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Doctor: I am going write you a prescription for a stimulant. It is called Cylert.	Section Header: MEDICATIONS Summary: Cylert.
Doctor: Are you married? Patient: Yes. I have been married for twenty two years. Doctor: Are you working? Patient: No. I am unemployed. I have not completed my collage degree yet. I have been in school for the last two years. Doctor: Keep at it.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: unemployed. 2 years of college education. Married 22 years.
Doctor: Nurse, do you have a report on my patient? Guest_clinician: I do. She has a two year history of small cell lung cancer, which spread to both femurs, lower lumbar spine, and pelvis. Doctor: Oh, no. Did she get chemotherapy? Guest_clinician: She's had chemotherapy and radiation treatments multiple times. She c...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is on my schedule today to explore treatment of the complaints. She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis. She states she has had numerous chemot...
Doctor: Any fever, chills or rigors? Patient: No. Doctor: Any blurring of vision or history of glaucoma or cataract? Patient: No. Doctor: Did you experience any shortness of breath? Patient: No. Doctor: Any stomach discomfort? Patient: No. Doctor: Did you observe blood in your stool or in vomit? Patient: No, nothing ...	Section Header: REVIEW OF SYSTEMS Summary: CONSTITUTIONAL: No history of fever, rigors, or chills. HEENT: No history of cataract, blurring vision, or glaucoma. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena. UROLOGICAL: No frequ...
Doctor: Have you experienced any diarrhea? Patient: Yes. I have been having diarrhea. When I think about it, it started happening around the same time that the mouth sores started. I didn't have any diarrhea today though. Doctor: Have you experienced any episodes of nausea or vomiting? Patient: No. Doctor: Have you...	Section Header: ASSESSMENT Summary: Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems. Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have becom...
Doctor: Are you on insulin? Patient: Yes. Doctor: Are you on metformin as well? Patient: Yes. Doctor: How about glucotrol? Patient: Yes I take that. Doctor: Are you on lipitor? Patient: Yes.	Section Header: MEDICATIONS Summary: Insulin, metformin, Glucotrol, and Lipitor.
Guest_clinician: What was he given in the E R? Doctor: Epi one M G, zero point three M L subcutaneously along with fifty M G of Benadryl intramuscularly. In about fifteen to twenty minutes, he reported his itching had improved. The rash itself faded a little bit and he began to feel a lot more comfortable.	Section Header: EMERGENCY DEPARTMENT COURSE Summary: The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly. After about 15-20 minutes he states that itching started to feel better. The rash has started to fade a little bit and feeling a lot more comfortab...
Doctor: Hello, how are you? Patient: I am good, Doctor. Doctor: So, what brings you here today? Patient: Well, I have many medical issues and I see Doctor X for them, but I wanted a second opinion, so he referred me here. Doctor: Yeah, he is a good man! Don't worry we will take care of you. Patient: Thank you. Doctor...	Section Header: REVIEW OF SYSTEMS Summary: The patient has multiple medical problems, for which she is under the care of Dr. X. She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease. There is a history of anemia and there is a history of sciatica, which has been cause...
Doctor: Welcome back to Sample Clinic, Mister Sample. Patient: Good afternoon, doctor. Doctor: What seems to be the problem today, sir? Patient: I'm having a lot of pain in my right heel. Doctor: How long have you had this pain? Patient: Um, it's been about two weeks now. Doctor: When is the pain the worst? Patien...	Section Header: HISTORY of PRESENT ILLNESS Summary: Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day...
Doctor: What is your family medical history? Patient: My family has a high blood pressure. I have a family member that had colon cancer. My daughter has a twitch. They don't know what caused it? Doctor: Okay.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: HTN, Colon CA, and a daughter with unknown type of "dystonia."
Doctor: Hello Miss Long, I see that you have been referred today by A B C, D O, for a reevaluation. Are you having issues with your hand eczema again? Patient: Yes, it has been flaring. Doctor: Can you confirm your age for the records please? Patient: Sure, I'm twenty nine. Doctor: If I'm not wrong, you are from Vi...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increa...
