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Doctor: Any medical problems that run in the family? Patient: No, nothing that comes to mind.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.
Doctor: Hi Mister B, nurse tells me you had a fall? Patient: Yes, a pretty bad one. Doctor: Okay, tell me what happened? Patient: Well, I was running to catch a taxi and stumbled upon a piece of rock, lost my balance and fell. Patient: I fell face down and my head hit the sidewalk. The next thing I remember is I am ...	Section Header: HISTORY of PRESENT ILLNESS Summary: Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a while after it happened. He complains of pain over the chin and right forehead where h...
Doctor: Let's talk about your family history. Patient: Okay. Doctor: Can you tell me about any kind of medical traits that run in your family? Patient: I think my family has been blessed or I don't know if any. Doctor: What about any heart disease? Patient: Nope. No heart disease or diabetes or any other kind of i...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Negative.
Doctor: Hello, Nurse. Could you give me a run down on the eleven month old patient? Guest_clinician: The patient was presented with stage two neuroblastoma on the left when he was six weeks old. It was completely resected. It was shown not to be N Myc amplified and had some favorable Shimada histology. Doctor: Great....	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected. It was felt to be stage 2. It was not N-Myc amplified and had favorable Shimada histology. In followup, he was found to ha...
Doctor: So, how are long have you had pain in this hip? Patient: It's been about eight or ten years now. It began while I was working in construction. Doctor: How old are you now? Patient: I'm thirty two now, so I've been in pain since I was in my twenties. Doctor: Have you seen another doctor for this, or am I the...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 32-year-old male seen by Dr. ABC several weeks ago for persistent left hip pain. He has a long eight to ten year history of pain into the left hip. He has been worked up by several specialists and evaluated. He was thought initially to have low ba...
Doctor: Let me examine your skin. Patient: Sure. Doctor: It looks normal and well hydrated. Any excessive sweating? Patient: No, not really. Doctor: I don't see any injury or wounds. Patient: Yeah. Doctor: Its just a normal protocol to ask these questions for every new patient. Patient: I understand. Doctor: Thank y...	Section Header: EXAM Summary: SKIN: Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound.
Doctor: Hi there! I am Doctor Kirkland. Patient: Hi. Doctor: How are you feeling? Patient: I feel weird. Like I feel confused. I don't know how I got here. Doctor: That's okay. Do you remember what happened to you before you came here? Patient: No. Doctor: Can you tell me about your past medical history? Patient:...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient himself is not able to give a good history. History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.
Doctor: Any issues from head to toe? Patient: No, everything is fine.	Section Header: REVIEW OF SYSTEMS Summary: Noncontributory.
Doctor: Hello, it's been two months already? Patient: I know right? Doctor: Just feels like yesterday.	Section Header: CHIEF COMPLAINT Summary: The patient is here for two-month followup.
Doctor: Tell me about your family medical history. Patient: No one in my family has any health problems.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Doctor: And are you working? What do you do? Patient: Oh, I am a catholic priest! Doctor: Oh wow! Patient: Yes. Doctor: And if you don't mind me asking, do you drink alcohol? Patient: Maybe that is something for my confession box but jokes apart I don't drink. Doctor: Sorry I need to ask these questions it's a protoc...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Catholic priest. Denied Tobacco/ETOH/illicit drug use.
Doctor: Okay, so where do you live? Patient: I live at an old age nursing home.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Not available. The patient lives at a skilled nursing facility.
Doctor: So, he is Arjun, and he is thirty seven years old and was complaining of chest pain. Patient: Hi Doctors, how are you? Doctor: We are good thanks for asking. Guest_clinician: Hi there Arjun, I am doctor J and I am assisting Doctor Wilson today. So, chest pain huh? Patient: Yep. Guest_clinician: And I see here...	Section Header: ASSESSMENT Summary: 1. Chest pain in a 37-year-old gentleman with negative cardiac workup, questionably right coronary spasm. 2. Hyperlipidemia. 3. Negative EKG and cardiac enzyme profile.
