbations . and then , from a depression standpoint , we'll go ahead and start you on a different medication , zoloft , um , 25 mg once a day and see how you tolerate that . does that sound okay ? [patient] perfect . [doctor] all right . so , the nurse will be in soon , and she'll get you situated with all of that , okay ? [patient] great . [doctor] it was good to see you . [patient] same here . [doctor] hey , dragon ? finalize the note .", "target": "ASSESSMENT AND PLAN\n\nMr. Joseph Fisher is a 59-year-old male who presents for routine follow up of his chronic problems.\n \n Asthma.\n \u2022 Medical Reasoning: His symptoms are exacerbated during warmer weather, but his recent pulmonary function tests were normal.\n \u2022 Medical Treatment: Continue on albuterol, 2 puffs every 4-6 hours as needed. Add Symbicort 2 puffs twice a day during the summer to help prevent exacerbation.\n \n Depression.\n \u2022 Medical Reasoning: The patient self-weened from Prozac 20 mg daily due to side effects.\n \u2022 Medical Treatment: We will start him on a different medication, Zoloft 25 mg once a day, to see how he tolerates this.\n \n Diabetes Type II.\n \u2022 Medical Reasoning: Recent blood glucose levels and hemoglobin A1c were elevated.\n \u2022 Additional Testing: Repeat hemoglobin A1c in 3 months. Continue to monitor blood glucose levels at home.\n \u2022 Medical Treatment: We will increase metformin to 1000 mg twice a day.\n \n "} {"idx": 2, "inputs": "[doctor] hi , andrew , how are you ? [patient] hi . good to see you . [doctor] it's good to see you as well . so i know that the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] okay ? so , andrew is a 62-year-old male with a past medical history significant for a kidney transplant , hypothyroidism , and arthritis , who presents today with complaints of joint pain . andrew , what's going on with your joint ? what happened ? [patient] uh , so , over the the weekend , we've been moving boxes up and down our basements stairs , and by the end of the day my knees were just killing me . [doctor] okay . is , is one knee worse than the other ? [patient] equally painful . [doctor] okay . [patient] both of them . [doctor] and did you , did you injure one of them ? [patient] um , uh , i've had some knee problems in the past but i think it was just the repetition and the weight of the boxes . [doctor] okay . all right . and , and what have you taken for the pain ? [patient] a little tylenol . i iced them for a bit . nothing really seemed to help , though . [doctor] okay . all right . um , and does it prevent you from doing , like , your activities of daily living , like walking and exercising and things like that ? [patient] uh , saturday night it actually kept me up for a bit . they were pretty sore . [doctor] mm-hmm . okay . and any other symptoms like fever or chills ? [patient] no . [doctor] joint pain ... i mean , like muscle aches ? [patient] no . [doctor] nausea , vomiting , diarrhea ? [patient] no . [doctor] anything like that ? [patient] no . [doctor] okay . all right . now , i know that you've had the kidney transplant a few years ago for some polycystic kidneys . [patient] mm-hmm . [doctor] um , how are you doing with that ? i know that you told dr. gutierrez- [patient] mm . [doctor] . a couple of weeks ago . [patient] yes . [doctor] everything's okay ? [patient] so far , so good . [doctor] all right . and you're taking your immunosuppressive medications ? [patient] yes , i am . [doctor] okay . all right . um , and did they have anything to say ? i have n't gotten any reports from them , so ... [patient] no , n- nothing out of the ordinary , from what they reported . [doctor] okay . all right . um , and in terms of your hyperthyroidism , how are you doing with the synthroid ? are you doing okay ? [patient] uh , yes , i am . [doctor] you're taking it regularly ? [patient] on the clock , yes . [doctor] yes . okay . and any fatigue ? weight gain ? anything like that that you've noticed ? [patient] no , nothing out of the ordinary . [doctor] okay . and just in general , you know , i know that we've kind of battled with your arthritis . [patient] mm-hmm . [doctor] you know , it's hard because you ca n't take certain medications 'cause of your kidney transplant . [patient] sure . [doctor] so other than your knees , any other joint pain or anything like that ? [patient] every once in a while , my elbow , but nothing , nothing out of the ordinary . [doctor] okay . all right . now i know the nurse did a review of systems sheet when you checked in . any other symptoms i might have missed ? [patient] no . [doctor] no headaches ? [patient] no headaches . [doctor] anything like that w- ... okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so here in the office , your vital signs look good . you do n't have a fever , which is good . [patient] mm-hmm . [doctor] your heart rate and your , uh , blood pressure look fine . i'm just gon na check some things out , and i'll let you know what i find , okay ? [patient] perfect . [doctor] all right . does that hurt ? [patient] a little bit . that's tender . [doctor] okay , so on physical examination , on your heart exam , i do appreciate a little two out of six systolic ejection murmur- [patient] mm-hmm . [doctor] . which we've heard in the past . okay , so that seems stable . on your knee exam , there is some edema and some erythema of your right knee , but your left knee looks fine , okay ? um , you do have some pain to palpation of the right knee and some decreased range of motion , um , on exam , okay ? so what does that mean ? so we'll go ahead and we'll see if we can take a look at some of these things . i know that they did an x-ray before you came in , okay ? [patient] mm-hmm . [doctor] so let's take a look at that . [patient] sure . [doctor] hey , dragon , show me the right knee x-ray . so here's the r- here's your right knee x-ray . this basically shows that there's good bony alignment . there's no acute fracture , which is not surprising , based on the history . [patient] mm-hmm . [doctor] okay ? hey , dragon , show me the labs . and here , looking at your lab results , you know , your white blood cell count is not elevated , which is good . you know , we get concerned about that in somebody who's immunocompromised . [patient] mm-hmm . [doctor] and it looks like your kidney function is also very good . so i'm , i'm very happy about that . [patient] yeah . [doctor] okay ? so i just wan na go over a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so for your knee pain , i think that this is an acute exacerbation of your arthritis , okay ? so i wan na go ahead and if ... and prescribe some ultram 50 milligrams every six hours as needed . [patient] okay . [doctor] okay ? i also wan na go ahead and just order an autoimmune panel , okay ? hey , dragon , order an autoimmune panel . and you know , i , i want , i want you to just take it easy for right now , and if your symptoms continue , we'll talk about further imaging and possibly referral to physical therapy , okay ? [patient] you got it . [doctor] for your second problem , your hypothyroidism , i wan na go ahead and continue you on this ... on the synthroid , and i wan na go ahead and order some thyroid labs , okay ? [patient] sure . [doctor] hey , dragon , order a thyroid panel . and then for your last problem , the arthritis , you know , we just kinda talked about that . you know , it's gon na be a struggle for you because again , you ca n't take some of those anti-inflammatory medications because of your kidney transplant , so ... [patient] mm-hmm . [doctor] you know , let's see how we do over the next couple weeks , and again , we'll refer you to physical therapy if we need to , okay ? [patient] you got it . [doctor] you have any questions ? [patient] not at this point . [doctor] okay . hey , dragon , finalize the note .", "target": "ASSESSMENT AND PLAN\n\nAndrew Perez is a 62-year-old male with a past medical history significant for a kidney transplant, hypothyroidism, and arthritis. He presents today with complaints of joint pain.\n \n Arthritis.\n \u2022 Medical Reasoning: The patient reports increased joint pain in his bilateral knees over the past weekend. Given that his right knee x-ray was unremarkable, I believe this is an acute exacerbation of his arthritis.\n \u2022 Additional Testing: We will order an autoimmune panel for further evaluation.\n \u2022 Medical Treatment: Initiate Ultram 50 mg every 6 hours as needed.\n \u2022 Patient Education and Counseling: I advised the patient to rest his knees. If his symptoms persist, we can consider further imaging and possibly a referral to physical therapy.\n \n Hypothyroidism.\n \u2022 Medical Reasoning: The patient is doing well on Synthroid and is asymptomatic at this time.\n \u2022 Additional Testing: We will order a thyroid panel.\n \u2022 Medical Treatment: Continue Synthroid.\n \n Status post renal transplant.\n \u2022 Medical Reasoning: He is doing well and has been compliant with his immunosuppressive medications. On recent labs, his white blood cell count was within a normal limits and his kidney function is stable.\n \u2022 Medical Treatment: Continue current regimen.\n \n "} {"idx": 84, "inputs": "[doctor] alright david so you were just in the emergency department hopefully you can hear me okay through the zoom meeting what happened [patient] well it seems that i was outside and i fell down i was walking a bit and i did have a pain in my chest but i did n't think anything of it and i just kept on going and then all of a sudden i'm here [doctor] hmmm my gosh so it looks like you you went into the er and looks like they said that your ankles were swelling a little bit too and did you have some shortness of breath [patient] i did but i did n't think anything of it [doctor] sure yeah okay yeah i know we've been talking through your hypertension looks like your blood pressure was two hundred over ninety have you been taking those meds that we have you on [patient] i have but i miss them every year and then so i think today i took one [doctor] okay alright yeah i have you on bumex cozaar and norvasc does that sound right [patient] i guess so that sounds about right [doctor] alright okay yeah you need to make sure that you're you're taking those consistently that's really important and i know that we talked a little bit about watching your diet how have you been doing with that [patient] i've just been eating anything honestly i try to watch it here and there but to tell you the truth i'd looks i was eating [doctor] yeah i i know it's hard around the holidays and everything but it is really important that we watch that diet what kind of things are you eating is it is it salty foods or pizza chicken wing kinda stuff or what are you standing or [patient] little bit of everything here and there i do lot of chips [doctor] sure [patient] they're pretty good i guess they're salty even though the light salt ones but [doctor] mm-hmm [patient] kinda whatever i can get my hands on really [doctor] okay alright how are you feeling right now [patient] i'm doing a little okay i guess i'm just out of breath a little bit but it's nothing i ca n't handle [doctor] sure yeah okay so you're taking your meds mostly we talked about getting you a blood pressure cuff at home did you end up getting one of those [patient] no i have n't got one yet i know i needed to get one [doctor] yeah that's that will be good if you can take your blood pressures at home and definitely track those what about any problems with shortness of breath lately [patient] just like i said when i was walking outside it helped a little bit but again i just walked it off [doctor] sure any problems sleeping [patient] no i sleep like a rock [doctor] good good to hear have you had any chest pain [patient] slightly here or there but i thought it was just heartburn [doctor] sure okay alright let me do a quick physical exam your blood pressure is pretty good in the office today it looks like it's one twenty eight over seventy two your other vital signs look good on your neck exam there is no jugular venous distention on your heart exam just gon na take a listen here i do appreciate a two out of six systolic ejection murmur but i heard that before and that is stable your lungs you want to take a deep breath for me lungs are clear bilaterally now i know we talked about you stopping smoking a a couple of years ago i have here have you kept up with that [patient] i've been pretty good on it very once every week maybe just one [doctor] okay alright good to hear alright and your lower extremities show a trace edema so megan david david i'm looking at your results of your echocardiogram that you got when you were in the er and it it does show preserved ejection fraction of fifty five percent and normal diastolic filling and mild to moderate mild to moderate mitral regurgitation so let me tell you about what that means for the chf that you were in the hospital with sounds like you know based on your diet this is likely caused by your dietary indiscretion and uncontrolled hypertension that we've been monitoring so what i want you to do is continue your bumex two milligrams once daily definitely stay on top of that make sure that you get those meds in every time i'm gon na write you a consult to nutrition since it sounds like maybe we can give you some advice on on watching your diet definitely watching the salty foods that you've been eating does that sound okay [patient] that sounds good document [doctor] awesome weigh yourself daily do you have a scale at home [patient] no but i can get one [doctor] okay good get a scale weigh yourself daily call me if you gain three pounds in two days for the hypertension that we've been treating i want you to continue the cozaar one hundred milligrams daily continue the norvasc five milligrams once daily so i'll be written down in your discharge summary and i'm gon na order a test i'm gon na order a renal artery ultrasound just to make sure that we're not missing anything there does that sound good [patient] that sounds good to me [doctor] great okay david do you have any other questions [patient] no other questions at this time just i guess i just need to make sure to take my medication on time that's about it [doctor] yeah definitely take your medication on time and see that nutritionist and hopefully we can get your get your diet on track as well [patient] i will do my best [doctor] alright thanks hope you feel better [patient] thank you", "target": "ASSESSMENT AND PLAN\n\n1. CHF.\n - Medical Reasoning: The patient\u2019s recent epsiode resulting in the emergency room visit was likely caused by his dietary indiscretion and uncontrolled hypertension that we have been monitoring.\n - Patient Education and Counseling: I reviewed the echocardiogram results with the patient and discussed the importance of following dietary restrictions. I encouraged the patient to take his medication on a consistent basis. I advised him to purchase a scale to weigh himself daily.\n - Medical Treatment: He will continue Bumex 2 mg once daily. He was provided with a referral to a nutritionist in consultation for further assistance with his dietary requirements to lower his sodium intake.\n \n 2. Hypertension.\n - Medical Reasoning: This is currently uncontrolled.\n - Patient Education and Counseling: I explained the importance of taking his medication on a daily basis. I encouraged the patient to purchase a blood pressure cuff and track his blood pressures.\n - Medical Treatment: He will continue Cozaar 100 mg daily as well as the Norvasc 5 mg once daily. I will order a renal artery ultrasound for further evaluation.\n \n 3. Systolic ejection murmur.\n - Medical Reasoning. Stable.\n \n "} {"idx": 8, "inputs": "[doctor] hi , stephanie . how are you ? [patient] i'm doing okay . how are you ? [doctor] i'm doing okay . um , so i know the nurse talked to you about dax . i'd like to tell dax a little bit about you , okay ? [patient] okay . [doctor] so , stephanie is a 49-year-old female with a past medical history significant for congestive heart failure , kidney stones and prior colonoscopy who presents today for an abnormal lab finding . so , stephanie , i called you in today because your hemoglobin is low . um , how have you been feeling ? [patient] over the past couple of months , i've been really tired and dizzy . lately , i've been really just worn out , even just , you know , walking a mile or going to work , doing things that i've done in the past every day that have been relatively okay , and i have n't gotten tired . and now , i've been getting tired . [doctor] okay , yeah . i , you know , the nurse told me that you had called with these complaints . and i know that we have ordered some labs on you before the visit . and it did , it c- you know , your , your , your hemoglobin is your red blood cell count . and now , and that came back as a little low on the results , okay ? so , have you noticed any blood in your stools ? [patient] uh , no , i have n't . i did about three years ago , um , and i did a colonoscopy for that , but nothing since then . [doctor] okay , yeah . i remember that , okay . and how about , you know , do your stools look dark or tarry or black or anything like that ? [patient] no , nothing like that . [doctor] okay . and have you been , um , having any heavy menstrual bleeding or anything like that ? [patient] no , not that i've noticed . [doctor] okay , all right . and any , have you passed out at all , or anything like that ? any weight loss ? [patient] no , no weight loss or passing out . i have felt a bit dizzy , but it has n't l- led to me passing out at all . [doctor] okay . so , you endorse some dizziness . you endorse some fatigue . have you , but you have n't had any weight loss , loss of appetite , anything like that ? [patient] no , nothing like that . [doctor] okay , all right . so , you know , let's talk a little bit about that colonoscopy . i know you had a colonoscopy about three years ago and that showed that you had some mild diverticuli- diverticulosis . um , no issues since then ? [patient] nope , no issues since then . [doctor] okay , all right . and then i know that , uh , you know , you have this slightly reduced heart function , you know , your congestive heart failure . how have you been doing watching your salt intake ? i know that that's kind of been a struggle for you . [patient] um , it's been more of a struggle recently . i've been traveling a lot . i went up to vermont , um , to go , um , explore the mountains . and along the way i stopped at , you know , mcdonald's and got two cheeseburgers . and so , i , i could be doing better . i've noticed some swelling in my , my legs . um , but nothing too extreme that where i thought i should call . [doctor] okay , all right . and any shortness of breath or problems lying flat at night , anything like that ? [patient] no , nothing like that . [doctor] okay , all right . and then in terms of the kidney stones , i know that you had those a couple years ago , as well . any recent flare ups ? have you