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Doctor: Have we gone over your survey results from your last visit? Patient: No, do you have those results with you right now? Doctor: Yes, I do, they show that you have anxiety disorder. Patient: That makes sense, thank you for sharing that with me.	Section Header: PAST MEDICAL HISTORY Summary: Significant for anxiety disorder.
Doctor: I see here that you've been having some chest pain. Where along the chest? Patient: It's mostly on the left side. Doctor: When did it start? Patient: Um a few days ago. Doctor: How'd you describe the pain? Patient: Kinda dull. Doctor: Any other symptoms with the pain, such as shortness of breath? Patien...	Section Header: CHIEF COMPLAINT Summary: For evaluation of left-sided chest pain, 5 days post abdominal surgery.
Doctor: It looks like he has a history of high blood pressure, high cholesterol, and Afib. Guest_clinician: Does he see a cardiologist for his Afib? Doctor: Not according to his chart. I'll see if I can call his emergency contact to confirm. Guest_clinician: Okay. Keep me posted.	Section Header: PAST MEDICAL HISTORY Summary: Per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia.
Doctor: Do you smoke or drink alcohol? Patient: No, I do not smoke or drink alcohol. Doctor: How about drugs? Patient: Nope, I have never. Doctor: Who do you live with? Patient: Just my family.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is a nonsmoker. Denies any alcohol or illicit drug use. The patient does live with his family.
Doctor: How old are you now? Patient: I am sixty five. My kids just through me a surprise birthday party last week. Doctor: Oh wow! That is so nice. Happy belated birthday. Patient: It was nice. Doctor: It looks like you are here today for a recheck for the prostatitis. Patient: Yeah. Doctor: I see you have been ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 65-year-old man with chronic prostatitis who returns for recheck. He follow with Dr. XYZ about every three to four months. His last appointment was in May 2004. Has had decreased libido since he has been on Proscar. He had tried Viagra with some ...
Doctor: Are you married, sir? Patient: Yes, I am, Doctor: Doctor: Is this your only marriage? Patient: Well, no. I've been married three times now. Doctor: If you don't mind my asking, how long was your longest marriage? Patient: I don't mind at all, my longest was two years. Doctor: Do you have any children, sir?...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Marital Status and Dependents: The patient has been married three times; longest marriage is of two years duration. He has two children. These dependents are ages 15 and twins and are his wife's dependents. Education: The patient has bachelor's degree. Militar...
Doctor: So, looks like you have stones in your C B D. I am not hundred percent sure but most likely its stones. Patient: C B D? Doctor: Yeah, short for common bile duct. It's a small tube like structure which connects your liver duct and gallbladder. Patient: Oh! Doctor: Yeah, and because of that you have inflammat...	Section Header: ASSESSMENT Summary: Choledocholithiasis, ? cholecystitis.
Guest_clinician: Has he had a blood transfusion in the past? Doctor: No, this is his first one. Guest_clinician: Okay, got it.	Section Header: CHIEF COMPLAINT Summary: I needed a blood transfusion.
Doctor: Can you tell me more about your son, please? Guest_family: Sure, he's ten years old now. Doctor: How long has he used his walker? Guest_family: Well, he's been using that since he started walking. Doctor: How old was he when he started walking? Guest_family: He was about a year old. Doctor: Good, what seems...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year. The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally. He does not walk with a crouched gait but does to...
Doctor: Did you ever have any reaction to any medication given? Any known allergies? Patient: No. Doctor: Was there any swelling where your lymphnodes are? Patient: No. Doctor: Was there ever any complaint of abnormal lymph nodes? Patient: No.	Section Header: REVIEW OF SYSTEMS Summary: LYMPH: No history of systemic allergy, abnormal lymph nodes or swelling.
Doctor: Do you have anyone with psychiatric symptoms in the family? Patient: No, I don't have family! Doctor: What do you mean? Patient: My mom dad died and I was raised in the Philippines. Doctor: Adopted? Patient: No by myself. Doctor: Wow that must have been tough. Patient: Oh it's a story for another day.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Listed as unknown in the chart as far as other psychiatric illnesses. The patient himself states that his parents are deceased and that he raised himself in the Philippines.