Doctor: So, do you live in the area? Patient: Yes, my husband and I have lived here for a long time. He died a few years back. Doctor: I'm sorry to hear that. Patient: It's alright. Doctor: Do you smoke or drink? Patient: No, I don't. Doctor: Do you use any illicit drugs or substances? Patient: No, I don't do an...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient lives locally. She is a widow. She does not smoke cigarettes or use illicit drugs.
Patient: Um, I take the generic for Ultracet. Sometimes I take as many as four times a day. Doctor: Does this help the pain? Patient: No, I'm still in pretty significant pain, doctor. Doctor: Good morning, sir. My nurse's chart says that you're thirty four years old. Is that correct? Patient: Yes, doctor, that's cor...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution. The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity. He denied any previous...
Doctor: Hello, miss. Doctor X and I will be going over your medical history with you. Before we begin, could you confirm your age for me? Patient: I'm twenty five years old. Doctor: Thank you. Doctor X, could you go over the diagnosis of erythema nodosum? Doctor_2: She was diagnosed in two thousand and four after a bi...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands. At that point, she had undergone workup w...
Doctor: Anyone sick in your family? Patient: Nope. Doctor: So, everyone is healthy? Patient: That's right.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.
Doctor: Mister Sunil, your blood pressure is high, and I am noticing this from past two-three times you have been here. It's been constantly high, you are not taking it seriously. Patient: No, nothing like that Doctor! It's been well under control. I have been monitoring at home. Doctor: Are you noting your readings? ...	Section Header: HISTORY of PRESENT ILLNESS Summary: His blood pressure up. The last two to three times he has been in here, it has been up. He has assured me before that his blood pressure is under good control at home, but he does not bring any blood pressures in with him this time, which bothers me.
Doctor: What is your family medical history? Patient: My dad had colon cancer. Doctor: Did your dad pass from colon cancer? Patient: No. They caught it early. He passed away from old age. My mom passed away when she was in her nineties from a stroke. Doctor: I am sorry. Do you have any family history of any neurologi...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders.
Doctor: Hello. I see you're here for a follow up. Did you get your blood work done? Patient: I did. Here are the results. Doctor: Let me take a look. Oh, wow. It looks like your blood sugar is high. Are you exercising every day? Patient: Not really. Is that bad? Doctor: You are at risk of developing type two diabetes...	Section Header: PAST MEDICAL HISTORY Summary: Adult-onset diabetes.
Doctor: Have you had ever had surgery? Patient: Yeah, I had my gallbladder removed a few years ago. Doctor: Thank you, what about any other parts of the body, like your eyes, ears, or nose? Patient: Oh yeah, I forgot. I had eye surgery too. Doctor: Thank you, think hard, any other surgeries you can remember? Patient:...	Section Header: PAST SURGICAL HISTORY Summary: Cholecystectomy, eye surgery, D&C.
Doctor: Hi there! How are you doing? Patient: Um. I am feeing really strange. Doctor: Strange how? Patient: I took Ecstasy over the weekend and I feel weird still. My heart is racing. I feel agitated and have been having waves of sadness. I cannot shake this feeling. Doctor: When did you take the Ecstasy? Patient...	Section Header: CHIEF COMPLAINT Summary: "I took Ecstasy."
Doctor: Do you live alone? Patient: I do. I lost my husband to prostate cancer last year. Doctor: Oh wow. I'm so deeply sorry for your loss. Losing a loved one is incredibly difficult. I lost my sister to cervical cancer two years ago. It was one of the hardest experiences of my life. Patient: I'm sorry for your los...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is a widow, lives alone. Denies any tobacco or alcohol use.
Doctor: Hello. How are you doing today? Patient: I feel depressed. Doctor: I'm sorry to hear that. What's been happening? Patient: My parents were fighting for a long time, and I think they're not together anymore. Doctor: That must be really hard. I'm sorry to hear that they're divorced. Who do you live with right n...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient's parents continued to undergo a separation and divorce. The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.
Doctor: What do you do for a living? Patient: I'm a real estate agent. Doctor: How long have you been working in the real estate business? Patient: Almost twenty years. Doctor: Wow. I know who to go to when I'm looking to buy a house. Patient: Happy to help. Doctor: So let's see here. Do you drink or smoke? Pat...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.