Doctor: Have you been applying Triamcinolone zero point one percent three times a day to your rash? Patient: The one on my left wrist? Doctor: Yes. And Bactroban ointment is also three times a day as needed for your bug bites. Patient: Yep. Doctor: Are you still using Nystatin on your lips once a day as needed? Pa...	Section Header: MEDICATIONS Summary: She is currently on her nystatin ointment to her lips q.i.d. p.r.n. She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs. Her other meds remain as per the dictation of 07/30/2004 with the...
Doctor: So, I am looking at your reports, you don't have anemia or any other blood disorders. Patient: Well, that's a relief! Doctor: Yeah. Doctor: Let me check your lymph nodes. They are nonpalpable. I don't see any swollen glands or anything. Patient: Great!	Section Header: REVIEW OF SYSTEMS Summary: HEMATOLOGIC/LYMPHATIC:: Normal; Negative for anemia, swollen glands, or blood disorders.
Guest_family: Hi, how are you? Doctor: I am well, how's the baby? I see that he is eight pounds and thirteen ounces, and he was born via…? Guest_family: Yes, C section. Yeah, he is he has never been hospitalized. He was born a week early. Doctor: Okay, I would like to ask you some questions about the pregnancy and othe...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS...
Doctor: Welcome to the clinic, sir. I am Doctor Jones. Patient: Thank you. It is nice to meet you. Doctor: Do you use tobacco products? Patient: Yes. I smoke cigarettes. I am working on quitting. Doctor: I am glad you are attempting to quit. We have a lot of tools now to help with cravings. How much do you smoke pe...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He lives with his wife. He works at Shepherd Pratt doing network engineering. He smokes a pack of cigarettes a day and is working on quitting. He drinks four alcoholic beverages per night. Prior to that, he drank significantly more. He denies illicit drug use...
Doctor: Are you married? Patient: I'm divorced. Doctor: So, do you live alone? Or do you have kids? Patient: I live with my girlfriend, and we have a kid together. I also have three other kids from my former wife. Doctor: Do you smoke? Patient: I used to smoke. But I, I've quit like fifteen years ago. Doctor: Wha...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.
Doctor: Do you want to go home? Patient: Yes, I do. Can I? Doctor: Yes, you sure can.	Section Header: DISPOSITION Summary: To home.
Doctor: Are you studying? Patient: Yes. I'm doing my major in computer science. Doctor: Do you live alone? Patient: No, I live in my family. Mainly my parents and my sisters.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: lives with parents and sisters.
Doctor: Have you ever had surgery before? Patient: No, not that I know of. Doctor: So, no gallbladder removal, or joint replacements? Patient: Unless they did it while I was sleeping, but none that I can remember.	Section Header: PAST SURGICAL HISTORY Summary: No previous surgeries.
Doctor: I remember you had mentioned that one of your family members had bone cancer. Are there any other medical problems that run in your family? Patient: Sadly, yes. Stroke and dementia are the other two big ones. Doctor: I'm sorry to hear that.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: stroke, bone cancer, dementia.
Doctor: Are you allergic to any meds? Patient: Me? Doctor: Yes. Patient: No, I am not. Doctor: Are you sure? Patient: Yes, I am damn sure. Doctor: Okay great!	Section Header: ALLERGY Summary: None known to medications.
Doctor: What's bringing her in today? Guest_family: Oh, doctor. She hasn't been doing well at all. Guest_family: I think she's actually gotten worse. Doctor: I understand. I'm sorry to hear that she hasn't been feeling well. Let me see what we can do for her today. Guest_family: I haven't taken her temperature sinc...	Section Header: DIAGNOSIS Summary: Upper respiratory illness with apnea, possible pertussis.
Doctor: And you've had recurring abscesses for the past two years, correct? Patient: Unfortunately, yes. Doctor: Where have they been located? Patient: Um in the public area and my thighs. Doctor: Have you ever needed to get an abscess drained? Patient: Yeah. I've gotten about four I and D's.	Section Header: CHIEF COMPLAINT Summary: Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.
Doctor: How's your overall health? Patient: Fine, I guess. I'm being treated for I B S by my G I. Last time I was in, they told me that my white blood cell levels aren't where they were supposed to be.	Section Header: PAST MEDICAL HISTORY Summary: Episodic leukopenia and mild irritable bowel syndrome.
