Split (2)

train · 1.2k rows

dialogue stringlengths 41 8.86k	summary stringlengths 39 6.29k
Doctor: Hello, sir. How are you doing today? Patient: I'm flustered. I brought my wife so she can speak for me. Doctor: Hello, ma'am. What seems to be the problem with your husband? Guest_family: He's been having some problems with his skin in his private region. He's too shy to talk about it himself.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is accompanied with his wife.
Doctor: Are you married, ma'am? Patient: Yes, to my wonderful husband. Doctor: Does he help you out around the house? Patient: Yes, he is just wonderful. Doctor: So, do you drink or smoke? Patient: No, I don't do any of that. Doctor: How about more illicit substances, do you use any of that? Patient: No, absolutel...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is married and has support at home. Denies tobacco, alcohol, and illicit drug use.
Doctor: Anything else going on from head to toe? Patient: No doctor, everything else is fine. Doctor: Are you sure? Patient: Yes I am sure.	Section Header: REVIEW OF SYSTEMS Summary: Not contributory.
Guest_family: How's my husband doing? Sorry, I had to take a call outside. Doctor: He's doing much better. He'll be going home today with a prescription for Zithromax. Guest_family: I'm glad he's able go home and get some rest. Doctor: However, I'd like to still see him in the office next week for a reevaluation. Gu...	Section Header: DISPOSITION Summary: The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week.
Doctor: How long have you been running a fever? Patient: It's been on and off for a few days now. I'm also having chills. Doctor: Have you taken anything for the fever? Patient: Tylenol and Advil. I've been taking them interchangeably. Doctor: When was the last time you took your temperature? Patient: An hour ago....	Section Header: REVIEW OF SYSTEMS Summary: CONSTITUTIONAL: No history of fever, rigors, or chills except for recent fever and rigors. HEENT: No history of cataract or glaucoma. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: Nausea and vomiting. No hematemesis or melena. UROLOGI...
Doctor: Hello, miss. It looks like some information is missing for your profile. Is it fine if I ask you a few questions? Patient: Of course. Go ahead. Doctor: Do you currently smoke? Patient: No, I finally stopped smoking cigarettes. Doctor: Did you smoke before? Patient: I did. I smoked a half a pack for about t...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient used to smoke cigarettes for about 20 years, one-half pack a day. She currently does not, which was encouraged to continue. She rarely drinks any alcohol-containing beverages.
Doctor: Hello, sir. So, remind me, how long ago was your procedure? Patient: Let me think. Now, it's been about four months. I just turned fifty nine. Doctor: Okay, and just to refresh your memory, we did a percutaneous screw fixation of a Schatzker I V tibial plateau fracture, and we've managed those toe fractures no...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures. He is currently at home and has le...
Doctor: Do you currently smoke? Or did you smoke in the past? Patient: Quit in nineteen seventy two. Doctor: Great to hear. Are you working right now? Patient: Yeah, I work at a nursing home. Doctor: Does your job allow you to take time for yourself? Patient: Yeah, my job is very supportive. I've actually been tr...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She works at nursing home. She is a nonsmoker. She is currently trying to lose weight. She is on the diet and has lost several pounds in the last several months. She quit smoking in 1972.
Doctor: Hello. Are you ready for your surgery today? Patient: Can we reschedule? I'm too scared to do it. Doctor: It'll be fine. Don't worry too much about it. Have you ever had a surgery before? Patient: Never. What if something goes wrong? Doctor: You have nothing to worry about. I've done this procedure multiple ...	Section Header: PAST SURGICAL HISTORY Summary: Denied.
Doctor: What is your family medical history? Patient: I don't really remember anyone having any major health problems. Doctor: Okay. Patient: Everyone is pretty healthy. Doctor: That is fortunate. Patient: Yeah, it is.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.
Doctor: How's it going? I haven't seen you in a long time. Patient: Hey, Doctor. My headaches have been getting worse. Doctor: Remind me again. Does you family have a history of migraines. Patient: I don't think so. Doctor: Okay. Let's perform some tests.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: unknown.
Doctor: Hello, this is your follow up visit, right? Welcome back! Have you been taking your Plaquenil for lupus, ma'am? Patient: Yeah, I am. Doctor: Your prescription is two hundred M G twice a day, correct? Patient: Yeah, that's it. Doctor: Do you have your eye report with you today? Patient: Yes, doctor. Here yo...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks...