Doctor: Welcome back in, Miss A. Patient: Thank you, doctor. Doctor: Do you remember the information about your operation? Patient: No, not really. Can you remind me? Doctor: Sure, you had a lap band replacement in January of O nine, and you had a band adjustment. Patient: Thank you. Doctor: How are you feeling toda...	Section Header: HISTORY of PRESENT ILLNESS Summary: Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of weeks ago and she ...
Doctor: So, where do you live? Patient: Ah, I now live in an assisted nursing facility. Doctor: Okay, and do you drink or smoke? Patient: No, neither.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.
Doctor: Any specific medical traits in the family? Patient: What do you mean by that? Doctor: I meant does anyone in your family or extended family have any medical problems that they were treated for? Patient: I'm not aware of any such thing in my family.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.
Doctor: Welcome in! I am Doctor Madison. Patient: Thank you. It's nice to meet you. Doctor: Are you married? Patient: Yes. We just got hitched last year. Doctor: Congratulations! Patient: Thank you. Doctor: Do you drink alcohol? Patient: No, I don't drink. Doctor: Do you smoke cigarettes? Patient: Yes. I know ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Marital status: Married. The patient smokes 1 pack of cigarettes per day. Denies use of alcohol.
Doctor: We have you scheduled for a follow up and to have the staples removed in one week with Doctor X Y Z. Do you have your wound care instructions? Patient: Yes. Doctor: Do you have any questions? Patient: No. Doctor: If you do have questions or concerns that may come up, please don't hesitate to call the office...	Section Header: PLAN Summary: The patient was instructed to contact us with any questions or concerns that may arise. In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site. He w...
Doctor: Have you had sinus issues before? Patient: I am not sure, maybe on and off. Doctor: Because this is more allergic. Patient: Okay. Doctor: So, we call it allergic rhinitis. Patient: Is it different than sinus infection? Doctor: Yes, it's it is different. Patient: Okay.	Section Header: ASSESSMENT Summary: I think this is still his allergic rhinitis rather than a sinus infection.
Doctor: She has a rare case of thrombocytopenia. I'd like her to come in for a consult. Guest_clinician: Any other medical history? Doctor: No, just the thrombocytopenia.	Section Header: CHIEF COMPLAINT Summary: Thrombocytopenia.
Doctor: Hi there how are you? Patient: I am good no problem at all other than the usual. Doctor: And what is that? Patient: You know, some discomfort I have on my right side. I have been feeling that since I had a stroke five years back. Doctor: Right, right. We did an E M G right? Patient: Yes. Doctor: And none of th...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medicatio...
Doctor: What is the strength of your Omeprazole? Patient: It is forty M G and I take it just once a day. Doctor: Any herbal medication? Patient: No I do not take anything like that.	Section Header: MEDICATIONS Summary: Omeprazole 40 mg once a day. Denies herbal medications.
Doctor: So, to double check, you have a history of hay fever and asthma, correct? Patient: Yes. I was also recently diagnosed with cervical dysplasia. I found out shortly after my last O B G Y N visit. Doctor: And are you planning to follow up with your O B G Y N in the upcoming months? Patient: Yeah, the next visit...	Section Header: PAST MEDICAL HISTORY Summary: Significant for asthma, allergic rhinitis and cervical dysplasia.
Doctor: So, do you have any family history of arthritis? Patient: Fortunately, no, not that I know of. Doctor: So, as far as you know, no one has had a joint replacement? Patient: No, it doesn't ring any bells.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Doctor: Please, tell me about your medical history. Patient: I've been dealing with depression and anxiety for some time now. Doctor: I'm sorry, that must be difficult. Patient: Thank you, it is, but I manage. Doctor: What about your joints? How do you move? Patient: Oh yes, I have arthritis as well. I also had scia...	Section Header: PAST MEDICAL HISTORY Summary: Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.