Doctor: Do you have any family history of chronic illnesses that I should know about? Patient: What do you mean by that? Doctor: Well, it could be anything from depression, to arthritis, to cancer. Patient: Oh yeah, my mom has arthritis.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Patient admits a family history of arthritis associated with mother.
Doctor: How are you moving around? Are you able to perform your day to day activities? Patient: Little bit, not so much. Doctor: So just listen to your body and go around as much as you can. Patient: Okay. Doctor: Do not overstress yourself. Patient: Okay I can do that.	Section Header: PLAN Summary: As tolerated.
Doctor: Are you allergic to anything? Patient: No, I am not allergic. Doctor: Okay. Patient: Yeah.	Section Header: ALLERGY Summary: No known drug allergies.
Doctor: Remind me, how did he hurt himself? Guest_family_1: He was riding quads on October tenth two thousand seven when he got thrown off. Doctor: Yes, and we did O R I F on his fracture dislocation of the left elbow. Guest_family_1: Yes, he also fractured the neck of his right glenoid, um, if I remember correctly. ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007. The patient underwent open reduction and internal fixation of his left elbow fracture dislocation. The patient also sustained a nondisplaced right glenoid neck fractu...
Doctor: Since you have a family history of coronary heart disease, let me check you for its risk factors. Patient: Yeah, my father had it. Doctor: Any history of high blood pressure or diabetes? Patient: No. Doctor: How about smoking, do you smoke? Patient: No, I don't smoke. Doctor: And in the past, did any other Do...	Section Header: HISTORY of PRESENT ILLNESS Summary: CORONARY RISK FACTORS: No history of hypertension or diabetes mellitus. Active smoker. Cholesterol status, borderline elevated. No history of established coronary artery disease. Family history positive.
Doctor: Who all are there in your family? Guest_family: It's me, my husband, my two older kids and this little baby. Doctor: Everyone living together? Guest_family: Yes Doctor: Is she going to any daycare? Guest_family: No, she's at home all the time.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Currently lives with her mom, dad, and two siblings. She is at home full time and does not attend day care.
Doctor: Do you drink? Patient: Oh, I do but occasionally. Who doesn't like a nice cocktail! Doctor: Okay. How about cigarettes, do you smoke? Patient: No, I don't smoke.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient does not smoke. She does have an occasional alcoholic beverage.
Doctor: I am okay. Patient: I have bad nausea. Doctor: Oh, so sorry. Patient: And I feel very dizzy like I am going to faint. Doctor: Okay let me see what is going on. Patient: Okay.	Section Header: CHIEF COMPLAINT Summary: Nausea and feeling faint.
Doctor: What brings you into the office today? Patient: I had a stroke about a month ago. The right side of my face is still not moving. Doctor: Is it only the right side of the face that is affected by paralysis? Patient: Yes. It has improved a little bit since I was in the hospital. Doctor: That is a good sign...	Section Header: CHIEF COMPLAINT Summary: Right-sided weakness.
Doctor: Do you use tobacco? Patient: What, like smoke cigarettes? Doctor: Yes ma'am, do you? Patient: Oh, no. I don't do anything like that.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is a nonsmoker.
Doctor: Have you ever had surgery, ma'am? Patient: Yes, I had it for melanoma some time ago. Doctor: I see here that you had a hysterectomy as well, is that correct? Patient: Oh, yes, that's true. I had that done too.	Section Header: PAST SURGICAL HISTORY Summary: Surgery for melanoma and hysterectomy.
Doctor: So, let's see here. You don't recall anyone in your family having a history of neuromuscular diseases, correct? Patient: No, no one I can think of. Doctor: Do you know of anyone who has had foot deformities or neuropathy in their arms or legs? Patient: No, not one person comes to mind. Doctor: Great. Does anyo...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases. His aunt has a history of type II diabetes.
Doctor: So, what I feel is you might have short term memory loss due to high stress, but I also feel it's probably due to your current situation. The other impression I have is that you have anxiety issues and again it's stress related. Patient: Yeah, I do have anxiety issues.	Section Header: ASSESSMENT Summary: 1. Short-term memory loss, probable situational. 2. Anxiety stress issues.
