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Doctor: Good morning, can you tell me more about your son, ma'am.
Guest_family: Sure, he's forty six, White, and he has Down syndrome.
Doctor: Great, thank you. Is he still having problems with his hypothyroidism and onychomycosis?
Guest_family: Yes, that's correct doctor.
Doctor: Has he remained complaint with his ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 46-year-old white male with Down's syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis. He has finished six weeks of Lamisil without any problems. He is due to have an ALT check today. At his appointment in April, I also... |
Doctor: Do you have any questions regarding your surgery?
Patient: Yes, I do, multiple.
Doctor: Go ahead shoot.
Patient: I have them all written down on this. | Section Header: CHIEF COMPLAINT
Summary: Surgery. |
Doctor: How about any drugs, alcohol, or tobacco?
Patient: No, no, and no. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Negative for illicit drugs, alcohol, and tobacco. |
Doctor: Hey, how are you?
Patient: I think I am better.
Doctor: So you do not have any more nausea or vomiting?
Patient: No I don't.
Doctor: How about any acidity?
Patient: I think it's all better.
Doctor: Great. | Section Header: ASSESSMENT
Summary: Severe nausea and vomiting likely secondary gastroenteritis, resolved. |
Doctor: How are you?
Patient: I am good.
Doctor: That's great. You are stable.
Patient: Can I go home now?
Doctor: Yes, you can.
Patient: Thank you! | Section Header: DISPOSITION
Summary: Stable. |
Doctor: Good afternoon, young man, are these your parents?
Patient: Yes, doctor.
Doctor: Can you tell me more about your son, please?
Guest_family: Well, he is seven years old, and he has had diarrhea for four days, and he's been throwing up for three days.
Patient: Yeah, my brother has been doing this too.
Guest_f... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea. Apparently, his brother had similar symptoms. They had eaten some chicken and then ate some more of it the next day, and I could not quite und... |
Doctor: Welcome into the clinic! I would like to start with your past medical history.
Patient: I have high blood pressure and macular deterioration. Last year I caught pneumonia but that has cleared up.
Doctor: Okay. What brings you in today?
Patient: I have had this cough and pain on the right side of my abdomen.... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient stated that the abdominal pain was onl... |
Doctor: Good afternoon, dear, how old are you?
Patient: I'm fourteen years old.
Doctor: Good, and what brings you in for a visit today?
Patient: My left knee hurts really bad.
Doctor: Oh no, how long has this knee been hurting you?
Patient: Well, since the fall of two thousand seven.
Doctor: Have you seen another ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 14-year-old girl who started having left knee pain in the fall of 2007. She was not seen in Orthopedic Clinic until November 2007. The patient had an outside MRI performed that demonstrated left patellar chondromalacia only. The patient was referr... |
Doctor: What brings you here today?
Patient: I have pain in my tummy.
Doctor: When did you first notice it?
Patient: It started suddenly around noon. | Section Header: CHIEF COMPLAINT
Summary: Abdominal pain. |
Doctor: Welcome to the clinic., ma'am
Patient: Thank you.
Doctor: What brings you into see me?
Patient: I have been struggling with pain and stiffness in my right neck and shoulder.
Doctor: How long has this been going on for?
Patient: Maybe for about four months.
Doctor: In these past four months have your sympt... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand ... |
Doctor: Is this baby number two?
Patient: Yes, this is baby number two.
Doctor: How many times have you been pregnant, including miscarriages or abortions if any?
Patient: I've been pregnant two times in total. No miscarriages or abortions.
Doctor: When was your last period?
Patient: About a month ago.
Doctor: An... | Section Header: GYNECOLOGIC HISTORY
Summary: Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal. |
Doctor: Okay, I want you to follow up with our hand therapist Doctor X at her A B C D office in one to two weeks.
Patient: Okay, I will make an appointment today. | Section Header: DISPOSITION
Summary: Follow up with Dr. X in ABC Office in 1 to 2 weeks. |
Doctor: So we're here to follow up on a few things. I'd like to know how you're keeping up with your blood sugar checks.
Patient: I've been checking my blood sugar one to two times a day.
Doctor: Have you been keeping a log?
Patient: Uh yeah, but I need to be better at it.
Doctor: Do you have the log with you today... | Section Header: CHIEF COMPLAINT
Summary: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. |
Doctor: What brings you in today?
Patient: My back started hurting last night. I have a stomachache. I have had pain with urination for the last two days.