Doctor: Do you have any past history of psychiatric treatment of struggles? Patient: I had some extreme fatigue back in nineteen ninety one. I was in therapy for six years. They had me on Prozac. I took in for that whole six years while I was in therapy. When I started the Prozac, I had just started working again. The...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue. She was also taking Prozac during that time. She then began taking Prozac again when she started working at secondary to stress with the work situa...
Doctor: How many other children do you have? Guest_family: My husband and I have three children, your patient today, and another boy, and girl. Doctor: How is everyone else doing? Guest_family: They're all doing very well, thank you for asking. Doctor: Do you live here in Easton? Guest_family: Yes, born and raised....	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He lives with mom, dad, brother, sister, and everybody is healthy. They live in Easton. They have 4 dogs, 3 cats, 3 mules and no deer. At school, he is in second grade and he is doing PE without any limitation.
Doctor: So let's start from the beginning. Patient: Okay. Doctor: You're seventy nine years old, correct? Patient: Yes. Doctor: Right or left handed? Patient: Right. Doctor: Do you remember when you had your first fall? Patient: Hm about a year and a half ago I fell while trying to walk from my bed to the living room....	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some ligh...
Doctor: Are you still doing water aerobics? Patient: Yeah, I've been hitting the pool five days outta the week. Doctor: How're you feeling? Have you noticed any changes in energy and strength? Patient: I feel a bit stronger now compared to when I first started. I'm also way, way more energized.	Section Header: PLAN Summary: As tolerated. Continue water exercise five days a week.
Doctor: Do you have any history of chronic pain? Patient: I got into a car accident a long time ago and I have always had neck pain. Doctor: Okay. Any other pain throughout the body? Patient: Sometimes I have back pain. Doctor: Okay.	Section Header: HISTORY of PRESENT ILLNESS Summary: Back and neck pain.
Doctor: How is your pain today? Patient: Eh it's been a rough few days that's for sure. The pain started almost instantly. Doctor: I'm sorry to hear that. Have you been taking anything for it? Patient: I actually saw a chiropractor the other day. My neck pain has been unbearable. Doctor: Is the pain localized to on...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains loc...
Doctor: I have reviewed your x rays from your emergency room visit. I agree with Doctor Jones that your lungs show no signs of infection or decreased lung capacity. Patient: Okay.	Section Header: IMAGING Summary: Chest x-ray ordered by ER physician is unremarkable, but to me also.
Doctor: Hello, how are you doing? What brings you here? Patient: I think I have allergies. I used to live in Seattle. I had allergies there, but I think they're getting worse after moving here. You see, I'm twenty three and I am a white female. I was in Seattle, I thought that the weather there is not for me. That's w...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effecti...
Doctor: Good afternoon, ma'am. Patient: Good afternoon doctor. Doctor: So, do you have any medical conditions I should know about. Patient: Actually, yes. I have a few. I have hyperthyroidism, and I've had gallbladder issues for some time now. Doctor: I see. How's your blood pressure? Patient: Oh, um, I have high ...	Section Header: PAST MEDICAL HISTORY Summary: The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.
Doctor: Are you a smoker, sir? Patient: Yes, I've been smoking about a pack, to about a pack and a half a day for more than forty years now. Doctor: What about alcohol, do you drink? Patient: Yeah, I drink a six pack of beer a day, doctor. Doctor: What about drugs? Do you use any illicit substances? Patient: No, I...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient smoked 1-1/2 packs for more than 40 years. He consumes 6 beers per day. He denies any drug use.
Doctor: I'd like her to come see you for a consult tomorrow. Guest_clinician: How long has she been suffering from migraines with aura? Doctor: About five years now. Guest_clinician: Does she have a neurologist she sees regularly? Doctor: Not since moving here.	Section Header: DIAGNOSIS Summary: Migraine with aura.
Doctor: So, sir, are you married? Patient: Yes, I'm married to my lovely wife. Doctor: That's great, so, what did you do for a living? Patient: I was a Pepsi Cola truck driver, but thankfully, I'm retired. Doctor: Congratulations on your retirement. What seems to be the problem today then? Patient: Thank you, it's n...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Married. He is retired, being a Pepsi-Cola driver secondary to his back and knees.