Doctor: Who's my patient today? Guest_family: Today, it's my brother. Doctor: What seems to be the problem today? Guest_family: Well, he's a vegetarian but he has high cholesterol and he's on a medication to control it. Doctor: Has he changed his diet? Guest_family: Yes, he did when he got a letter saying that his fat ...	Section Header: HISTORY of PRESENT ILLNESS Summary: His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy ...
Doctor: The patient has possible free air in their diaphragm. Guest_clinician: How old is the patient? Doctor: Seventy six. Guest_clinician: Past medical history? Doctor: Unknown as of now.	Section Header: CHIEF COMPLAINT Summary: Possible free air under the diaphragm.
Doctor: Out of ten, ten being the worst pain imaginable, how would you rate your pain today? Patient: Today it's about a six or seven, and it's usually pretty constant there. Doctor: Does the pain change with the weather? Patient: Yes, when it's cold out it turns to ten out of ten. It's better when it's warm out. D...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather. The patient states that pain is dramatically less, when the weather is warmer. The patient also states that pain worsens ...
Guest_family: For as long as I have been taking care of her, she has had this tracheal tube and she barely speaks. She mostly signals if she needs anything. Doctor: Okay. It's mentioned in her report that she has a history of smoking. Guest_family: She is nodding yes. Doctor: Well, it's alright. I think it's going to ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient had been previously a smoker. No other could be obtained because of tracheostomy presently.
Doctor: Have you been taking anything for high blood pressure? Patient: Yeah, I started taking Toprol and uh the one that starts with an A. I forget what it's called. Doctor: Hm are you talking about Avalide? Patient: Oh right, yeah that's the one.	Section Header: MEDICATIONS Summary: Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned.
Doctor: Good afternoon, ma'am. Before we begin, may I ask how old you are? Patient: Good afternoon, doctor. I'm fifty six years old, now. Doctor: Great, thank you. What seems to be the problem today, ma'am? Patient: Well, I need some support for dietary recommendations for healthy eating for my husband and me. Doct...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some s...
Doctor: Hello! What brings you into the office today? Patient: Hi! I have not been able to go pee, and I have had this sharp pain in my left side. Doctor: Have you recently had any surgical procedures? Patient: No. Doctor: Do you have a history of an enlarged prostate or kidney stones? Patient: No. Doctor: I would ...	Section Header: CHIEF COMPLAINT Summary: Left flank pain and unable to urinate.
Doctor: Has he ever had any mental retardation problems in the past? Guest_family: No. Doctor: Did he go through mainstream education? Guest_family: Yes, he graduated high school last year. He had an I E P. He has a job now. Doctor: Oh really. That's great. Guest_family: We went through a program for the disabled ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled.
Doctor: And you are- Guest_family: Hi, I am her nurse. Doctor: So, do you know about her past medical history? Guest_family: I have very limited information, as I very recently started working with her. She does have dementia and that's the main reason why I was hired. Her family wanted someone to look after her twent...	Section Header: PAST MEDICAL HISTORY Summary: Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.
Doctor: Your last visit was on April seventh two thousand five, correct. Patient: Ah no, it was on April eighth two thousand five, doctor. Doctor: That's right. So, has anything changed since then? Patient: No, everything is the same really.	Section Header: PAST MEDICAL HISTORY Summary: Essentially unchanged from my visit of 04/08/2005.
Doctor: Any nausea, vomiting or diarrhea? Patient: Nope.	Section Header: REVIEW OF SYSTEMS Summary: No nausea, vomiting, or diarrhea.
Guest_family: What do you think doctor, what does she have? Doctor: Well, I think she has hay fever. Otherwise she looks like a healthy two year old. Guest_family: Hm, okay.	Section Header: ASSESSMENT Summary: Allergic rhinitis. Otherwise healthy 2-year-old young lady.
Doctor: Hello, sir. I'll be your doctor today. How are you feeling? Patient: Um uh who? Where am I? Doctor: You're in the emergency room. Patient: I'm where? Doctor: The police found you outside of the local bar. Do you remember what happened prior to your arrival here? Patient: I'm no longer at the bar? Doctor: ...	Section Header: REVIEW OF SYSTEMS Summary: Not obtainable as the patient is drowsy and confused.