had any , any back pain , flank pain , anything like that ? [patient] no , nothing like that . [doctor] okay . any blood in your urine that you've seen ? [patient] no . [doctor] okay , all right . um , okay . well , i know that the nurse did a review of system sheet when you came in . and we've just talked a lot about your , your s- your symptoms , you know , your dizziness , your fatigue and that type of thing . anything else that i might have missed , fever chills , any nasal congestion , sore throat , cough ? [patient] uh , i've had a little bit of nasal congestion just because with the seasons changing , i , i get seasonal allergies . but everything else has been okay . [doctor] okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ? [patient] okay . [doctor] hey , dragon , show me the vital signs . so , here in the office today , your vital signs look great . your blood pressure is fine . your heart rates r- right where it should be , which is good , okay ? i'm just gon na do a quick exam . and i'll let you know what , what i find , okay ? [patient] okay . [doctor] all right . so , your physical , physical examination looks fine . so , on your heart exam , i do hear a three out of six systolic ejection murmur , which we've heard in the past , okay ? and on your lower extremities , i do notice some trace to one plus pitting edema in your ankles , which is probably from the salt intake , okay ? [patient] mm-hmm . [doctor] so , we'll talk about that . i wan na just look at some of your results , okay ? [patient] okay . [doctor] hey , dragon , show me the echocardiogram . so , i just wanted to go over the results of your last echocardiogram , that was about six months ago . that shows that you do have the low pumping function of , of your heart at about 45 % , which is not terrible . and it does show that you have some moderate mitral regurgitation . so , that's that slight heart murmur i heard in your exam , okay ? hey , dragon , show me the hemoglobin . and here , this is the hemoglobin that i was referring to . it's low at 8.2 , okay ? so , we'll have to talk a little bit about that , all right ? [doctor] so , let me go over a little bit about my assessment and my plan for you , okay ? so , for you first problem this new anemia , uh , i wan na go ahead and send off some more labs and anemia profile , just to see exactly what type of anemia we're dealing with . i also wan na go and refer you back to the gastroenterologist for another evaluation , okay ? hey , dragon , order referral to gastroenterology . so , they're gon na do , uh , probably do an endoscopy and another colonoscopy on you . um , but again , i wan na send off those labs just to make sure that it's not something else , okay ? [patient] okay . [doctor] for your next problem your congestive heart failure , um , i do think you're retaining a little bit of fluid . so , i'm gon na go ahead and start you on some lasix 40 milligrams once a day . i want you to continue you on your toprol 50 milligrams daily . and as well your , as well , as your lisinopril 10 milligrams a day . i really want you to watch your salt intake , okay ? get a scale , weigh yourself every day . and call me if your weight starts to go up , okay ? [patient] okay . [doctor] 'cause i might need to give you more diuretic . [patient] all right . [doctor] and for your last problem your kidney stones , uh , i think everything seems to be fine right at this time . again , continue to watch your diet and stay hydrated . um , and i know that might be a little difficult with the diuretic , but do your best . uh , and give me a call if you have any question , okay ? [patient] okay . [doctor] all right . any questions right now ? [patient] not that i can think of . [doctor] okay , great . hey , dragon , finalize the note .", "target": "ASSESSMENT AND PLAN\n\nMs. Stephanie Diaz is a 49-year-old female with a past medical history significant for congestive heart failure, kidney stones, and prior colonoscopy, who presents today for abnormal labs.\n \n Anemia.\n \u2022 Medical Reasoning: This is a new issue. Her recent hemoglobin level was low at 8.2, but she denies any signs of gastrointestinal bleeding or urinary tract bleeding, as well as any abnormal menstrual bleeding. Her colonoscopy from 3 years ago demonstrated mild diverticulosis.\n \u2022 Additional Testing: We will order an anemia profile for further evaluation.\n \u2022 Specialist Referrals: We will refer her back to gastroenterology for repeat evaluation with possible endoscopy and colonoscopy.\n \n Congestive heart failure.\n \u2022 Medical Reasoning: She has noticed some lower extremity edema. Her echocardiogram from 6 months ago demonstrated a reduced ejection fraction of 45%, as well as moderate mitral regurgitation.\n \u2022 Medical Treatment: We will initiate Lasix 40 mg once daily, and continue with Toprol 50 mg daily and lisinopril 10 mg daily.\n \u2022 Patient Education and Counseling: She should continue to limit her sodium intake. I advised her to monitor her daily weights and notify me if these start to increase.\n \n Kidney stones.\n \u2022 Medical Reasoning: She as asymptomatic denies any recent flare ups.\n \u2022 Patient Education and Counseling: I encouraged her to continue with dietary modifications and proper hydration. She will contact me with any questions or concerns.\n \n "} {"idx": 120, "inputs": "[doctor] hello larry how are you doing today [patient] i've been better my primary care doctor wanted me to see you for this back pain that i've been having for a couple of years now [doctor] okay [patient] and i have tried so many things and just nothing seems to work [doctor] i'm sorry to hear that now do you remember what caused the pain initially [patient] you know i never fell or was in an accident but i do remember it all happened like i started having back pain after i was moving furniture one weekend [doctor] okay and now can you describe the pain for me [patient] yeah it feels like a sharp stabbing pain in my back and it does go down even down to my right leg sometimes all the way down to my toe it feels like my big toe [doctor] okay [patient] and i also feel like i just ca n't get comfortable which is worse when i sit down okay yeah [doctor] okay now with that do you have any numbness or tingling associated with your back pain [patient] yeah i do get some numbness and tingling especially to my right leg that goes down to my foot [doctor] okay [patient] let me separate these [doctor] and how about a loss of sensation in the genital or the rectal area [patient] no nothing like that [doctor] okay now do you have any weakness [patient] i would n't say i have any weakness no [doctor] okay do you experience like any loss of control of your bladder or your bowels [patient] no [doctor] okay now you mentioned earlier that you you have some tried tried some things in the past so tell me what were they [patient] so i've tried some physical therapy before and so when it gets really bad they've even had to prescribe some strong pain medications for me but that was only temporary and they even mentioned surgery to me in the past but i really would like to avoid surgery [doctor] okay sure so tell me what is your day like [patient] my day so i try to be as active as i can but of course it's been difficult with my back pain and so because of that i have gained some weight over the past years [doctor] okay alright well i'm sorry to hear that i know that you used to like playing golf [patient] yeah i and you know golf is relatively new for me i've been trying to get into it but this has definitely set me back [doctor] yeah i'm sorry yep probably now at the peak of you know just learning it and being able to do more with it this comes and this happens right [patient] exactly [doctor] well let's see what we can do for you here so you can go out into the you know the golf course again now do you tell me do you have any family members with spine conditions [patient] no i ca n't recall any family members [doctor] okay alright and do you smoke [patient] not now i i quit about twenty years ago [doctor] okay alright well alright well i like to do a quick physical exam on you here [patient] okay [doctor] i'm gon na go ahead here i reviewed your vitals and they overall look pretty good so that's a good sign now on your musculoskeletal back exam there is no overlying erythema and that just means redness or ecchymosis and that just means bruising of the skin now there is midline tenderness at l4 l5 disk space with right-sided lumbar paravertebral tenderness so do me a favor and i'm gon na just have you you know bend forward and straighten up a bit [patient] okay that's painful [doctor] sorry so definitely some pain with lumbar flexion and supine straight leg test is positive so on your neurological examination there is decreased sensation to light touch at the right lateral thigh at l4 dermatome okay and i'm just gon na take a look at your knees here real quick and then your your ankles so patellar and achilles reflexes are symmetrical so good now i reviewed the results of your mri and it shows disk herniation with nerve impingement so let me tell you about my assessment and plan here larry so for your problem of chronic lumbar back pain so based on your symptoms your exam and reviewing your mri results your symptoms are consistent with an l4 l5 herniated disk with radicul radiculopathy so this means that one of your disks that sits between your spinal vertebrae is bulging out and this bulge is pinching on some nerves and that's why you feel that tingling in your leg so yeah yeah so i am recommending a spinal injection with a strong inflammatory medication called a corticosteroid and what i do is i will inject the corticosteroid into that lumbar spine under fluoroscopy which you can think of you know an x-ray to help localize to the exact area of your pain now this should this should help the inflammation that is causing the pain so what do you think about that [patient] is there something i'm gon na have to do all the time [doctor] well you know patients are different so what we do is we will monitor you and we see how you respond to the injection and the patient's intervals can be different as well but we usually do not do more than four times a year [patient] okay okay [doctor] alright and it's not a long procedure it's it's relatively quick and common and you should be out of the office within an hour [patient] okay [doctor] okay [patient] alright sounds good [doctor] alright well let's go ahead and get you started on the first one today if that works for you if not we'll get you scheduled to start your first injection [patient] alright thank you [doctor] alright thank you [patient] bye", "target": "ASSESSMENT\n\nL4-5 herniated disc with radiculopathy.\n\nPLAN\n\nAfter reviewing the patient's examination and MRI findings today, I have discussed with the patient that his symptoms are consistent with an L4-5 herniated disc with radiculopathy. I have recommended that we treat the patient conservatively with a corticosteroid injection under fluoroscopy. With the patient's consent, we will proceed with a cortisone injection into the lumbar spine today.\""} {"idx": 67, "inputs": "[doctor] hi elizabeth so i see that you were experiencing some kind of injury did you say that you hurt your knee [patient] yes i hurt my knee when i was skiing two weeks ago [doctor] okay skiing that sounds exciting alright so what happened what what's when did the injury like what sorry what happened in the injury [patient] so i was flying down this black diamond you know like i like to do [doctor] yes [patient] and this kid who was going faster than me spent by me so then i tried to speed past them and then i ran into a tree and twisted my knee [doctor] so we were downhill skiing racing at this point okay is it your left or your right knee [patient] it's my right [doctor] okay and does it hurt on the inside or the outside [patient] the inside [doctor] okay so the medial aspect of the right knee when you fell did you hear a pop [patient] i did yes [doctor] okay alright [patient] i think that was my left knee [doctor] okay okay alright so we got we got ta pick one if it if it [patient] i'm just trying to be real [doctor] no [patient] what happens in the in a real [doctor] a hundred percent so how about this right now you're like i what i'm hearing is that you're experiencing bilateral knee pain like both of your knees hurt but i'm assuming that like your right knee hurts more is that correct [patient] yeah my left knee does n't really hurt [doctor] uh uh [patient] that's the one that popped it the left knee just feels unstable but my right knee hurts [doctor] gotcha gotcha okay yeah i think hmmm alright so we're gon na we're gon na go ahead and look at this sort of but on a scale of one to ten how severe is your pain [patient] it's a seven [doctor] okay that's pretty bad alright and does it has it been increasing or like rapidly or slowly over the last few days [patient] it's been slow [doctor] okay alright [patient] but sometimes it gets to an eleven [doctor] okay what would do you know if you are doing something that would cause it to be an eleven are you back on your ski's [patient] no i ca n't ski [doctor] okay [patient] usually when i walk my dog [doctor] okay does it hurt more when you walk for longer periods of time [patient] yes [doctor] okay how long does the pain last [patient] for as long as my walk is and i do n't sometimes i walk five minutes kinda depends on the wind [doctor] okay alright [patient] sometimes i walk there is [doctor] okay alright have you done anything to help with the pain [patient] well i wear a brace and i have used a lot of thc cream on it [doctor] okay alright thc cream is an interesting choice but do you think that's been helpful [patient] yes [doctor] alright have you taken [patient] reasons [doctor] not a problem have you taken any medications [patient] no just gummies [doctor] okay like vitamins or more thc [patient] kind of like thc gummies [doctor] thc gummies [patient] my grandma gave them to me [doctor] thc gummies from grandma that's an excellent grandmother that you have okay have you noticed any swelling stiffness tenderness [patient] yeah i i get a lot of swelling and it really is it's very stiff in the morning until i get walking [doctor] okay alright and then have you had any hospitalizations or surgeries in the past [patient] well i had surgery on my right knee before [doctor] okay so you've had surgery before alright do you remember what kind of surgery [patient] i do n't know they told me they reconstructed the whole thing i was fourteen i was a really good gymnast back then really good [doctor] okay [patient] and i was doing a back summer salt and i felt a pop then and then since that time i've really had problems with my knee [doctor] uh uh [patient] but you know the athlete that i am i can still really ski very well so i just kept going [doctor] okay [patient] and i'm really tough my pain tolerance is very high [doctor] okay okay okay how so do you have any other exercises that i might wan na know about outside of intense gym and ski events [patient] no i think that's about it [doctor] okay and how frequently do you normally ski [patient] i ski probably three times a week [doctor] okay and then are you on any medications at this time other than the thc [patient] no [doctor] okay alright what [patient] nothing no [doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and start my examination i'm just gon na call it out for the sake of being able to document it appropriately and you or just just let me know if you want me to explain anything further so with your knee i know that you said it hurts on the right inside a lot right so when i press on the inside of your knee does that hurt [patient] yes [doctor] okay and when i press on the outside of your left of your right knee sorry does that hurt [patient] no [doctor] okay alright so when i move your your kneecap does that hurt [patient] no it kinda makes a shooting pain down to my ankle though [doctor] okay [patient] but it does n't hurt my knee [doctor] okay so does the pain radiate frequently [patient] no [doctor] okay [patient] i've never really noticed it just messed with my kneecap [doctor] okay alright on your skin exam i do appreciate some mild swelling and bruising that's really interesting since it's been two weeks with your knee are you able to bend it [patient] yes [doctor] okay and then when you walked in on your gait i think i think i did appreciate a slight limp are you i i i i think you are you are protecting one of your knees does that sound familiar [patient] yeah i waddle pretty pretty good now [doctor] okay alright and when you move your knee away from your body you're bending like your you're pulling it towards me does that hurt [patient] yes [doctor] okay and then when you pull your knee back towards you does that hurt [patient] no [doctor] alright so pain on dorsiflexion but not on plantar flexion plantar flexion okay alright so what we are gon na do right now i think i'm gon na look at your x-rays but when i when i look at the results of your x-ray i do not appreciate any fracture what i am noticing is the development of a little bit of arthritis and that could explain like why you say that your joints hurt a bit more during like windy weather and what not so this is what we're gon na do for my assessment and plan right the first thing is i think you have a strain of your posterior cruciate ligament what that means is what that will mean for you though is that we are gon na continue to brace your right knee that's gon na hopefully take off some of the stress that you might be putting on it especially since you're limping i am going to recommend you for physical therapy i think it would be an i think it's a good idea to maybe start three times a week to get your strength back into your knee i would recommend not skiing or doing any gymnastics for now and i think that physical therapy will really help considering the injury that you had when you were fourteen i'm gon na prescribe you some medications i do n't necessarily recommend consuming gummies at the same time but the medications i'm gon na give you are gon na be meloxicam fifteen milligrams you're gon na take that once a day that will help with like the swelling and the bruising i'm also gon na prescribe you just like a higher strength nsaid so ibuprofen eight hundred milligrams a day you can take that twice a day as needed for your left knee i think you are i think you just kind of like strength a little bit but like not enough to necessarily require any kind of like medication or bracing i think you just take it easy on your body i know that you're like very active from what i hear and i i think that that's really exciting but i think you might need to listen to your body and give yourself a bit of a break you'll be able to do like several workouts when you go to when you go to physical therapy but you know let the yeah let your therapist be your guide about like what you should and should not be putting your body through does that make sense [patient] yes [doctor] alright do you have any questions right now [patient] no thank you so much [doctor] no problem", "target": "ASSESSMENT\n\n1. Right knee posterior cruciate ligament strain.