Doctor: Tell me about your family medical history. Patient: The only thing that I know about is that my grandma has diabetes.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Positive for diabetes mellitus in the maternal grandmother.
Doctor: Hello, Mister G, how are you today? Patient: I am good doctor thank you for asking. I am here to talk to you about my will. Doctor: Yeah, nurse informed me. So, tell me how can I help you? Patient: As you know I have terminal cancer. I have decided I do not want to be resuscitated. I have appointed my daughter ...	Section Header: EXAM Summary: CODE STATUS: Do not resuscitate, healthcare proxy, palliative care orders in place.
Doctor: Do you smoke? Patient: Nope. Doctor: What about alcohol? Or any kind of drugs? Patient: Nope.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No smoking or drinking. No drugs.
Doctor: History of any illnesses, surgeries, or hospitalizations? Patient: I dislocated my wrist when I was a kid but that's all.	Section Header: PAST MEDICAL HISTORY Summary: Surgeries: None. Injuries: Dislocated wrist. Illnesses: None.
Doctor: Any pain while peeing? Patient: No. Doctor: Any change in frequency or feeling the urgency to pee? Patient: No. Doctor: And what about bladder control, any accidents? Patient: No. Doctor: Any history of syphilis or any other S T D? Patient: No, never. Doctor: Okay.	Section Header: REVIEW OF SYSTEMS Summary: GENITOURINARY: Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs.
Doctor: Is there any history of heart disease in your family? Patient: Yes, my dad and brother had heart vessel blockage type of disease in their forties.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Positive for coronary artery disease in her father and brother in their 40s.
Doctor: If I'm understanding correctly, you sustained an elbow injury during a fight with some other kids in Juvenile Hall? Patient: Yeah. My left elbow is killing me. Doctor: How old are you? Patient: Seventeen. Doctor: Are you having pain anywhere else? Patient: Yeah. My left ankle also hurts. Doctor: Are you a...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He denies any pa...
Doctor: Hello. Before we begin your visit, I noticed some information missing. Could I verify the information with you? Patient: Of course. Doctor: Does your family have a history of any health related problems? Patient: Oh, yeah. A lot of my family have heart problems and cancer. Doctor: I see. Do you know what kin...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension.
Doctor: Okay I am looking at you for multiple issues today. One of the biggest being swelling on your left leg. Can you tell me more about that? Patient: Yes sure. I got this swelling for almost three years now, and it has been worse for the past two to three months. Sometimes it gets better in the morning when I get u...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 44-year-old white female who is here today with multiple problems. The biggest concern she has today is her that left leg has been swollen. It is swollen for three years to some extent, but worse for the past two to three months. It gets better in...
Doctor: What do you do for living? Patient: I am an officer at United States Marine office, artillery repair specialist. Doctor: Do you drink alcohol? Patient: I use to drink socially but stopped two years back. Doctor: How about smoking and drugs? Patient: No not that.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs.
Doctor: How are you today? Patient: I am good. Doctor: What is your past medical history? Patient: I don't have any health problems. Not yet at least. Doctor: Let's keep try to keep it that way. Patient: Yes please.	Section Header: PAST MEDICAL HISTORY Summary: Essentially noncontributory.
Doctor: Well, I am looking at your ultrasound report and honestly the only significant finding of this area is that it shows to be related to bone. Patient: Oh okay.	Section Header: LABS Summary: The only significant finding in the ultrasound of the area is that it shows this to be related to bone.
Doctor: Tell me about your family. Did anyone have any medical issues? Patient: My father is alive. He is sixty nine right now. He did have some strokes in the past. My mom on the other hand died at the age of sixty two of many kinds of heart diseases. Doctor: What about your grandparents? Patient: My maternal grandfa...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.
Doctor: Hi there! What brings you back to see me so soon? Patient: Hi! I have had these sores in my mouth. Doctor: How long have you had the sores? Patient: They started about ten to twelve days ago. Doctor: We have been currently treating your rheumatoid arthritis with methotrexate. How much have you been taking? ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days. The patient has a long history of severe and debilitating rheumatoid arthritis for whic...
