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Doctor: Any past medical history?
Patient: No. | Section Header: PAST MEDICAL HISTORY
Summary: Nonsignificant. |
Doctor: With ten being the worse pain ever, how would you rate your pain out of ten today, ma'am?
Patient: Um, out of ten, I'd say it's about a two.
Doctor: That's good. What helps the pain feel better?
Patient: Um, it gets better with elevation, and when I just rest. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient rates the pain at 2/10 on the pain analog scale. The patient states that with elevation and rest, her pain subsides. |
Doctor: Nurse, did you get the documents from the patient?
Guest_clinician: I did. Here is her full history and notes from her physical examination. She also completed the patient questionnaire before arriving. You can review that.
Doctor: Thank you, Nurse. What is she here for today?
Guest_clinician: She came in for ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. I obtained and documented a full history and physical examination. I reviewed the new patient questionnaire, which she completed prior to her arrival ... |
Doctor: Do you drink?
Patient: I used to drink before, but now I have stopped it completely.
Doctor: How would you rate your pain?
Patient: It is tolerable, like five out of ten but I do need some pain medications.
Doctor: Then why do you need more pain medications?
Patient: Sometimes it gets hard, I really need so... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: History of alcohol use in the past. He is basically requesting for more and more pain medications. He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid. His pain is tolerable. |
Guest_clinician: She has a vast history of surgeries.
Doctor: Yeah, I am looking at her reports. She had surgery for spina bifida when she was a baby and they had to put a shunt.
Guest_clinician: Yeah, later she had her uterus removed and also had to undergo a breast reduction surgery.
Doctor: Hm. | Section Header: PAST MEDICAL HISTORY
Summary: Back closure for spina bifida, hysterectomy, breast reduction, and a shunt. |
Doctor: Are you married or divorced?
Patient: I am married.
Doctor: Okay.
Patient: Hm.
Doctor: Do you smoke cigarettes or drink alcohol?
Patient: No, I have never. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She is married and does not smoke or drink nor did she ever. |
Doctor: What is your family medical history?
Patient: I am not sure. Everyone is healthy as far as I know. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: unremarkable. |
Doctor: Good morning, ma'am. My chart says that you're forty nine years old, and White, is that correct?
Patient: Yes, that's all correct.
Doctor: What do you do for a living?
Patient: I'm a secretary.
Doctor: Great, welcome back to the Dermatology office, do you remember when your last appointment was?
Patient: U... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004. She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and ... |
Doctor: It looks like your Xrays show bronchitis.
Patient: Is there anything I can take for it?
Doctor: Yes, I'm going to prescribe you something that will help clear your lungs. | Section Header: ASSESSMENT
Summary: Bronchitis/URI. |
Doctor: How's it going X Y Z? I see you're in a walking boot. What happened?
Patient: I hurt my foot pretty bad yesterday.
Doctor: How'd it happen?
Patient: Basketball. I play for the University of Houston. I went up for a three and came down and landed on this guy's foot. I was so pissed.
Doctor: Dang, that sucks.... | Section Header: HISTORY of PRESENT ILLNESS
Summary: XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able ... |
Guest_family: So apart from constipation what is his problem? What is up with his lungs?
Doctor: Yeah so, we call it foreign body impaction. It is mostly affecting his right nostril and as you said there is constipation. | Section Header: ASSESSMENT
Summary: 1. Infected foreign body, right naris. 2. Mild constipation. |
Patient: I was working when it happened so we are going through workers comp.
Doctor: Okay. Don't worry. Let's see. Oh wow!
Patient: Yeah, this arm, it was a hot oil.
Doctor: Yeah, too bad, looks like from elbow to wrist. The whole medial side is burnt.
Patient: I am using cool packs since it happened. My friend is hel... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend... |
Doctor: Do you have any medical conditions that I should know about?
Patient: Um, I have high blood pressure, and asthma.
Doctor: I also see here that you have cervical cancer, can you tell me more about that?
Patient: Yeah, I got diagnosed at fifteen years old.
Doctor: How would you describe the progression of you... | Section Header: PAST MEDICAL HISTORY
Summary: Significant for hypertension, asthma, and cervical cancer. The cervical cancer was diagnosed as 15 years old. The patient states that her cancer is "dormant." |
Doctor: You can take Ibuprofen as needed for pain. | Section Header: MEDICATIONS
Summary: Ibuprofen PRN. |
Doctor: Do you take anything for acid reflux?