Doctor: Do you have any other symptoms?
Patient: I just started coughing and now I have a fever.
Doctor: Do you have any history of kidney stones?
Patient: Y... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient complains of backache, stomachache, and dysuria for the last two days. Fever just started today and cough. She has history of kidney stones less than a year ago and had a urinary tract infection at that time. Her back started hurting last night. |
Guest_clinician: When did she have lumbar discitis?
Doctor: A little over a year ago. She received antibiotic therapy and ended up having debridement and instrumentation with Doctor XYZ.
Guest_clinician: How's she doing today?
Doctor: Really quite well.
Guest_clinician: She also had a P E with that prior hospitali... | Section Header: PAST MEDICAL HISTORY
Summary: Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well. She had a pulmonary embolus with that hospitalization. |
Doctor: Do you have sugar or blood pressure problems?
Patient: Oh, I have high blood pressure but it's well under control. I make sure to keep it under normal range.
Doctor: Good. Any other health issues?
Patient: Yeah, I have history of high triglycerides. But otherwise, I am pretty healthy.
Doctor: Okay. Do you smok... | Section Header: HISTORY of PRESENT ILLNESS
Summary: She has had hypertension very well controlled and history of elevated triglycerides. She has otherwise been generally healthy. Nonsmoker. |
Doctor: Hello, miss. The nurse who seated you tells me you are here for a second opinion on surgery.
Patient: Hello, doctor. Yes, I have been told that both eyes need cataract extraction. I came for a second opinion because I will only have surgery if necessary. I am nervous.
Doctor: What is the reason for the extract... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient seeks evaluation for a second opinion concerning cataract extraction. She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery. Past ocular surgery history is significant for neurovascular age-related ma... |
Doctor: Any allergies?
Patient: Um yeah. I'm trying to remember the name. It's a pain killer that starts with an L. Oh Lortab.
Doctor: What happens when you take Lortab?
Patient: Really bad hives. I've only ever taken it once.
Doctor: I'll make note of that in your chart so we have it in your records. | Section Header: ALLERGY
Summary: She is allergic to Lortab. |
Doctor: Do you have any known drug allergies?
Patient: No, none that I know of. | Section Header: ALLERGY
Summary: None. |
Doctor: Welcome in.
Patient: Thank you.
Doctor: What do you do for work?
Patient: I work in Human Resources for the State of Maryland.
Doctor: Do you live alone or with others?
Patient: I live alone.
Doctor: Do you smoke cigarettes?
Patient: I used to smoke like a chimney. I quit smoking a while back. I had been... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use.... |
Doctor: Hi, tell me about your family? Did anyone have any medical diseases?
Patient: Both of my parents were healthy, but my maternal grandfather had a stroke.
Doctor: Did anyone in your family ever have migraines?
Patient: No, not that I know. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family. |
Doctor: Do you have any chronic medical conditions that I should know about?
Patient: What do you mean by that, doctor?
Doctor: Well, it could be anything from high blood pressure, to depression, to cancer. Do any of those sound familiar?
Patient: Oh, yeah, I have a few things like that. I have anemia, high choleste... | Section Header: PAST MEDICAL HISTORY
Summary: Anemia, high cholesterol, and hypothyroidism. PAST |
Doctor: How old are you?
Patient: Oh, I am fifty eight now.
Doctor: So, you are here today because you are having some vision difficulties? Tell me about what has been going on, ma'am.
Patient: Yeah. Okay. It all started a year ago. It started with losing the color in my vision.
Doctor: Was the loss sudden or gradu... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. ... |
Doctor: How are you feeling today?
Patient: I have been having some trouble breathing. I had tightness in my chest after walking up stairs.
Doctor: Let me listen to your lungs. | Section Header: CHIEF COMPLAINT
Summary: "Trouble breathing." |
Doctor: Good afternoon, ma'am. Before we begin, can you confirm your age for me, please?
Patient: Sure, I'm fifty six years old.
Doctor: Great, thank you. What seems to be the problem today?
Patient: Well, I have a history of systemic lupus erythematosus.
Doctor: How have you been treated for this in the past?
Pat... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater than right. The patient was seen on 10/30/07. She had the same compla... |
Doctor: Do you remember the name of the medication you are taking?
Patient: I have two, but I do not remember their name or why I am taking it.
Doctor: That is fine, we will figure it out. | Section Header: MEDICATIONS
Summary: She is on two different medications, neither of which she can remember the name and why she is taking it. |
Doctor: I wanted to talk to you about your family medical history.