Doctor: How's your husband doing? Patient: He's good. He usually comes with me to my appointments, but he had to run some errands this morning. Doctor: Happy to hear that he's also doing well. Patient: Me too. Doctor: I just have one more question for you regarding your social history. Do you smoke? Patient: No,...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is married. She is a nonsmoker.
Doctor: How are you feeling today? Patient: I am doing good, considering. Doctor: Are you sleeping well? Patient: Yes. I was able to get some good sleep last night. Doctor: Have you been able to eat without any trouble? Patient: Yes. I ate a little bit of breakfast this morning. Doctor: Have you been able...	Section Header: REVIEW OF SYSTEMS Summary: The patient has been eating fairly well, sleeping well, doing well with her sprints. A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.
Doctor: Our records show that he is up to date with his vaccinations. Guest_family: Okay.	Section Header: IMMUNIZATIONS Summary: Up-to-date.
Doctor: Are you allergic to any medications? Patient: No	Section Header: ALLERGY Summary: None.
Doctor: So, do you remember when your last pap smear was? Patient: I have it written down right here in my notes. It was in October of two thousand one. Doctor: Great, do you have any children? Patient: Yes, I have a beautiful daughter. Doctor: That's wonderful. Have you only been pregnant once? Patient: Yes, I've ...	Section Header: GYNECOLOGIC HISTORY Summary: Last pap performed 10/2001. Gravida: 1. Para: 1.
Doctor: Have you undergone any surgeries? Patient: I had both my tubes tied in O one and I had a polyp removed when I was fourteen. Doctor: And that was a- Patient: Oh, sorry I didn't mean to interrupt. Doctor: It's alright. I just wanted to know if that polyp was found in your colon? Patient: Yes, it was.	Section Header: PAST SURGICAL HISTORY Summary: Bilateral tubal ligation in 2001, colon polyp removed at 14 years old.
Guest_family: Doctor can you check my baby boy? Doctor: Yes for sure. Guest_family: He has a fever.	Section Header: CHIEF COMPLAINT Summary: Fever.
Doctor: Where's your rash? Patient: All over my torso and arms. Doctor: When did you first notice it? Patient: Well, it started on my back and then it made its way to my torso and arms. Doctor: Have you found yourself itching it? Patient: Yes. Doctor: Any potential triggers for the rash, such as dietary changes,...	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: Are you allergic to anything? Patient: As in drugs? Doctor: Yes, sorry. I was referring to drug allergies. Patient: Oh yeah. I'm allergic to Sulfa drugs. Doctor: What happens when you take Sulfa drugs? Patient: Break out in a terrible rash. I remember I had to go to the E R the first and last time I took it...	Section Header: ALLERGY Summary: Sulfa.
Doctor: Do you smoke? Patient: Yes. Doctor: How much do you smoke? Patient: Honestly, I smoke every day.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient current smokes.
Doctor: Does any of your family member have any major medical problems? Patient: Yeah, my mother died of heart attack. She was seventy years old. My father died of cancer; it was prostate cancer. He was around eighty. Doctor: Anything anyone else? Patient: Hm, my brother had both heart disorder and prostate cancer and ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74.
Doctor: Where's your pain? Patient: Right above my belly button. It's been bothering me for three weeks now. Doctor: Does the pain come and go? Patient: Um it's pretty constant, but it does seem to get worse at night. Doctor: Do you find that sitting or laying down in certain positions helps the pain? Patient: Eh...	Section Header: CHIEF COMPLAINT Summary: Abdominal pain and discomfort for 3 weeks.
Patient: Good morning, doctor. Doctor: So, I've reviewed your past notes, are there any other diagnoses I should know about? Patient: Well, I've had depression for a while now. Doctor: Thank you for sharing that with me.	Section Header: PAST MEDICAL HISTORY Summary: Depression
Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: So, what do you do for a living? Patient: Right now, actually, I'm not working. Doctor: That's okay, I'm not here to judge. Are you married? Patient: No, I'm happily single right now. Doctor: Good for you, do you have any kids? Patient: No, ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is not working. Rates her stress level as an 8/10. She is single with no children. Does not smoke, drink, or utilize illicit substances.