Patient: Yeah, I take Aciphex.
Doctor: Is that twenty M G once a day?
Patient: It is. I also take one baby Aspirin in the mornings. | Section Header: MEDICATIONS
Summary: Aciphex 20 mg q.d. and aspirin 81 mg q.d. |
Doctor: Do you smoke?
Patient: Yes.
Doctor: How much do you smoke?
Patient: I smoke about two packs of cigarettes a day.
Doctor: Okay. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Smokes 2ppd cigarettes. |
Doctor: Any numbness or tingling?
Patient: No.
Doctor: Are your experiencing any muscle weakness?
Patient: No.
Doctor: Any problem walking, or did you lose balance or fall?
Patient: Nope.
Doctor: So, your gait is fine. Any stroke in the past?
Patient: No, nothing like that. | Section Header: REVIEW OF SYSTEMS
Summary: NERVOUS SYSTEM: No gait problems, strokes, numbness or muscle weakness. |
Doctor: Past surgeries I should know of?
Patient: I had my gallbladder, appendix, and uterus removed.
Doctor: Oh wow, I see. When did you get these surgeries?
Patient: I had my gallbladder removed in O eight, appendix removed in twenty twelve, and uterus removed this past year.
Doctor: Any other medical history?
P... | Section Header: PAST SURGICAL HISTORY
Summary: Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted. |
Doctor: Do you have allergies? How old are you, young man?
Patient: Yes ragweed. I am twelve.
Doctor: So basically, you are just congested?
Patient: Yes that's right. The last ten days.
Doctor: Any headache? What comes out of your nose?
Patient: Yes I had a little yesterday. Clear boogers.
Doctor: You feel hot?
Patien... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion. He does have significant allergies including ragweed. The drainage has been clear. He had a little bit of a headache yesterday. He has had no fever. No one else is ill at ... |
Doctor: Are you married?
Patient: I'm divorced.
Doctor: Do you have any kids?
Patient: Yes, I have two boys and they live with me.
Doctor: Any abnormal pregnancy. Any abortions?
Patient: No, none of them.
Doctor: Do you smoke or consume alcohol or have ever used any illicit drug?
Patient: No. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use. |
Doctor: I want to go over your medical history. I see here you saw the dermatologist a month ago.
Patient: Yeah. She said that I um have an overactive sweat gland.
Doctor: Does hidradenitis suppurativa sound familiar?
Patient: It does.
Doctor: I ask because it's also included in your last visit with your dermatolog... | Section Header: PAST MEDICAL HISTORY
Summary: 1. History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years. Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa. Probably, she has h... |
Patient: Hello, how are you?
Doctor: I am good, tell me what brings you here?
Patient: I am having this chest pain. I was hospitalized last year in October and at that time they put this catheter in my heart. I also underwent a heart scan. It's here in this report.
Doctor: Yeah, I see that you got nuclear and myocardi... | Section Header: PAST MEDICAL HISTORY
Summary: Hyperlipidemia, smoking history, and chest pain. He has been, in October of last year, hospitalized. Subsequently underwent cardiac catheterization. The left system was normal. There was a question of a right coronary artery lesion, which was thought to be spasm. Subs... |
Doctor: I am sorry about that.
Patient: Yes, for assault, that's why I was in detention.
Doctor: Okay.
Doctor: When was this?
Patient: Around December of two thousand nine.
Patient: Not sure if I am under legal contraints right now.
Doctor: Okay so we don't know. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: He had an assault in December 2009, which led to his previous detention. It is unknown whether he is under legal constraints at this time. |
Doctor: Do you smoke cigarettes?
Patient: Yes, I do.
Doctor: How many packs a day.
Patient: Maybe one a day.
Doctor: Okay, you should think about quitting. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient is still a smoker. |
Doctor: What happens when you take Sulfa drugs?
Patient: Oh man, I get a really ugly looking rash.
Doctor: I'll make note of that so we have it in your chart. | Section Header: ALLERGY
Summary: Sulfa (rash). |
Doctor: Any known drug allergies?
Patient: Nope, none whatsoever. | Section Header: ALLERGY
Summary: No known drug allergies. |
Doctor: Do you smoke cigarettes or drink alcohol?
Patient: No.
Doctor: Any use of recreational substances or IV drug abuse?