Doctor: Do you have any chronic conditions I should know about, sir? Patient: No, not that I can think of. Doctor: What about injuries, have you ever broken a bone? Patient: Yes, I have. I've broken my hand and tibia before.	Section Header: PAST MEDICAL HISTORY Summary: The patient has no significant past medical history with the exception of previous hand fracture and tibia fracture.
Doctor: Welcome to the clinic. Patient: Thank you. Doctor: Do you have any family history of cancer? Either solid tumors or blood malignancies? Patient: No. None that I know of.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: There is no history of solid tumor or hematologic malignancies in his family.
Doctor: Can you tell me what surgeries have you had in the past? Patient: I have had appendix surgery when I was twenty one years old and eight years back I had C Section. Doctor: Okay. I want to know how many pregnancies you had and how many babies? Patient: Sure, I have only two. Doctor: Okay. Do you have any issues ...	Section Header: PAST SURGICAL HISTORY Summary: Appendectomy at age 21. C-Section 8 years ago. Ob/Gyn: G2P2; last menstrual period 3 weeks ago. Heavy menses due to fibroids.
Doctor: Hello, sir. Before we begin your visit, could you verify your age and ethnicity for me, please? Patient: I'm forty nine years old, and I identify as white. Doctor: Thank you. What brought you in today? Patient: I was referred to you so that I could get whatever's wrong with me under control. Doctor: I see. W...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive...
Doctor: And are you working? Patient: Ah yes, I am a painter. Doctor: Okay good. Doctor: Do you smoke? Patient: Yes, I do. Doctor: Hm and how much do you smoke? Patient: Well, about two packs a day. Doctor: And how about alcohol, do you drink? Patient: No sir, I don't drink. Doctor: Any drugs? Patient: You mean li...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He does smoke two packs of cigarettes per day. He has no alcohol or drug use. He is a painter.
Doctor: Welcome to the clinic, ma'am. I am Doctor Smith. Patient: Thank you. It is nice to meet you. Doctor: Doctor X referred you to us, is that correct? Patient: Yes. He is my primary care doctor. Doctor: It looks like you have a birthday coming up. Happy early birthday! Patient: Thank you. Yes, I am going to be...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain. The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history. The patient has had pain in the abdomen and across the back for ...
Doctor: Good afternoon, ma'am. You're forty one years old, correct? Patient: Good afternoon, doctor. Yes, that's correct. Doctor: Thank you, have you followed up with Doctor X since your surgery? Patient: Why would I do that? Doctor: Oh, just because she referred you to me. Patient: Oh, no, I haven't yet. Doctor:...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy. She was referred to me by Dr. X. The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with...
Doctor: Is everything fine? Guest_family: My mom is not well. Doctor: When did this start? Guest_family: I don't know but she is not in her correct state of mind. Doctor: Okay let's see what we can do, how old is she? Guest_family: She is around seventy four years old. Doctor: Okay. Don't worry, we will see what we can...	Section Header: CHIEF COMPLAINT Summary: A 74-year-old female patient admitted here with altered mental status.
Doctor: Welcome in, sir. Patient: Thank you. Doctor: Let us start off with a little background. Patient: Okay. Doctor: What is your current living status? Do you live with others or on your own? Patient: Well, right now I am living with my sister in Sacaton. I am currently looking for my own place, but I am stayin...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He lives in Sacaton with his sister. He is separated from his wife who lives in Coolidge. He smokes one or two cigarettes a day. Denies drug abuse. He used to be a heavy drinker, quit alcohol one year ago and does not work currently.
Doctor: How are you feeling after that insulin drip, Miss A B C? Patient: I am feeling much better. My sugar levels are normal. Doctor: Yes, between one hundred fifteen and one thirty four. So, on the second day after your admission they did laparoscopic removal of your gallstones. You were very difficult to intubate....	Section Header: EMERGENCY DEPARTMENT COURSE Summary: Ms. ABC was admitted to the hospital. She was seen by Dr. A. He put her on an insulin drip. Her sugars slowly did come down to normal down to between 115 and 134. On the next day, she was then taken to the operating room, where she underwent her laparoscopic cho...
Doctor: Good morning, ma'am. Patient: Good morning, doctor. Doctor: Welcome to A B C D General Hospital. My nurse says that you are forty one years old, and you identify as a White female, is that correct? Patient: Yes, that's all correct. Doctor: Thank you, so, what seems to be the trouble today? Patient: Well, I'...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 41-year-old Caucasian female who presents to ABCD General Hospital. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed wit...