Patient: Okay, how this will be helpful?
Doctor: Family history plays an invaluable role in your health. It provides us with important clues and insight to predict and detect diseases before obvious symptoms appear.
Patient: My mom dealt a long time w... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Patient admits a family history of anxiety, stress disorder associated with mother. |
Doctor: Okay, let's review your family history.
Patient: Ready when you are.
Doctor: Does anyone in your family have high blood pressure or high cholesterol?
Patient: Both my parents have high blood pressure.
Doctor: Are they being treated for it?
Patient: Um yes. Oh they also have E T.
Doctor: Do any of your siblings ... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Both parents have ET and hypertension. Maternal cousin with lupus. |
Doctor: What are you taking as a maintenance treatment?
Patient: Oh, I take Flonase.
Doctor: And do you have a lot of issues after taking that?
Patient: No I do not.
Doctor: That is good. | Section Header: MEDICATIONS
Summary: He is maintained on Flonase and denies much in the way of nasal symptoms. |
Doctor: Hello. Looks like we are here for a six months follow up. How are we doing?
Patient: I have stayed relatively the same. My main complaint is that I feel tired throughout the day. The C P A P is doing fine and I wake up refreshed, but I don't like how I crash.
Doctor: Alright. How are the thyroid issues?
Patien... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 years old. Her last visit was about 6 months ago. Since that time, the patient states her health has remained unchanged. Currently, primary complaint is one of f... |
Doctor: So I understand you had a fainting episode yesterday?
Patient: Yes, I did.
Doctor: Has this happened to you before?
Patient: Yes. It happens whenever needles are involved.
Doctor: You had a Vasovagal Syncope. How are you feeling today?
Patient: I feel normal today. | Section Header: CHIEF COMPLAINT
Summary: Syncope. |
Doctor: Hello, how are you?
Patient: I am not so good.
Doctor: Oh, what is going on with you?
Patient: Well, I have lot of swelling in my legs.
Doctor: Hm, okay. | Section Header: CHIEF COMPLAINT
Summary: I have a lot of swelling in my legs. |
Doctor: Hi there, sir! I am Doctor Frankland.
Patient: Hi! It's nice to meet you.
Doctor: What brings you into see me today?
Patient: I have had this pain in my finger and wrist for about a month. I have had some numbness too. The numbness started in the finger and is now in the wrist too.
Doctor: Which wrist and fi... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pa... |
Doctor: Good morning. How are you feeling today?
Patient: I feel good, considering. I slept well last night.
Doctor: Are you expensing any pain or discomfort?
Patient: No. I feel fine. | Section Header: EXAM
Summary: GENERAL: The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted. |
Doctor: How are you doing with everything?
Patient: I'm good. It's hard when you are in quarantine. I hope things will get back to normal soon.
Doctor: So, you are here for your breast examination.
Patient: Yes, it was due for so long.
Doctor: I'm going to touch both of your breasts one by one to check for any lump ... | Section Header: EXAM
Summary: BREASTS: The breasts show no masses or tenderness. No axillary adenopathy. |
Doctor: How's your wife doing? I think the last time I saw her was two weeks ago. She was telling me about the remodeling you've been doing around the house.
Patient: She's doing well, thanks for asking. Oh yeah, the remodeling has been a lot. I didn't think it'd take as long as it has.
Doctor: Yeah, it can take some... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology. |
Doctor: My nurse tells me you're thirty four years old, is that correct?
Patient: Yes, I just had my birthday, doctor.
Doctor: You identify as African American, correct?
Patient: Yes, that's right, sir.
Doctor: You're here for a follow up? What brings you back in today?
Patient: Well, I don't really have a single a... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 34-year-old African American female who comes today for routine followup. She has no acute complaints. She reports that she has a muscle sprain on her upper back from lifting. The patient is a housekeeper by profession. It does not impede her work in an... |
Doctor: How can I help you today.
Patient: I have been having irregular periods.
Doctor: When was your last menstrual period?
Patient: My last period was on June first two thousand and four.
Doctor: Are you currently sexually active? Is there a possibility of pregnancy?
Patient: No! There is no possibility that... | Section Header: PAST MEDICAL HISTORY
Summary: She denies sexual activities since two years ago. Her last menstrual period was 06/01/2004. Her periods have been irregular. She started menarche at 10 years of age and she is still irregular and it runs in Mom's side of the family. Mom and maternal aunt have had total... |
Doctor: How have you been feeling? How is your leg feeling?