Patient: No. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs. |
Doctor: Tell me what brings you here today?
Patient: I'm having some issues with my right hand.
Doctor: What kind of issues?
Patient: I'm having these pins and needles kind of feeling in my hand and it has been going on for several weeks. Sometimes I feel it gets numb. I think it might be carpal tunnel, but I'm not ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This patient presents to the office today because of some problems with her right hand. It has been going tingling and getting numb periodically over several weeks. She just recently moved her keyboard down at work. She is hoping that will help. She is worried ab... |
Doctor: Have you been in any accident?
Patient: I have been a truck driver for some time but luckily have not been in any major auto accident. I had hit a moose once, where I bumped my head but do not remember getting hurt anywhere else. I had broken my ankle in the past.
Doctor: Hm, I see here you mentioned to the nu... | Section Header: HISTORY of PRESENT ILLNESS
Summary: He had a broken ankle in the past. They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. He said he bumped his head once, but not his chest, although he told the nurse that a c... |
Doctor: Did you ever had pneumonia?
Patient: No, never.
Doctor: Do you have any history of lung disease?
Patient: No.
Doctor: Any history of tuberculosis?
Patient: No.
Doctor: Are you feeling any shortness of breath or difficulty breathing?
Patient: No.
Doctor: Okay. Do you have any wheezing?
Patient: No. | Section Header: REVIEW OF SYSTEMS
Summary: RESPIRATORY: No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias. |
Doctor: Tell me about your past medical history. Is there anything that I should be aware of?
Patient: No, I don't think so.
Doctor: Any known allergies?
Patient: No.
Doctor: Have you ever been diagnosed with diabetes or high blood pressure?
Patient: Oh, last year I did have some incidents of high blood pressure, ... | Section Header: PAST MEDICAL HISTORY
Summary: Unremarkable. There is no history of allergies. He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year. |
Doctor: How did your treatment for the thrombosis go? I believe we did it on February nineteen of two thousand and seven. We finished the note the next day in order to send to your other following doctor.
Patient: The treatment went well. Thanks! | Section Header: PAST SURGICAL HISTORY
Summary: The treatment of the thrombosis was documented on 02/19/2007 and 02/20/2007. |
Doctor: Where are you having numbness?
Patient: In my left hand.
Doctor: And no other symptoms? Any coughing or chest pain?
Patient: No. Just that weird feeling in my left hand.
Doctor: Any visual changes or motor changes.
Patient: Nothing.
Doctor: Great. What about any phlegm or shortness of breath?
Patient: Nope. | Section Header: REVIEW OF SYSTEMS
Summary: No coughing, sputum production, dyspnea or chest pain. No vomiting or abdominal pain. No visual changes. No neurologic deficits other than some numbness in his left hand. |
Doctor: How are you feeling?
Patient: I've been having a lot more joint pain lately.
Doctor: You're seventy seven, correct?
Patient: Don't remind me.
Doctor: When did you first start experiencing joint pain?
Patient: Couple years ago.
Doctor: In what ways has it worsened?
Patient: It's caused me to become less a... | Section Header: HISTORY of PRESENT ILLNESS
Summary: A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Daypro generic does not seem to be helpi... |
Doctor: Anyone in your family been sick lately?
Patient: Yes, my sister has sinus problems. She was seen today.
Doctor: Okay that means she will be treated.
Patient: Yes.
Doctor: How about other family members?
Patient: No, my mom and dad are healthy.
Doctor: Good. Good.
Patient: Hm! | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The sister is in today with clinical sinusitis. Mother and father have been healthy. |
Doctor: So, tell me what's going on with you?
Patient: Well, yesterday evening between seven or eight I developed nausea and suddenly it started hurting on the right side of my chest?
Doctor: Where exactly did it hurt?
Patient: Ah, my upper chest part and it went all around my right side till my back.
Doctor: Okay, h... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently w... |
Doctor: Okay, so it looks like your blood work shows that your sodium levels are very low. This could explain some of the symptoms you've been having lately.
Patient: What does that mean? Why are my sodium levels so low?
Doctor: It could be due to a number of-
Patient: Should I start eating more salt?
Doctor: Not n... | Section Header: ASSESSMENT
Summary: 1. Acute tiredness. 2. Anemia of unknown etiology. 3. Acute hyponatremia. |
Doctor: So, you are a cigarette smoker?
Patient: Yeah.