Doctor: On April twenty two four we went over your list of medication and allergies. Patient: Okay. Doctor: Let me check something. Patient: Sure.	Section Header: PAST SURGICAL HISTORY Summary: As listed on 04/22/04 along with allergies 04/22/04.
Doctor: How's the low fat and low cholesterol diet going? Have you been finding it manageable? Patient: Yeah, I guess. I've tried to also reduce my salt intake to about two grams.	Section Header: PLAN Summary: 2 g sodium, low fat, low cholesterol diet.
Doctor: Hello. Before we begin your visit, could I ask a few questions to fill in some missing information? Patient: Yeah, that's fine. Doctor: Does your family have any health related problems? Patient: Yeah, we do. We have a strong history of heart disease. I think it could be because we drink a lot. Doctor: So, ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Strong for heart disease and alcoholism.
Doctor: Are you working these days? Patient: No, sir. I've been retired for a couple years now. Doctor: Congratulations. I hope you're enjoying your time off. Patient: You bet. Doctor: You mentioned having a smoking history. When did you quit and approximately how much did you smoke? Patient: Uh I quit about twenty sev...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars. He has not smoked for the past 27 years. He hardly ever uses alcohol. He is currently retired.
Doctor: Good morning, sir, welcome to A B C D General Hospital. Patient: Thank you, doctor. I hope you can fix me up quickly. Doctor: We'll do our best. Um, before we begin, I just need some background information. So, how old are you? Patient: I'm forty seven years old. Doctor: Good, and what race do you identify w...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot. The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size. The patient also has history of sha...
Doctor: What do you do for a living? Patient: Actually, I'm retired now, but I was an engineer, and I did some real estate brokering as well on the side. Doctor: Wow, that's a lot. Congratulations on your retirement! Patient: Thank you, now I get to spend more time with my wife. Doctor: Wonderful, do you have any ch...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse.
Doctor: As per your chart I am going to put some of the following things in your diagnosis. Patient: Yes, I have diabetes, hypertension and gallstones. Doctor: Yes I can see that in your chart over here. Patient: What are the new things? Doctor: We now have added hyperglycemia and obstructive sleep apnea.	Section Header: DIAGNOSIS Summary: Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.
Doctor: Do you smoke? Patient: Nope. I quit like fifteen years ago.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Quit smoking 15 years ago.
Doctor: Do you have any orthopedic conditions that run in your family that I should know about? Patient: What, like arthritis? Doctor: Yeah, does anything like that sound familiar? Patient: No, not that I know of.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Guest_clinician: Hi there! Welcome to the clinic. Patient: Hi! Thank you. Guest_clinician: I'm going to get a little background information from you today. Patient: Okay. Guest_clinician: What are any of your medical history conditions? Past and present? Patient: I have Crohn's disease. Guest_clinician: How long have ...	Section Header: PAST MEDICAL HISTORY Summary: He has had diabetes for five years. He also has had hypercholesterolemia. He has had Crohn's disease for 25 or 30 years. He has had a colostomy for four years. He has arthritis, which is reportedly related to the Crohn's disease. He has hypertension and coronary arter...
Doctor: Any sugar or B P problem? Patient: No, it is normal. Doctor: Okay, how about thyroid or any other hormone related problem? Patient: No, everything is fine. Doctor: Cholesterol? Patient: No cholesterol problem.	Section Header: REVIEW OF SYSTEMS Summary: ENDOCRINE: Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.
Guest_clinician: What's her diagnosis? Doctor: Refractory anemia. Guest_clinician: Gotcha.	Section Header: DIAGNOSIS Summary: Refractory anemia that is transfusion dependent.
Doctor: Do you have patient's family history? Guest_clinician: At this point of time, we don't have it. Doctor: Hm, okay.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unknown.
Doctor: Hello, miss. How can I help you today? The nurse said the matter was urgent. Patient: Yes, I have been having dizzy spells. I have also noticed a new rash on my right calf. Doctor: Can you describe what type of dizzy spells you are having? What do they feel like? Patient: It is general dizziness and vertigo. ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf. She describes her dizziness as both vertigo and lightheadedness. She does not have a headache at present but has some intermittent headaches, neck pa...