Doctor: So, I know you're technically not allowed to drink, but I'm required to ask this anyway. Do you drink at all? Patient: No, actually. I try to steer clear of drinking while training for my marathon. Doctor: When is that by the way? Patient: Next summer. Doctor: Wow, good luck. It'll be yet another big accomp...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient denies smoking and drinking.
Doctor: Welcome in. Patient: Thank you. Doctor: Let us start with your family medical history. Patient: I have a lot of diabetes in the family. Doctor: Who has diabetes? Patient: My father had diabetes. He passed away. Doctor: I am so sorry. How did he pass away? Patient: He had cancer. He actually had breast ca...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: His father died from breast cancer. He also had diabetes. He has a strong family history of diabetes. His mother is 89. He has a sister with diabetes. He is unaware of any family members with neurological disorders.
Doctor: How're your other children doing? Guest_family: Not so wonderful. They're all on antibiotics. Doctor: For the same? Guest_family: Yep. They all have ear infections and chest colds. Doctor: Your hands are full then. Guest_family: Tell me about it, doctor. I can't seem to catch much of a break. Doctor: It's...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: All siblings are on antibiotics for ear infections and URIs.
Doctor: Do you use tobacco or other drugs? Patient: No. Doctor: Do you drink? Patient: No.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No smoking, alcohol, or drug abuse.
Doctor: Is this your mother with you today? Patient: Yes, this is my mommy. Doctor: Great, welcome, what did you do this this ankle, young lady? Patient: Well, I was running when I twisted my ankle. Doctor: Which ankle did you twist? Patient: It was my right ankle. Doctor: Where does it hurt the worst? Patient: R...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient was running and twisted her right ankle. There were no other injuries. She complains of right ankle pain on the lateral aspect. She is brought in by her mother. Her primary care physician is Dr. Brown.
Doctor: Good afternoon, young lady. Patient: Hello, doctor. Doctor: What grade are you in, young lady? Patient: I'm in middle school, um, I'm in the eighth grade. Doctor: Do you play any sports? Patient: Yes, I love to play basketball. Doctor: Good, are both of your parents at home? Patient: Yes, I live with my m...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is currently an eighth grader at Middle School and is interested in basketball. She lives with both of her parents and has a 9-year-old brother. She had menarche beginning in September.
Doctor: How many children do you have, ma'am? Patient: I was blessed with four beautiful children. Doctor: That's wonderful. Did you have any complications with the pregnancies? Patient: Actually, I had two c sections for both of my sons.	Section Header: PAST SURGICAL HISTORY Summary: Cesarean section x 2.
Patient: I'm right handed. Doctor: Tell me what brings you here, sir? Patient: I'm having these cramps in my feet, in my hand and I just wanted to get checked. It has been happening for like six months. I develop muscle contractions in my toes and both feet. It only happens in night. Doctor: How frequent is it? Pat...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the...
Doctor: So, this is your follow up? How are you doing so far with Lamictal? Patient: Yes, it's the follow up. Lamictal was okay. There was no side effect with that. But I had twitching in my muscles a lot of times. It was not generalized, but I was very afraid that this will happen. Doctor: What time of day was it? T...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient returns for followup. Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking. She has not had a generalized seizure. She is very concerned that this will occur. Most of the myoclonus is in the mo...
Doctor: What types of surgeries have you had in the past? Patient: I had gall bladder and appendix surgery then they also took out my ovaries. Doctor: Okay.	Section Header: PAST SURGICAL HISTORY Summary: Cholecystectomy, appendectomy, oophorectomy.
Doctor: Have you had any surgeries in the past? Patient: Yeah, I have, I actually had it to repair an undescended testicle. Doctor: Oh, wow, do you remember it at all? Patient: No, nothing about it, I had that done when I was a baby.	Section Header: PAST SURGICAL HISTORY Summary: He had a history of surgery for an undescended testicle.
Doctor: Do you smoke cigarettes? Patient: I don't smoke cigarettes but I do have one on a rare occasion. Doctor: Do you drink alcohol or use any recreational drugs? Patient: I don't drink but I do occasionally smoke weed. Guest_family: He has a drink every now and again when we get together with friends. Doctor: Ok...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.
