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med_intent_classification

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no okay so no frontal sinus tenderness how about when i press on the on your cheeks here
[ "Physical Examination" ]
[ "Objective" ]
100
good . it's always great to hear . well let's take a look . uhm , i'm gon na listen to your heart and lungs .
[ "Physical Examination" ]
[ "Objective" ]
101
okay yeah that's understandable so do you have any children or have you ever been pregnant
[ "Other Socials" ]
[ "Subjective" ]
102
okay and when you take your ibuprofen what can you what's your pain level then
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
103
okay . all right . um , and i know that they removed a cataract from your eye-
[ "Personal History" ]
[ "Subjective" ]
104
uh , we have plenty of data that says normal reflex time is returned at six weeks , and then your return to driving is determined by when you're ready and feel safe to be driving .
[ "Discussion" ]
[ "Plan" ]
105
yeah , i do n't know either . um , sometimes with the aging process , that can happen too .
[ "Personal History" ]
[ "Subjective" ]
106
okay and then what have you been doing for your foot or ankle pain since that happened
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
107
okay . and i saw you went through a review of systems sheet with a nurse . i just want to ask you a few more questions from that standpoint . so you have had any fever or chills ?
[ "Vegetative History" ]
[ "Subjective" ]
108
okay . how many times did you do that ?
[ "Therapeutic History" ]
[ "Subjective" ]
109
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 ?
[ "Vegetative History" ]
[ "Subjective" ]
110
okay so we have noticed an increase in urine output okay how do you have like any normal activities are you playing any sports
[ "Other Socials" ]
[ "Subjective" ]
111
okay , well great . let's go ahead and ... i'm gon na go ahead with , um ... and , you know , i know that the nurse did a review of systems sheet on you when you came in , and i know that you were endorsing that left elbow pain .
[ "Acute Symptoms" ]
[ "Subjective" ]
112
okay . all right . are you excited for halloween ?
[ "Chitchat" ]
[ "Null" ]
113
perfect . so how does that compare ?
[ "Therapeutic History" ]
[ "Subjective" ]
114
hey dragon , show me the vital signs . so your vital signs here in the office they look really good . i'm just going to listen to your heart and lungs and let you know what i find .
[ "Physical Examination" ]
[ "Objective" ]
115
hey lawrence how're you doing
[ "Greetings" ]
[ "Subjective" ]
116
yes , and keep using the face wash.
[ "Discussion", "Medication" ]
[ "Plan" ]
117
okay and then i think we have you on five hundred milligrams correct
[ "Therapeutic History" ]
[ "Subjective" ]
118
okay did you try anything for the pain
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
119
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 .
[ "Physical Examination" ]
[ "Objective" ]
120
okay and alright fair enough so so let's go ahead and and examine you now karen so on your physical exam pretty normal and and unremarkable for the most part on your on your heart exam i do hear that grade three out of six systolic ejection murmur that you've still got that's unchanged from prior exam that just means i hear some heart sounds you know as i'm listening to your heart there i'm not too concerned about that we'll watch that otherwise normal cardiovascular exam and then your your abdominal exam gastrointestinal exam you have some tenderness in the right upper quadrant i would say mild to moderate tenderness and now if you take a deep breath does that and i press here does that hurt you
[ "Physical Examination" ]
[ "Objective" ]
121
all right . and go ahead and straighten out as much as you can .
[ "Physical Examination" ]
[ "Objective" ]
122
good , how are you ?
[ "Chitchat" ]
[ "Null" ]
123
it's not ? okay . well , let's look around really quick because if you use a goodrx coupon , it will be around 30 to $ 40 or something .
[ "Discussion", "Medication" ]
[ "Plan" ]
124
alright now i'm poking i'm poking i'm poking so on the inside part here is this where it hurts
[ "Physical Examination" ]
[ "Objective" ]
125
okay and do you have any other symptoms like abdominal pain nausea vomiting diarrhea
[ "Vegetative History" ]
[ "Subjective" ]
126
okay . all right . well , let me ask you a little bit about how's the , the copd doing . i , i know that , you know , you've stopped smoking several years ago , but , you know , you still have that em- those emphysema changes on your chest x-ray . so , how are you doing with that ? how's your breathing ?