Doctor: How much do you some?
Patient: Not as much as some people.
Doctor: How much is that exactly?
Patient: Well, I probably buy a new pack once a week.
Doctor: Okay. So that is about four packs a month and fifty packs a year.
Patient: Yeah, I guess so. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 50+pack-yr cigarette use. |
Doctor: Are you married, sir?
Patient: Yes, to my wonderful wife.
Doctor: Great, can I assume you support each other at home?
Patient: Yes, doctor, that's correct.
Doctor: Do you smoke or drink, sir?
Patient: Well, I don't smoke, and I don't do anything harder, either. But I drink just about every day.
Doctor: How... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: He is married and has support at home. He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week. |
Doctor: Do you know if anyone in your family has history of heart disease, stroke anything of that sort?
Patient: Let me think. You mean only blood relatives?
Doctor: Yes.
Patient: Yes. We have some of those diseases in our family. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Remarkable for coronary artery disease, stroke, and congestive heart failure. |
Doctor: What kinds of surgeries have you had in the past?
Patient: I have had a heart bypass surgery.
Doctor: Is that C A B G?
Patient: Maybe. And I have had my tonsils and appendix taken out.
Doctor: Sure. Okay. | Section Header: PAST SURGICAL HISTORY
Summary: CABG, appendectomy, tonsillectomy |
Doctor: Good morning, ma'am. Can you tell me more about this low back pain?
Patient: Well, I'm not as young as I used to be, I'm fifty nine.
Doctor: What set this pain off? Is there any injury?
Patient: Yes, I had a fall in the beginning of two thousand six. I slipped on a freshly waxed floor.
Doctor: What part of ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. T... |
Doctor: Have you ever had surgery, ma'am?
Patient: Yeah, doctor, I've had a whole lifetime worth of back surgeries.
Doctor: How many surgeries have you had?
Patient: I've had four.
Doctor: Do you know the surgeries you've had?
Patient: Actually, I have the op notes here.
Doctor: I see, you've had an anterior cervic... | Section Header: PAST SURGICAL HISTORY
Summary: She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L. She is G10, P7, no cesarean sections. |
Doctor: Have you ever had any major surgeries?
Patient: I had a skin tag removed but no. No major surgeries.
Doctor: Okay. | Section Header: PAST SURGICAL HISTORY
Summary: No significant past surgical history. |
Doctor: With ten being the worst pain imaginable, out of ten, how would you describe your pain today?
Patient: I'd say its about a six out of ten today.
Doctor: What makes the pain worse?
Patient: It's worse when I try to walk around on it.
Doctor: Do you have any pain at night?
Patient: No, thankfully I don't.
Doc... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard. |
Doctor: I need to ask you a few questions.
Patient: Sure.
Doctor: Do you feel any weakness or tiredness?
Patient: No.
Doctor: Any uneasiness or illness?
Patient: No, nothing of that sort.
Doctor: Any chills or high temperature?
Patient: Nope.
Doctor: Any excessive sweating or night sweating?
Patient: Um, no.
Doctor:... | Section Header: REVIEW OF SYSTEMS
Summary: GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies. |
Doctor: Do you smoke or drink?
Patient: No.
Doctor: Any drug use?
Patient: No. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: No alcohol, drugs, or tobacco. |
Doctor: Do you smoke?
Patient: Yes!
Doctor: How about alcohol, do you drink?
Patient: Yes, I do.
Doctor: And how much do you drink and is it occasional or on daily basis?
Patient: Well, I love my wine, I drink about four to five glasses per day.
Doctor: Wow! That's a lot. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient is a smoker and drinks alcohol daily in considerable amounts. |
Doctor: Do you smoke cigarettes?
Patient: Yes. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient is a smoker. |
Doctor: Any important family history, any medical issues in the family?
Patient: Well, my father died of a heart attack. I don't remember how old he was, but I do remember that he had some long run heart issues.
Doctor: What about your mom?
Patient: My mom's death was a mystery for all of us. She died of some complic... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy. |
Doctor: Hi there! How are you today?
Patient: Hi. I am not doing so well. I have had this cough and a pain in my stomach. Right here by my belly button.
Doctor: How long has this been going on?
Patient: Two days. It has been very painful.
Doctor: I would like to examine your abdomen. Is that okay?