Doctor: Do you smoke or drink? Patient: No, neither. Doctor: Any history of drug abuse? Patient: No, I have never used any illegal drugs in my life. Doctor: Okay.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She denies the use of alcohol, illicits, or tobacco.
Guest_clinician: Is the patient being admitted for disseminated C M V infection? Doctor: Yes. I suspect they have possible C M V pneumonitis as well. Guest_clinician: Are they on immunosuppressants? Doctor: Yes. They have polymyositis and they're taking Prednisone and Methotrexate. Guest_clinician: Got it.	Section Header: DIAGNOSIS Summary: 1. Disseminated CMV infection with possible CMV pneumonitis. 2. Polymyositis on immunosuppressive therapy (methotrexate and prednisone).
Doctor: Alright we already spoke about your past medical history, anything else you might want to add? Guest_family: Oh, dad did you also talk about your depression? Doctor: Depression? I don't think we spoke about that. Patient: Yeah we didn't, it slipped out of my mind. Guest_family: My father has a history of depres...	Section Header: PAST MEDICAL HISTORY Summary: He also has anxiety and depression.
Doctor: How are you? Patient: Not good. Doctor: What brings you here today? Patient: This ulcer in my ankle is just not healing. Doctor: Is it on both sides? Patient: No, just on the right side.	Section Header: CHIEF COMPLAINT Summary: Nonhealing right ankle stasis ulcer.
Doctor: Do you remember the details of your surgery, sir? Patient: No, can you remind me? Doctor: We did a left inguinal hernia repair. Patient: Thank you for reminding me. Doctor: You have a history of prostate cancer as well, correct? Patient: Yes, they said it was Gleason, um, three plus four. Doctor: Yes, that sou...	Section Header: PAST MEDICAL HISTORY Summary: 1. He is status post left inguinal hernia repair. 2. Prostate cancer diagnosed in December 2004, which was a Gleason 3+4. He is now receiving Lupron.
Doctor: How many people do you have in your family? Patient: Well, I have four children, all healthy with no medical conditions. Doctor: Wow, that's great! Patient: My father passed away at the age of sixty nine due to C V A. And my mom died exactly ten years later, her heart just suddenly stopped. She was seventy nin...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her "heart stopped". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The ...
Doctor: You are referred for some abdominal infection right? Patient: Yes, they told me I might have C Diff? Doctor: Yes that's what we will evaluate you for.	Section Header: CHIEF COMPLAINT Summary: I was asked to see the patient for C. diff colitis.
Doctor: Hi, how are you doing? How old are you? Patient: I am good, how are you? I am seventy two years old. Doctor: Good. How can I help? Patient: Actually, there is a wooden splinter stuck beneath my left fifth fingernail. I am an American farmer by blood, so this has happened before. Doctor: Oh, when did this happen...	Section Header: HISTORY of PRESENT ILLNESS Summary: Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday. He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him. ...
Doctor: Have you had a recent vaccination? Patient: I had a flu shot last winter but I have not had and recent vaccines. Doctor: Do you have any planned in the near future? Patient: I was going to get another flu shot but I don't think I am due for that for another three months. Doctor: Great.	Section Header: IMMUNIZATIONS Summary: Nothing significant.
Doctor: How old are you? Patient: Seventy one. Doctor: Are you right handed or left handed? Patient: Right handed. Doctor: What exactly happened? Patient: I, I had this bad headache on fifth of November and then I had a big sneeze, like it was too loud. I had-- it was going on for like three to four days. Then, on...	Section Header: HISTORY of PRESENT ILLNESS Summary: 71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to ...
Doctor: I see here that you're in for a med refill. Is that correct? Patient: Yep. I ran out of Klonopin one or two days ago. Doctor: What are you taking it for? And how long have you been on it? Patient: Panic attacks. I have really bad episodes without it. Um I think I started it about four months ago. I could be ...	Section Header: CHIEF COMPLAINT Summary: I need refills.
Doctor: How are you? I haven't seen you in a long time. Patient: I'm doing fine. I hurt my hand the other day. Doctor: How did that happen? Patient: My husband and I moved into our new home, and we were building a desk. I tried to nail something in, and I hammered my hand. Doctor: Oh, no. So, you and your husband li...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is married. She lives with her spouse.
Patient: Man, what a night. Doctor: What kind of car were you driving that night? Patient: I was driving my small sports car through an intersection when another car hit me from the left side. The impact forced my car off the road and into a utility pole. Doctor: I'm so sorry to hear that. I'm glad that you are her...	Section Header: HISTORY of PRESENT ILLNESS Summary: Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient's vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a util...