Patient: My right leg is in a lot of pain. The nurse just changed the bandage. I only have a rash where the bandage is.
Doctor: It looks like we have you taking Vicodin for the pain. Is the medication not helping?
Patient: The pain medication is horrible. I ... | Section Header: REVIEW OF SYSTEMS
Summary: He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint ... |
Doctor: Does anyone in your family have a neurological disorder?
Patient: No, not to my knowledge. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: unremarkable. |
Doctor: Do you smoke, sir?
Patient: Well, I used to a long time ago, but I don't anymore.
Doctor: Good, what about alcohol, do you drink?
Patient: Well, my wife and I have a drink or two a day. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: He has a very remote history of tobacco use. He has one to two alcoholic drinks per day. He is married. |
Doctor: Did you had any medical issues in the past?
Patient: No, nothing major.
Doctor: You said nothing major, so, what was there?
Patient: I had a little curve in the spine. It was not major. Doctor said that it can be corrected by exercises. | Section Header: PAST MEDICAL HISTORY
Summary: Also positive for some mild scoliosis. |
Doctor: Do you have any medical conditions that I should know about?
Patient: Yeah, I have chronic diarrhea, and C O P D.
Doctor: Are you a smoker?
Patient: Yes, I have been for a long time.
Doctor: How would you characterize your smoking level?
Patient: Um, I'd say it's pretty heavy. | Section Header: PAST MEDICAL HISTORY
Summary: Includes chronic diarrhea as I mentioned before and chronic obstructive pulmonary disease secondary to heavy smoking. |
Doctor: You have atrial fibrillation from the past?
Patient: Yes, rhythm problem is bad.
Doctor: And no dizziness?
Patient: Yes. I do.
Doctor: Okay well... | Section Header: ASSESSMENT
Summary: 1. Atrial fibrillation. 2. Dizziness. |
Doctor: Do you have any allergies?
Patient: No allergies.
Doctor: Nothing? Cat dander, pollen?
Patient: Nope. | Section Header: ALLERGY
Summary: None. |
Doctor: Do you live with your husband?
Patient: Yes, we live on a ranch about twenty miles away.
Doctor: Do you have children?
Patient: We had six children all together, but two of them passed away suddenly.
Doctor: I'm so sorry to hear that. How old were they?
Patient: One was forty years old and the other was fo... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She is married, lives with her husband, has 2 children that passed away and 4 surviving children. No history of tobacco use. No history of alcohol use. Family history is noncontributory. |
Doctor: So let's see here. Any history of high blood pressure or diabetes?
Patient: No, sir.
Doctor: How about heart disease?
Patient: No, no heart disease.
Doctor: And no cancers?
Patient: No and for that I'm thankful. | Section Header: PAST MEDICAL HISTORY
Summary: None. No history of hypertension, diabetes, heart disease, liver disease or cancer. |
Doctor: What is your family medical history?
Patient: My dad had Alzheimer's disease. He is in a facility that cares for him now.
Doctor: I am sorry that must be hard.
Patient: It is. My aunt, his sister helped me get everything set up for him. She had a stroke last month.
Doctor: Oh no. How is she doing now?
Patie... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Alzheimer's disease and stroke on paternal side of family. |
Doctor: So, how much longer are you in juvie, young man?
Patient: I've got about three weeks left, sir. Twenty five days, if you want to be exact.
Doctor: Good, time to make the best of getting out, right?
Patient: Absolutely, I don't want to go back.
Doctor: Good. Do you smoke, young man?
Patient: No sir, absolutel... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: He is in Juvenile Hall for about 25 more days. He is a nonsmoker. |
Doctor: Hello, I am Doctor Rez. I will ask you a few questions about your personal and family history, okay?
Patient: Yes, that's okay.
Doctor: Did any one in your family get diagnosed with any medical conditions?
Patient: My mom has lumps in her breast but it is benign, however my granny on my father side had cancer.... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis. |
Doctor: Any history of smoking?
Patient: Uh yeah, but I quit in two thousand seven.
Doctor: On average, how many packs per day did you smoke?
Patient: Uh if I were to guess, I'd say one pack per day.
Doctor: Any other drugs?
Patient: I used to do coke, but I quit that in two thousand five.