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have explained to her that her x-rays did not reveal any signs of a fracture. I have recommended that we treat the patient conservatively with continued bracing. We will initiate formal physical therapy 3 times per week to strengthen her right knee. Additionally, I have prescribed the patient meloxicam 15 mg and ibuprofen 800 mg twice daily as needed. She should discontinue the use of her THC gummies while taking these medications.\n \n Regarding her left knee, I do not believe she will need any further medications to treat this. I have advised her to avoid skiing or gymnastics at this time.\n \""} {"idx": 57, "inputs": "[patient] hi good afternoon joseph how are you doing today [doctor] i'm doing well but my my big toe hurts and it's a little red too but it really hurts okay how long has this been going on i would say you know off and on for about two weeks but last week is is when it really became painful i was at a a trade show convention and i could n't walk the halls i could n't do anything i just had to stand there and it really hurt the whole time i was there [patient] okay does it throb ache burn what kind of pain do you get with it [doctor] it's almost like a throbbing pain but occasionally it becomes almost like a a sharp stabbing pain especially if i move it or spend too much time walking i i find myself walking on my heel just to keep that toe from bending [patient] okay sorry i got a text and [doctor] well that's okay you know what i i you know i what i really you know i love to ride bikes have you you ride bike at all [patient] no i hate riding a bike i'm more of a runner [doctor] my gosh i love to ride i ride the lot of rails the trails i mean i go all the last year i put in over eight hundred miles on rails the trails [patient] yeah those those are nice [doctor] yeah [patient] does it does riding your bike bother your big toe [doctor] no because i i kinda pedal with the the back of my feet you know on that side [patient] okay do do you wear clips or are you just wearing a regular shoe and on a regular pedal [doctor] i'm on a regular shoe some most of the time i'm in my flip flops [patient] okay okay the how is there anything that you were doing out of the ordinary when this started [doctor] no i do n't that's the thing i do n't remember an injury if it was something that i injured i think i would have just ignored it and would n't have showed up here but when it got red and warm to touch that's when i i was really concerned [patient] okay do does even light pressure to it bother it like at night when you're laying in bed do the sheets bother [doctor] absolutely i was just gon na say when i'm in bed at night and those sheets come down on it or i roll over yeah that hurts a lot [patient] okay have you done anything to try to get it to feel better any soaks or taking any medicine [doctor] i take you know like a two ibuprofen a day and that does n't seem to help [patient] okay [doctor] alrighty [patient] let me see your your foot here and let me take your big toe through a range of motion if i push your top to bottom [doctor] yeah ouch [patient] big toe joint that okay and let me move it up where as i bend it up does that hurt [doctor] it hurts but not as much as when you moved it down [patient] okay so i'm moving it down here and it i've got about ten degrees of plantar flexion does that hurt [doctor] yeah it a little when you take it a little further [patient] if i go a little bit further to twenty degrees does that hurt [doctor] that hurts more yeah [patient] okay if i push in on your big toe and move it back and forth does that hurt [doctor] yes it does and it it's almost like those joints that when you push it back it's almost like it's grinding a little bit too [patient] okay if i push in between your big toe and your second toe here does that hurt [doctor] a little bit but not terrible [patient] okay what about if i push on the other side here [doctor] yeah yeah right there on the outside of it absolutely [patient] okay [doctor] yep [patient] okay and i'm feeling a little bit of bone spur here as well let me let me get an x-ray [doctor] okay [patient] and after we take a peek at that we'll develop a plan [doctor] okay [patient] so at this point what would i do if i'm going out of the room and then coming back [doctor] you could hit pause or hit the stop button and just restart it the next time you come in [patient] okay alrighty so taking a look at your x-ray and you do have you you have a large spur there on the top of your big toe joint [doctor] oh [patient] and you've lost a lot of the cartilage [doctor] oh [patient] and so you you've got some arthritis in there we we call this hallux rigidus and treatment for this to start off with we we put an insert in your shoe called an orthotic and we give you a little bit of anti-inflammatory medication or like a drug called meloxicam you only have to take it once a day [doctor] okay [patient] it's usually pretty well tolerated have you ever had any trouble with your stomach [doctor] no never never had any problems with my stomach i love the i love the mexican's food the hotter the better so i hope i never get a problem with my stomach [patient] i hope you do n't either one of the things that we get concerned about with an anti-inflammatory like that is that it can irritate the stomach so if you do start to notice that you're getting heartburn or pain right there [doctor] yeah [patient] below your your sternum you would need to stop taking the medicine and give me a call [doctor] okay [patient] okay [doctor] okay [patient] and i wan na see you back in two weeks to see how you're doing with that if you're not seeing significant improvement then we may have to talk about doing things that are a little more invasive like doing a shot [doctor] okay [patient] or even surgery to clean out the joint sometimes [doctor] is that surgery [patient] i have to [doctor] would that be [patient] i'm sorry [doctor] would that be surgery clean out the joint [patient] yeah that would [doctor] okay [patient] that would be surgery if if we went in and cleaned out the joint sometimes in really severe cases we even just have to fuse the big toe joint we put it in a position of optimal function and we fuse it there and then your pain goes away you lose some motion but you've already lost quite a bit of motion and and the pain goes away so that that surgery really is very effective but let's try to run from my knife a little bit longer [doctor] okay well you know i do n't think i'm gon na be able to do my work job i'm on my feet every day and i it's and and quite frankly it's fishing season so do you think you can give me a couple weeks off so i can get out and get some fishing done [patient] no i want you to be doing your regular activities i want to know how this because if i put you out of work can you come back in and say it feels better well is was it because of the treatment or because of the rest so no i want you to keep working i want you to do your regular activities and i really want you to put these orthotics to the test and this medicine to the test and we will see how you're doing in two weeks [doctor] okay where i really like catching blue going croppy so okay we'll we'll i'll i'll keep working then i'll find time to do that later [patient] very good we will see you in two weeks [doctor] okay thank you", "target": "ASSESSMENT\n\nRight foot hallux rigidus.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays revealed hallux rigidus. We discussed treatment options for this and I have recommended that we begin with conservative treatment in the form of custom orthotics. I have also prescribed the patient meloxicam once a day to treat the pain. The patient was instructed to discontinue use and contact the office if gastrointestinal issues develop. I advised the patient that I want him to continue his regular activities."} {"idx": 113, "inputs": "[doctor] hi jacqueline how are you doing today [patient] i'm doing okay i'm just really anxious about my recent blood work that my pcp did and said that i have hepatitis c i'm just really surprised because i've been feeling fine [doctor] okay so were you ever told in the past that you have hepatitis c [patient] no never [doctor] okay and do do you have any history like iv drug use known that you know or do you have any known to have any like hepatitis c positive partners [patient] i mean like years ago i used to party a lot and even use iv drugs but i've been clean for over fifteen years now [doctor] okay well very good you know congratulations on that that's that's a great great achievement so tell me though how about alcohol use [patient] i used to drink a lot a lot more alcohol now i probably would say i drink about a beer a day [doctor] okay [patient] and maybe slightly more on the weekends but nothing like how i used to [doctor] okay alright how about smoking have you ever smoked [patient] i do smoke i'm down to one to two cigarettes a day it's just really been tough to just get rid of those two but i've cut down a lot i used to i was up to one point or a pack and a half a day [doctor] wow okay alright so yeah you you definitely have decreased that so that's again good for you on that one so hopefully you keep you keep that up [patient] thing [doctor] so tell me do you have any other medication conditions [patient] do i do i no otherwise i'm i'm feel pretty good i had my physical there was nothing else the the only thing i was telling my pcp is i do feel like tend to be really tired at the end of the day after working but otherwise i've been good [doctor] okay and and has work been not hard lately you've been busy it sounds like [patient] i know i have been busy but not really much more than usual [doctor] okay [patient] so that's why i was kind of marking because i mean i used to you know be able and be fine but i just lately have been feeling like i'm getting enough sleep but i still get very tired at the end of the day [doctor] okay alright well i hope you're not working too much and then you'll able to at least find some time with the family [patient] yeah i'm i yeah i tend to be a workaholic but yes i i am working on that [doctor] okay well i hope kids are doing okay [patient] they are thank you [doctor] okay good so tell me what conditions what kind of conditions run in your family like is there do you have hypertension diabetes or [patient] yeah all of all of the above [doctor] okay [patient] hypertension diabetes and also depression [doctor] okay and depression okay alright well let's go ahead and do a quick physical exam on you here i reviewed your vitals and everything there looks good so that's good and now on general appearance you appear in no distress and no jaundice on skin exam let me go ahead and listen to your heart here great on your heart exam you have a nice regular rate and rhythm with a two out of six six systolic murmur appreciate appreciated that's that has n't changed from last year so we will just continue to monitor that monitor that as well okay [patient] okay [doctor] alright now let me listen to your lungs here very good so your your lungs are clear with no wheezes rales or rhonchi and let me go ahead and listen to your abdomen great your bowel sounds are present your abdomen is soft with no hepatospleno splenomegaly ca n't talk to appreciated so let me now check your musculoskeletal exam here great i i did n't see any gait disturbance and no edema so that's great so jacqueline i did review the results of your recent blood blood work and your hcv antibody test was positive and your liver panel that was done showing an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so what that all means and let me go ahead and tell you about my assessment and plan here for your first problem of hepatitis c your initial labs are consistent with hepatitis c so based on the the once i just discussed with you there now hepatitis c is a viral infection that affects the liver so you most likely may have had it for years now so the next step that i would like to do is to confirm the diagnosis with some additional blood work that includes checking the hep c rna and also the hcv genotype okay now i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and i'm gon na do this by ordering a special ultrasound and with this information i'm gon na be able to know how to proceed as far as treatment [patient] okay [doctor] alright now i know that was a lot of information do you have any questions for me [patient] yeah so should i be worried about my wife and my kids should they be tested as well [doctor] yes so we can start with the same screening that you have had for you for all of them first okay [patient] okay alright so i'll make sure i'll have them set up an appointment with our our family doctor [doctor] okay great so if you do n't have any other questions i'm gon na have the nurse check you out and get all that scheduled and i'm gon na see you in about three weeks [patient] alright perfect [doctor] alright [patient] thank you [doctor] take care jacqueline [patient] okay bye [doctor] bye", "target": "ASSESSMENT AND PLAN\n\n1. Hepatitis C.\n - Medical Reasoning: Her recent blood work revealed a positive HCV antibody. She does have a history of intravenous drug use, but she has not used drugs in over 15 years.\n - Patient Education and Counseling: We discussed the nature of hepatitis C in detail. I advised the patient to have her spouse and children tested for hepatitis C as well.\n - Medical Treatment: I'm going to order additional labs including a hepatitis C RNA and HCV genotype to confirm the diagnosis, as well as a Fibroscan to assess the severity of the condition.\n \n "} {"idx": 71, "inputs": "[doctor] i know the nurse told you about dax . [patient] mm-hmm [doctor] i'd like to tell dax a little bit about you , okay ? [patient] sure . [doctor] so ralph is a 62-year-old male with a past medical history significant for depression and prior lobectomy as well as hypertension , who presents for his annual exam . so , ralph , it's been a while since i saw you . how are you doing ? [patient] um , relatively speaking , okay . it was kind of a , a tough spring with all the pollen and everything and , uh , we dropped my oldest daughter off at college and moved her into her dorm , so little stressful , little chaotic , in the heat of the summer , but so far , so good . [doctor] okay . i know . i know . that's a , that's a hard thing to get over , moving kids out of the house and that type of thing . [patient] yeah . [doctor] so , um well , how are you doing from , you know , let's talk a little bit about your depression . how are you doing with that ? i know that we had put you on the prozac last year . [patient] yeah , i've been staying on top of the meds , and i have n't had any incidents in a while , so it's , it's been pretty good , and everything's managed and maintained . um , still kind of working with my hypertension . that's been a little bit more of a struggle than anything . [doctor] okay . yeah , i , i see that we have you on the norvasc . and so are you taking it at home ? is it running high , or ... [patient] i ... i'm pretty regular with the medications during the business week , but on there's weekends , you know , if i'm on the fly or doing something , sometimes i forget , or i forget to bring it with me . uh , but for the most part , it's been okay . [doctor] okay . all right . um , and then i know that you've had that prior lobectomy a couple years ago . any issues with shortness of breath with all the allergies or anything ? [patient] other than during the heat and the pollen , it's been pretty good . [doctor] okay . all right . so i , i know that the nurse went over the review of systems sheet with you , and , and you endorsed some nasal congestion from the pollen , but how about any shortness of breath , cough , muscle aches ? [patient] sometimes i , i regularly , uh , go for a run in the morning . that's my workout , and sometimes if it's , uh , relatively humid , i'll struggle a little bit , and i might feel a little bit of pounding in my chest . it usually goes away , but , uh , again , for the most part , it's been pretty good . [doctor] okay , so you also have some shortness of breath with with exertion . [patient] correct . correct . [doctor] all right , and how far are you running ? [patient] uh , like 4 to 5 miles a day . [doctor] okay , great . all right . well , let's go ahead . i'd like to do a quick physical exam . let's look at your blood pressure . [patient] mm-hmm . [doctor] hey , dragon , show me the vital signs . so here in the office today , your blood pressure looks quite well , at 120 over 80 . let's look at your prior trends . hey , dragon , show me the blood pressure readings . so , yeah , it looks , it looks good . i think you're doing a good job . it looks lower than it has in the past , so continue on the current medication . [patient] mm-hmm . [doctor] all right , so i'm just gon na listen to your heart and lungs and check you out , okay ? [patient] you got it . [doctor] okay , so on exam , everything seems to be good . your heart , i hear a slight two out of six systolic ejection murmur , and your lungs sound nice and clear , and you do n't have any lower extremity edema . um , your ... you do have some pain to palpation of the , of the sinuses here , so i think you do have a little bit of congestion there . let's go ahead and look at some of your results , okay ? hey , dragon , show me the ekg . so they did an ekg before you came in today . [patient] mm-hmm . [doctor] and in reviewing the results , it looks like your ekg is completely normal , so that's good . [patient] good . [doctor] so i'm not too concerned about that , that chest pounding . hey , dragon , show me the chest x-ray . and we also did a chest x-ray , which , which looks really good , uh , and you know , your prior lobectomy , there's no ... everything looks good , okay ? it looks normal . so let's talk a little bit about my assessment and my plan for you . so for your first problem , your , your depression , it seems , again , like you're doing really well- [patient] mm-hmm . [doctor] . with your current strategy . let's continue you on the prozac 20 milligrams a day and do you need a refill on that ? [patient] uh , actually , i do need a refill . [doctor] okay . hey , dragon , order a refill of prozac , 20 milligrams daily . from a ... for your next problem , the lobectomy , i think , you know , i do n't think we need to do any more workup of that . it seems like you're exercising a lot . your breathing function is fine . so , uh , i , i do n't think you need to follow up with the surgeon anymore . and then for your last problem , your hypertension . [patient] mm-hmm . [doctor] you're doing a great job of keeping it controlled . i know you said you have n't been taking it that much on the weekends , but your blood pressure here looks good , and it's much better over the last several years . so let's go ahead . i do wan na order just , um , an echocardiogram for that murmur . hey , dragon , order an echocardiogram . and i'll just follow up with the results , and we'll go ahead and order , um , your routine blood work , and i'll be in touch with you through the patient portal , okay ? [patient] perfect . [doctor] all right . good to see you . [patient] same here . [doctor] hey , dragon , finalize the note . the nurse will be in . [patient] thank you .", "target": "ASSESSMENT AND PLAN\n\nRalph Barnes is a 62-year-old male who presents for his annual examination.