Doctor: Hello. How are you doing today? Patient: My head has been hurting a lot. Doctor: I see. Did the nurse come in and ask you questions about past medical history? Guest_clinician: Sorry, Doctor. I was looking for you. I reviewed his history with him, and nothing has changed. Doctor: Perfect. Let's do some tests ...	Section Header: PAST MEDICAL HISTORY Summary: otherwise unchanged.
Doctor: We're going to check around your knee now. Patient: Okay, sounds good. Doctor: Looks like your deep tendon reflexes are the same on both legs. Sensation seems great and intact.	Section Header: EXAM Summary: NEUROLOGIC: Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch.
Doctor: Can you tell me something about your family? Any illnesses in family? Patient: My dad's mom has diabetes and hypertension and my dad's dad had emphysema and he was a smoker. Doctor: Okay. Patient: Yeah. Doctor: Is there any history of death of child who was less than a year maybe? Patient: No, there isn't. D...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.
Doctor: Alright, I am looking at your urine report and it confirms what I was suspecting. You have a urinary tract infection. Patient: I kind of knew it was a U T I. I have had it before, but nothing this painful and severe. I feel like I am going to die! Doctor: Oh yes, it is because you got something called as acute ...	Section Header: ASSESSMENT Summary: Diabetes type II uncontrolled. Acute cystitis.
Doctor: Good morning, ma'am. Patient: Good morning, doctor. Doctor: Before we begin, I just have a few questions. Do you remember what illnesses you had as a child? Patient: Yes, I got a few. I had strep throat, mumps, and, um, chickenpox growing up.	Section Header: PAST MEDICAL HISTORY Summary: Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox
Doctor: Hi there! I am Doctor Sherman. Patient: Hello! It is nice to meet you. Doctor: It looks like your P C P sent you to us for a possible prostate problem. Patient: Yes. I am nervous. Doctor: Do not be nervous. We will start with discussing the symptoms you have been experiencing, a physical exam and then we wi...	Section Header: CHIEF COMPLAINT Summary: Urology.
Doctor: What are you taking for allergies? Patient: Claritin. Doctor: Okay. Patient: For my allergic rhinitis.	Section Header: MEDICATIONS Summary: Claritin for allergic rhinitis.
Doctor: Do you have any known allergies to medication? Patient: Nope. None that I know of.	Section Header: ALLERGY Summary: None.
Doctor: What is your family medical history? Patient: My dad had a heart attack and passed away at sixty one. Doctor: I am so sorry to hear that. Patient: Thank you. Doctor: Do you know of any other major health conditions in your family? Patient: No. None that I know of. Everyone is relatively healthy. Doctor: T...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father died, MI age 61.
Doctor: Hello, sir how are you feeling today? Patient: I feel terrible. Very sick and I can barely move. I feel so weak.	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient states that he feels sick and weak.
Doctor: So, we looked at your previous blood work results, now let me see what these reports say from today's C B C exam. Patient: Sure. Doctor: Okay so your hemoglobin levels look within range, white counts are thirteen point three, then seven point six lymphocytes and twenty six thousand platelets. Doctor: Okay? Pati...	Section Header: IMAGING Summary: The patient's CBC results from before were reviewed. Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.
Doctor: Welcome back. Patient: Thank you. Doctor: You are back for a follow up on your right arm pain, right? Patient: Yes. It has been almost a year since the pain first started. Doctor: How has your arm been feeling? Patient: I still have this dull pain in my upper outer area of my arm. Doctor: How long does th...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain. He states that a little less than a year ago he developed pain in his right arm. It is intermittent, but has persisted since that time. He describes that he ...
Doctor: What type of surgery have you had in past? Anything big or small? Patient: I had a C section for my kiddo and one D and C. Doctor: Okay.	Section Header: PAST SURGICAL HISTORY Summary: C-section and D&C.
Doctor: Are you currently taking any medications? Patient: No.	Section Header: MEDICATIONS Summary: None.
Doctor: So are you allergic- Patient: To any medications? No allergies here.	Section Header: ALLERGY Summary: No known medical allergies.