Doctor: And any history... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient is a former smoker, reportedly quit in 2007. He used cocaine in the past, reportedly quit in 2005. He also has a history of alcohol abuse, but apparently quit more than 10 years ago. |
Doctor: Can you tell me more about your family's medical history? Are there any conditions of note?
Patient: Well, my dad died from prostate cancer, and my mom died as well, she was an alcoholic.
Doctor: I'm so sorry to hear that, ma'am, how old were they?
Patient: Well, my father was eighty, and my mother was sixty... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Her father died at the age of 80 from prostate cancer. Her mother died at the age of 67. She did abuse alcohol. She had a brother died at the age of 70 from bone and throat cancer. She has two sons, ages 37 and 38 years old who are healthy. She has two daught... |
Doctor: Are you married?
Patient: Yes.
Doctor: Where do you work?
Patient: I work as a secretary in a law firm.
Doctor: Do you smoke or drink? Have you ever tried any illegal drug?
Patient: No, none of these. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Married, Secretary, No h/o tobacco/ETOH/illicit drug use. |
Doctor: It looks like E M S found you in bad shape?
Patient: What?
Guest_family: My mother is hard of hearing. She is eighty five. They found her on the toilet.
Doctor: Did your mother tell you anything about her condition before E M S arrived?
Guest_family: She said she threw up right before they came and she had... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diar... |
Doctor: Do you have kids, ma'am?
Patient: Yes, I do. I have two sons and we adopted a girl.
Doctor: Where did you adopt?
Patient: Just here.
Doctor: and you are married right? Are you working?
Patient: Yes, I have been married a long time. I retired from Avon.
Doctor: Do you smoke cigarettes or drink?
Patient: I do n... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She has two sons and an adopted daughter. She is married long term, retired from Avon. She is a nonsmoker, nondrinker. |
Doctor: How's the little dude?
Guest_family: He has fever and bad congestion for the last two days. He has had a fever for one. I try to suck the discharge out through nose.
Doctor: I am guessing he has some mild problems with breathing while feeding.
Guest_family: Yes, that is correct. He is drinking milk every coupl... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractio... |
Doctor: Are you taking Benicar?
Patient: Yes, twenty daily.
Doctor: And what else?
Patient: I take some multivitamin, glucosamine, Vitamin B complex, Vitamin E and a low dose Aspirin.
Doctor: Okay that's good information. | Section Header: MEDICATIONS
Summary: Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin. |
Doctor: Do you smoke?
Patient: Nope.
Doctor: How about alcohol intake?
Patient: Nope.
Doctor: What about any kind of drug usage?
Patient: Nope. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Denies ETOH/illicit drug/Tobacco use. |
Doctor: Hi, how are you?
Patient: I am okay.
Doctor: Do you have any bone pain or issues around that?
Patient: No, I do not.
Doctor: So, they gave you a dose of Tylenol here in the emergency department to treat your pain. Is your pain under control?
Patient: Yes, with medication I feel it is better, but I want to b... | Section Header: EMERGENCY DEPARTMENT COURSE
Summary: The patient was removed from the backboard within the first half hour of her emergency department stay. The patient has no significant bony deformities or abnormalities. The patient is given a dose of Tylenol here in the emergency department for treatment of her p... |
Doctor: Lets talk about your family history, does cancer run in your family ma'am?
Patient: Oh yes! My family has a history of lung, liver and prostate cancer.
Doctor: Oh wow!
Patient: Yeah.
Doctor: And you mentioned that your mother had Alzheimer's?
Patient: Well, I am not sure about Alzheimer, but she had some demen... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Significant for lung, liver, and prostate cancer. Her mother died in her 80s of "old age," but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient.... |
Guest_clinician: What's their medical history?
Doctor: I have here hypertension, diabetes, diabetic retinopathy, and elevated lipids. They're in post C V A.
Guest_clinician: Do you know their neurologist?
Doctor: I can have the nurse or scribe go in and ask again.
Guest_clinician: Great. | Section Header: PAST MEDICAL HISTORY
Summary: Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy. |
Guest_clinician: Were you able to get a history from her?
Doctor: I tried but was unsuccessful. She's very out of it.
Guest_clinician: Does she have a history of alcohol abuse?
Doctor: According to her records, she has a long history of alcohol abuse. | Section Header: PAST MEDICAL HISTORY
Summary: Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded. |
Doctor: The patient has a history of C A D.
Guest_clinician: Are they being followed by a cardiologist?
Doctor: Not to my knowledge. I can check their electronic medical records. One sec. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Positive for coronary artery disease. |
Doctor: Hi sir, how old are you?