Doctor: Does anyone in your family have or have history of any colon cancer or unusual polyps? Patient: No. Doctor: Any other family history? Patient: Yes, my father died of a cancer called mesothelioma and my mother died of Hodgkin's Lymphoma.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Negative for any colon cancer or polyps. Her father died of mesothelioma, mother died of Hodgkin lymphoma.
Doctor: Any known medical history in the family? Patient: Nope. Doctor: How about anyone with high blood pressure or heart disease or diabetes in the family? Patient: Nope.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Doctor: How are you feeling today? Patient: I am feeling very tired. Doctor: According to your chart, you have seen with us for three separate self harm attempts. Have you had any other self harm events that you have not come to see use for? Patient: No. I have been seeing Doctor Lin. Doctor: I also see that this is ...	Section Header: HISTORY of PRESENT ILLNESS Summary: As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X. She has a remote history of being on Lexapro for depression.
Doctor: Do you have any drug allergies? Patient: No. None that I know of.	Section Header: ALLERGY Summary: No known drug allergies.
Doctor: So, if you see here Doctor Patrick there are multiple areas with hypergranulation tissue on the left leg posteriorly and I get a sense that it's associated with the trauma to the back of his right leg. Guest_clinician: Yeah, I agree.	Section Header: ASSESSMENT Summary: Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.
Doctor: How're you today? Patient: Not too bad. I'm hanging in there. My asthma has been acting up. Doctor: Oh no. How long has this been going on? Patient: For the past three months. I've been using my inhaler every day. I used to use it every now and again. This is definitely new for me. Doctor: Are you experienc...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma. She says her asthma has been worse over the last three months. She has been using her inhaler daily. Her allergies seem to be a little bit worse as well. Her hu...
Doctor: Okay, so your psych evaluation came out unremarkable. Do you have any other problems? Patient: I have this acne. I hate it. I am not feeling comfortable in my own skin.	Section Header: PAST MEDICAL HISTORY Summary: Acne. Psychiatric history is unremarkable.
Doctor: Hello there, how are you? Guest_family: I am little scared. Doctor: I understand, so how old is she? Guest_family: She is ten days old today. Doctor: And just wanted to confirm the ethnicity is Caucasian, right? Guest_family: Yes. Doctor: Okay, so tell me what's going on with her? Guest_family: I was feedin...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These movements are witho...
Doctor: Has anyone in your family had heart diseases? Patient: Yes my father. They did his heart bypass surgery when he was sixty. Doctor: Is he alright now? Patient: Yes I know what you mean. Patient: Yes by God's grace, both my parents are alive. Doctor: What exactly was the heart disease named? Do you know? Patien...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Strongly positive for heart disease in his father. He had a bypass at age 60. Both parents are alive. Both have dementia. His father has history of coronary artery disease and multiple vascular strokes. He is in his 80s. His mother is 80, also with dementia....
Doctor: Are you on steroids? Patient: No. Doctor: Any history of cancer, chemotherapy or anything related? Patient: No.	Section Header: REVIEW OF SYSTEMS Summary: IMMUNOLOGIC: Negative; Negative for steroids, chemotherapy, or cancer.
Doctor: How have you both been doing? Guest_family: We are good. Doctor: I see she has been gaining weight since she has been home. Have you been following the meal plan that we discussed? Guest_family: Yes. It has been helping. Doctor: Great!	Section Header: DISPOSITION Summary: Stable disposition to home with her mother.
Guest_clinician: I don't see any past medical history here in this report. Doctor: We don't have any record of P M H for this patient. Guest_clinician: Okay.	Section Header: PAST MEDICAL HISTORY Summary: None.
Doctor: Oh, dear God! What happened? Guest_family: Hi Doctor, I am his mom. Doctor: Hello, so what happened? Guest_family: He was trying to climb a tree, slipped from there and got a deep cut on his thigh. Doctor: So, you fell from the tree? Patient: Yes.	Section Header: CHIEF COMPLAINT Summary: Fall and laceration.
Doctor: What is up with your teeth man? It's been giving you problems huh? Patient: Yes, yes, many, many problems. Firstly, they pulled out so many teeth and now I have this bad tooth problem. Doctor: Oh, so this is new? Patient: Yes, it's a new pain. Right now it has been going on for three days on left side's upper...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left side for...