Patient: Yes. | Section Header: CHIEF COMPLAINT
Summary: Cough and abdominal pain for two days. |
Doctor: Can you please confirm the medications that you have already taken?
Patient: Yeah, I just finished the course for Minocin. I also took Duraphen II D M. | Section Header: MEDICATIONS
Summary: Recently finished Minocin and Duraphen II DM. |
Doctor: Has anyone in your family had a history of heart disease or issues?
Patient: Well, yeah. Actually, my dad passed away due heart disease.
Doctor: Oh, I am sorry to hear that. Do you know what kind of heart problem he had?
Patient: Yeah, it is called co-
Doctor: Oh, coronary heart disease?
Patient: Yes, exactly... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: His father died of coronary artery disease. |
Doctor: Good morning, ma'am. Just to confirm, you're thirty two years old, correct?
Patient: Yes, doctor, that's correct.
Doctor: Good, so, have you been able to get a P C P yet?
Patient: No, I haven't gotten one just yet.
Doctor: Are you in the process of getting one?
Patient: Yeah, Project Access is trying to fi... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 32-year-old female comes in again still having not got a primary care physician. She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect. She says that... |
Doctor: Do you smoke or drink?
Patient: No.
Doctor: Any drugs?
Patient: You mean like meth?
Doctor: Yeah.
Patient: No, never did it.
Doctor: Okay. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: denied ETOH/Tobacco/illicit drug use. |
Doctor: Hello, miss. How are you? What brings you to my office today?
Patient: I am doing well. Just here for a refill on my medication.
Doctor: Great. That should be easy. How has the stress management been going to control the acne?
Patient: It is going well. My husband has been on board with my meditations and yoga... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient is married. She is a nonsmoker and nondrinker. |
Doctor: So I have here that you're taking three different medications.
Patient: Yeah. I've been taking them every day just like they told me to.
Doctor: I see. That's good. Did you refill your prescriptions with the newly revised doses? It looks like they changed the dosing of your medications at the hospital.
Patie... | Section Header: MEDICATIONS
Summary: I reviewed his medication list in the chart. He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription. |
Doctor: Any major surgeries in the past?
Patient: Not too many, but a catheter was put in my heart.
Doctor: Oh, so cardiac catherization, correct?
Patient: Yep. | Section Header: PAST SURGICAL HISTORY
Summary: No major surgery except for prior cardiac catheterization. |
Doctor: Hello, sir. I see you're being seen for an evaluation for your allergy. Can you please confirm your age?
Patient: Yeah, that's right. Thirty four.
Doctor: Let me take a look at your medical records. I see you were treated at the A B C Medical Center for an allergic reaction, correct?
Patient: Yeah. I was rushe... | Section Header: HISTORY of PRESENT ILLNESS
Summary: A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment. Please refer to chart for history and physical, as well as the medical records regarding his a... |
Guest_family: Doctor, you must tell her. She has stopped taking her medications. And her blood pressure is out of control, she is angry all the time and not looking after herself at all.
Patient: That is not true!
Doctor: Miss Tara, you need to take your medications on time. You are hypertensive and your readings don'... | Section Header: PAST MEDICAL HISTORY
Summary: Hypertension. The patient noncompliant |
Patient: I think I got some allergy, my lips are swollen and its causing me difficulty in swallowing.
Doctor: Oh, let me take a look. | Section Header: CHIEF COMPLAINT
Summary: Swelling of lips causing difficulty swallowing. |
Doctor: Any medical history?
Patient: Um I suffer from depression and high blood pressure.
Doctor: Are you taking anything for either?
Patient: Only for high blood pressure.
Doctor: Have you had surgeries in the past?
Patient: I had surgery to get a few hemorrhoids removed back in two thousand and ten. | Section Header: PAST MEDICAL HISTORY
Summary: Significant only for hemorrhoidectomy. He does have a history of depression and hypertension. |
Doctor: Do you have a family history of any medical conditions, such as diabetes or heart disease?
Patient: No, nothing. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Noncontributory. |
Doctor: How's your family?
Patient: They're doing well, thank you. My three boys are all grown up. Hard to believe they're living their own as young professionals. One of them is actually a G I doctor in San Diego, California.
Doctor: You must be so proud of your boys.
Patient: My wife and I always say how lucky we ... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. The patient is married. She has three grown sons, all of which are very successful in professional positions. One son is a gastroenterologist in San Diego, Cal... |
Doctor: How's it going, buddy? I haven't seen you in a long time
Patient: Hey, Doctor. It's been a while. I've been doing well. Just here for my check up.