Patient: I am thirty.
Doctor: We are following up today for your moderate to severe apnea, right?
Patient: Yes, that is correct, I still can't sleep.
Doctor: Okay and you did the CPAP?
Patient: Yes.
Doctor: Okay, let's review it today.
Patient: Sure. | Section Header: HISTORY of PRESENT ILLNESS
Summary: Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP. |
Doctor: Any smoking or alcohol?
Patient: No, I don't smoke but I drink wine.
Doctor: Are you married?
Patient: Yes, I am.
Patient: I have three stepchildren and one of my own and I work for A B C D. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: He is a non-cigarette smoker. He has occasional glass of wine. He is married. He has one biological child and three stepchildren. He works for ABCD. |
Doctor: Congratulations on your new baby! How are you doing today?
Patient: I'm doing well, no headaches, and I'm breastfeeding well.
Doctor: Have you had any bleeding?
Patient: Nope, none.
Doctor: Are you using a mini pad?
Patient: Yeah, I use it twice a day.
Doctor: Do you have any cramping or clotting?
Patient: ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown t... |
Doctor: Do you have any major medical conditions that run in your family that I should know about?
Patient: What do you mean by that?
Doctor: Well, it could be anything from diabetes to high blood pressure to cancer.
Patient: Oh, yeah. My brother had prostate cancer. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: His brother had prostate cancer. |
Doctor: Hi, how are you?
Patient: Hi! I am okay other then this back pain.
Doctor: I am so sorry. Tell me about your back.
Patient: Three nights ago, I fell on my steps bringing in the groceries from the car.
Doctor: How did you land when you fell?
Patient: I fell and landed on my right hip. I hit my low back on t... | Section Header: HISTORY of PRESENT ILLNESS
Summary: Back pain after a fall. |
Doctor: Have you seen your lab results?
Patient: No, do you have those in today?
Doctor: Yes, I have them right here. They're essentially negative, except it appears that you had C difficile in the past. Do you remember that?
Patient: Yes, I got it when I worked at a hospital after graduating.
Doctor: Yeah, its unfo... | Section Header: PAST MEDICAL HISTORY
Summary: Essentially negative other than he has had C. difficile in the recent past. |
Doctor: Breath in breath out, let me tap it and see. Well, your lungs sound clear.
Patient: Okay. | Section Header: EXAM
Summary: CHEST: Lungs bilaterally clear to auscultation and percussion. |
Doctor: Are you still taking the Trizivir?
Patient: Yes.
Doctor: How much are you taking?
Patient: I take one pill two times a day.
Doctor: Are you taking any other medications?
Patient: I take Ibuprofen for body aches from time to time but that's it. | Section Header: MEDICATIONS
Summary: 1. She is on Trizivir 1 tablet p.o. b.i.d. 2. Ibuprofen over-the-counter p.r.n. |
Doctor: I just need to confirm some information before we begin sir, you're forty one, correct?
Patient: Yes sir, that's correct.
Doctor: Good, so what happened?
Patient: Well, I work at A B C, and about two days ago I slipped on some oil that had spilled.
Doctor: How did you fall?
Patient: I fell with both my arm... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 41-year-old male presenting for initial evaluation of his left shoulder. He works at ABC and two days ago was walking though an area, where there was some oil spilled on the floor. He fell and landed on bilateral outstretched arms and then further ... |
Doctor: Hi there! It is good to see you both. How has everything been going for the both of you?
Patient: Hi Doctor.
Guest_family: Things have been pretty good. She has been having some new emotional outbursts. I made an appointment with the down syndrome behavioral specialist that you recommended from the last time... | Section Header: ASSESSMENT
Summary: 1. Down's syndrome. 2. Onychomycosis. 3. Hypothyroidism. |
Doctor: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: Have you ever had surgery, ma'am?
Patient: Actually, yes I have. I had pinning surgery done on both of my ears.
Doctor: Do you remember how old you were when you had surgery?
Patient: Um, I was five or six years old. It was when I was a kid, I... | Section Header: PAST SURGICAL HISTORY
Summary: Bilateral pinning of her ears. |
Doctor: Do you have any allergies?
Patient: Not that I know of.
Doctor: Okay. | Section Header: ALLERGY
Summary: None known. |
Doctor: What is your family medical history?
Patient: My dad has high blood pressure. My mom has had a ton of skin cancer removed.