Doctor: How're you doing? Patient: Good for the most part. I'm still pretty tired most days, but I'm trying to stay more active. I'm wondering if it has to do with my sugar levels? Doctor: Hm let's see. I'd like to check your glucose and lipid panels and get you back in here again. Patient: And oh I've noticed some...	Section Header: REVIEW OF SYSTEMS Summary: Significant for occasional tiredness. This is intermittent and currently not severe. She is concerned about the possibly of glucose abnormalities such diabetes. We will check a glucose, lipid profile and a Hemoccult test also and a mammogram. Her review of systems is othe...
Doctor: Hello, ma'am. How are you doing? Patient: My knees hurt. They've been slowly getting worse each year. Life's getting hard at seventy two. Doctor: I'm sorry to hear that. Have you always had knee pain? Patient: I have. Both knees are messed up. Doctor: Are you able to do any activities still? Patient: Nope. ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs. She wishes to proceed with arthroplasty at this time.
Doctor: How's he doing? Guest_family: Not so great. He's been out of it. He hasn't been acting like himself. Doctor: How long has it been since you noticed any behavioral changes? Guest_family: A few days now. Doctor: Is he complaining of any pain? Guest_family: Yeah he's been- Doctor: He's been? Guest_family: S...	Section Header: CHIEF COMPLAINT Summary: Abdominal pain, nausea, vomiting, fever, altered mental status.
Doctor: Good morning, sir. Remind me please, when was your surgery? Patient: Hello, doctor. It was about a week ago now. Doctor: Great, and just to remind you, you had a removal of Ex Fix from the right knee with an M U A following O R I F of a right tibial plateau fracture. Patient: Yes, that all sounds familiar. W...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture. The patient states that this pain is well controlled. He has had no fevers, chills or ni...
Doctor: Hi, how are you doing? Patient: I'm good. Thank you. Doctor: How old are you, young lady? Patient: Eighty four. Doctor: What brings you here? Patient: I had a fall. And I was told to consult you for my heart conditions. Doctor: Okay. Um? Can you tell me a little detail about anything you experienced before or ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology co...
Doctor: So just a few quick questions before we wrap up. Do you smoke or drink? Patient: I drink sometimes. I've never smoked. Doctor: Any drug use? Patient: No. Doctor: Are you sexually active? Patient: Uh I was back in Haiti, but that was back in eighty two. I had several male partners, but no sex since moving h...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use. The patient is currently employed.
Doctor: Are you taking any medications for your pain? Patient: Yeah, occasionally. Doctor: Which one? Patient: Just a regular pain medicine.	Section Header: MEDICATIONS Summary: Occasional acetaminophen.
Doctor: Good morning, sir, I hear you're a patient of Doctor A. Patient: Yes, that's correct. Doctor: Did she refer you to me? Patient: Yeah, I'm fifty five, so I'm not too young anymore, but I have developed iron deficiency anemia with blood in my stool. At least, that's what she's told me so far. Doctor: Are you ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 55-year-old gentleman, a patient of Mrs. A, who was referred to me because the patient developed iron deficiency anemia and he had blood in his stool. The patient also has chronic diarrhea. His anemia was diagnosed months ago when he presented with...
Doctor: Good afternoon, before we begin, what are your pronouns? Patient: I identify as a female, and I use she her pronouns. Doctor: Thank you, so, have you ever had surgery? Patient: Yes, I actually have a list of them written down. Doctor: That's really helpful, may I see it? Patient: Absolutely, here you go. Do...	Section Header: PAST SURGICAL HISTORY Summary: She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy. She also has a diagnosis of polymyalgia rheumatica.
Doctor: Hello Mister Strange, can you please confirm your age and ethnicity for the records. Patient: Hi Doctor, I am fifty five now and would identify myself as a white male. Doctor: Let's first talk about your medical condition. There has been a diagnosis of polycythemia vera with secondary myelofibrosis. Also, you ...	Section Header: HISTORY of PRESENT ILLNESS Summary: A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. Initially, he underwent phlebotomy. He subsequently transferred his care here. In the past, he has been on hydroxyurea a...
Doctor: Do you have any family history of neurological disorders, such as multiple sclerosis, Parkinson's or dementia? Patient: Nope. Fortunately, no one in my family has neurological problems.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.