\n \n Annual visit.\n \u2022 Additional Testing: I have ordered his routine blood work and will follow up with the patient via the portal once results are back.\n \n Depression.\n \u2022 Medical Reasoning: He is doing well with his current regimen.\n \u2022 Medical Treatment: He can continue Prozac 20 mg a day and I provided a refill of that today.\n \n History of lobectomy.\n \u2022 Medical Reasoning: I do not think we need to do any more work up for this issue. He is able to exercise a lot and his breathing function is back. I do not think he needs to follow up with the surgeon anymore.\n \n Hypertension.\n \u2022 Medical Reasoning: He is doing well on his current regimen. His blood pressure was normal today and has been trending well over the past several years.\n \u2022 Additional Testing: I ordered an echocardiogram to evaluate his murmur.\n \u2022 Medical Treatment: He can continue Norvasc.\n \n "} {"idx": 27, "inputs": "[doctor] eugene walker , n- date of birth 4/14/1960 . he's a 61-year-old male who presents today , uh , for a routine follow-up with chronic medical conditions . [doctor] of note , the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 1/22/2013 . regarding his blood work from 4/10/2021 , the patient's alkaline phosphatate- phosphatase , excuse me , was elevated to 156 . his lipid panel showed elevated total cholesterol of 247 , hdl of 66 , ldl of 166 , and triglycerides at 74 . the patient's tsh was normal at 2.68 . his cbc was unremarkable . his most recent vitamin d level was at the high end of normal at 94 . [doctor] good morning , mr. walker . how are you doing ? i mean , it's been a crazy year . [patient] i'm doing fine , for the most part , but there are a few things i want to cover today . [doctor] sure . go right ahead . [patient] uh , well , i'm having more fatigue , but i do n't know if it's age or if it's just , you know , drained at the end of the day . but i still ride my bike . i ca n't go as fast as i used to . i'm still riding , and , you know , after a long bike ride , i'll sit down and then boom . i'm out , you know ? [doctor] yeah . what's a long bike ride to you ? [patient] uh , 20 to 30 miles . [doctor] 20 to 30 miles on a road bike ? [patient] yeah , road bike . i think it's a time thing . if i had more time , i would try to do my 40 miles , but i have n't done that . obviously , we're too early in the season so my typical ride is , like , 20 , 30 . in years back , i could do 40 on a good day . i can still do 20 but , you know , i'm tired and have to take a break when i get home . [doctor] yeah , i understand . [patient] and tyler's my buddy . he's always nice and waits for me , but i used to be able to beat him . but now , he waits for me all the time . he's older than me and it- it kills me . [doctor] yeah , i can imagine that would upset me too . [patient] well , the last time , you know , you found a heart thing , then . just making sure that the valve is holding out , you know ? [doctor] right . so , when was your last stress test ? [patient] it was september 9th , 2019 , because i'm eight years out from surgery , and back then , they said , you know , it's going to last eight years . and i'm at that year , so i just want to make sure . i asked dr. lewis for an echocardiogram to see how i'm doing . [doctor] yeah . [patient] but it's not ... like , nothing has changed drastically since i saw you . [doctor] okay , good . do you still go down to hopkins at all ? [patient] no , not at all . i just get follow-ups intermittently , here . going there is just ... it's too much stress . [doctor] okay . [patient] one more thing , i want to make sure i do n't forget . my wife and friends tell me that when i walk , i purse my lips when i'm breathing . other doctors have said , did you notice your pursed lips breathing ? i do n't know if that's a bad habit or what . [doctor] okay . is there any wheezing associated with that ? [patient] no , no wheezing . [doctor] and you're able to bike 30 miles and mostly keep up with your friend , tyler , correct ? [patient] yeah . the only other thing i want to mention is it's not like i do routine testicular exams , but i know i have this little nodule on my right testicle . [doctor] on the testicle or the epididymis ? [patient] epididymis . uh , i really do n't know . i'm not super concerned . i read a little online . just wanted to ask you . [doctor] and did you have a vasectomy ? [patient] no . let me pull my notes out and make sure i mentioned everything i wanted to tell you . those were the only things and it's not like my tiredness is depression or anything . i'm a pretty happy guy overall , you know ? i just know you would ask those questions . [doctor] what time are you going to sleep , and about how many hours do you sleep a night ? [patient] um , it varies . usually , i get six to seven hours of sleep . i get out of bed some days to be at work by 7:00 , lecture , and i try to work out in the morning . i- i do n't ... i'm not ... i'm not always successful , and now what i do is i- i do make reservations twice a week for a 5:45 swim in the morning . [doctor] okay , so you're getting six to seven hours of sleep , and has your wife ever mentioned if you snore or stop breathing at any time ? [patient] i believe i snore a little bit , but she's never said anything about me not breathing . [doctor] okay . so , you're currently taking vitamin d3 , around 5000 units on sundays , and two thous ... or 50,000 units on sundays , excuse me , and 2000s on the other six days , and then clindamycin prior to dental procedures , correct ? [patient] yeah , that's right . [doctor] have you had a covid-19 shot yet ? [patient] i've received both . my first dose on january 15th , '21 and my second on february 5th , '21 . [doctor] good . if you'd hop up here on the table , we're just going to do a physical exam . [doctor] well , mr. walker , overall you're doing well . i'm going to order an echocardiogram and a stress test . i also recommend that you follow up with cardiology , i think dr. vincent sanchez would be a great fit for you . [patient] all right . [doctor] also your recent labs showed an elevated alkaline phosphatase level at 156 . now this could be related to your liver but most likely related to your bone health . we're going to check a few labs today . [patient] you're going to have them done today ? [doctor] yes , sir , and we will send the results through your patient portal unless something is way off then we'll give you a call . [patient] sounds good . [doctor] now as far as your breathing , i observed the pursed lip breathing and your exhalation is low . i think you should do a pulmonary function test to further evaluate , and i'll order that as well . [doctor] now the nodule in your right testicle should be evaluated by urology , and we will place that referral today , also . [patient] sounds like i'm going to be busy getting this all checked out . [doctor] yes , sir . now you are due for your mmr and i'm recommend you get the shingles vaccine as well . you have completed your covid-19 , so that's good . [doctor] now i'm going to have , uh ... have you return in about a year for your wellness visit . we'll see you back sooner if needed after i review all those labs and those other studies . [doctor] do you have any other questions for me ? [patient] no , doc . i think you covered it all . [doctor] great . okay , the nurse will , uh , be back in a minute to give you mmr today , and the front desk will line up a time to do the shingles vaccine next month . [patient] thanks , doc . have a great day . [doctor] all right , i used my general physical exam template for respiratory notate : pursed lip breathing , low exhalation phase , clear to oscillation , no wheezing . uh , genitalia notate : right testicle with two to three millimeters palpable nodule does not feel as if it will ... does not feel as if with the epididymis or variococele ; left testicle , normal ; no hernia . all other portions of the physical exam are normal default . [doctor] assessment history of the aortic aneurysm repair : the patient underwent and aortic valve replacement and ascending aortic aneurysm repair on 1/20/2013 . he is doing well overall and currently asymptomatic . he is currently not seen by cardiology routinely . suggest the following up and suggested vincent sanchez as his physician . we will perform an echocardiogram , eh , slash , stress test . [doctor] elevated alkaline phosphatase level . most recent cmd showed elevation at 156 . this could be related to his liver but most likely re- related to his bone health . i've ordered an alkaline phosphatase and again a gt . [doctor] lung field abnormal finding on exona ... excuse me , on examination . the patient has been noted to purse his lips while breathing . he was found himself ... he has found himself feeling more fatigued at the end of the day . he does bicycle around 20 to 30 miles at a time . his exhal- exhalation phase is low on exam , and i've ordered pfts today to further ... for further evaluation . [doctor] the right testicular nodule is about two to three millimeters , i've noted on the exam . there's no hernia palpable , and i have suggested reaching out to ro ... urology for a possible ultrasound . [doctor] preventative health : the most recent blood work was reviewed with no significant abnormalaries ... abnormalities other than the cmv . uh , we will perform mmr titer today . i have suggested the shingles vaccine and he is fully vaccinated against covid-19 . [doctor] patient will return , uh , for a follow-up in one year for a wellness visit , sooner if needed . he is to call with any questions or concerns .", "target": "ASSESSMENT\n\n\u2022 History of aortic aneurysm repair.\n \u2022 Elevated alkaline phosphate level.\n \u2022 Lung field abnormal finding on examination.\n \u2022 Right testicular nodule.\n \u2022 Preventative health.\n\nPLAN\n\nMr. Eugene Walker is a 61-year-old male who presents today for a routine follow-up of his chronic medical conditions.\n \n History of aortic aneurysm repair.\n - Overall, he is doing well and currently asymptomatic.\n - Currently he is not seen by cardiology routinely and I have suggested he follow up with Dr. Tyler Sanchez.\n - Ordered echocardiogram and stress test.\n \n Elevated alkaline phosphate level.\n - Most recent CMP showed elevation at 156 IU/L.\n - This could be related to his liver but most likely related to his bone health.\n - Ordered an alkaline phosphatase and gamma GT.\n \n Lung field abnormal finding on examination.\n - The patient has been noted to purse his lips while breathing.\n - He had found himself feeling more fatigued at the end of the day.\n - He does cycle 20 to 30 miles at a time.\n - His exhalation phase was low on exam.\n - Ordered pulmonary function testing for further evaluation.\n \n Right testicular nodule.\n - 2 to 3 mm nodule noted on exam. There is no palpable hernia.\n - Referral placed to urology for possible ultrasound.\n \n Preventative health.\n - Most recent blood work reviewed with no significant abnormalities.\n - He is fully vaccinated against COVID-19.\n - Recommend shingles vaccine next month.\n - MMR titer performed today."} {"idx": 82, "inputs": "[doctor] alright [patient] you're ready just [doctor] ready [patient] hi kyle how are you today [doctor] i'm doing well i'm just anxious about my pcp told me that i had some abnormal lab work and why she wanted me to be seen by you today [patient] yeah i bet that did make you nervous i i see that she referred you for a low immunoglobulin a level is that your understanding [doctor] yeah i mean i do n't even really understand what that means but yeah that's what she told me [patient] yeah that's a mouthful [doctor] yeah [patient] it it's the the one of the antibodies in your body and that that really makes that your body makes to fight infections it's a little bit low i'm happy to explain it a little bit more to you i just have a few more questions okay so let's start again here [doctor] i'll do this [patient] i i think i would break that [doctor] yeah i just saw that [patient] if you can do that [doctor] okay [patient] yeah so we'll we'll just [doctor] okay [patient] you can leave it the way it is for now i just i think break that up [doctor] okay alright so yeah that sounds fine for me [patient] yeah i do you know why she checked these levels in the first place that you've been having problems getting frequent infections [doctor] yeah yeah i had a recent physical and she did this as part of her my physical i do tend to get infections but i do n't know i i'm so used to it so i do n't know if this is more than usual in the wintertime i get a lot of colds and they do seem to i always say that my colds kind of linger for a long time but i do n't know if it's more than usual [patient] okay how about any abdominal infections [doctor] diarrhea no [patient] frequently [doctor] no not that i can not that i say can think of [patient] okay what about your family are are anyone in your family that you know have immune deficiencies [doctor] no my family is actually pretty healthy [patient] okay and how about do you have any other medical conditions [doctor] yeah my pcp just started me on metformin i just got diagnosed with type two diabetes [patient] okay okay yeah diabetes your family your family owns that donut shop right i mean down at the end of the street [doctor] yes and that's probably part of the cause of my diabetes yes [patient] yeah well i guess you're gon na have to watch that [doctor] i know i know [patient] but you know everything in moderation i mean just you know you just need to be careful you ca n't does n't have to go away [doctor] right [patient] but have you ever needed to receive a blood transfusion or blood products [doctor] no i actually tried to give blood but they i did n't qualify because i had recently traveled internationally [patient] okay where did you go [doctor] i was in zambia [patient] hmmm i heard that's beautiful [doctor] it's so beautiful it's so beautiful i had a great time [patient] okay well let me let me go ahead and do a physical examination here i reviewed your vitals you know that the the assistants collected when you first came in including your weight and everything looks good there there is no fever there there is nothing that i'm concerned about there now on your heart exam you have a nice regular rate and rhythm and i do n't appreciate any murmurs that's kind of those extra sounds that i would hear and that that all sounds good on lungs lung exam your lungs are clear there's no wheezes rales or rhonchi now on your neck exam i do n't appreciate any lymph lymphadenopathy swollen lymph glands and then let me just go ahead and i wan na press on your belly a little bit is that tender anywhere that i press it does n't seem like you making any facial [doctor] no [patient] no okay so your you know your abdominal exam is your belly is soft there is no tenderness as i i push around there now i did review the results of your recent lab work and it is consistent as as your pcp noted with an iga deficiency that's that immunoglobulin a that we talked about so let me tell you a little bit about the assessment and plan so for your first problem the that a iga deficiency is it very common immunodeficiency your your body makes many different types of antibodies in one of your z iga is just a little bit lower than normal now most of the time people live their entire life without even knowing they have that deficiency and function perfectly normal now some people may find that they get tend to get frequent respiratory tract or sinus or abdominal infections but this does n't necessarily seem to be the case for you now it can go along with other immunodeficiencies but i think there is a low likelihood hood in your case but we're gon na order some additional blood work that includes checking those other antibodies now do you have any questions on what i just told you [doctor] yeah so is there anything i need to do or should be watching for or should i be worried [patient] no i i really do n't think you need to be worried now we're gon na check these additional studies and that will give us some more guidance but really i think this is just a finding that's common to you and you know it it's many people have have have these type of you know immunodeficiency what i want you to watch for is those infections that do n't stop you have trouble getting it under control or you know any changes to your abdominal tract you know severe diarrhea [doctor] anything like that then you know we may want to look at it a little bit further but for now i do n't think there is anything significant we want to do now go ahead and get your lab work and [patient] bring you in for that now the only other thing that i would say is if you eat end up needing any blood products between now and when i see you next make sure you tell them that you have that iga deficiency [doctor] why is that [patient] well there is a risk that your body can strongly react to some blood products and they just need to know that so they're prepared so anytime you get blood just make sure you say that you have a history of a an an iga deficiency [doctor] okay okay thank you [patient] you're welcome [doctor] okay", "target": "ASSESSMENT\n\nIgA deficiency.\n\nPLAN\n\nAfter reviewing the patient's examination today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that the results of his recent lab work is consistent with an IgA deficiency. I have recommended that we obtain additional blood work to check his other antibodies. I encouraged the patient to be aware of lingering infections or abdominal changes including diarrhea. If he experiences these issues, he should report them to my office so we may investigate further, however I do not believe there is a need for that at this time. In the meantime, he should report this IgA deficiency in the event that he needs any blood transfusions. Questions were invited and answered today.