Doctor: Hello, miss. How are you feeling today? Patient: Terrible. My allergies are killing me right now. Doctor: Do you have a history of allergies? Patient: Yeah, I do. I had them all the time when I lived in Seattle, but they got a lot worse when I moved here. I am a strong German woman and I hate how something a...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effecti...
Doctor: How are you doing young man? Patient: I'm good. Thank you. Doctor: Let's see how your chest is doing. Patient: Okay. Doctor: Chest measurements look nice. No issue there. The outline also looks great. Also, there is no hunchback?	Section Header: EXAM Summary: CHEST: Normal AP diameter and normal contour without any kyphoscoliosis.
Doctor: I see here that Doctor- Patient: Yes, Doctor X referred me. My thyroid is an absolute mess. I have never been in so much pain in my seventy one years. Doctor: I'm so sorry to hear that. I hope we're able to get you the care that you need. Patient: I've been coughing up a storm. It's gotten to be way too enla...	Section Header: HISTORY of PRESENT ILLNESS Summary: Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. She presented now after informed consent for the procedure, understanding the inherent risks and complications and risk-benefit ratio.
Doctor: Are you allergic to any medications? Patient: No, I am not allergic to any drugs. Doctor: Okay. Are you sure? Patient: Yes.	Section Header: ALLERGY Summary: No drug allergies.
Doctor: I see here that you're allergic to grapefruit and peanuts. Do you happen to be allergic to any medications you've taken in the past? Patient: Nah, just allergic to grapefruit and peanuts. Doctor: Gotcha. Do you carry an Epi pen around with you? Patient: I try to bring it with me everywhere I go.	Section Header: ALLERGY Summary: There are no known allergies.
Doctor: So, tell me about your family, any illness or anything that runs in the family. Patient: Um, not that I know of. Doctor: Okay.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.
Doctor: Any medical issues in the past? Patient: No, I have a very clean history. Doctor: That's good for you. Any kind of surgery or hospitalization? Patient: No.	Section Header: PAST MEDICAL HISTORY Summary: Noncontributory.
Doctor: Let's talk a little bit about your family, okay? Doctor: Does anyone in your family had any medical issues? Patient: Yeah, my parents died of cancer. Doctor: Which cancer? How old were they? Patient: I don't know which cancer they had, but my mother was forty two and dad was sixty two. Doctor: Who else is the...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother died age 42 of unknown type cancer. Father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. One of the half-brothers has asthma.
Doctor: So, tell me something, does asthma run in your family? Patient: No, I think I am the only one who has it. Even my parents were surprised when I developed it, as no one else has it. Doctor: Yeah, it happens.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No significant family history.
Doctor: Welcome in, sir. I am Doctor Gray. Patient: Thank you. It's nice to meet you. Doctor: What is your past medical history? Patient: I had surgery on my shoulder thirteen years ago and after the surgery I lost my sense of smell. I still can't smell. I also can't see very well in my right eye. Doctor: How old a...	Section Header: HISTORY of PRESENT ILLNESS Summary: 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.
Doctor: Do thyroid problems run in your family? Patient: No.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Doctor: Are you taking any medicines? Patient: Just Tylenol for my pain. Doctor: Okay.	Section Header: MEDICATIONS Summary: Tylenol for pain.
Doctor: Good afternoon, sir. Did you see the nurse already? Patient: Yes, I just saw her. Doctor: Great, you're seventy eight years old, correct? Patient: Yes, I'm not as young as I used to be. Doctor: Who is? What seems to be the problem today, sir? Patient: I have right hand pain, and it's been there for a while...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking. The patient was diagnosed with carpal tunnel syndrome on bilateral hands the ri...
Doctor: Hi are you married? Patient: Yes, I am. Doctor: Do you have kids? Patient: Yes, I had a son, but unfortunately, he died in a car accident. It was five years ago. Doctor: Where do you work? Patient: I work in a pharmaceutical company as a salesperson. Doctor: Do you smoke or drink or at any time tried any ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use.