Doctor: Nice. How's the family doing? Are they all well?
Patient: Yeah, they're doing great. Nobody has been sick for a while.
Doctor: That's great to hear. Nobod... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Reviewed and unchanged. |
Doctor: So, you and your husband live together, correct?
Patient: Yes. It's a miracle we've lasted this long.
Guest_family: Can't argue that.
Doctor: Are you able to walk any distance without assistance?
Guest_family: She's most comfortable in her wheelchair, but she usually walks with a walker if she's at home.
Patie... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows. No history of alcohol abuse or smoking. |
Doctor: You do not look so well today. What seems to be the problem?
Patient: Well‚ I am having a hard time. My whole body aches and I am in pain.
Doctor: Do you have a history of drug use?
Patient: Well yes. I am detoxing.
Doctor: What kind of drugs have you been using?
Patient: Heroin.
Doctor: Okay. How long h... | Section Header: CHIEF COMPLAINT
Summary: Detox from heroin. |
Doctor: How would you rate your general health?
Patient: I've been in reasonably good health at least physically. I try to go on frequent walks and eat a clean diet. However, there was one instance where I was not well mentally. After my husband died in nineteen seventy five, I had what I believe was a nervous breakdow... | Section Header: PAST MEDICAL HISTORY
Summary: The patient has generally been in reasonably good physical health. She did have a "nervous breakdown" in 1975 after the death of her husband. She was hospitalized for several weeks and was treated with ECT. This occurred while she was living in Korea. She does not smoke... |
Doctor: Are you experiencing any headaches, or do you have any history of migraine?
Patient: No.
Doctor: Any temporary loss of consciousness?
Patient: No.
Doctor: Any feeling of being off balance or fainting?
Patient: No.
Doctor: Any continuous sound you may hear?
Patient: No.
Doctor: Okay so no tinnitus. Any mouth ... | Section Header: REVIEW OF SYSTEMS
Summary: HEENT: No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter. |
Doctor: Hello, miss. How can I help?
Patient: Well, I just turned fifty seven this year and I would like to get rid of these wrinkles on my face. I don't like them one bit.
Doctor: You look beautiful and actually have a lot of fullness in the face. It is great that you do not smoke and do not have history of skin dis... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and ... |
Doctor: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: Remind me, how young are you?
Patient: Oh doctor, you flatter me. I'm sixty two years old.
Doctor: Great, and you've had a rotator cuff repair before, correct?
Patient: Yes, that's correct.
Doctor: Good, well, what seems to be the problem toda... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 62-year-old female who previously underwent a repair of rotator cuff. She continued to have pain within the shoulder. She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff. She wished to proceed with a repa... |
Doctor: What brings you in today?
Patient: I dropped a glass and one of the broken pieces cut my foot pretty badly. There was a lot of blood.
Doctor: Is the area still bleeding?
Patient: I got it to stop bleeding while I was waiting for my ride.
Doctor: Is there any pain in the area?
Patient: No, it doesn't hurt.... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use... |
Doctor: What do you do for a living, sir?
Patient: I'm actually retired, but I used to work as a dock hand.
Doctor: That's great, congratulations on your retirement!
Patient: Thank you so much, doctor.
Doctor: I just need some background information on you, sir. Do you smoke?
Patient: Sure, I smoke about a half a ... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand |
Doctor: Any surgical history?
Patient: I had my thyroids taken out.
Doctor: When did you have them taken out?
Patient: Hm three years ago. Man, time flies.
Doctor: Did you experience any complications post surgery?
Patient: Nothing out of the ordinary.
Doctor: Who was the surgeon who did your thyroidectomy?
Pati... | Section Header: PROCEDURES
Summary: Total thyroidectomy. |
Doctor: Welcome in. I am Doctor Welch.
Guest_family: Thank you! It is nice to meet you.
Doctor: How old is your daughter?
Guest_family: She is three years old now.
Doctor: Hi there!
Patient: Hi!
Doctor: Mom I would like to start off with some questions regarding pregnancy, childbirth, and prior children.
Guest_f... | Section Header: HISTORY of PRESENT ILLNESS
Summary: Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother. Birth weight 7#10oz. No instrumentation required. Labor = 11hours. "Light gas anesthesia" given. Apgars unknown. Mother reportedly had the "flu" in the 7th or 8th month of gestation. Patient discharg... |
Doctor: Okay and are you working?