\""} {"idx": 79, "inputs": "[doctor] hi wayne how're you today [patient] i'm doing okay aside from this left shoulder pain that i've been having [doctor] okay and how long have you had this pain [patient] about i want to say a few weeks i think it's been about three weeks now [doctor] okay and do you remember what you were doing when the pain started [patient] honestly i've been trying to recall if i had any specific injury and i ca n't think of that [doctor] okay [patient] of anything the only thing i can think of is that i you know i am active and we've just been doing a lot of work in our basement so if i do n't know if i did something while doing that [doctor] okay alright tell me have you ever had pain in that shoulder before [patient] you know i i'm really active and so i i will get some aches and pains here and there but nothing that tylenol ca n't take care of [doctor] okay good but now are you able to move your arm [patient] you know i have trouble when i'm trying to reach for something or lift any objects and i do n't even try to reach it for anything over my head because then it'll really hurt [doctor] okay alright and and now are you having the pain all the time or does it come and go [patient] the pain is always there and then it gets worse like if i try to put any pressure on it it gets worse so if i'm laying at night if i try to even lay on that shoulder it's unbearable [doctor] okay and then tell me what have you taken for your pain [patient] i've been taking two extra strength tylenol every six to eight hours [doctor] alright and and did that help [patient] it does take the edge off but i still have some pain [doctor] okay well i'm sorry to hear that you know you know renovating the basement it can be quite a task and it can take a toll on you [patient] yeah i mean it's been fun but yeah i think it really did take a toll on me [doctor] yeah what what are you doing with your basement are you are you doing like a a man cave or [patient] yeah yeah that's exactly right [doctor] that is awesome great well that sounds like fun i hope you get to set it up just the way you you would like for your man cave to be so congratulations to you there so tell me have you experienced any kind of numbness in your arms or in your hands [patient] no no numbness or tingling [doctor] okay alright so let's just go ahead and do a quick physical exam on you here i did review your vitals everything here looks good now lem me take a look at your shoulder alright now on your left shoulder exam you have limited active and passive range of motion and how does that feel here [patient] that hurts [doctor] okay sorry there is tenderness of the greater tuberosity of the humerus but there is no tenderness at the sternoclavicular or acromioclavicular joints you have good hand grips alright and then now on your neurovascular exam of your left arm your capillary refill is less than three seconds and your sensation is intact to light touch alright so what does that all mean well firstly lem me go ahead and take a look at your results of your shoulder x-ray here now i reviewed the results and there are no fractures so that's good so let's go ahead and talk about my assessment and plan here wayne so for your problem of left shoulder pain your symptoms are most likely due to a rotator cuff tendinopathy so this means that you injured the tendons of the muscles that help make up your shoulder muscles so i will be ordering an mri for your left shoulder to be sure that there is nothing else going on with your shoulder okay [patient] okay [doctor] now i'm also going to refer you to physical therapy for approximately six to eight weeks and during that time you may also continue to take tylenol now if your symptoms do n't improve we can consider a steroid injection for your shoulder which can provide some relief do you have any questions about your plan at all [patient] so do you think this pain will ever go away [doctor] now well many patients are very successful with the physical therapy those will those help strengthen you know they do a lot of strengthening exercises with you to help strengthen you know your muscles so that it's not your movements not always relying on those joints predominantly so we're gon na go ahead and start with that and then see how you do okay [patient] okay okay [doctor] alright okay well do you have any other questions for me [patient] no i think that's it [doctor] okay well i'm gon na have the nurse check you out and she's also gon na give you some educational materials on the physical therapy and what to expect and and then go ahead and schedule a follow-up visit with me as well after you you do your physical therapy okay [patient] okay [doctor] alright well have a good day [patient] okay you too [doctor] thanks [patient] okay bye", "target": "ASSESSMENT\n\nLeft shoulder pain, most likely due to rotator cuff tendinopathy.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that his symptoms are most likely due to rotator cuff tendinopathy. I recommend obtaining an MRI of the left shoulder to further assess the rotator cuff. I will also refer him to formal physical therapy to strengthen his left shoulder for approximately 6 to 8 weeks. The patient was provided with educational materials regarding expectations related to his physical therapy. He may continue to take Tylenol as needed. If his symptoms do not improve with physical therapy, we will consider a steroid injection to the left shoulder. All questions were answered."} {"idx": 41, "inputs": "[doctor] hi teresa what's going on i heard that i heard that you're having a sore throat you're not feeling well [patient] yeah my throat has been hurting me for like four four days now and i think i had a fever last night because i was really sweaty but i did n't take my temperature because i was already in bed [doctor] okay alright so four days ago you started feeling badly okay now were you having chills [patient] yeah last night i was chills and i had lot of sweating and it's really hard to swallow [doctor] it's really hard to swallow okay now do you have pain every time you swallow or is it just periodically [patient] every time i swallow i'm even having trouble eating i can drink okay the like really cold water feels good [doctor] okay that's what i was gon na ask you okay so you're able to drink water and are you able to drink any other fluids have you been able to drink any you know i do n't know juices or milk shakes or anything like that [patient] well besides my wine at night i really just drink water all day [doctor] okay well i like to drink wine too what's your favorite type of wine [patient] peanut grooves yes [doctor] it's a good one i like that too i am also a pino navar fan so there you go alright well let's now do you feel sick to your stomach at all [patient] no i have a little bit of a stuffy nose not too bad it's really just my throat but i think my tonsils are swollen too [doctor] and your tonsils are swollen too now has anyone else sick in your household [patient] i do have little kids that go to school so they've always got you know those little runny noses or cough but nobody is really complaining of anything [doctor] okay alright now have you had strep throat in the past [patient] when i was a kid i had strep throat but i have n't had anything like that as an adult [doctor] okay alright and what do you do for work [patient] i i work as a cashier in a supermarket [doctor] okay alright and did you get your covid vaccine [patient] yep i did get my covid vaccine but it really made me feel sick so i'm hoping i do n't have to get another one later this year [doctor] okay did so you just got the two vaccines you did n't get the booster [patient] no i did n't get the booster because i really have n't had time to feel that sick again it really knocked me down for like two days and with the little kids it's really hard [doctor] okay alright well i saw that they did a rapid covid test when you came in here and that was negative so that's good so you do n't have covid which is which is good now let's talk a little bit about your hypertension and hypertension since i have you here did you ever buy that blood pressure cuff that i asked you to buy [patient] yes i did i blood the blood pressure cuff and my blood pressure is like all over the place sometimes it could be like one twenty for the top number sometimes it could be one forty for the top number i i do n't really remember the bottom number though [doctor] okay that's okay are you taking the lisinopril i think we have you on twenty milligrams a day [patient] yep i take it every morning with my multivitamin and my vitamin d [doctor] okay alright and are you watching your salt intake [patient] i really like my chips with my wine [doctor] is n't that the best we we could get along really well outside of here alright and then tell me a little bit about your diabetes now are you are you watching your blood sugars are you taking them at home [patient] sometimes i take that all that often again that could be all over the place sometimes i get if i take it first thing in the morning it'll be like eighty or ninety but at night sometimes it could be one forty [doctor] okay alright and i are you still taking the metformin we have you on a thousand milligrams twice a day [patient] uh uh yes i do take it i take it with my breakfast and with my dinner [doctor] okay alright great alright now are you are you a meds fan or a yankie's fan or god for a bit of filly's fan [patient] nope [doctor] no [patient] no do n't do n't like sports [doctor] do n't like sports just the wine [patient] no [doctor] okay alright well let's go ahead i wan na just do a quick physical exam now i'm gon na be calling out some of my findings and i'm gon na let you know what that means when i'm done okay so looking here first at your vital signs your vital signs look pretty good you do have a low-grade fever of about a hundred . four right now but otherwise your blood pressure is pretty good it's about one thirty two over eighty and your heart rate is eighty four now that looks pretty good so i'm just gon na go ahead and examine you so on your facial exam i'm gon na just press on your face here does this hurt [patient] no not no it does n't bother me [doctor] okay on facial examination the patient has no pain to palpation of the frontal or maxillary sinuses on nasal examination there is edema and erythema of the nasal turbinates bilaterally with associated clear discharge open up your mouth and say [patient] ah [doctor] on throat examination there is bilateral erythema and edema of the peritonsillar space with exudates present bilaterally the uvula is midline on your neck exam i do appreciate some cervical lymphadenopathy on the right hand side on your lung exam your lungs you have some coarse rhonchi at the bases that clear with cough and on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur or or rub so what does all of that mean teresa so all of that means is that yes you're showing signs of what we call an upper respiratory infection and i'm concerned that you might have some strep in the back of your throat based on the findings so let's just talk a little bit about my assessment and plan for you okay so for your first problem of your sore throat i'm gon na go ahead and have the medical assistant come in and swab you for a rapid strep test and if that's positive i wan na go ahead and place you on or prescribe amoxicillin five hundred milligrams three times a day for ten days and i'm gon na give you some lidocaine swish and swallow so that will help with some of the pain and you can take some ibuprofen as needed which will also help with the pain and some of that fever okay i do want you to go ahead and continue to to hydrate as much as possible what kind of questions do you have about that [patient] no that sounds good i just wanted to be sure i was okay because of the little kids [doctor] sure now for your next problem of your hypertension i wan na go ahead and order a lipid panel on you and i think i do wan na increase i do wan na increase the lisinopril to forty milligrams once a day just to get your blood pressure under better control and we'll see how you do on the forty milligrams once a day for your third problem of your diabetes let's go ahead and order a hemoglobin a1c and just to make sure that we do n't have to make any adjustments to your metformin how does that sound [patient] sounds good [doctor] any questions [patient] nope that's everything [doctor] okay bye good to see you i'll be in touch", "target": "ASSESSMENT AND PLAN\n\n1. Sore throat.\n - Medical Reasoning: The patient has experienced sore throat, fever, chills, profuse sweating, and difficulty swallowing for 4 days. There is erythema and edema of the peritonsillar space with exudates present bilaterally as well as edema and erythema of her turbinates, bilaterally.\n - Patient Education and Counseling: We discussed treatment options today. I have stressed the importance of hydration.\n - Medical Treatment: We will perform a rapid strep test today. If she is positive for strep, I will prescribe amoxicillin 500 mg 3 times a day for 10 days. Prescription for lidocaine swish and swallow provided for pain relief. ibuprofen can also be taken for pain and fever relief.\n \n 2. Hypertension.\n - Medical Reasoning: The patient states her blood pressure fluctuates often. Her blood pressure today in office was 132/80 mm Hg. - Patient Education and Counseling: We discussed treatment options including increasing her lisinopril and diet modifications.\n - Medical Treatment: Lipid panel ordered. Prescription for lisinopril 40 mg once a day is also provided.\n \n 3. Diabetes.\n - Medical Reasoning: The patient\u2019s blood sugar fluctuates between 80 to 90 in the morning to 140 in the evening. She is already at 1000 mg of metformin twice a day, which she does take with meals.\n - Patient Education and Counseling: We discussed the importance of achieving a healthy lifestyle and what effects that can have on her diabetes.\n - Medical Treatment: I have placed an order a hemoglobin A1c.\n \n "} {"idx": 56, "inputs": "[patient] alright thanks for coming in today i see on my chart here that you had a bunch of lower respiratory infections so first tell me how are you what's going on [doctor] you know i'm doing better now but you know last week i was really sick and i just have had enough like i was coughing a lot a lot of mucus even had some shortness of breath and even a low-grade fever [patient] wow that is a lot so what did you do for some of those symptoms [doctor] you know i ended up drinking a lot of fluid and taking some robitussin and i actually got better over the weekend and now i'm feeling much better but what concerns me is that i i tend to get pneumonia a lot [patient] okay so when you say a lot like how frequently does it occur i would say it seem honestly it seems like it's every month or every other month especially over the past six six months that i just keep getting sick and i usually will end up having to go to my primary care doctor or [doctor] urgent care and i'll get prescribed some antibiotics and one time i actually ended up in the emergency room [patient] wow and how long do your symptoms normally last for [doctor] you know it could be as few as like a couple of days but sometimes it could go even up to a week [patient] mm-hmm you mentioned that you are a farmer did you do you notice that your symptoms occur while doing certain things on the farm [doctor] you know i was trying to think about that and i've been working on the farm for some time but the only thing i can think about is that i've been helping my brother out and i've been started like unloading a lot of hay which i do n't usually do and i wan na say that my symptoms actually start the days that i'm unloading hay [patient] alright do you wear a mask when you're unloading hay [doctor] no i do n't do that [patient] okay [doctor] none of us do [patient] okay yeah so like that your brother does n't either [doctor] no i'm the only one who seems to be getting sick [patient] alright so i know you said you were trying to like help out your brother like what's going on with him [doctor] you know we've just been getting really busy and so he has been working around doing other things so i've just been helping him just cover the extra load [patient] mm-hmm okay alright do you have any other siblings [doctor] yeah there is actually ten of us [patient] wow okay that's that's a lot of siblings [doctor] yeah i'm okay [patient] maybe maybe we could we could always stick them in they could get some work done the holidays must be fun at your place [doctor] yeah we do n't need to hire any i mean have anyone else this is our family [patient] you're right keep it in the family okay so speaking of family do you have do you or anyone have a history of seasonal allergies [doctor] no no i have never had any problems with allergies [patient] okay and do you smoke [doctor] i do n't smoke [patient] do you live with anybody who does [doctor] i do not [patient] okay alright so okay so now i i wan na go ahead and do my physical exam i'm gon na call out some of my findings just to make sure that i'm documenting everything and if you have any questions about what it is that i'm saying please feel free to ask okay [doctor] okay [patient] so i reviewed your vitals and you appear to be breathing a little fast your respiratory rate is twenty but but your oxygen is you're satting kind of fine at ninety nine percent on room air so i'm not too worried about that on for on your heart exam i do you have a regular rate and regular rhythm i do not appreciate any murmurs rubs or gallops on your lung exam you know i do you do have some fine rales on your lung exam but no wheezes and on your musculoskeletal exam i do not appreciate any clubbing of your fingers so for your results i did review the results of your chest x-ray and i noticed some round glass opacities so let me tell you a little bit about like my assessment and plan for your first problem of recurrent lung infections your symptoms seem consistent with a condition we call hypersensitivity pneumonitis in your case another name is farmer's lung which you know is appropriate considering your job this could be caused by bacteria and or mold that is found in the hay when you inhale it it leads to an allergic reaction in your lungs this is why your symptoms occur every time you move hay for your current symptoms i'm gon na prescribe you a a course of an oral steroid this will help to decrease the inflammation that is occurring in your lungs i will also be ordering a cat scan of your lungs which will help confirm the diagnosis as as well a pulmonary function test to assess how severe your respiratory impairment is it would be best if you could eliminate your exposure to the hay or prevent further to prevent further damage to your lungs however if you are unable it's very important that you wear a respirator when moving hay around i know that that was a lot of information i think it boils down to pull in more of your siblings to help work around but do you have any questions [doctor] yeah so is this gon na help so i do n't keep getting sick [patient] so ideally what we are doing i think this is the best course of action to deal with the deeper problem right of these infections and to kind of like clear up the pneumonia everything seems to hint on so what we're gon na do is treat your current infection we're going to either prevent you from being around hay or make it so that it's safe for you to be with hay and then we're gon na see like what we need to do moving forward does that help [doctor] okay it does [patient] alright [doctor] thank you [patient] okay no problem [doctor] alright", "target": "ASSESSMENT AND PLAN\n\n1. Recurrent lung infections.