"Where does it hurt" - Medical Intent Classification
Collection
Collection of assets for the ECAI 2025 paper "Where does it hurt?"
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7 items
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you do have a little bit of periphe- peripheral neuropathy . um , there is a medication we can use if they get really bad , but you're already on so many medications .
|
[
"Discussion",
"Medication",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 0 |
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 ?
|
[
"Physical Examination",
"Radiology Examination"
] |
[
"Objective"
] | 1 |
which elbow is it
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 2 |
okay alright any loss in sensation
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 3 |
alright alright well let's just go ahead and i'm gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so on your musculoskeletal exam on your right knee i do appreciate some slight edema you do have a slight effusion does it hurt when i press on the outside of your knee
|
[
"Physical Examination"
] |
[
"Objective"
] | 4 |
okay , great . all right , well , you know , i know that you did the review of systems sheet when you checked in , and i know that you're endorsing some nausea and some joint pain and some body aches . any other symptoms ? abdominal pain ? diarrhea ? anything like that ?
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 5 |
and where would you say the tingling and numbness is ?
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 6 |
okay .
|
[
"Acute Symptoms",
"Vegetative History"
] |
[
"Subjective"
] | 7 |
alright did you hear a pop or anything like that
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 8 |
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
|
[
"Chitchat"
] |
[
"Null"
] | 9 |
well i'm not sure yet it's because we might have to do surgery on your knee here and take that leg off
|
[
"Chitchat"
] |
[
"Null"
] | 10 |
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 . good afternoon . how are you today ?
|
[
"Greetings"
] |
[
"Subjective"
] | 11 |
do you use it more just as needed in the summer ?
|
[
"Therapeutic History"
] |
[
"Subjective"
] | 12 |
hi matthew how are you the medical assistant told me that you injured your shoulder
|
[
"Acute Symptoms",
"Greetings"
] |
[
"Subjective"
] | 13 |
okay and did the headache start all of a sudden carolyn or has it been gradual or what
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 14 |
okay so how long have you been playing soccer
|
[
"Other Socials"
] |
[
"Subjective"
] | 15 |
okay alright yeah but yeah i can feel it here so it does feel a little bit warm so i said you've been in a little bit of pain so have you taken anything for it
|
[
"Acute Symptoms",
"Therapeutic History"
] |
[
"Subjective"
] | 16 |
okay . all right . well , um , have you had any , any high fevers ?
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 17 |
but in the meantime , i really want you to avoid , uh , foods high in sugar . um , and the , the nurse will come in and she'll give you a glucometer and teach you how to do blood sugar testing . okay ?
|
[
"Other Treatments"
] |
[
"Plan"
] | 18 |
doctor: alright thanks good seeing you thanks for coming in to them
|
[
"Chitchat"
] |
[
"Null"
] | 19 |
okay so supine straight leg test positive alright just a couple more things on neurological examination there is decreased sensation to light touch at the right lateral thigh at l4 dermatome patella and achilles reflexes are symmetrical so i just wanted to make sure that i documented all of that in your chart and in a you can ask me any questions but i did look over the results of the
|
[
"Physical Examination"
] |
[
"Objective"
] | 20 |
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
|
[
"Discussion"
] |
[
"Plan"
] | 21 |
all right , well , let's just repeat it then .
|
[
"Diagnostic Testing"
] |
[
"Plan"
] | 22 |
so i will say , " apply to rash on face twice daily , until resolved . "
|
[
"Discussion",
"Medication"
] |
[
"Plan"
] | 23 |
alright so wrist abduction adduction positive for pain on movement are you able to make a fist
|
[
"Physical Examination"
] |
[
"Objective"
] | 24 |
okay well that that's not good do you
|
[
"Chitchat"
] |
[
"Null"
] | 25 |
okay alright and then how about you able to bear any weight on it or walk on it at all
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 26 |
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
|
[
"Chitchat"
] |
[
"Null"
] | 27 |
. while it's healing .
|
[
"Discussion"
] |
[
"Plan"
] | 28 |
i'm well .
|
[
"Greetings"
] |
[
"Subjective"
] | 29 |
really ? okay , maybe it's just your black shirt . makes you look thin .
|
[
"Chitchat"
] |
[
"Null"
] | 30 |
okay alright and has anyone discussed the option of like just no has anyone discussed surgery with you
|
[
"Personal History"
] |
[
"Subjective"
] | 31 |
to help with that do you have any questions about that
|
[
"Discussion"
] |
[
"Plan"
] | 32 |
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 ?
|
[
"Personal History"
] |
[
"Subjective"
] | 33 |
doctor: hey dragon , finalize the note .