[ "Drug History" ]
[ "Subjective" ]
127
okay have you taken anything for the pain
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
128
okay . i can s- i can bet it's the alfredo sauce .
[ "Acute Symptoms" ]
[ "Subjective" ]
129
let's take a look at your pictures here and alright so this looks pretty just looking at it looks pretty normal looks pretty healthy you can see how i all the edges of the bones here look pretty good i do n't see any bone spurs of that i do n't see anything broken everything looked looks pretty good kneecap's tracking good you can see the space here there's no real space there that's actually cartilage so that looks pretty healthy and you can see the other side looks both both look the same so x-rays look i do n't see anything obvious on that but looking at your knee here you may have hit that tibia bone and kinda pushed that bone back it feels to me like you may very well have sprained your or injured your posterior cruciate ligament that's what it's feeling like
[ "Acute Assessment", "Radiology Examination" ]
[ "Objective", "Assessment" ]
130
yeah i know i i i will say i think jason tatum and jaylen brown paid played phenomenally so i do think that they help with the cell fix over the edge so but that's all we'll talk about that what's that
[ "Chitchat" ]
[ "Null" ]
131
no you did n't mention that but one of the cool things about being a doctor is i can write you a note so you're gon na do it and then you can go to the class and we could figure it but like it's really cool that you're changing jobs i'm happy for you i hope you know that like it's always great to be able to make some income and make some decisions that means that you'll be able to start paying for your test soon uh
[ "Discussion" ]
[ "Plan" ]
132
do you take any medications for it ?
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
133
good for your second problem of your stage three chronic kidney disease i am gon na reach out to doctor miller and make an appointment for you to be seen just because again i think it's important for you to follow up with your nephrologist okay
[ "Referral", "Reassessment" ]
[ "Assessment", "Plan" ]
134
hi ms. hernandez , dr. fisher , how are you ?
[ "Greetings" ]
[ "Subjective" ]
135
well at least you're eating the fish but but they can be very high in sodium especially the fast foods so we'll have to talk about maybe they can look at you know some some diet changes as well so the other thing is for your for your blood sugar here i see that you know you're running a bit high as well it looks like you're like you're about one seventy this morning and i i i i assume that you were fasting last night is that right okay so that's that's a little higher than what we want it's not bad it's below two hundred but it's getting kinda close to the borderline from where our limit is so we will take we take a look at that and also we'll figure out what we can do with that as well alright so at this point how about are you how is how is work how is life it's been good otherwise how's the family
[ "Other Socials" ]
[ "Subjective" ]
136
next is betty hill , uh , date of birth is 2/21/1968 . she has a past medical history of uterine fibroids and anemia . she's a new patient with a referral from the er of esophagitis . um , i reviewed our records from the er , including the normal cardiac workup , and we're about to go in and see her now . good morning . you miss hill ?
[ "Personal History", "Greetings" ]
[ "Subjective" ]
137
okay and then have you experienced any numb numbness or tingling
[ "Acute Symptoms" ]
[ "Subjective" ]
138
okay can you tell me a little bit about them what how do they how do they feel when they come on
[ "Personal History" ]
[ "Subjective" ]
139
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 .
[ "Discussion" ]
[ "Plan" ]
140
doing okay . so i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ?
[ "Chitchat" ]
[ "Null" ]
141
okay okay and anything into that little into your fifth finger your little finger any numbness there at times no
[ "Acute Symptoms" ]
[ "Subjective" ]
142
okay . so , a little bit of a low-grade fever there , definitely . and , how was his appetite ? did he eat last night ?
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
143
okay , so did ... did you try the coupon that i gave you ?