Patient: Oh yes, I am a farmer. I have a farmland and my wife, and I do farming.
Doctor: Good, so you are one happy married couple working together.
Patient: Ah, yes.
Doctor: And how about tobacco, do you smoke or eat?
Patient: Absolutely not.
Doctor: Any use of drugs or alcohol?
P... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Farmer, Married, no Tobacco/ETOH/illicit drug use. |
Doctor: Well, looking at your hand x ray, the bone looks in alignment, and I don't see any effusion.
Doctor: Any tenderness or pain?
Patient: Ah, not really!
Doctor: There is no asymmetry. Can you move your hand up and down? Now rotate it. Can you move your fingers?
Patient: Yes, I can do all of that, no problem at al... | Section Header: EXAM
Summary: BONE: No misalignment, asymmetry, defect, tenderness or effusion. Capable of from of joint above and below bone. |
Doctor: How about any surgeries in the past?
Patient: Well, I had colon surgery in nineteen eighty nine or was it ninety, oh yeah in nineteen ninety.
Doctor: Okay and anything else?
Patient: Ah yes, I had three surgeries for my sinus one was the same year as my colon surgery, one was before that. So, the first one was... | Section Header: PAST SURGICAL HISTORY
Summary: Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005. |
Doctor: So, do you drink or smoke, sir?
Patient: I'd say I have the occasional drink, but I don't smoke.
Doctor: What do you do for a living?
Patient: I'm a nursing aid in a nursing home right now.
Doctor: Do you work the normal day shift?
Patient: No, I work the second shift, so I work some late nights and early ... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Only occasionally drinks alcohol and he is a nonsmoker. He currently is working as a nurse aid, second shift, at a nursing home. He states that he did not enroll in Wichita State this semester. Stating he just was tired and wanted to take some time off. He sta... |
Doctor: What brings you in today, miss?
Patient: I haven't been feeling well since I went to the dentist.
Doctor: When did you go to the dentist?
Patient: It was in May last year.
Doctor: What happened at the dentist? Also, sorry, but how old are you.
Patient: It was after I left the dentist. I was driving home, a... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo l... |
Doctor: Oh wow, you got stung quite a few times.
Patient: Yeah, you're right about that. In my seventy six years this i have never gotten stung. This is new.
Guest_family: He got stung around noon while I was inside preparing lunch.
Patient: Yeah, they got both my hands and right knee. Those little monsters.
Docto... | Section Header: HISTORY of PRESENT ILLNESS
Summary: Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today. He did not note any immediate reaction. Since that time, he has noted some increasing redness... |
Doctor: What is your family medical history?
Patient: I was adopted. I don't know my family medical history. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Unknown. |
Doctor: Were you ever diagnosed with any blood or heart disease?
Patient: Uh no.
Doctor: Any other past medical issues?
Patient: No. | Section Header: PAST MEDICAL HISTORY
Summary: None. |
Doctor: Any major or minor surgeries done in the past?
Guest_family: Sorry, I have no idea about it.
Guest_family: I just started working for him. | Section Header: PAST SURGICAL HISTORY
Summary: Unknown. |
Doctor: I can see your medication list here.
Doctor: Do you take Accutane and Ovcon?
Patient: Yes, I do.
Doctor: Okay.
Patient: Okay. | Section Header: MEDICATIONS
Summary: Accutane and Ovcon. |
Doctor: What are you taking?
Patient: I take Tylenol.
Doctor: Is that only for pain?
Patient: Yes it is. | Section Header: MEDICATIONS
Summary: Tylenol. |
Guest_clinician: Hello, doctor. Let me give you a run down as to what we are dealing with today. This patient was last seen in January two thousand and four. She is coming for a follow up on interstitial disease secondary to lupus pneumonitis. I will let her tell you more about what happened yesterday.
Doctor: Thanks,... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. She was last seen in the Pulmonary Medicine Clinic in January 2004. Since that time, her respiratory status has been quite good. Sh... |
Doctor: Hello sir, it's been a while since your last visit. How have you been?
Patient: Hello doctor, yes, I have come a long way. I guess last time I was here was in two thousand and two if I am not wrong. Was does your system say?