|
[
"Chitchat"
] |
[
"Null"
] | 34 |
okay positive pain to palpation and let's bring your leg out are you having pain when with flexion or extension
|
[
"Physical Examination"
] |
[
"Objective"
] | 35 |
yes , zarbee's .
|
[
"Discussion",
"Medication"
] |
[
"Plan"
] | 36 |
okay alright well it was very nice seeing you today call me if you need anything
|
[
"Chitchat"
] |
[
"Null"
] | 37 |
alright can you bend your knee and straighten it
|
[
"Physical Examination"
] |
[
"Objective"
] | 38 |
all right . next , i'd like you to lay back so i can examine your abdomen .
|
[
"Physical Examination"
] |
[
"Objective"
] | 39 |
doctor: you're welcome
|
[
"Chitchat"
] |
[
"Null"
] | 40 |
okay and then if you kinda push on your neck around here any tenderness
|
[
"Physical Examination"
] |
[
"Objective"
] | 41 |
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 .
|
[
"Discussion",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 42 |
okay . have you noticed any change in your vision or with your balance ?
|
[
"Vegetative History"
] |
[
"Subjective"
] | 43 |
that will be our next step so we'll get you scheduled for the mri probably get you in pretty quick here since we're a private practice
|
[
"Diagnostic Testing"
] |
[
"Plan"
] | 44 |
how can i help you today ?
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 45 |
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
|
[
"Personal History"
] |
[
"Subjective"
] | 46 |
sure . i'll have my nurse anna give it to you .
|
[
"Discussion"
] |
[
"Plan"
] | 47 |
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
|
[
"Physical Examination",
"Medication",
"Other Treatments",
"Diagnostic Testing",
"Acute Assessment"
] |
[
"Objective",
"Assessment",
"Plan"
] | 48 |
okay . and any family history of any heart disease ?
|
[
"Family History"
] |
[
"Subjective"
] | 49 |
okay and are you do you know if you're particularly focused on your salt like is it like a low salt diet
|
[
"Personal History"
] |
[
"Subjective"
] | 50 |
doctor: you're welcome . 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 .
|
[
"Follow-up",
"Medication",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 51 |
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
|
[
"Other Socials"
] |
[
"Subjective"
] | 52 |
okay have you tried taking melatonin to sleep
|
[
"Personal History",
"Therapeutic History"
] |
[
"Subjective"
] | 53 |
hi , anna . how are you ?
|
[
"Greetings"
] |
[
"Subjective"
] | 54 |
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
|
[
"Discussion"
] |
[
"Plan"
] | 55 |
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
|
[
"Personal History",
"Therapeutic History"
] |
[
"Subjective"
] | 56 |
okay . all right . and , and then , um , i know you've had high blood pressure , hypertension . how is , how have your blood sugars been ? have you been checking them ?
|
[
"Personal History"
] |
[
"Subjective"
] | 57 |
okay now i do want you to see a nutritionist too and give you some education about what foods you can eat
|
[
"Referral"
] |
[
"Plan"
] | 58 |
alright okay theresa so i understand that you're you're having a bit of some headache here and then your blood pressure has been running high can you tell me a little bit about what's happening
|
[
"Acute Symptoms",
"Personal History",
"Greetings"
] |
[
"Subjective"
] | 59 |
you have any questions ?
|
[
"Discussion",
"Chitchat"
] |
[
"Plan"
] | 60 |
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 .
|
[
"Physical Examination"
] |
[
"Objective"
] | 61 |
okay now tell me is there any history at all of like maybe heart disease or sudden death you know like early early in those your family's years
|
[
"Family History"
] |
[
"Subjective"
] | 62 |
okay so why do n't we go ahead and i'm gon na place a referral to psychiatry for you know you know difficulty adjusting after having a heart attack maybe some some mild depression okay does that sound okay okay
|
[
"Discussion",
"Referral",
"Reassessment"
] |
[
"Assessment",
"Plan"
] | 63 |
yeah it can cause sometimes it can cause a little bit of make you go to the bathroom a little bit more often in the evening but generally most people do n't have a whole lot of side effects i'll give you a handout of the side effects but sometimes you can have a cross reaction with some other medications like sulfa medications but generally most people tolerate this pretty well
|
[
"Discussion",
"Medication"
] |
[
"Plan"
] | 64 |
okay . so obstructive neuropathy . uh , it sounds like he was born with it and something , uh ... something made it so he could n't urinate correctly . does that sound right ?
|
[
"Family History"
] |
[
"Subjective"
] | 65 |
have you lost some weight or are you at least putting on some muscle ? you look trim .