\n - Medical Reasoning: The patient's symptoms seem consistent with hypersensitivity pneumonitis. He is a farmer and has been moving hay quite frequently recently.\n - Patient Education and Counseling: The nature of the diagnosis was discussed with the patient. I explained that hypersensitivity pneumonitis could be caused by bacteria and/or mold that is found in the hay. We discussed that when inhaling this, it leads to an allergic reaction in the lungs, which would explain why symptoms occur every time he moves hay. He was advised that it would be best to eliminate his exposure to hay in order to prevent further damage to his lungs, however, if he is unable to do this then it would be recommended that he wear a respirator when working. Questions were invited and answered today.\n - Medical Treatment: A course of oral steroids were prescribed today to help decrease his lung inflammation. CT of the lungs will also be ordered today to confirm the diagnosis. A pulmonary function test was also ordered to assess the severity of his respiratory impairment.\n \n "} {"idx": 112, "inputs": "[doctor] hey matthew i see here that you've had some back pain for a while and your pcp sent you over to see me how're you doing today [patient] pretty good i'm feeling pretty good do n't like the weather you know i've been sitting in the waiting area for you know thirty minutes and that definitely makes the symptoms worse [doctor] okay well first of all i i agree with you the weather has kinda been all over the place been hot and been cold and and and now it seems like we've had a week of pretty chilly weather hopefully that changes pretty soon so tell me a little bit about when when your back pain started and and and what happened there [patient] well you wan na hear the long story or kind of the short story because my back has been bothering me for a long time [doctor] so let's do let's do the reader's digestive version [patient] well i ca n't i ca n't really tie my shoes you know standing really makes it bad you know when i go to the mall it really really i do n't know all i i've just been bedridden [doctor] okay and i know it got real bad about a month ago that's what the report here from the pcp said but can you tell me exactly where the pain is in your lower back can you kinda point to where that's at [patient] yeah it's right here and you know like thirty years ago when i fell off the roof it was really really bothersome they they said maybe there was a fracture or something and you know i do n't know i just could n't play football and then i had to you know kinda try to take care of myself but you know it's it's been really bad for about a month [doctor] okay and then do you still have that pain that radiates down your left leg sometimes [patient] yeah of course yeah it goes all the way through here [doctor] okay and then so it looks like you pointed to your lower back area and then pointed down through your hip and down into your to your left leg can you describe that pain for me [patient] it's like a electrical tooth ache and it it it goes down the whole leg [doctor] okay and can you rate that pain for me right now zero being none ten being the worst pain you've ever been in in your life [patient] right now it's less bad i did n't take my medications because i wanted you to see me as as i am but it's six out of ten but when it gets really bad i'd say it's thirteen out of ten [doctor] okay and anything that you do make it feel better you mentioned that you know sometimes sitting or laying down anything there make that better [patient] yeah like i said it the only thing that seems to make it better is laying down [doctor] okay [patient] you know standing walking seems to make it worse coughing sneezing makes it worse and you know i had a friend that saw you and you know you burned some nerves or something like that and so i was just seeing if there was something that you could do to get me out of this pain and hopefully you can do it today [doctor] okay and then any numbness or tingling in in your lower extremities or any weakness there in your legs [patient] you know it it's my back that's weak and my legs are weak both of them you know coughing sneezing seem to make it worse so sorry i'm just trying to be like a typical patient because most patients they do n't answer the darn questions so you you know all this time i still have n't gotten a chief complaint out of them so i love the way that you're trying to redirect and so you know what your doctor said you had back pain and leg pain but for me the most important thing for me to capture is that it's in the hip side of the leg side of the calf goes to the big toe and so i need them to be able to give me a perfect sort of root signature so i can hone in is that four five disk seen on the mri really significant or is it on the opposite side but again i'm sorry i'm purposely trying to be in a difficult patient because some of these patients he asked them fifty different questions they wo n't answer any of them so anyway sorry about well [doctor] that's okay [patient] to explain but this is what i deal with every single day [doctor] absolutely [patient] lot of pain yeah you know what my pain is eight out of ten it goes in the back goes into the hip side of the leg side of the calf goes to the big toe my foot kinda drags when i walk i've been having to use a cane nothing seems to make it better and but very few patients will give you the perfect history and most people will start talking about you know when something happened or go back to thirty years ago and you wan na redirect them to their current symptom but the patients wo n't rarely ever tell you what the chief complaint is you you got ta pull it out of them [doctor] so let's take a a quick look at you here okay let's do a physical exam real quick so your vitals look good which is a good thing now on your back exam i do n't see any bony abnormalities no redness or no and no bruising present now do you have pain when i press here [patient] no it's right here [doctor] okay so positive for pain to palpation at the l4 vertebrae and if you bend forward do you have pain there [patient] it hurts all the time especially sitting in these run office desks [doctor] okay so you are positive for pain with flexion and extension of your back i'm going to go ahead and test the strength of your legs now push out against my hands for me please [patient] okay that's it that's all i got [doctor] alright so four out of five strength in the left and five out of five on the right does look like that reflexes are brisk and motor and sensory is intact in both lower extremities i do wan na review the results of your mri the mri shows a disk herniation at the level of l4 l5 vertebrae and it is associated with some nerve root impingement and what that means is the nerve is being compressed by that herniation so let me tell you a little bit about my assessment and plan okay so for the diagnosis of of acute disk herniation at l4 l5 with that nerve root impingement that's causing that pain down your leg and your lower back pain now i know you've tried nsaids in the past without relief and you've done some pt so what i'm going to do is i'm gon na recommend an epidural steroid injection and we're gon na do that today for you if you agree to it what that means is gon na place some anti-inflammatory medication right at the spot of inflammation and once that's in place i wan na refer you back to pt and we wan na strengthen that area mkay you're young and otherwise healthy i think you'll do well but it can take about two to three weeks for that injection really to take full effect so then i want you to see pt and i want you to see me again in about a month are you okay with that treatment plan [patient] sure sounds good [doctor] alright sounds good i'm gon na have the nurse come in and get you prepped and then we'll get that injection for you", "target": "ASSESSMENT\n\nAcute disc herniation at L4-5 with nerve root impingement.\n\nPLAN\n\nI have recommended that we treat the patient conservatively with a epidural steroid injection and formal physical therapy. With the patient's consent, we will proceed with a epidural steroid injection into the lumbar spine today. He will follow up with me in 4 weeks to check on his progress.\""} {"idx": 96, "inputs": "[doctor] um , hi mrs. anderson . right ? [patient] yeah . yes , doctor . [doctor] what brings you here today ? [patient] hi , doctor . um , i'm having this left shoulder pain lately , uh , and it's paining a lot . [doctor] okay . all right . hey , dragon . i am seeing mrs. anderson , a 44-years-old female , uh , complaining to check the left shoulder pain . um , so how long how has this lasted ? [patient] it's been a week , doctor . yeah . [doctor] a week . [patient] yeah . [doctor] um , did you take any medication yourself ? [patient] no , i did not take any pain medications . actually , i did . i did take a tylenol for two or three days , but then that did n't help at all . so , uh , the reason why it started or when it started to happen is- [doctor] yeah . [patient] . i was actually in gymnastics class . [doctor] yeah , okay . [patient] and , uh , i do n't know . maybe i must have toppled over into some weird position , so it started to pain since then , uh , because of a certain move . [doctor] okay , uh- [patient] i went overboard , i think . yeah . [doctor] all right , lem me , uh , take a quick look . uh , can you move up a little bit ? yeah . [patient] uh , yeah . in fact , that's hurts . [doctor] does that- does it hurt ? [patient] yeah , it does . [doctor] what if you move back a little bit ? [patient] uh , that also hurts , doctor . [doctor] yeah , okay . [patient] any kind of movement on my left shoulder actually hurts . [doctor] okay . all right , um , so let's ... hey , dragon . show me the last x-ray . all right , from the x-ray , it does n't look like there is any , uh , broken bone or fracture . my guess is you probably , um , hurt your joint , uh- [patient] uh- . [doctor] . a little bit . [patient] mm-hmm . [doctor] so i would , uh , suggest you continue using the pain reliever , maybe just like 600 milligram of ibuprofen three times a day and use it for a week . [patient] and for how long ? yes . [doctor] for a week . [patient] a week , okay . [doctor] and then if you ... if it's still painful , you can use , uh , ice or , um , heat pad- [patient] okay . [doctor] . 'cause that might help relieve your pain . [patient] okay . [doctor] um ... [patient] but i wanted you to know that i did have past surgery on my , um , left arm- [doctor] mm-hmm . [patient] . so , um , i hope that should n't matter , right ? [doctor] um , that does n't seem related to your pain . [patient] okay . [doctor] so ... but i would try to rest my , your left arm- [patient] okay . [doctor] . while it's healing . [patient] okay . [doctor] so , um- [patient] can i , uh , carry any heavy weights or- [doctor] no , no . definitely not . [patient] . anything like that ? [doctor] definitely not . [patient] okay . okay . [doctor] yeah , use , um , right hand- [patient] okay . [doctor] . instead- [patient] mm-hmm . [doctor] . for the next , uh , at least just three to four weeks . [patient] mm-hmm . [doctor] uh , come back to see me if the pain , you know , still there after maybe three weeks- [patient] sure . [doctor] . so we can take a further look . [patient] okay . sure . [doctor] but you should be fine- [patient] yeah . [doctor] . after just resting and regular pain reliever . [patient] okay . all right . [doctor] um- [patient] should we take another x-ray when i come back , if the pain does n't improve ? [doctor] um , maybe . let's see how you're doing in the next three weeks . [patient] uh . [doctor] hey , dragon . um , order medications and procedures as discussed . all right . [patient] okay . [doctor] um , i think that's good for today . hope you feel better soon . [patient] okay . thank you , doctor . [doctor] yeah . [patient] hopefully , the pain reliever , uh , ibuprofen actually helps . [doctor] yeah . [patient] yeah , and if i have more pain , can i call you ? can i fix up another appointment earlier than three weeks ? [doctor] um , you can also try advil . [patient] okay . [doctor] yeah , so , um ... [patient] yeah . [doctor] ale- , aleve . i mean , aleve . [patient] i see . okay , thank you , doctor . [doctor] thank you .", "target": "PLAN\n\nAt this point, I discussed the diagnosis and treatment options with the patient. I have recommended taking ibuprofen 600 mg three times per day for one week. If the patient does not have relief from the ibuprofen she will take Aleve. The patient may also utilize ice or heat packs. She should rest her left arm and may not lift or carry heavy objects with her left arm. The patient should follow up in three to four weeks if the pain persists. We may repeat the left shoulder x-ray at that time.\n \""} {"idx": 72, "inputs": "[doctor] hi , ms. brooks . i'm dr. baker . how are you ? [patient] hi , dr. baker . [doctor] is your , is your right finger hurting ? [patient] yes . [doctor] okay . hey , dragon , uh , sharon brooks is a 48 year old female here for right finger pain . all right . so , tell me what happened . [patient] well , i was skiing over the weekend- [doctor] okay . [patient] . and as i was , um , coming down the hill , i tried moguls , which jumping over those big hills , i tend to get my strap caught on my finger- [doctor] [patient] . and it kind of bent it back a bit . [doctor] okay . [patient] yeah . [doctor] and when did this happen ? [patient] it happened , uh ... that was sunday . [doctor] okay . and have you tried anything for this or anything made it better or worse ? [patient] i tried , um , putting ice on it . [doctor] okay . [patient] uh , and then i- i've been taking ibuprofen , but it's still very painful . [doctor] okay . and , uh , is it worse when you bend it ? or anything make it ... so , just wh- [patient] yeah , movement . [doctor] okay . [patient] yes . [doctor] okay . so , it sounds like you were skiing about four about days ago and you went over a mogul and got it hyper extended or got it bent backwards a little bit , ? okay . do you have any other past medical history at all ? [patient] um , i have been suffering from constipation recently . [doctor] okay . all right . and do you take ... what medicines do you take for constipation ? [patient] um , i've just been taking , um , mel- um ... [doctor] miralax ? [patient] miralax . that's it . [doctor] okay . miralax is sufficient . [patient] miralax . yes . [doctor] and any surgeries in the past ? [patient] i did have my appendix taken out when i was 18 . [doctor] okay . let's do your exam . uh , so , it's this finger right here . and does it hurt here on your , on this joint up here ? [patient] no . [doctor] okay . and how'bout right there ? no ? [patient] no . [doctor] right here ? [patient] that hurts . [doctor] all right . uh , can you bend your finger for me ? [patient] yeah . [doctor] all right . and how about extend it ? all right . and can you touch your thumb with it ? [patient] yes . [doctor] all right . so , on exam , you do have some tenderness over your distal phalanx , which is the tip of your finger . there is , uh , some tenderness over that joint itself . i do n't feel any tenderness over your proximal joint or your metacarpophalangeal joint , which is right above your knuckle . uh , you have some pain flexion as well . so , let's look at your x-rays . hey , dragon , show me the x-rays . [doctor] all right . so , on this x-ray. everything looks normal right now . uh , i do n't see any fractures . everything lines up pretty well . uh , so , your x-ray looks normal with no fractures . so , based on the x-ray and your exam , you have some tenderness right here . i think you've got a little contusion right here . there's no fracture on the tip of your finger . uh , so , the diagnosis would be a right hand , uh , index finger contusion on the tip of your finger , okay ? so , i would recommend we get you a s- uh , aluminum foam splint and we'll get you some motrin . uh , we'll give you 600 milligrams every six hours and we'll take that for about a week . and if it does n't get better , why do n't you call us and come back at that point ? [patient] okay . [doctor] okay . do you have any questions ? [patient] no . i think that sounds good . [doctor] okay . hey , dragon , order the medication and procedures we discussed . all right . and why do n't you come with me and we'll get you signed out . [patient] okay . thank you . [doctor] all right . finalize report , dragon .", "target": "PLAN\n\nAt this point, I discussed the diagnosis and treatment options with the patient. I have recommended a splint. She will take Motrin 600 mg every 6 hours for a week. If she does not improve, she will follow up with me. All questions were answered.