Doctor: How long have you had this rash? Patient: Not long. Less than a day if I had to guess. Doctor: Is it causing you any pain? Patient: No, it's just really itchy. I tried applying Cortisone to it, but it didn't help much. Doctor: Is the rash localized to the left arm? Patient: Yeah. I've only noticed it on my...	Section Header: CHIEF COMPLAINT Summary: Itchy rash.
Doctor: Hello. How are you both doing today? Guest_family: We're doing great. The E D told us to come here. We're here to see if we could get the stuff in his leg taken out. Doctor: I see. Did he have a fracture before? Guest_family: Yeah, he did. Here's the report from the surgery from October two thousand and seve...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture. He underwent screw compression for the fracture in October 2007. The fracture has subsequently healed and the patient presents for hardware r...
Doctor: I am looking at her x ray report and she had a sternotomy in the past. Guest_clinician: Yes, and we placed an I C D implant and an aortic valve mechanical implant. Her pleural effusion was really worrisome causing left sided opacification of her diaphragm. Doctor: Oh I see!	Section Header: IMAGING Summary: Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.
Doctor: What happened to your right leg? Patient: I had a little accident with a dog, he bit me. I got really scared. Doctor: Don't worry we will take care of this.	Section Header: CHIEF COMPLAINT Summary: Dog bite to his right lower leg.
Doctor: We've been following you for several conditions for a while now. What seems to be the problem today, sir? Patient: Um, I was peeing blood, it's back again. Doctor: Did you do anything that could have provoked it to come back? Patient: No, not that I know of. Doctor: Have you been taking the Flomax for your B...	Section Header: HISTORY of PRESENT ILLNESS Summary: I am following the patient today for multiple issues. He once again developed gross hematuria, which was unprovoked. His Coumadin has been held. The patient has known BPH and is on Flomax. He is being treated with Coumadin because of atrial fibrillation and strok...
Doctor: Good morning. Patient: Good morning, Doctor. Doctor: Are you married? Patient: No sir, I'm happily single. Doctor: Good for you, what do you do for a living? Patient: I'm actually not working right now, I go to college full time. Doctor: Even better for you, so do you drink or smoke? Patient: No, I don't...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is single. She is a full-time student at University. Uses no tobacco, alcohol, or illicit drugs. She exercises weekly, mainly tennis and swelling.
Doctor: Has anyone in your family suffered from dementia? Patient: Not that I'm aware of. Doctor: Is there any other medical history in your family? Any other medical issues? Patient: My mom died of a stroke. Doctor: How old was your mom when she died? Patient: She was sixty two.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Negative for dementia. Her mother died of a stroke at the age of 62.
Doctor: When was the last time you had a cigarette? Patient: Seventeen years back. Doctor: Okay, and how much did you used to smoke? Patient: About one pack per day. I smoked for forty four years. Doctor: Okay, how about any I V drugs? Patient: No I have not done that.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years. Denies any alcohol use. Denies any IV drug use.
Doctor: What brings this little guy in today? Guest_family: He's been complaining of a sore throat since last night. I noticed his eyes were really puffy before he went to bed and that's when I gave him some Benadryl. At that time, he also seemed nasally. Doctor: Sorry to hear that. Did he have a fever? Guest_family...	Section Header: HISTORY of PRESENT ILLNESS Summary: Mom brings patient in today because of sore throat starting last night. Eyes have been very puffy. He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday. He has had low-grade fever and just felt very run down, appear...
Doctor: Do you have any major medical conditions that I should know about, sir? Patient: Maybe, I might. What exactly do you mean by that, doctor? Doctor: Well, it's broad, but it could be anything from depression to high blood pressure, to cancer. Patient: Okay, that's what I thought. I have high blood pressure. Doc...	Section Header: PAST MEDICAL HISTORY Summary: Hypertension and anxiety.
Doctor: Are you a student? Patient: Yes, I am. I go to the University. Doctor: What are you majoring in? Or do you know yet? Patient: Yes! I am studying biology. Doctor: Excellent! Do you live in the dorms? Patient: Yes. Doctor: Are you from the area? Patient: I am from Breckenridge. That is where my parents li...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well.
Doctor: Do you have any history of surgical procedures? Patient: No, none.	Section Header: PAST SURGICAL HISTORY Summary: None.