|
[
"Personal History",
"Vegetative History"
] |
[
"Subjective"
] | 66 |
okay . uh , and we'll get rid of the clindamycin from your list as well .
|
[
"Discussion",
"Medication"
] |
[
"Plan"
] | 67 |
okay . are you taking any supplements such as iron or vitamin b12 ?
|
[
"Therapeutic History"
] |
[
"Subjective"
] | 68 |
yeah that's perfect as long as you take it once a day and you're able to afford the brilinta any issues with cost with that
|
[
"Other Socials"
] |
[
"Subjective"
] | 69 |
alright i'm gon na press here on your back
|
[
"Physical Examination"
] |
[
"Objective"
] | 70 |
okay , great . um , uh , this is christine . she's a 63-year-old female patient . you're here for your routine , um , yearly exam . um , i know you have a history of high blood pressure and you've had some depression in the past . and i also know you did have a carpal tunnel release done about two years ago . um , how have you been doing ?
|
[
"Personal History"
] |
[
"Subjective"
] | 71 |
okay . all right . and any weakness in , in your legs ?
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 72 |
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
|
[
"Physical Examination"
] |
[
"Objective"
] | 73 |
hey betty how're you
|
[
"Greetings"
] |
[
"Subjective"
] | 74 |
okay so that's not near the knee problem okay and have you had any have you been to the hospital or been to the emergency room or anything like that for your coughing and coughing up blood
|
[
"Personal History"
] |
[
"Subjective"
] | 75 |
yeah that's exactly what it is
|
[
"Chitchat"
] |
[
"Null"
] | 76 |
okay . and how about any recent weight gain or anything else like that ?
|
[
"Vegetative History"
] |
[
"Subjective"
] | 77 |
okay . all right . um , and do you have any other ... i know that you are endorsing this fatigue and you feel kind of dizzy and that type of thing . do you have any other symptoms like chest pain , shortness of breath , fever , chills , body aches , anything ?
|
[
"Vegetative History"
] |
[
"Subjective"
] | 78 |
what where is your favorite place to go mountain biking
|
[
"Chitchat"
] |
[
"Null"
] | 79 |
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
|
[
"Other Socials"
] |
[
"Subjective"
] | 80 |
okay . and no injury ?
|
[
"Personal History"
] |
[
"Subjective"
] | 81 |
landscaping okay so a lot of raking a lot of digging so a lot of repetitive type movements
|
[
"Personal History",
"Other Socials"
] |
[
"Subjective"
] | 82 |
good for you . um ... have you ever had any surgeries before ?
|
[
"Personal History"
] |
[
"Subjective"
] | 83 |
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
|
[
"Chitchat"
] |
[
"Null"
] | 84 |
did you have a headache ?
|
[
"Vegetative History"
] |
[
"Subjective"
] | 85 |
alright so little bit of pain on flexion and extension little bit of limited range of motion on extension of the arm how about if you twist like you're opening a door
|
[
"Physical Examination"
] |
[
"Objective"
] | 86 |
nausea or vomiting
|
[
"Vegetative History"
] |
[
"Subjective"
] | 87 |
these these deform these deformities that really that really kind of hurt is the short version alright no problem any other questions
|
[
"Discussion"
] |
[
"Plan"
] | 88 |
right here ?
|
[
"Physical Examination"
] |
[
"Objective"
] | 89 |
you're doing well
|
[
"Acute Symptoms"
] |
[
"Subjective"
] | 90 |
no shots today just stopped
|
[
"Discussion"
] |
[
"Plan"
] | 91 |
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 .
|
[
"Physical Examination",
"Acute Assessment"
] |
[
"Objective",
"Assessment"
] | 92 |
okay good . what kind of numbers are you seeing ?
|
[
"Personal History"
] |
[
"Subjective"
] | 93 |
so , in both of your hands ?
|
[
"Personal History"
] |
[
"Subjective"
] | 94 |
um , and then we'll go ahead and refer you to some physical therapy once we get the mri results back , okay ?
|
[
"Discussion",
"Medication",
"Referral"
] |
[
"Plan"
] | 95 |
that's your kidney doctor
|
[
"Personal History"
] |
[
"Subjective"
] | 96 |
alright so we will see you next time and my nurse will be in with those prescriptions
|
[
"Chitchat"
] |
[
"Null"
] | 97 |
and then just do it until it's gone , and then do it for once a day for another week before stopping .
|
[
"Medication"
] |
[
"Plan"
] | 98 |
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
|
[
"Therapeutic History"
] |
[
"Subjective"
] | 99 |
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