Doctor: Do you know what type of skin cancer she has removed?
Patient: I have no idea. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: HTN and multiple malignancies of unknown type. |
Doctor: Hello, miss. Today we're going to do a recheck for your hypertension. Sound good?
Patient: Yes, of course.
Doctor: I just want to check to see if you have any symptoms that can possibly raise alarm.
Patient: I have been coming to you for the last fifteen of my seventy eight years on Earth. I know how a follow ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 78-year-old female who returns for recheck. She has hypertension. She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema. |
Doctor: Hello, it's nice to meet you.
Patient: It's nice to meet you as well.
Doctor: My name is Doctor X and I will be taking care of you today.
Patient: Thank you.
Doctor: I've been told that you'd like a refill on your Xanax prescription and something to help you break your smoking habit.
Patient: Yes, I feel l... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cause her some ... |
Doctor: Are you allergic to anything?
Doctor: Like any medications?
Patient: No, I am not allergic to anything.
Doctor: Perfect!
Patient: Hm. | Section Header: ALLERGY
Summary: None. |
Doctor: Welcome to the clinic.
Patient: Thank you. It is nice to meet you.
Doctor: It is nice to meet you to. I hear an accent. Where are you from?
Patient: I am from Denmark. I speak Danish as my first language. Me and my husband have been in the States for many many years. When we first got here, we did not speak a... | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband. With respect to her walking and balance... |
Doctor: I mean, I am so happy to see your report today, your blood pressure looks much better. That's amazing given your past few visits your B P was out of control and even with changing your medications we were having tough time bringing it down.
Patient: Yeah, I feel much better, I read about my condition and it is... | Section Header: ASSESSMENT
Summary: This is a return visit for this patient who has refractory hypertension. This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. We had discussed with her in the past beginning to see an internist at the ... |
Doctor: Did you ever visit any hospital for any kind of surgery?
Patient: No. | Section Header: PAST SURGICAL HISTORY
Summary: No previous surgeries. |
Doctor: Hi there! How are doing today?
Patient: I am doing well.
Doctor: How have you been doing with keeping your hemoglobin levels between four and five point six prercent?
Patient: I have been doing well. I have been able to keep it within that range. | Section Header: CHIEF COMPLAINT
Summary: Followup diabetes mellitus, type 1. |
Doctor: So, are you married, ma'am?
Patient: Well, no I'm not. My husband and I got a divorce.
Doctor: I'm sorry to hear that, do you have any children?
Patient: It's okay, it was for the best. Yes, I have two.
Doctor: Do you live with either of them?
Patient: Yeah, um, I live with my son right now.
Doctor: Do you s... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Denies any tobacco or alcohol use. She is divorced with 2 children. She lives with her son. |
Doctor: Good afternoon, so, who is the patient today?
Guest_family: Good afternoon, doctor. My granddaughter is your patient today.
Doctor: What seems to be the problem today, young lady?
Patient: Well, I'm having a lot of headaches, I feel it in my face.
Doctor: Does it feel like pressure?
Patient: That, and I ha... | Section Header: HISTORY of PRESENT ILLNESS
Summary: Grandfather brings the patient in today because of headaches, mostly in her face. She is feeling pressure there with a lot of sniffles. Last night, she complained of sore throat and a loose cough. Over the last three days, she has had a rash on her face, back and ... |
Doctor: Did you have any surgeries in the past?
Patient: Yes, I had a partial removal of my ovaries and then I also had my appendix removed.
Doctor: Okay anything else?
Patient: Yeah, I also got my tummy tucked.
Doctor: Okay. | Section Header: PAST SURGICAL HISTORY
Summary: Significant for partial oophorectomy, appendectomy, and abdominoplasty. |
Doctor: Good afternoon, young man.
Patient: Hello, doctor.
Doctor: How old are you, young man?
Patient: I'm thirteen, sir.
Doctor: Thank you, so, what happened?
Patient: I sliced my right ring finger with a piece of glass while I was playing around with my friends.
Doctor: You need to be more careful, young man. Wha... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger. |
Doctor: Hello. How are you feeling today?
Patient: Not so well. I went to a party last night and my chest and body have been hurting a lot.
Doctor: I see. Did you smoke at the party?
Patient: Nope. I never smoked in my life.
Doctor: Great. Where on your body does it hurt?
Patient: Like my upper right side of my sto... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Denies tobacco or alcohol use. |
Patient: And do I have to restrict my movement or activities?