Doctor: Are you going to visit rehab? Patient: Yes, what choice do I have? Doctor: Yes, please do visit Mercy Manor for P T and Rehab. Patient: Yes, I will. Doctor: That will help your right side hip pain. Patient: I think so too.	Section Header: ASSESSMENT Summary: Right hip pain, the patient to undergo physical therapy and rehabilitation at Mercy Manor.
Doctor: Can you tell me about your Immunizations? Patient: Yeah, I had them all. Doctor: Good, looks like you are up to date.	Section Header: IMMUNIZATIONS Summary: Up-to-date.
Doctor: Welcome back to the clinic. How are you feeling today? Patient: Thank you. I am doing better. Doctor: It looks like we are following up on your severe osteoarthritis in both knees. And you also have been experiencing some flexion contracture limitations. Patient: Um hum. Doctor: How is your physical therapy ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left. Pain: Localized to the bilateral knees...
Doctor: Hi, what is going on? Guest_family: She was doing well until this morning, but now she can barely move her right arm and is having speech issues. She can't seem to comprehend words. I think it is a stroke. Doctor: We see this a lot at A B C Medical Center. I am glad you came. You just saw Doctor H, right? Gues...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head C...
Doctor: I think you have a muscular strain. Patient: Yeah. Doctor: So right side shoulder strain and maybe a little bit of nerve compression. Patient: Oh really! Doctor: Maybe. I will do further evaluation and treatment. Patient: Okay.	Section Header: ASSESSMENT Summary: Right shoulder pain, most likely secondary to muscular strain. He does have a very mild evidence of impingement.
Doctor: Can you tell me more about your daughter, ma'am? Guest_family: Sure, well she's fourteen now, um, she's right handed, and she just started high school. Doctor: Has she ever had surgery? Guest_family: Yeah, she had an, um, lipomyomeningocele repair when she was about three days old, and then again when she wa...	Section Header: HISTORY of PRESENT ILLNESS Summary: Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 03/95. She did well; however, in the past several months has had some leg...
Guest_clinician: How is the patient's condition now? Doctor: Well, he has improved clinically but would require acute care. Guest_clinician: Oh, I see.	Section Header: DISPOSITION Summary: Clinically improved, however, requiring acute care.
Doctor: Good morning, ma'am. Can you confirm your age for me, please? Patient: Good morning, I'm sixty five years old, doctor. Doctor: How are you recovering from your operation? Patient: I'm doing okay. Can you remind me what operation I had? Doctor: Um, we did a left upper lobectomy for your stage I A non small c...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit. She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the lef...
Doctor: Let's talk about your family's medical history. Patient: Hm, well both my father and my brother had colon cancer. My daughter was detected with breast cancer. Doctor: Do you remember what her age was? Patient: Yeah, she was forty. Doctor: I see. Anything else? Patient: Well, I have a heart condition and high bl...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Positive for heart disease, hypertension and cerebrovascular accidents. Family history is positive for colon cancer affecting her father and a brother. The patient has a daughter who was diagnosed with breast cancer at age 40.
Doctor: Any fever? Patient: No. Doctor: No nausea and vomiting or black stool? Did you notice any blood in your stools? Patient: Nope, nothing like that. Doctor: Did you notice any blood in urine or painful urination? Patient: No. Doctor: Okay, any chest pain? Patient: Um, no. Doctor: Any shortness of breath, cough or...	Section Header: REVIEW OF SYSTEMS Summary: CONSTITUTIONAL: No fever. ENT: Not remarkable. RESPIRATORY: No cough or shortness of breath. CARDIOVASCULAR: The patient denies chest pain. GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed. GENITOURINARY: No dysuria. No hematuria. ENDOCRINE: Negative...
Doctor: How are you doing miss? How are your sugar numbers coming along? Patient: I'm doing good. Thank you. Sugar has consistently been one hundred and thirty five or under it. Doctor: How are you checking it? Patient: I have a glucose monitor at home I'm using that only. Doctor: Nice. Did you eat anything in the ...	Section Header: HISTORY of PRESENT ILLNESS Summary: Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable.