[ "Therapeutic History", "Other Socials" ]
[ "Subjective" ]
144
okay any spasms
[ "Vegetative History" ]
[ "Subjective" ]
145
okay so i know we ordered it for six to eight weeks but i wan na see you again in two weeks and we'll evaluate how you're doing and make some additional treatment plan at that at that time okay
[ "Follow-up" ]
[ "Plan" ]
146
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
[ "Personal History" ]
[ "Subjective" ]
147
okay let's take a quick look yeah i do appreciate a little bit of bruising here are you having any problem raising it up or or with movement with your range of motion
[ "Physical Examination" ]
[ "Objective" ]
148
okay how often are you checking it
[ "Personal History" ]
[ "Subjective" ]
149
so elizabeth is a 53 -year-old female today complaining of chest pain and she has a past medical history of diabetes and high blood pressure so elizabeth tell me what's going on with your with your chest pain
[ "Acute Symptoms", "Personal History", "Greetings" ]
[ "Subjective" ]
150
how about when i extend it
[ "Physical Examination" ]
[ "Objective" ]
151
okay and you're taking the medication ?
[ "Therapeutic History" ]
[ "Subjective" ]
152
okay now turn your wrist in so do you have any pain when you do that
[ "Physical Examination" ]
[ "Objective" ]
153
okay , so when you're constipated , do you not have a bowel movement or is the stool hard ?
[ "Vegetative History" ]
[ "Subjective" ]
154
hey dragon , show me the vital signs . so , here it ... your vital signs look great . your oxygenation is 96 % . so that's very good . okay ? uh , i'm just going to check out your heart and lungs , and i'll let you know what i find . okay ?
[ "Physical Examination" ]
[ "Objective" ]
155
do you do you play sports in in college or high school
[ "Personal History" ]
[ "Subjective" ]
156
. and a little dizziness and we just talked a lot about a lot of other symptoms .
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
157
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
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
158
yeah , those , um , are the types of , of jobs that take a good three months until you're kind of ready to get back to doing that kind of labor-intensive work .
[ "Discussion" ]
[ "Plan" ]
159
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
[ "Acute Symptoms" ]
[ "Subjective" ]
160
and you've been taking a little bit of ice , uh , putting some ice on it , and has n't really helped and some ibuprofen . is that right ?
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
161
yeah . come this way , we'll get your things lined up . please call if you think of any questions .
[ "Chitchat" ]
[ "Null" ]
162
okay . all right . and you said you're noticed some swelling in your legs ?
[ "Vegetative History" ]
[ "Subjective" ]
163
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
[ "Acute Symptoms" ]
[ "Subjective" ]
164
okay . all right . um , now , have you had ... have you noticed any blood in your stools at all ?
[ "Vegetative History" ]
[ "Subjective" ]
165
uh , can you tell me which medications you're taking ?
[ "Therapeutic History" ]
[ "Subjective" ]
166
okay . for medications , i have that you take coq10 , vitamin d , vitamin c , fish oil , and elderberry fruit . is that all right ?
[ "Therapeutic History" ]
[ "Subjective" ]
167
okay . do you have problems lying flat in bed ?
[ "Acute Symptoms" ]
[ "Subjective" ]
168
okay are you able to turn your neck from side to side
[ "Acute Symptoms" ]
[ "Subjective" ]
169
okay . so you feel like you're able to walk a little bit further now ?
[ "Personal History" ]
[ "Subjective" ]
170
okay alright and are you watching your salt intake
[ "Vegetative History" ]
[ "Subjective" ]
171
mm-hmm .
[ "Acute Symptoms" ]
[ "Subjective" ]
172
i mean it should take a a couple of days i mean i think in a day or two you will be able to walk on it but still think it will be sore for the next couple of weeks you know your ankle sprain seems to be not the worst but it's kinda you know medium grade ankle sprain so as i would say about two to three weeks you should be back to normal you will see some of that bruising go away
[ "Discussion", "Reassessment" ]
[ "Assessment", "Plan" ]
173
okay . and then about 30 % of patients say that they can not breastfeed after a breast reduction , and the reason is the breast is made up of fat . and it's also made up of a gland . and the gland is what produces the milk .
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
174
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 ?