Doctor: How's your jaw doing? Patient: The pain seems to have gotten worse. Doctor: Do you mind if I take a look? Patient: Sure. Ow, ow, ow. That's the spot that hurts the most. What's causing it? Doctor: It's hard to say, but I'm thinking it could be T M J. I'd like to get you in to see a T M J specialist.	Section Header: CHIEF COMPLAINT Summary: Jaw pain.
Doctor: Are you taking Citalopram for depression? Patient: Yes, I take it once a day. Patient: It is ten M G tablet. Doctor: Is that so? Patient: Yes. Doctor: What do you take for pain? Patient: Just Tramadol as needed.	Section Header: MEDICATIONS Summary: Citalopram 10mg once daily for depression; low dose tramadol PRN pain.
Doctor: What is your family health history? Patient: My mom and dad are both diabetics. My mom has high blood pressure. My brother is having some issues with his liver.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented).
Doctor: Can you tell me about your family? Patient: I have or had two sons both born normally without any complications. Doctor: Why did you say had? Patient: One of my sons was a heavy smoker, he uses to smoke a whole packet or more in a day. We tried everything possible, but he just couldn't quit. He died of clots. ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Her father died with heart disease in his 60s and her mother died of colon cancer. She has a sister who she believes is probably healthy. She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. She has two ...
Doctor: Do you smoke cigarettes? Patient: Yes. Doctor: How about alcohol? Patient: No, I don't consume alcohol. Doctor: Okay. And any history of using drugs like marijuana or stuff like that for fun? Patient: No.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Active smoker. Does not consume alcohol. No history of recreational drug use.
Doctor: Are you married, sir? Patient: No divorced. I live a lone. Doctor: What work do you do? Patient: I am a retired postal worker. Doctor: Do you have kids? Patient: Yes, I have three of my own and seven grandkids. Doctor: Do you smoke cigarettes? Patient: Yes I do. Doctor: How much and what kind? Patient: I keep c...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren. He smokes 1 pack a day of Newport for 30 years and is a social drinker. He denies any illicit drug use.
Doctor: Hello! How are you doing? Patient: Hello Doctor! I am good. Patient: I am here today for my follow-up, as suggested. Doctor: Has it been a month already? Patient: Yes, seeing you after a month.	Section Header: CHIEF COMPLAINT Summary: One-month followup.
Doctor: Do you have any allergies? Patient: I am allergic to IV contrast. Doctor: Are you sure? Patient: Yes.	Section Header: ALLERGY Summary: IV contrast.
Doctor: Just to debrief, we will rule out angina related heart problems while evaluating your jaw pain. Patient: Oh can that be related to each other? Doctor: Yes they might be. Patient: What else? Doctor: Pardon? Patient: I am asking anything else? Doctor: We have discussed this before, but keep track of your high ch...	Section Header: ASSESSMENT Summary: 1. Jaw pain, sounds musculoskeletal. We will rule out angina equivalent. 2. Hypercholesterolemia. 3. Hypothyroidism.
Doctor: Hello, sir. How are you feeling today? Patient: Very itchy. I just keep scratching myself. Doctor: Oh, wow. I can see the rashes all over your arms. Are there rashes anywhere else? Patient: Yeah, it's all over my back and stomach. Doctor: I see it on your torso. When did this all start? Patient: I woke up ...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheez...
Doctor: Do you have any family medical history of migraines? Patient: I know that my brother has them too. Mom, do you know if anyone else gets them? Guest_family: Your grandfather had migraines. Doctor: Okay.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: There is a history of migraine in the family. The condition affects the patient's brother and maternal grandfather.
Doctor: What do you do for work? Patient: I am retired now. I was a school teacher. Doctor: Are you a smoker? Patient: Yes. Doctor: How much do you smoke per day? Patient: I would say about a half to a full pack a day. Doctor: How long have you been a smoker. Patient: Probably sixty years.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.
Doctor: Are you allergic to anything? Patient: No, I am not. Doctor: Are you sure? Penicillin or sulfa? Patient: Nope nothing. Doctor: That's good.	Section Header: ALLERGY Summary: Denies any drug allergies
Doctor: Hi there, sir! How are you doing today? Patient: I feel out of it. Doctor: Have you been using any substances? Patient: I did a little heroin and some coke earlier today. I still feel high. Doctor: Okay. Any shortness of breath, chest pain, abdominal pain or back pain? Patient: No. Doctor: Are you having a...	Section Header: REVIEW OF SYSTEMS Summary: The patient states that he did use heroin as well as cocaine earlier today and feels under the influence. Denies any headache or visual complaints. No hallucinations. No chest pain, shortness of breath, abdominal pain or back pain. Denies any abscesses.