Doctor: Um, I have taken the plaster off and your foot looks good. I don't want you to restrict your activities, but you are the best judge of the situation. So, I will advise you to take it slow and do as much as you can tolerate.
Patient: Got it. Thank yo... | Section Header: PLAN
Summary: As tolerated. |
Doctor: What is your family medical history?
Patient: My dad had stomach cancer.
Doctor: How old was he when he was diagnosed?
Patient: I think he was seventy something. My sister has breast cancer. She is in her fifty's.
Doctor: Any family history of uterine, ovarian or colon cancer?
Patient: No. Not that I am a... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 1. A sister with breast carcinoma who was diagnosed in her 50s. 2. A father with gastric carcinoma diagnosed in his 70s. 3. The patient denies any history of ovarian, uterine, or colon cancer in her family. |
Doctor: Do you drink or smoke?
Patient: No I don't. I have to care for my daughter. She is a widow.
Doctor: So you live with her?
Patient: Yes, she lives at home. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She denies alcohol or tobacco use. She is the caretaker for her daughter, who is widowed and lives at home. |
Patient: I think I need help.
Doctor: I am here to help. Tell me what's going on.
Patient: I am having mood swings, sometimes I feel super happy and sometimes I am just super sad and angry with myself. I find myself in tears thinking about things or situations which are not even real.
Doctor: How old are you ma'am?
P... | Section Header: HISTORY of PRESENT ILLNESS
Summary: A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which... |
Doctor: Any known past medical history?
Patient: I have high blood pressure.
Doctor: Anything else?
Patient: Yeah, I remember I also had higher number of fat in my blood. | Section Header: PAST MEDICAL HISTORY
Summary: Include dyslipidemia and hypertension. |
Doctor: Good morning, ma'am, welcome in. I believe this is our first time meeting.
Patient: Good morning, doctor. Yes, this is my first time in.
Doctor: Great, how old are you?
Patient: I'm fifty five, doctor.
Doctor: Thank you, what seems to be the problem today?
Patient: Well, I'm having a laundry list of sympto... | Section Header: HISTORY of PRESENT ILLNESS
Summary: A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies. P... |
Doctor: What's your family history?
Patient: Both my parents are deceased.
Doctor: I'm so sorry to hear that. I offer you my sincerest condolences.
Patient: Thank you. My dad passed away at seventy five from leukemia and my mom fell victim to heart problems and alcoholism at thirty eight.
Doctor: Does anyone else i... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia. One of her uncles was diagnosed with leukemia. |
Doctor: Any fever or chills?
Patient: No.
Doctor: Any headache or body pains?
Patient: No.
Doctor: Any nausea vomiting?
Patient: I had vomiting a few times.
Doctor: Did you observe any blood?
Patient: No.
Doctor: Okay, any diarrhea?
Patient: No, on the contrary I am having constipation every now and then, it's reall... | Section Header: REVIEW OF SYSTEMS
Summary: General review of system is significant for difficulty with intermittent constipation, which has been problematic recently. He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough. |
Doctor: Do you take Diovan, estradiol, Norvasc, Wellbutrin?
Patient: Yes, and the Wellbutrin is an inhaler.
Doctor: Okay so inhaler SR?
Patient: Yes.
Doctor: Do you take oxygen therapy at home?
Patient: Yes.
Doctor: Okay. | Section Header: MEDICATIONS
Summary: Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2. |
Doctor: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: How long have you and your husband been married?
Patient: Oh, at this point I don't even know how long its been.
Doctor: I assume you live together?
Patient: Yes, we do.
Doctor: What do you do for a living?
Patient: I'm a school nurse for the... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient is married. She lives with her husband and is employed as a school nurse for the School Department. She had quit smoking cigarettes some 25 years ago and is a nondrinker. |
Guest_clinician: Any past surgeries?
Doctor: It looks like she had an appendectomy along with a total abdominal hysterectomy and bilateral salpingo oophorectomy sometime ago.
Guest_clinician: Okay, noted.
Doctor: Oh and it looks like she had a right hip fracture back in O five after a fall. | Section Header: PAST SURGICAL HISTORY
Summary: Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO. |
Doctor: Before we begin today, sir, I just need a few pieces of background information. I see here on my chart that you're thirty years old, is that correct?
Patient: Yes doctor, that's correct.
Doctor: Okay, and which hand is your dominant hand?
Patient: I use my right hand for everything.
Doctor: Now, take me thr... | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local ne... |
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