Doctor: Hello Hello! Patient: Hi there, how are you? I have a bad headache so can you please switch off the lights, it's too bright and uncomfortable. Doctor: Sure thing. Let's see what is going on here. How about that? Patient: Much better.	Section Header: CHIEF COMPLAINT Summary: Headache.
Doctor: Okay, let's talk about your family history. Patient: Oh, I have very disturbing family history! Doctor: Why do you say so? Patient: Well, my mother passed away due to heart attack in her late sixties and my father had liver cancer and he passed away from that. Doctor: Oh- Patient: Oh, that is not all. My one...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Positive for mother passing away in her late 60s from heart attack, father had liver cancer, and passed away from that. One of his children suffers from hypothyroidism, 2 grandchildren has cerebral palsy secondary to being prematurely born.
Patient: Hey, man. Doctor: Hey, how's it going? It's been a while. Patient: Yeah, it's been a while that's for sure. Doctor: So anything new I should know of? Patient: Uh I had some stuff on my chest that I saw a dermatologist for. Doctor: What type of stuff? Patient: I think they were cysts. Doctor: Any cause f...	Section Header: PAST MEDICAL HISTORY Summary: Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994.
Doctor: Have you notied her behaving strangly in any way? Guest_family: No. She is acting perfectly normal. Doctor: Has she been gagging, coughing, vomiting or any other symptoms? Guest_family: No. The only thing that I noticed is that she spilled the liquid all over her clothes, the ground and on her hands. Doctor:...	Section Header: REVIEW OF SYSTEMS Summary: The child has not been having any coughing, gagging, vomiting, or other symptoms. Acting perfectly normal. Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes. They did not witness that she ingested any, but did not...
Doctor: Any past medical problems I should know of? Patient: No, ma'am. I am forty three and this is the first time I have had a major issue. It's only been this past month where I've felt weaker than usual. I'm much more tired and short of breath whenever I move around. Doctor: Any recent weight loss? Patient: Yeah...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies f...
Doctor: Do you have any allergies? Patient: No I do not. Doctor: Are you sure? Patient: Yes I am.	Section Header: ALLERGY Summary: No known drug allergies.
Doctor: What is your family medical history? Patient: Nothing that I know of.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Doctor: Did you have a full term delivery? Guest_family: No, he is premature born. Doctor: Was he hospitalized? Guest_family: Yes. Doctor: Was he on any machine like the ones that help breathing? Guest_family: No. Doctor: Was he ever hospitalized afterwards? Guest_family: No. Doctor: Did he have any surgery? Guest_f...	Section Header: PAST MEDICAL HISTORY Summary: Baby was born premature and he required hospitalization, but was not on mechanical ventilation. He doesn't have any hospitalizations after the new born. No surgeries.
Doctor: Do you have any allergies? Patient: No I do not. Doctor: Okay. Patient: Okay. Patient: Are you only asking for medical allergies? Doctor: No, I want to know about all allergies.	Section Header: ALLERGY Summary: There are no known allergies.
Doctor: Anyone smokes in the house? Guest_family: Yes, we do. Doctor: Both of you? Guest_family: Yes, but outside, not inside. Doctor: Okay. Guest_family: We are careful.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Parents do smoke around the house.
Doctor: Do you use any tobacco, inhalation or recreational drugs? Patient: No.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No use of ethanol, tobacco, illicit, or recreational substances.
Doctor: How're you feeling today? Patient: Not great. Doctor: I'm sorry, why is that? Patient: I've had a headache all week along with neck and lower back pain. Doctor: How would you describe the headache? Patient: Throbbing pain. Doctor: Is it constant? Patient: It comes and goes for the most part. Doctor: How...	Section Header: CHIEF COMPLAINT Summary: Headache and pain in the neck and lower back.
Doctor: Do you have any other problems? Patient: I do actually, I have back disc degeneration. Doctor: Oh really? Patient: Yeah. Doctor: When were you diagnosed with it? Patient: Maybe twenty ten?	Section Header: PAST MEDICAL HISTORY Summary: Significant for degenerative disc disease in the back.
Doctor: Any family history of disease? Guest_family: To be honest, I'm not sure. Possibly? I'd have to check and get back to you.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: unknown.
Doctor: Do you have any history of surgical procedures? Patient: I remember having surgery as a child, but I don't know what the surgery was for. It was so long ago.	Section Header: PAST SURGICAL HISTORY Summary: Years ago she had surgery that she does not recall.