Doctor: You are right! It was August second of two thousand and two to be very precis... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. It cleared for awhile. Th... |
Doctor: Are you finished with your cancer treatments?
Patient: Yes. I am in remission now.
Doctor: That is great! When was your last radiation treatment?
Patient: It has been over two years since my last treatment. | Section Header: IMAGING
Summary: She has had no recent radiological procedures. |
Doctor: Do you smoke?
Patient: Yeah. I smoke about a pack a day.
Doctor: Do you have any plans of quitting?
Patient: Eh not really.
Doctor: As your doctor, I'd advise that you consider nicotine patches and find ways to break your smoking habit.
Patient: Okay. I'll see what I can do.
Doctor: Do you drink?
Patie... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: He smokes one pack of cigarettes per day. He is a social drinker. He is not married, but has two children. Hobbies: Computers, hiking, camping, fishing. |
Doctor: Good morning, ma'am. Before we begin today, can you confirm your age for me?
Patient: Good morning, doctor. Sure, I'm seventy nine years old.
Doctor: Great, thank you. What seems to be the problem today, ma'am?
Patient: Well, I have this arthritis, as you know.
Doctor: Yes, how would you describe your arthr... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed wit... |
Doctor: Welcome to the clinic.
Patient: Thank you.
Doctor: Are you from the area?
Patient: I was born and raised in Iowa. My husband and I moved here twenty years ago, and we have been here ever since.
Doctor: It is a wonderful city. Do you have kids?
Patient: Yes! We have two kids.
Doctor: Do you have any histor... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use. |
Doctor: Any of your family members have issues like seizures?
Patient: None on my father's side, but, yeah, on my mom's side some of the family members had seizures. Like, my mom had them during her childhood. I know that my great grandmother had it and so does my great aunt. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt. There is no other significant neurological history... |
Doctor: Do you have a sore throat, cough or earache?
Patient: No. | Section Header: REVIEW OF SYSTEMS
Summary: Negative as far as sore throat, earache, or cough. |
Doctor: Can you tell me what are the diseases you have been diagnosed with in the past?
Patient: Sure, I have had hypertension, diabetes, asthma and cholesterol problem.
Doctor: Ok, is there anything else?
Patient: Nope.
Doctor: And it is type two diabetes, right?
Patient: Yes.
Doctor: Thank you! | Section Header: PAST MEDICAL HISTORY
Summary: Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol. |
Doctor: Good afternoon, sir. Do you remember the details of your surgery?
Patient: No, can you remind me?
Doctor: Well, um, we did a right orchiectomy due to your testicular cancer, when did you have that?
Patient: Um, it was about eighteen years ago now, so that was about nineteen eighty nine.
Doctor: Good, while ... | Section Header: PAST MEDICAL HISTORY
Summary: Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdomin... |
Doctor: Good morning, Miss X Y Z, correct?
Patient: Yes, that's me, good morning doctor.
Doctor: Before we begin, I just need a few pieces of information. How old are you?
Patient: I'm forty four years young, doctor.
Doctor: Good, thank you. Next, which hand do you write with?
Patient: I write with my right hand. ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: Ms. XYZ is an otherwise fairly healthy 44-year-old right-handed aircraft mechanic. On her date of injury, she reports that she was working on an aircraft when she fell between the airplane and a stand with about an 18-inch gap in between. She injured her left knee ... |
Doctor: How old are you?
Patient: I'm eighty six years old.
Doctor: What gender do you identify with?
Patient: I identify as a female.
Doctor: How long have you had this back and buttock pain?
Patient: Its been a while, now. I know I have a fracture in my lower back.
Doctor: How have you been managing this?
Pati... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture. The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was t... |
Doctor: Good afternoon, sir, and who's the patient today? You, or your daughter?
Guest_family: Not me today, its my daughter.
Doctor: And how old are you, dear?
Patient: I'm eighteen.
Doctor: What seems to be the problem today?
Patient: I hurt my right knee while playing tennis, um, it was about three days ago now. It... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swell... |
Doctor: How're you feeling today?
Patient: Much better. The antibiotics seemed to really help.
Doctor: Are you still experiencing any symptoms?
Patient: Um no, thankfully. I had some wheezing when I first started the antibiotics, but it's improved a ton. I don't think the wheeze is even there anymore.
Doctor: Good,... | Section Header: PAST MEDICAL HISTORY
Summary: He has had some wheezing in the past but nothing recently. |
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