Doctor: Have you had any surgical procedures done? Patient: Yes, in fact I had a hysterectomy back in March of ninety nine. I believe it was done on the twentieth of the month. Doctor: Got it.	Section Header: PAST SURGICAL HISTORY Summary: Hysterectomy (3/20/99).
Patient: You know Doctor, I am widowed for eighteen years now. Never remarried, I live by myself in my house. Doctor: Oh okay, are your still working? Patient: No, I use to run a restaurant, but now retired. Doctor: Hm. And you smoke cigarettes? Patient: No, I don't! Never liked the smell. Doctor: How about alcohol?...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is a nonsmoker and nondrinker. She has been widowed for 18 years. She lives alone at home. She is retired from running a restaurant.
Doctor: How old are you, sir? Patient: I'm sixty five years old. Doctor: Are you right handed or left handed? Patient: I'm right handed. Doctor: When was your last stroke? Patient: Well, it was on January seventeenth. I had these episodes where I was like always so confused and looks like I lost everything. All my...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently pl...
Doctor: Any medical disorders in the family? Patient: Yeah, my father had a special kind of tumor, which doctors said is very rare. Doctor: Do you know the name of the tumor? Patient: I don't remember the exact name of the disease, but it was a big name and it started with something with V.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father with Von Hippel-Lindau Disease.
Doctor: Do you have any major medical conditions that I should know about? Patient: Actually, I have a whole list of conditions. I have them written down here. Doctor: Thank you, so I see congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, and a history of paroxysm...	Section Header: PAST MEDICAL HISTORY Summary: Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Do...
Doctor: Doctor Shami, can you please take down the notes as I examine the patient? Guest_clinician: Sure. Doctor: Can you put the heading as cervical lymph nodes. Guest_clinician: Okay. Doctor: I am going to check for any swelling in your neck okay? Can you look down? Patient: Okay. Doctor: Alright, I do not feel a...	Section Header: EXAM Summary: LYMPH: Cervical lymph nodes. No lymphadenopathy.
Doctor: You have chronic pain? Patient: Yes I do. Doctor: You use tobacco also? Patient: Yes. Doctor: And you have a history of hepatitis C, right? Patient: That sounds right. Doctor: Okay. Patient: Yeah.	Section Header: DIAGNOSIS Summary: 1. Chronic pain. 2. Tobacco use. 3. History of hepatitis C.
Doctor: Have you had any surgeries in the past? Patient: No, none.	Section Header: PAST SURGICAL HISTORY Summary: None.
Doctor: Do you live close to the office, or did you have to drive a long way here? Patient: I live right around here, I'm a local girl. Doctor: Good, are you working right now? Patient: Yes, doctor, I work full time. Doctor: That's good, sometimes it's nice to stay busy. Is there any history of drug or alcohol abuse...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time.
Doctor: How are you, Mary? Patient: I am okay, I have got this ulcer on my right hip again. Doctor: Oh, is it like the one you got last time? Patient: Pretty much. Doctor: Oh, I remember that one. It took almost three treatment cycles to get resolved. Patient: Yeah. They keep saying I have some hidden split in my spi...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida, thus spending most of her time in a w...
Doctor: Do you have any history of heart disease that you know of? Patient: Nope, nothing like that. Doctor: How about diabetes? Patient: No, there's no sugar here that I know of. Doctor: Good, and how about your lungs? Do they work well. Patient: Absolutely, they're in great shape. There's nothing like that here.	Section Header: PAST MEDICAL HISTORY Summary: Denies diabetes, cardiovascular disease, or pulmonary disease.
Doctor: How about allergies to medications? Patient: Nope.	Section Header: ALLERGY Summary: No known drug allergies.
Doctor: Your chest x ray showed diffuse pulmonary edema. This means that you have fluid in your lungs. That would explain your chest pain and the difficulies with your breathing. I would like to start you off with a course of antibiotics to prevent any possible infection. I will also send in a prescription for Furosemi...	Section Header: IMAGING Summary: Chest x-ray revealed a diffuse pulmonary edema.