Doctor: Who all are there in your family? Patient: Well, it's just me and my brother now. My mom passed away due to stroke at the age of seventy nine. Patient: My father had a good life with no medical conditions. He passed away due to old age, he was ninety one. Doctor: Wow! Any family history of heart disease or dia...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother died at age 79 of a stroke. Father died at age 91 of old age. Her brother had prostate cancer. She has one brother living. No family history of heart disease or diabetes.
Doctor: And are you allergic to any drugs? Patient: Oh yes, I am allergic to what you call Cipro- Doctor: Ciprofloxacin? Patient: Yes! And also, Asprin but that coated one, what is called? Doctor: Oh, you mean enteric coated Aspirin? Patient: Yes, yes, that one!	Section Header: ALLERGY Summary: Ciprofloxacin and Enteric coated aspirin
Doctor: Hi, I am Doctor Chandler. Patient: Hello Doctor. Doctor: So, tell me what's going on? Patient: I am having a headache.	Section Header: CHIEF COMPLAINT Summary: Headache.
Patient: In the past I have been treated for osteomyelitis of my right fifth toe with I V antibiotics therapy. Doctor: Oh, how long back was that? Patient: Ah, about five years back! I was treated for six weeks. Doctor: Oh, Okay. You also have a history of diabetes mellitus? Patient: That is correct.	Section Header: PAST MEDICAL HISTORY Summary: Positive for: 1. Diabetes mellitus. 2. Osteomyelitis of the right fifth toe, which was treated with intravenous antibiotic therapy for 6 weeks about 5 years back.
Doctor: Do you have any major medical conditions that I should know about? Patient: Oh, yeah, I have a whole list of things going on, doctor. Doctor: Like what, ma'am? Patient: Well, I have high blood pressure, hypothyroidism, arthritis, and G E R D. Doctor: I see, what about any mental health, or neurological disea...	Section Header: PAST MEDICAL HISTORY Summary: Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago.
Doctor: I will ask you a few questions about your past medical history. Were you ever diagnosed with anything medically related? Patient: No. Doctor: Were you ever diagnosed with diabetes or any heart conditions? Patient: No. Doctor: Did you ever take medications for any long-term disease? Patient: No. Doctor: Did...	Section Header: PAST MEDICAL HISTORY Summary: Unremarkable.
Doctor: So, who is in your family? Patient: Well, my mom, dad, and I have four brothers aged eighteen, sixteen, fourteen and twelve and I also have a younger sister. She is only three. Doctor: Wow, and you all stay together? Patient: Yes, and we also have two dogs and two cats. Doctor: Okay. And everyone at home is ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister. All the residents at home are sick currently with cold, cough, runny nose, except for mom. At home also live 2 dogs and 2 outside cats. Mom denies any recent travel history...
Doctor: So, are you on any medication currently? Patient: Yes, I am taking Atenolol and Mevacor. Doctor: Hm, and no allergy to any medicine? Patient: Not that I know of.	Section Header: MEDICATIONS Summary: She is on atenolol and Mevacor. ALLERGIES: NO KNOWN DRUG ALLERGIES.
Doctor: I think you are good to go home. I am going to prepare your discharge paper. Patient: That's great!	Section Header: DISPOSITION Summary: The patient is discharged home.
Doctor: So how long have you two been married? Guest_family: We've been together for twenty seven years now. Doctor: Oh wow, that's so wonderful to hear. How did you guys meet? Guest_family: We actually met in high school. We dated for some time and then we took a break, but we ultimately got back together. Doctor: Aw...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her. Unremarkable FHx.
Doctor: I would like to get a detailed history of your inperforated anus and the curvature of the penis. It is a genetic condition. And do you know if you had surgery soon after birth? Patient: Yeah, my mother said that I had to have surgery after she gave birth to me. Doctor: Do you know all the surgeries that you h...	Section Header: HISTORY of PRESENT ILLNESS Summary: Soon after birth for treatment of an inperforated anus and curvature of the penis. At the age of 70 had another penile operation. At the age of 27 and 28 he had repeat operations to correct this. He did have complications of deep vein thrombosis and pulmonary embo...
Doctor: As per your chart, I see you have C O P D and hypertension. Patient: Yes that is right. Doctor: Okay.	Section Header: PAST MEDICAL HISTORY Summary: COPD and hypertension.
