[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 ...

Medical orders:
description: lasix 40 milligrams a day
order_type: medication
reason: hortness of breath acute heart failure exacerbation
description: hemoglobin a1c
order_type: lab
reason: type i diabetes