[ "Discussion", "Medication" ]
[ "Assessment", "Plan" ]
175
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
[ "Family History" ]
[ "Subjective" ]
176
alright have you taken
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
177
doctor: alright so my nurse will be in with the those orders and we will see you next time
[ "Chitchat" ]
[ "Null" ]
178
okay yeah that yeah you ca n't take too much of that tylenol because it'll it'll mess up your liver definitely
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
179
how severe is the pain on a scale of one to ten
[ "Personal History" ]
[ "Subjective" ]
180
okay . all right . well , the nurse is gon na come in soon , and she's gon na check you , get you checked out . okay ?
[ "Chitchat" ]
[ "Null" ]
181
okay so when you are swallowing i know some of my patients feel this do you feel like the food is getting stuck
[ "Vegetative History" ]
[ "Subjective" ]
182
probably . uh , do you notice that moving your neck or turning your head seems to bother your arm ?
[ "Acute Symptoms" ]
[ "Subjective" ]
183
doctor: alright
[ "Chitchat" ]
[ "Null" ]
184
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
[ "Acute Symptoms", "Personal History", "Greetings" ]
[ "Subjective" ]
185
okay and what would you say the pain is you know on a scale of zero to ten
[ "Acute Symptoms" ]
[ "Subjective" ]
186
okay when did you first notice this
[ "Acute Symptoms" ]
[ "Subjective" ]
187
okay sorry about that alright so you're definitely having some difficulty with some passive range of motion here and you're lacking a few degrees of terminal extension to about a hundred and fifteen degrees as well as lacking about maybe twenty to thirty degrees of terminal flexion on the secondary secondary to the pain here and you do have a positive lachman exam so one more thing i wan na take a look at real quick i'm gon na take a look at your toes here real quick very good so neurovascularly your bilateral lower extremities are intact and it looks like you have a muscle strength of a five out of five so scott you know based on my examination here your right knee injury is really suggestive of anterior cruciate ligament tear and you've heard of it probably even heard as acl tear sometimes especially when a lot of people do sports and they injure their knee that that can happen so my plan for you though is i wan na i wan na go ahead and order an mri because i wan na evaluate the integrity of that acl now you may need surgery but we'll we'll first take a look at that mri result and reevaluate and reevaluate that first but in the meantime i wan na go ahead and order some anti-inflammatory medication meloxicam fifty milligrams a day it's gon na help reduce that swelling and the pain and then i want you to go ahead and ice the knee if you need to if you're still seeing some swelling and some pain you can go ahead and use ice as well but i definitely would like for you to moderate your activities so i would like for you to wear a knee immobilizer and then also use crutches when you walk around just to help you a little bit so not to put too much stress and strain on that knee does that sound like a plan
[ "Physical Examination", "Discussion", "Medication", "Other Treatments", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
188
okay . all right . so that's good to hear . how about your blood pressure ? did you buy the blood pressure cuff that i-
[ "Personal History" ]
[ "Subjective" ]
189
okay yeah i know especially this this winter has been rough so you got ta watch for those little ice patches sometimes well okay so this occurred yesterday after falling on the ice so have you been able to walk on it at all
[ "Acute Symptoms" ]
[ "Subjective" ]
190
so we were downhill skiing racing at this point okay is it your left or your right knee
[ "Acute Symptoms" ]
[ "Subjective" ]
191
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
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
192
third time alright
[ "Acute Symptoms" ]
[ "Subjective" ]
193
that's good . that's good . tell me what's brings you in today .
[ "Acute Symptoms" ]
[ "Subjective" ]
194
dewey beach wow that sounds like fun i wish i could be a mab right now but all or as lucky as i guess as you are to go to dewey beach okay so does it hurt
[ "Acute Symptoms" ]
[ "Subjective" ]
195
. some time during the day to take them , okay ?
[ "Discussion", "Medication" ]
[ "Plan" ]
196
doctor: you're welcome and so now just
[ "Chitchat" ]
[ "Null" ]
197
yeah . you can set an alarm so that it reminds you to take your medication . but yeah , you can , you can take them altogether .
[ "Discussion", "Medication" ]
[ "Plan" ]
198
yeah , they are . uh , well now i do n't know , because if it was the progesterone , they would've gone away .
[ "Physical Examination" ]
[ "Objective" ]
199