Doctor: How did your last visit go with the cardiologist? Patient: Good. Doctor: It looks like they diagnosed you with sick sinus syndrome. Do you have any questions about this new diagnosis? Patient: No, she explained everything to me. I'm planning to follow-up with her in the next two weeks. Doctor: Great. So it...	Section Header: DIAGNOSIS Summary: Sick sinus syndrome. The rest of her past medical history remained the same.
Doctor: So Mister J, where do you stay? Patient: Oh, I stay at a care facilit. It's very near to your clinic. Have you heard about this place called South Valley Care Center? Doctor: Oh yes, I have heard of it.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient has been residing at South Valley Care Center.
Doctor: How are you Mister James? Patient: I have been better! Doctor: Oh, tell me what's going on with you? Patient: I have this leg pain on my left side. Doctor: Hm, left leg pain? Patient: Yeah.	Section Header: CHIEF COMPLAINT Summary: Left leg pain.
Doctor: Have you ever had an allergic reaction to drugs you've taken in the past? Patient: More than once. I've reacted poorly to sulfa drugs, penicillin, and some mycins. I also think I'm allergic to contrast medium.	Section Header: ALLERGY Summary: She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.
Doctor: Hey, do you smoke cigarettes? Patient: Yes I do smoke. Do you? Doctor: Nope. Are you planning on quitting? Patient: No, I just smoke one pack per day, it's not bad. Doctor: Oh my God. No. It is bad. You should think about quitting. Patient: Okay I will think about it. Doctor: Where do you work? Patient: I work ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient works at a local Christmas tree farm. He smokes cigarettes approximately one pack per day.
Doctor: Are you still working? Patient: Retired some time ago. Doctor: What was your profession? Patient: I used to work at a car repair shop called Champion Automotive Company. Doctor: Nice. How did you enjoy the work? Patient: I liked it a lot, but there came a time where I knew it was the end of the road for me. I'm...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Retired employee of Champion Automotive Co. Denies use of TOB/ETOH/Illicit drugs.
Guest_clinician: Do you have his full medical history? Doctor: Yes, I confirmed with his wife. He had a CABG done in ninety one. He has a history of radical prostate cancer for which he underwent a radical prostatectomy and nephrectomy. Guest_clinician: Any additional surgeries? Doctor: Yes. He had lumbar surgery t...	Section Header: PAST MEDICAL HISTORY Summary: Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed ...
Doctor: Do you have any history of major surgeries? Patient: No. Nothing major.	Section Header: PAST SURGICAL HISTORY Summary: Nothing significant.
Doctor: Good morning, sir. Patient: Good morning, doctor. Doctor: Before we begin, have you ever had surgery? Patient: Yes, I had a vasectomy some time ago.	Section Header: PAST SURGICAL HISTORY Summary: Vasectomy.
Doctor: Okay, so let's go over your medications. I'd like you to take these to help your muscle spasms. Patient: Sounds good. Doctor: I've prescribed eight hundred milligrams of Ibuprofen to be taken every eight hours as needed along with Tylenol number three every six hours as needed. Patient: What does the number ...	Section Header: MEDICATIONS Summary: Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.
Doctor: How are you doing today, sir? Patient: Honestly, I'm pretty sick today. I've got a lot going on. Doctor: How long have you been feeling this way? Patient: Well, it's been off and on for about a month now. Doctor: Has it been getting worse recently? Patient: Yeah, it has over the last couple weeks. Doctor: ...	Section Header: HISTORY of PRESENT ILLNESS Summary: This patient presents to the office today for a checkup. He has several things to go over and discuss. First he is sick. He has been sick for a month intermittently, but over the last couple of weeks it is worse. He is having a lot of yellow phlegm when he coughs...
Doctor: Hi, how's it going? Patient: Not too bad, can't complain. Doctor: It looks like the weather's been warming up, which is nice. Patient: Yeah, I can't wait to spend some time with my kids this afternoon. Doctor: Aw, how many kids do you have? Patient: Two. Doctor: And are you single, dating, married? Pati...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children.

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