Doctor: Do you use any tobacco products? Patient: No. Doctor: Do you drink alcohol or use any recreational drugs? Patient: No. Doctor: Any history of needle drugs or prescription drug abuse? Patient: No.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Denied Tobacco/ETOH/illicit drug use.
Doctor: Hi! Patient: Hello, how are you? Doctor: I am good. Patient: I think I am all well now. Doctor: Yes, looking at your results I think your kidney failure is resolved too.	Section Header: ASSESSMENT Summary: Acute renal failure, resolved.
Doctor: How old are you, young man? Patient: I am twenty one. Doctor: Are you right handed or left handed? Patient: I am right handed. Doctor: So, tell me what brings you here today? Patient: Everything started on the fifth of November. Then after I saw the gradual increase in my symptoms. So it was all like numbn...	Section Header: HISTORY of PRESENT ILLNESS Summary: 21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremi...
Doctor: What brings you in to the clinic today? Patient: Well, I have had a progressive loss of my vision in my right eye. My eye doctor told me that I should come and see a neurologist. So here I am. Doctor: Okay. How long has the vision loss been progressing for? Patient: About two months. It seems like it has bee...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.
Doctor: Do you have any history of rheumatic fever as a child? Patient: No. Doctor: Any history of anything other then usual childhood illnesses? Patient: No.	Section Header: HISTORY of PRESENT ILLNESS Summary: Negative for rheumatic fever. The patient has usual childhood illnesses.
Doctor: So, tell me a little bit more about your family history, please. Patient: Sure, I know that my grandmother on my mom's side had pancreatic cancer, and my dad had prostate cancer. Doctor: Besides cancer, are there any other conditions that you know run in your family? Patient: Um, I know that my dad had heart ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father.
Doctor: What do you do? Patient: I am a registered nurse. Doctor: That's nice. Doctor: And do you smoke or drink? Patient: No sir. Doctor: Any history of drug abuse or anything? Patient: Absolutely not! Doctor: Okay, good.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No history of any smoking, alcohol, or drug abuse. The patient is a registered nurse by profession.
Doctor: Hello, sir. How are you doing? Patient: I am doing well, thanks. Just trying to come to you more regularly to make sure my lungs and heart are okay. Doctor: That's great. The previous notes said that you quit smoking. Are you still off? Patient: Yes, I quit in nineteen ninety six. I come yearly to the doctor's...	Section Header: HISTORY of PRESENT ILLNESS Summary: Quit smoking in 1996. He occasionally drinks alcoholic beverages.
Guest_family: Hello Doctor. I am from High Hope assisted living center. I am Mister Rath's assigned assistant. Doctor: Right. What brings you here? Guest_family: I got some of Mister Rath's food diary sheets here. He has already lost fifteen pounds in the last three months. We were just wondering if he needed to lose ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight.
Doctor: Your condition and all your vital signs look stable to me right now. You must be very careful as your condition can get poor or it might improve as well. Patient: Okay, so what do you recommend? Doctor: Do you have any support system? Is there anyone at home to take care of you? Patient: Yes, my son and his f...	Section Header: DISPOSITION Summary: Guarded.
Doctor: Where do you work? Patient: I'm a truck driver. It's a big construction company. I work for them. Doctor: Do you smoke? Patient: Yeah. Doctor: Cigarette or something else? Patient: I do Cigar.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Cigar smoker. Truck driver.
Doctor: Good morning, ma'am. I just need a few pieces of information before we get started today. Patient: Good morning, doctor. Absolutely, that's not a problem at all. Doctor: Do you smoke or drink, ma'am? Patient: I don't smoke, and I drink, um, I'd say on occasionally. Doctor: What about harder drugs, do you use...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She has no tobacco use. Only occasional alcohol use. She has no illicit drug use. She has two grown children. She is married. She works as a social worker dealing with adult abuse and neglect issues. Her husband is a high school chemistry teacher.
Doctor: Did both your parents have heart complications. Patient: Unfortunately, yes. My mom passed from a heart attack at seventy three and my father at eighty. Doctor: I'm so sorry to hear that. Patient: I lost my brother as well. He passed away from a brain tumor when he was nine years old. Doctor: I can't imagine h...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father died of MI, age 80. Mother died of MI, age73. Brother died of Brain tumor, age 9.

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