\n \""} {"idx": 61, "inputs": "[doctor] hi virginia how're you today [patient] i'm good thanks how are you [doctor] good so you know you got that knee x-ray when you first came in but tell me a little bit about what happened [patient] i was playing basketball and jerry ran into me and the inside of my knee hurts [doctor] okay did you fall to the ground or did you just kinda plant and he pushed and you went one way and your knee did n't [patient] i did fall to the ground [doctor] you did fall to the ground okay and did you land on the kneecap i mean did it hurt a lot were you able to get up and continue on [patient] i landed on my side i was not able to continue on [doctor] okay so you get off the off the court is jerry a good player you just got ta ask that question [patient] not really [doctor] no [patient] he does n't have much game [doctor] okay okay well you know i love basketball i'm a little short for the game but i absolutely love to watch basketball so it's really cool that you're out there playing it so tell me about a little bit about where it hurts [patient] on the inside [doctor] on the inside of it okay and after the injury did they do anything special for you or you know did you get ice on it right away or try anything [patient] i had ice and an ace wrap [doctor] you had ice and what [patient] an ace wrap [doctor] and an ace wrap okay now how many days ago was this exactly [patient] seven [doctor] seven days ago okay yeah your right knee still looks a little swollen for seven days ago so i'm gon na go ahead and now i also see that you're diabetic and that you take five hundred milligrams of metformin twice a day are you still you're still on that medication is that correct [patient] correct [doctor] and do you check your blood sugars every morning at home [patient] every morning [doctor] okay great and since this i'm the reason i'm asking all these questions i'm a little concerned about the inactivity with your your knee pain and you know how diabetes you need to be very you know active and and taking your medicine to keep that under control so you know may wan na continue to follow up with your pcp for that diabetes as we go through here and just watch your blood sugars extra as we go through that now i'm gon na go ahead and examine your your right knee and when i push on the outside does that hurt at all [patient] no [doctor] okay and when i push on this inside where it's a little swollen does that hurt [patient] yes [doctor] yeah okay i'm just gon na ask a question did you hear or feel a pop in your knee when you were doing this [patient] i did not no [doctor] you did not okay okay what are you doing for the pain today [patient] some exercises ice and mobic [doctor] okay okay so i'm gon na continue all of my exam when i go ahead and pull on your knee the first thing i'm looking at is i do see some ecchymosis and swelling on the inside of that right knee and when i push around that knee i can see that there is fluid in the knee a little bit of fluid in the knee we call that effusion so i can appreciate some of that effusion and that could be either fluid or blood at this point from the injury that you had now you do have pain with palpation on the medial aspect of that right knee and that's that's concerning for me when i'm gon na just i just wan na move your knee a little bit it does n't look like when i extend it and flex it that you have a full range of motion does it hurt a lot when i moved it back a little more than normal [patient] yes it hurts [doctor] okay okay yeah so you do have some decreased range of motion in that right knee now i'm just gon na sit here and and lay you back and i'm gon na pull on your knee and twist your knee a little bit okay you currently there is a negative varus and valgus stress test that's really important so here's what i'm thinking for that right knee i think you have may have a medial collateral ligament strain from you know maybe the twisting motion be right before you fell to the ground i want you to continue to use an ace wrap i'm gon na give you a right knee brace we're gon na wear that for a few days and then i'm gon na send you to physical therapy so we can continue strengthening the muscles around the right knee now that x-ray as far as the x-ray results that x-ray that i did it this morning in the office the the bony alignment's in good position i do n't see any evidence of any fractures i do notice the the effusion around the right knee just a small amount of fluid but we're just gon na continue to watch that i'm gon na give you a prescription i'd like you to stop taking any of the nonsteroidals that you're taking the motrin or advil whichever one of those and i'm gon na give you meloxicam fifteen milligrams and i want you to take that daily for the pain and swelling i want you to just continue exercising with the the braces and everything on so if you can you can get out and do some light walking that'll be good and then again for your diabetes like i said just continue to watch those blood sugars daily and if you start to see any significant increase in them because of your loss of activity just reach out to your primary care physician now do you have any questions for me [patient] when can i play basketball again [doctor] yeah that's a great question i'm gon na ask well my first off i want to see you back here in in seven days you know in a week i want you to make an appointment we're gon na relook at it we're gon na determine if that swelling got any worse and if we need to go on to potentially ordering like a cat scan or an mri of that knee to look and see if there was any significant damage to the ligament so that's for for sure for seven days you're not gon na be playing basketball now are you in a ligue or is that just you get like pick up basketball [patient] i just played the wife with fun [doctor] okay okay good that's a great activity like i said i wish i could play now i i also know your your family do n't they own that sports store down right off a main street that sells a lot of sporting equipment [patient] yeah they do [doctor] okay i you know i'm i'm just thinking you know i need to get some new shoes for some of it my activities i love the i wish i could play basketball but i do a lot of bike riding so i'm always looking for anything that's gon na help me on the bike do you does your family have supplies like that [patient] we do let me know and i can get you the hook up [doctor] okay great great so i'll i i will let you know i'll just get on and take a look first but i'm gon na go ahead and get get you discharged i'll have my assistant come in we will get you discharged and like i said we will make an appointment for seven days and we will go from there any questions [patient] i think you've answered them all thank you [doctor] okay great", "target": "ASSESSMENT\n\nRight knee pain, possible medial collateral ligament strain.\n\nPLAN\n\nAfter reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have prescribed the patient meloxicam 15 mg once a day to treat the pain and swelling. She was advised to stop taking any anti-inflammatory such as Motrin or Advil. I have also recommended that the patient attend formal physical therapy to strengthen her right knee. I have also advised her to continue to use the ACE wrap and wear a right knee brace for a few days. She should continue light walking with her brace on. The patient was advised to stop basketball until she follows up in 7 days.\n \n Regarding her diabetes, she should continue to monitor her blood sugars daily. She should reach out to her primary care physician if she sees an increase in her blood sugars due to loss of activity."} {"idx": 43, "inputs": "[doctor] how are you doing [patient] i'm doing i'm good i'm i'm doing really good i'm here i'm just ready to quit smoking and but i've been having quite a hard time with it [doctor] well i'm glad that you're taking the first steps to quit smoking would you tell me a little bit more about your history of smoking [patient] yeah so i've been smoking for some time now i started in high school and was just you know just experimenting and smoking here and there with friends or at parties and then it just started getting more regular and regular and i do n't even know how i'm 44 now and i'm smoking everyday so yes now i'm up to a pack and a half a day [doctor] okay do you use any other type of tobacco products [patient] no smoking is enough [doctor] okay and i understand that so when you wake up in the morning how soon after waking up do you smoke your first cigarette [patient] i would say probably within an hour of waking up i'll have my first cigarette [doctor] okay so i'm really excited that you wan na quit and i know that you probably heard this multiple times before but this really is one of the best things that you can do to help your health especially since you have the history of gout and type two diabetes this is really gon na be a great step in you having better long term health outcomes [patient] yeah i know and you know i'm really motivated now because i am about to be a father any day now and i just really wan na be there for my daughter growing up [doctor] hey that's great and that's great to hear congratulations i'm so excited to hear about the new baby [patient] yeah [doctor] i i have a daughter myself have have you picked out any names [patient] we're you know we're deciding between a few names but we're kinda just waiting to see her to see which name fits [doctor] okay alright that sounds good well congratulations again i'm very excited for you and your and and your wife that that's this is great [patient] thank you [doctor] so you mentioned you tried to quit before can you tell me a little bit about the methods that you used or or what you tried [patient] yeah actually i just went cold turkey one day i woke up and i said you know i've had enough and i know that smoking is not good for me so i woke up and stopped and i actually did really well and i was able to quit smoking for almost a year and then things just started getting really stressful at work they started laying people off and i'm happy i still have a job but that also meant that i was responsible for more things so things just got stressful and i and just started picking it up again [doctor] well you are absolutely correct you know stress can often be a trigger for things like smoking and drinking have you thought what you would do this time when you encountered the stressful situations [patient] yeah i i did n't think about that a lot actually and one thing is i have started learning and trying to do more meditation and then i also just recently joined the gym so i'm really looking forward to working out again [doctor] okay well that's great to hear that you're getting back in the gym that will be good for your long term health too you know helping to maintain that type two diabetes you know those are really great strategies talking about gym for stress relief and and you know we have other products as well that you can use for an additional aid to help you stop smoking have you given any thought to using some type of smoking cessation aid at this time or or what do you think about that [patient] you know i've had you know because i've been trying to do cold turkey and it's not working and some of my friends actually have mentioned using a patch and they they've had some success with that so i think i would i would probably wan na start with that [doctor] okay alright that that sounds good it's good that you've you've picked out one of those aids and have you thought of a quit date i mean we we really wan na talk about when you're gon na say this is the day [patient] yeah you know next monday is actually my birthday so i think that's a good day [doctor] that's a fantastic day and happy birthday coming up on monday [patient] thank you [doctor] so let's talk a little bit about your exam here okay i'm gon na go ahead and do a quick physical exam and i reviewed your vitals and everything looks good including your oxygen saturation blood pressure for today was one twenty eight over eighty eight heart rate was sixty eight respirations were sixteen and your pulse ox was ninety eight percent on room air so those were all really good now on your heart exam you do have a nice regular and your your rate is of regular rate and rhythm or i'm sorry your heart exam for your heart exam notice that your heart is regular in rate and rhythm i do however still appreciate that two over six systolic murmur that we talked about in the past now that's okay we'll just continue to monitor that now for your lung exam i'm gon na go ahead and listen to your lungs your lungs are clear and equal bilateral with no expiratory wheezes and no rales or rhonchi are appreciated on your neck exam i do n't appreciate any lymphadenopathy when i listen i do n't hear any extra noises so i do n't hear any hearing any carotid bruit which is a good thing now for my impression and plan let's talk a little bit about my assessment and plan for you so for your first problem of nicotine dependence first of all i just want to apply you on making this first step to stop smoking and i want you to know with absolute one hundred percent certainty that i'm gon na be with you every step of the way i think it's fantastic that you're very welcome i i i think it's fantastic you've chosen next monday as a quit date and on that day i'm gon na start you with a twenty one milligram nicotine patch and the goal will be to decrease that over time okay now we will work together to decrease that so there is no necessarily hard dates in mind okay be sure to change the patch location each day and that's going to help reduce or avoid that skin irritation that can occur if you use the same location over and over again i would like to see you again in two weeks just to see how things are going and we will reevaluate at that time the dosage for your nicotine patch now we also see further need to discuss any handouts you received today for those common smoking triggers i really want you to keep an eye on and monitor your stress level not only about work but also the fact that you are experiencing are going to be be a new father and we really want to watch any stress you will be experiencing around the birth of your new child so please keep an eye on that and let me know how that goes now for now until we meet in two weeks go ahead and keep up your exercise routine i think that's a great plan and just try to monitor your stress and and maybe think about some things like meditation or adding in some yoga and that type of thing to help further work with your your stress levels so do you have any questions for me [patient] no not at this time [doctor] okay so for your other conditions that we talked about briefly your second condition of type two diabetes we'll let's go ahead and continue to maintain that with diet and exercise and we'll just monitor your type two diabetes i am gon na go ahead and order a hemoglobin a1c for your next blood draw since i'll see you in two weeks go ahead and have that done and we will talk about that when you come back in now for your third problem of your history of gout let's go ahead and continue you on your allopurinol and just you know continue to watch those foods that will exacerbate your uric acid levels any other questions about those [patient] no i think that's it thanks so much [doctor] alright sounds good i'll see you in two weeks congratulations on the baby and and we're excited about next monday that's your quit date [patient] alrighty thank you [doctor] you're welcome i'll see you in two weeks thanks bye-bye [patient] alright bye", "target": "ASSESSMENT AND PLAN\n\n1. Nicotine dependence.\n - Medical Reasoning: The patient has a long history of smoking cigarettes. He is currently smoking 1.5 packs per day. He is highly motivated to cease smoking as he is preparing to become a father.\n - Patient Education and Counseling: I applaud the patient on making this first step to stop smoking. I reassured him that with absolute 100% certainty that I will be with him every step of the way. I explained to the patient that stress can often be a trigger for smoking. He received handouts today for common smoking triggers. I advised him to be watchful and monitor his stress level, not only regarding work, but also his impending fatherhood. The patient and I discussed coping mechanisms for when he encounters stressful situations. I encouraged him to maintain his gym routine, engage in meditation, and try adding in yoga to help further reduce his stress levels. We discussed additional cessation aids.\n - Medical Treatment: The patient has chosen his birthday, as a quit date. On that day, I am going to start him with a 21 mg nicotine patch, and the goal will be to decrease that over time. We will work together to decrease the dosage of the nicotine patch, so there are not necessarily any hard dates in mind. I recommend he change the patch location each day as that will help reduce or avoid any skin irritation that can occur if he re-uses the same location repeatedly.\n \n 2. Type 2 diabetes.\n - Medical Reasoning: Stable.\n - Patient Education and Counseling: We discussed that continuing to follow a healthy diet and perform regular exercise will help to maintain his blood glucose levels.\n - Medical Treatment: We will continue to monitor his type 2 diabetes. Hemoglobin A1c is ordered to be completed by his next visit in 2 weeks.\n \n 3. History of gout.\n - Medical Reasoning: Stable with medication.\n - Patient Education and Counseling: I advised him to continue to watch for foods that will exacerbate his uric acid levels.\n - Medical Treatment: He will continue his allopurinol.\n \n "} {"idx": 88, "inputs": "[doctor] hi , andrew . how are you ? [patient] hey , good to see you . [doctor] i'm doing well , i'm doing well . [patient] good . [doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] uh , so , andrew is a 59-year-old male with a past medical history , significant for depression , type two diabetes , and hypertension who presents today with an upper respiratory infection . so , andrew , what's going on ? [patient] yeah . we were doing a bit of work out in the yard in the last week or so and i started to feel really tired , was short of breath . um , we- we're not wearing masks as much at the end of the summer and i think i caught my first cold and i think it just got worse . [doctor] okay . all right . um , now , have you had your covid vaccines ? [patient] yeah , both . [doctor] okay . all right . and , um , do you have any history of any seasonal allergies at all ? [patient] none whatsoever . [doctor] okay . all right . and when you say you're having some shortness of breath , did you feel short of breath walking around or at rest ? [patient] uh , usually , it was lifting or carrying something . we were doing some landscaping , so i was carrying some heavy bags of soil and i , i got really winded . it really surprised me . [doctor] okay . and are you coughing up anything ? [patient] not yet , but i feel like that's next . [doctor] okay . and fevers ? [patient] uh , i felt a little warm , but i , i just thought it was because i was exerting myself . [doctor] okay . all right . and any other symptoms like muscle aches , joint pain , fatigue ? [patient] my elbows hurt quite a bit and my knees were pretty tired . l- like i said , i really felt some tension around my knees , but , uh , i think that was a lot to do with , uh , lifting the bags . [doctor] okay . all right . um , so , you know , how about , how are you doing in terms of your other medical problems , like your depression ? how are you doing with that ? i know we've , you know , talked about not putting you on medication for it because you're on medication for other things . what's going on ? [patient] i- it's been kind of a crazy year and a half . i was a little concerned about that but , for the most part , i've been , been doing well with it . my , my wife got me into barre classes , to help me relax and i think it's working . [doctor] okay . all right , great . and , and in terms of your diabetes , how are you doing watching your , your diet and your sugar intake ? [patient] uh , i've been monitoring my sugar levels while i am going to work during the week . uh , not so , uh , if its saturday or sunday i usually don't remember . uh , the diet's been pretty good for the most part , except for , you know , some house parties and things like that . but , uh , been good for the most part . [doctor] okay and have they been elevated at all since this episode of your- [patient] no . [doctor] okay . and then , how , lastly , for your high blood pressure , have you been monitoring your blood pressures at home ? did you buy the cuff like i suggested ? [patient] uh , same thing . during the while i'm going to work, i'm regular about monitoring it, but if its a saturday or sunday, not so much . but , uh , it's , it's been under control . [doctor] but you're taking your medication ? [patient] yes . [doctor] okay . all right . well , you know , i know that , you know , you've endorsed , you know , the shortness of breath and some joint pain . um , how about any other symptoms ? nausea or vomiting ? diarrhea ? [patient] no . [doctor] anything like that ? [patient] no . [doctor] okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so , your vital signs here in the office look quite good . [patient] mm-hmm . [doctor] you know , everything's looking normal , you do n't have a fever , which is really good . um , i'm just gon na go ahead and listen to your heart and your lungs and , kind of , i'll let you know what i hear , okay ? [patient] sure . [doctor] okay . so , on your physical exam , you know , your heart sounds nice and strong . your lungs , you do have scattered ronchi bilaterally on your lung exam . uh , it clears with cough . um , i do notice a little bit of , um , some edema of your lower extremities and you do have some pain to palpation of your elbows bilaterally . um , so , let's go ahead , i want to look at some of your results , okay ? [patient] mm-hmm . [doctor] hey , dragon . show me the chest x-ray . [doctor] so , i reviewed the results of your chest x-ray and everything looks good . there's no airspace disease , there's no pneumonia , so that's all very , very good , okay ? [patient] good . [doctor] hey , dragon . show me the diabetic labs . [doctor] and here , looking at your diabetic labs , you know , your hemoglobin a1c is a little elevated at eight . [patient] mm-hmm . [doctor] i'd like to see that a little bit better , around six or seven , if possible . [patient] mm-hmm . [doctor] um , so let's talk a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so , for your first problem , this upper respiratory infection , i believe you , you have a viral syndrome , okay ? we'll go ahead and we'll send a covid test , just to make sure that you do n't have covid . [patient] mm-hmm . [doctor] uh , but overall , i think that , um , you know , this will resolve in a couple of days . i do n't think you have covid , you do n't have any exposures , that type of thing . [patient] mm-hmm . [doctor] so , i think that this will improve . i'll give you some robitussin for your cough and i would encourage you take some ibuprofen , tylenol for any fever , okay ? [patient] you got it . [doctor] for your next problem , your depression , you know , it sounds like you're doing well with that , but again , i'm happy to start on a med- , a medical regiment or ... [patient] mm-hmm . [doctor] . refer you to psychotherapy , if you think that that would be helpful . [patient] mm-hmm . [doctor] would you like that ? [patient] u- u- um , maybe not necessarily . maybe in a , uh , few months we'll check on that . [doctor] okay . all right . [doctor] for your third problem , your type two diabetes , i want to go ahead and increase your metformin to 1000 milligrams , twice daily . [patient] mm-hmm . [doctor] and i'm gon na get an- another hemoglobin a1c in four months , okay ? [patient] okay , sure . [doctor] hey , dragon . order a hemoglobin a1c . [doctor] and lastly , for your high blood pressure , it looks like you're doing a really good job managing that . i want to go ahead and continue you on the , um , lisinopril , 20 milligrams a day . [patient] mm-hmm . [doctor] and i'm gon na go ahead and order a lipid panel , okay ? [patient] sure . [doctor] do you need a refill of the lisinopril ? [patient] actually , i do . [doctor] okay . hey , dragon . order lisinopril , 20 milligrams daily . [doctor] so , the nurse will be in , she'll help you , uh , make a follow-up appointment with me . i want to see you again in about four months . [patient] okay . [doctor] let me know if your symptoms worsen and we can talk more about it , okay ? [patient] you got it . [doctor] all right . hey , dragon . finalize the note .", "target": "ASSESSMENT AND PLAN\n\nAndrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection.\n \n Upper respiratory infection.\n \u2022 Medical Reasoning: I believe he has contracted a viral syndrome. His chest x-ray was unremarkable and he has received both doses of the COVID-19 vaccination.\n \u2022 Additional Testing: We will obtain a COVID-19 test to rule this out.\n \u2022 Medical Treatment: I recommend he use Robitussin for cough, as well as ibuprofen or Tylenol if he develops a fever.\n \n Depression.\n \u2022 Medical Reasoning: He has been practicing barre classes and is doing well overall.\n \u2022 Medical Treatment: I offered medication or psychotherapy, but the patient opted to defer at this time.\n \n Diabetes type 2.\n \u2022 Medical Reasoning: His blood glucose levels have been well controlled based on home monitoring, but his recent hemoglobin A1c was elevated.\n \u2022 Additional Testing: We will repeat a hemoglobin A1c in 4 months.\n \u2022 Medical Treatment: We will increase his metformin to 1000 mg twice daily.\n \n Hypertension.\n \u2022 Medical Reasoning: He has been compliant with lisinopril and his blood pressures have been well controlled based on home monitoring.\n \u2022 Additional Testing: We will order a lipid panel.\n \u2022 Medical Treatment: He will continue on lisinopril 20 mg once daily. This was refilled today.\n \n Follow up: I would like to see him back in approximately 4 months.\n \n "} {"idx": 10, "inputs": "[doctor] hi keith , how are you ? [patient] ah , not too good . my blood sugar is n't under control . [doctor] and , uh , so keith is a 58-year-old male here for evaluation of high blood sugar . so , what happened ? ha- have you just been taking your blood sugars at home and noticed that they're really high ? or ? [patient] yeah i've been taking them at home and i feel like they've been creeping up slightly . [doctor] have- ... what have they been running , in like the 200's or 300's ? [patient] 300's . [doctor] they've been running in the 300's ? and tell me about your diet . have you been eating anything to spark- ... spike them up ? [patient] to be honest my diet has n't changed much . [doctor] okay . have you- ... go ahead . [patient] actually it has n't changed at all . much of the same . [doctor] okay and what do you con- consider the same ? are you eating lots of sugar ? like , teas and coffees and- [patient] i do n't take sugar with my tea . [doctor] okay , all right . and how about , um , like any added sugars into any kind of processed foods or anything like that ? [patient] uh , i think most of my sugars come from fruit . [doctor] from what ? [patient] fruit . [doctor] fruit , okay . [patient] yeah . [doctor] all right . um , and have you been feeling sick recently ? have you had any fever or chills ? [patient] uh , i have not . [doctor] body aches , joint pain ? [patient] uh , a bit of joint pain . [doctor] multiple joints , or just one joint ? [patient] uh , my knee . uh , sorry , right knee to be more exact . [doctor] your right knee ? [patient] yeah . [doctor] okay . and what happened ? [patient] ah , to be honest , nothing much . i just noticed it when you said it . [doctor] okay , all right . um , and how about any nausea or vomiting or belly pain ? [patient] uh , i was nauseous a couple of days back but , uh , that's just because i was sitting in the back of a car . i hate that . [doctor] okay . all right . and no burning when you urinate or anything like that ? [patient] not at all . [doctor] okay . all right . so , um ... you know , i know that you've had this reflux in the past . how are you doing with that ? are you still having a lot of reflux symptoms or do you feel like it's better since we've put you on the protonix ? [patient] i think it's a bit better . uh , i do n't get up at night anymore with reflux and that's always a good thing . [doctor] okay , all right . and i know you have this history of congestive heart failure . have you noticed any recent , uh , weight gain or fluid retention ? [patient] um , not really . [doctor] no ? okay . um , and any problems sleeping while laying flat ? [patient] uh , i- i prefer to sleep on my side so i ca n't really say . [doctor] okay , but even then , you're flat . [patient] yup , yeah . [doctor] okay . all right . and i know that we had an issue with your right rotator cuff , is that okay ? [patient] it's surprisingly good now . [doctor] okay , all right . all right , well let's go ahead and we'll do a quick physical exam . so ... feeling your neck , i do feel like your thyroid's a bit enlarged here . um , your heart is nice and regular . your lungs are clear . your abdomen , um , is nice and soft . your right knee shows that you have some erythema and- and an insect bite with associated fluctuants . and , um , you have some lower extremity edema on the right hand side . so let's go ahead and look at some of your results . i know the nurse had reported these things and we ordered some labs on you before you came in . hey dragon , show me the vital signs . okay , well your- your vital signs look good , which is good . hey dragon , show me the lyme titer . okay , so , you know , your lyme titer is a little elevated , so i think we'll have to go ahead and- and look into that a little bit , okay ? [patient] makes sense . [doctor] that can certainly cause your blood sugar to be elevated . um , hey dragon , uh , show me the rapid strep . and you also have , uh , positive for strep . so i think we have some reasons as to why your blood sugar is so high . so my impression of you , you know , you have this hyperglycemia , which is probably related to some infections going on in your body . um , from a- a- a rapid strep standpoint we're gon na go ahead and treat you with penicillin or , i'm sorry , amoxicillin , 500 milligrams , three times a day . uh , make sure you take it all , even if you start feeling better , okay ? [patient] for sure . [doctor] hey dragon , order amoxicillin , 500 milligrams , three times a day for 10 days . um ... okay . and from ... , and from all- ... a positive lyme titer aspect , we should go ahead and order a western blot , just pcr to see if you have any , um , to see if it's actually acute lyme , okay ? [patient] okay . [doctor] okay . um , hey dragon , order a western blot pcr for lyme . okay . all right . well we'll go ahead and , um , the nurse will come in soon and she'll set you up with these tests , okay ? [patient] yeah . you said lyme . is that related to lyme disease ? [doctor] yes it is , yeah . [patient] you're certain i do n't have alpha-gal syndrome though , right ? i'm terrified of that one . [doctor] have what ? [patient] alpha-gal syndrome , the one where a tick bites you and you get an allergic reaction to meat . [doctor] yeah , i do n't think so . have you eaten meat over the last couple of days ? [patient] i have . [doctor] okay . well i- ... it's , you know , your blood sugar's elevated so you might be having an inflammatory response to that , but we'll go ahead and order some tests to look into it , okay ? [patient] that sounds good . [doctor] all right . call me if anything happens , okay ? [patient] definitely . [doctor] all right . hey dragon , finalize the note .", "target": "ASSESSMENT AND PLAN\n\nThe patient is a 58-year-old male who presents for evaluation of high blood sugar.\n \n Hyperglycemia\n \u2022 Medical Reasoning: This is likely related to an inflammatory response as the patient had an elevated Lyme titer and positive rapid strep test.\n \u2022 Additional Testing: We will order a western blot PCR to evaluate for Lyme disease.\n \u2022 Medical Treatment: We are going to treat him with amoxicillin 500 mg 3 times a day for 10 days.\n \n "} {"idx": 94, "inputs": "[doctor] hey , ms. james . nice to meet you . [patient] nice to meet you , dr. cooper . how are you ? [doctor] i'm well . hey , dragon , i'm seeing ms. james . she's a 42-year-old female , and what brings you in today ? [patient] i hurt my , uh , finger when i was skiing this past weekend . [doctor] really ? [patient] yeah . yeah , so , um , i was going down hill , double diamonds , uh , double black diamonds , and i just lost control , and i , you know , flipped down a few ways , but , uh , somewhere along the way , i , i jammed my , my index finger on something . i'm not sure what . [doctor] okay . so this happened last saturday , you said ? [patient] it was saturday , yes . [doctor] okay . so about five days of this right index finger pain . [patient] mm-hmm . [doctor] have you taken any medicine for it ? [patient] i took some ibuprofen . um , did n't really seem to help . [doctor] okay . have you iced it or put a splint on it ? [patient] no . [doctor] okay . and what would you rate your pain ? [patient] it's about a seven . [doctor] a seven out of 10 pain . um , and no other injuries while you went down this double black diamond ? [patient] no , interestingly enough , this is the only one . [doctor] okay . well , i guess you escaped ... i mean ... [patient] could have been much worse . [doctor] could have been much worse , yes . so , um , do you have any medical problems ? [patient] um ... yeah , i'm ... i have chronic constipation . [doctor] do you take any medicine for it ? [patient] miralax . [doctor] and does that help ? [patient] seems to flow nicely . [doctor] good for you . [doctor] um ... have you ever had any surgeries before ? [patient] yes , i had my appendix out when i was seven . [doctor] okay . um , let's look at your x-ray together . hey , dragon , show me the last x-ray . all right . so looking at your right hand here , and that index finger looks great . so all the joints , bones are in the right places , no fractures , so you've got a normal right hand x-ray . um , let's go ahead and check your finger out . now does it hurt when i push on your finger like this ? [patient] yes . [doctor] does it hurt when i pull your finger like this ? [patient] yes . [doctor] does it hurt when i squeeze over this joint here ? [patient] yes . please do n't do that . [doctor] does it hurt when i squeeze over this ? [patient] yes . [doctor] okay . um ... so with your x-ray , and with your exam , looks like you have a sprain of your distar- distal interphalangeal joint . it's called your dip joint , of your right index finger , and so what we're gon na do for that is we're gon na put a splint on that right finger . i'm gon na give you a strong antiinflammatory called mobic . you'll take 15 milligrams once a day . i'll prescribe 14 of those for you . and i want you to come back and see me in two weeks , and let's make sure it's all healed up and if we need to start any hand therapy at that point , then we can . do you have any questions for me ? [patient] no questions . thank you . [doctor] you're welcome . hey , dragon , order the medications and procedures mentioned . and why do n't you come with me , and we'll get you checked out ? [patient] okay . [doctor] hey , dragon , finalize the report .", "target": "PLAN\n\nAt this point, I discussed the diagnosis and treatment options with the patient. I have recommended a splint. A prescription is provided for Mobic 15 mg once a day, dispense 14. She will follow up with me in 2 weeks for a repeat evaluation. If she is unimproved, we will consider hand therapy at that time. All questions were answered.\n \""} {"idx": 104, "inputs": "[doctor] judy gomez , mrn 869723 . date of birth , 5 , 7 , 1961 . she's in office today for ongoing management of psoriatic arthritis . hello , judy , how are you doing today ? [patient] i'm doing good , thank you . how are you ? [doctor] i'm great , thanks . so how have you been since the last time ? i know the last time we were talking about decreasing your prednisone dose , correct ? [patient] yes . i'm just on one now and that seems to be enough . [doctor] aw , that's great to hear . [patient] yeah , there were a couple days there i took an extra one , just because there was a little extra pain in my feet . and i do have a desk job , so when i have a day off where i'm moving around a lot they do tend to hurt a bit more . [doctor] okay . how many times did you do that ? [patient] um , it was n't often , maybe once a week . [doctor] okay . so it sounds like we're still on track for discontinuing the prednisone . we'll do that today and you can let me know how it goes on your next visit . and how about the methotrexate , do you think that helped with your joint pain ? [patient] yeah , definitely . because i went to get my covid shots , um , but from the letter i got about it , it said that it could interfere with the vaccine , you know , reduce the efficacy . so i did n't take it on the week that i got the first shot . [doctor] okay . and what happened ? [patient] i felt absolutely horrible until i took it again a week later . [doctor] i'm sorry to hear that . and- and what did you do about the second dose ? [patient] well , i called into the hotline because i was in so much pain with the first one . and they said , no , just go ahead and take it , so i did . [doctor] okay . that's good then . we do have to keep an eye out on it since it's a high-risk medication . do you have an appointment to get your blood drawn for the next time ? [patient] no , they did n't give me one . [doctor] okay . so we can do that for you too . uhm , so what questions do you have for me , judy ? [patient] well , i just wanted to know why i was getting all these bruises here , so like when i bump myself . i do n't know where they're coming from . [doctor] okay . that's probably from the prednisone , it can increase bruising . [patient] okay . i did n't know that . um , i do n't even feel it when it happens , they just show up . [doctor] yeah . unfortunately that can happen , but we're working on discontinuing that so let's see if the bruises do go away . [patient] okay . that sounds good , thanks . [doctor] okay , judy , please , um , sit up here and i'll take a look . shoes and socks off please . [patient] all right . [doctor] all right . let me see here . okay . so where is it hurting ? in your joints right here ? [patient] yeah , a little . also in my feet joints as well . [doctor] okay . and how about when you bend the knee like this ? [patient] well , it hurt before we increased the methotrexate , but it's doing pretty good now . [doctor] okay , good . can you flex your toes please ? good range of motion . also ridges in nails , that's from the psoriasis . [patient] yeah . they've been like that for a long time now . [doctor] okay . all right , uhm , ms gomez , it looks like we're moving along with your treatment nicely . we'll stop your prednisone and continue with the methotrexate . make sure to stop by the front desk and make an appointment for the blood work , and i'll see you in three months . [patient] all right . it sounds good . thank you so much , it was great to see you . [doctor] it was great seeing you too . thank you .", "target": "ASSESSMENT\n\n\u2022 Psoriatic arthritis.\n \u2022 High risk medication use.\n\nPLAN\n\nPsoriatic arthritis.\n Stable on methotrexate and prednisone 1 mg daily. The patient will discontinue prednisone and continue methotrexate."}