Doctor: Any headaches? Patient: No. Doctor: Any history of seizures or epilepsy? Patient: No. Doctor: Any sudden loss of consciousness or have you blacked out? Patient: Um, no. Doctor: Any weakness? Feeling any tremors in your body? Patient: No, nothing like that. Doctor: Any history of stroke or any brain related cond...	Section Header: REVIEW OF SYSTEMS Summary: NEUROLOGIC: Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. No history of strokes, no history of other neurologic conditions.
Doctor: Are there any known disease running in your family? Patient: My dad has high blood pressure, and he takes medication for it. He is now eighty two years old. He had a stroke around two years ago. This was his second stroke. First one he had when he was forty five. Doctor: What about your mom? How old is she? Pa...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80.
Doctor: Are you currently living alone? Patient: Yep. Just me, myself, and I. Doctor: What do you do for a living? Patient: I've been working as a plumber for the last five years. Doctor: Nice. Where do you work? Patient: Mostly in the city. Doctor: Do you drink, smoke, or do injection drugs? Patient: I drink an...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No...
Doctor: Good afternoon, champ, how you holding up? Patient: Good afternoon, Doctor, I have a lot of lower back pain. Doctor: Oh no, before we begin, how old are you, sir and which hand do you write with? Patient: I'm seventy five now. Right. Doctor: Great, so tell me, how long have you had this lower back pain? Patie...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physici...
Doctor: Alright. So this is going to be a complex case. Your wound is complicated by methicillin-resistant staphylococcus aureus cellulitis. Patient: Is there a treatment for my right leg? Doctor: There is. It will be more aggressive, but we can do it.	Section Header: DIAGNOSIS Summary: Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.
Doctor: What is going on with him? Guest_family: He is complaining of chest pain.	Section Header: CHIEF COMPLAINT Summary: Chest pain.
Doctor: Good morning, young man. You're a patient of Doctor X Y Z, correct? Patient: Yes sir, that's right. I've seen him for years. Doctor: I just need to confirm some demographic information before we get started today. So, you're a twenty nine year old white male, correct? Patient: Yes, doctor. That's all right. ...	Section Header: HISTORY of PRESENT ILLNESS Summary: He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm. He says that he has been stung by wasps before and had sim...
Doctor: When was your last menstrual period? Patient: Um, it was around June third of two thousand nine. Doctor: Okay so it says you have had an abortion recently? Patient: Yes I have, but I am not sure if it is finished, because I am still bleeding. Doctor: Okay. Patient: Do you want me to do a pregnancy test? Doctor:...	Section Header: GYNECOLOGIC HISTORY Summary: Her last menstrual period was 6/3/2009. The patient is admitting to having a recent abortion done. She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN.
Guest_family: My nipples are cracked, and they are bleeding. Doctor: Oh, I am so sorry to hear that. Guest_family: He has some fluid coming out of his belly button as well as his penis. Doctor: Okay I will look at it. But other than that, everything else looks good? Any other problems related to circumcision? Guest_fam...	Section Header: REVIEW OF SYSTEMS Summary: Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative.
Doctor: Welcome to the clinic, Miss A. Patient: Thank you. Doctor: Let's start with your medical history. What medical conditions do you have? Patient: Okay. I have high blood pressure, asthma and sleep apnea. I had blood clots in my left leg about six months ago. I also have cancer. Doctor: What kind of cancer do ...	Section Header: HISTORY of PRESENT ILLNESS Summary: Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly. She was diagnosed with sleep apnea approximately two years ago and was recently coun...
Doctor: They gave you Procrit for your anemia? Patient: Yes I think so. That is how they treated it in the past. Doctor: Okay. Are you married? Who do you live with? Patient: Oh I am by myself. Doctor: Okay, and do you smoke or drink alcohol? Patient: No I do not. Doctor: Great. Patient: Okay.	Section Header: PAST MEDICAL HISTORY Summary: As above plus history of anemia treated with Procrit. No smoking or alcohol use and lives alone.
Doctor: Hello. How are you doing? Patient: Not doing that good. I'm here so that you can help me. Doctor: Tell me how can I do that? What's bothering you? Patient: I have gestational diabetes and I'm here for consultation related to my diet. No matter what I eat, I'm kind of scared that it will spike up my numbers. ...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 38-year-old female who comes for dietary consultation for gestational diabetes. Patient reports that she is scared to eat because of its impact on her blood sugars. She is actually trying not to eat while she is working third shift at Wal-Mart. Historica...
Doctor: How old are you? What brings you here today? Patient: I am fifty six years old. I am here for this pain in my legs. It hurts mostly in the night. Doctor: Does changing positions helps you? Patient: Yeah, it helps. Whenever I stand it just goes away. Doctor: Is it only in your legs or it starts there and goe...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle. She has noticed it since she has been on Lipitor. She has had some night sweats occasionall...
Doctor: Are you married? Patient: Yes. Doctor: Do you have kids? Patient: Yes, I do have seven. I have a handful. Doctor: Do you work? Patient: Yeah, I'm a driver for FedEx. Doctor: Did you ever smoke? Patient: Nope. Doctor: What about alcohol or any other kind of drugs? Patient: Nope. None of that.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.
Doctor: Is patient allergic to any medication? Guest_clinician: Yes, actually he is allergic to quite a few medicines. I have noted them down, here is the list. Doctor: Okay, so he is allergic to Lamisil, Equagesic. Oh, he is allergic to Bactrim too. Guest_clinician: Yeah, and Dilatrate and cyclobenzaprine. Doctor: T...	Section Header: ALLERGY Summary: Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine.
Doctor: Hi there! I am Doctor Smith. Patient: Hello! It is nice to meet you. Doctor: Let's start with your family medical history. Patient: My mother had breast cancer. My father had lung cancer that ended up taking his life. He was seventy nine when he passed. My mother also passed but not from an illness but from ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father died from CA at the age of 79. Mother died from postoperative infection at the age of 81. Brother died from pancreatitis at the age of 40 and had a prior history of mental illness. Father also had a prior history of lung cancer. Mother had a history of ...
Doctor: I will ask some simple questions, okay? Patient: Hm Doctor: How old are you and how would you define yourself in terms of ethnicity? Patient: Well, I am forty seven and would proudly call myself as Latin American. Doctor: Great. What brings you to the emergency room? Patient: I had a blood test before and the...	Section Header: HISTORY of PRESENT ILLNESS Summary: A 47-year-old Latin American man presented to the emergency room after being told to come in for a high potassium value drawn the previous day. He had gone to an outside clinic the day prior to presentation complaining of weakness and fatigue. Labs drawn there reveal...
Doctor: Have you ever had surgery, ma'am? Patient: Yeah, I've had a few. First, I had, um, tubal ligation, and three milk ducts removed. Doctor: What year was that in? Patient: That was in, um, nineteen seventy nine. Doctor: Great, thank you. What else have you had done? Patient: I had a breast biopsy in nineteen eig...	Section Header: PAST SURGICAL HISTORY Summary: In 1979, tubal ligation and three milk ducts removed. In 1989 she had a breast biopsy and in 2007 a colonoscopy. She is G4, P3, with no cesarean section.
Doctor: Did you had any surgery in the past? Patient: No.	Section Header: PAST SURGICAL HISTORY Summary: Noncontributory.
Doctor: Any allergies? Patient: Yes just molds. Doctor: Okay so molds reaction.	Section Header: ALLERGY Summary: Molds.
Doctor: Hi there, how are you dear? Patient: I am fine, thank you. Guest_family: Hi Doctor, I am her mother. Doctor: Nice to meet you. So I see you have been referred by Doctor X. Guest_family: Yes, she is our family doctor. Doctor: Okay, so you noticed some behavioral problems with your daughter and reported to her, i...	Section Header: MEDICATIONS Summary: Adderall and clonidine for attention deficit hyperactivity disorder.
Doctor: He had circumcision? Patient: Yes. Doctor: Do you remember the date? Patient: No I do not. But it should be in the chart.	Section Header: PAST SURGICAL HISTORY Summary: Circumcision.
Doctor: Good morning, sir. You're sixty one years old, correct? Patient: Good morning, doctor. Yes, that's correct. Doctor: Great, and you identify as Caucasian, right? Patient: Yes, that's correct as well. Doctor: Thank you, do you have any medical conditions that I should know about? Patient: Yes, I have diabete...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus. The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot. He notes some itching as well as incr...

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