Doctor: Hello again! Patient: Hi! Doctor: The results from you M R I showed nothing concerning. The growth factors were normal with normal cell function and no signs of decreased blood supply to the brain. Patient: That's great news. Doctor: Yes it is.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: GF with CAD, otherwise unremarkable.
Doctor: So, I understand that you had a fall. Patient: Yes. I did fall. Doctor: What happened? Patient: I don't really know. I have balancing problems. I have been to my P C P for this issue a few days ago. I saw her about a week and a half ago because I had another fall. Maybe around late December since today is Ja...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and fa...
Doctor: Do you smoke? Patient: Yes, I do. Doctor: How much? I mean can you tell me approximate amount? Patient: Yes sure, I smoke half a pack a day. Doctor: How about alcohol and drugs? Patient: No, I do not drink or use. I have a five month old baby.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She had a baby five months ago. She smokes a half pack a day. She denies alcohol and drug use.
Doctor: With ten being the worst pain imaginable, how would you rate your pain today out of ten, ma'am? Patient: Well, out of ten, I'd say it's about a seven. Doctor: How would you describe your pain? Patient: Um, I'd say it's deep, and it really aches. Doctor: Where is your pain located? Patient: It's in my right...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse. The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region. Aggravating factors include stairs and prolonged driving, as well as general l...
Doctor: Welcome in! Patient: Thank you. Doctor: Let us get a little background. What is your medical history? Patient: I have some memory loss problems. Doctor: What kind of memory problems? Patient: Well, I have seizures. Doctor: Do you know what kind of seizures that you have? Patient: I have temporal lobe sei...	Section Header: PAST MEDICAL HISTORY Summary: Significant only for hypertension and left temporal lobe epilepsy.
Doctor: Did you have any medical issues? Patient: Nope. Doctor: What about surgery. Patient: No, I never had a surgery.	Section Header: PAST SURGICAL HISTORY Summary: She has undergone no surgical procedures.
Doctor: How old are you? Patient: I am seventy three. Doctor: Are you right handed or left handed? Patient: Right. Doctor: So, I see the chief complaint is memory loss and cognitive decline. Tell me what exactly happened, and how did you notice the symptoms? Let me document that today is January twelfth of ninetee...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94. Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play "Murder She Wrote" at family gathering. Un...
Doctor: You are not allergic to anything? Patient: No, I am not. Doctor: Any food or other pollen? Patient: No, I am not allergic to anything. Doctor: Great!	Section Header: ALLERGY Summary: None.
Doctor: April twenty two three we checked your list of medications. Doctor: We saw that it lifts up in the morning and evening. Doctor: Yeah. Patient: Yeah.	Section Header: MEDICATIONS Summary: Her list of medicines is as noted on 04/22/03. There is a morning and evening lift.
Doctor: How old is the baby? Guest_family: He is twenty one months old. Doctor: What brings you here today? Guest_family: I have concerns about his motor development. Many times he seems to have lazy eyes and sometimes I can notice his jaw quivering. Doctor: How was your pregnancy? Guest_family: I had no complicati...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no know...
Doctor: What brings you back into the clinic today? Patient: I have been having some severe bruising. I have been taking Coumadin for three months now. Am I taking to much Coumadin? Doctor: You are taking a normal start dose. Some people do not metabolize the medication as well as others. I would like to get you teste...	Section Header: CHIEF COMPLAINT Summary: Probable Coumadin hypersensitivity.
Doctor: Let me examine you. Tell me, did you have any fever or chills, any sweating or that sort of thing? Patient: Um no. Doctor: How about abnormal weight loss or weight gain? Patient: No. Doctor: Are you experiencing any chest pain on exertion or shortness of breath normally or when you try to sleep? Patient: No, n...	Section Header: REVIEW OF SYSTEMS Summary: General: No fevers, chills, or sweats. No weight loss or weight gain. Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations. Neurologic: No paresis, paresthesias, or syncope. Eyes: No double vision or blurred vision. Ears: No tinnitu...
Doctor: Are you allright? Patient: Yes I am fine. Doctor: That's great. Patient: Thanks. Doctor: I think you can go home now.	Section Header: DISPOSITION Summary: Stable.
Doctor: I'm reviewing my notes from your last visit. Your last visit was on May tenth two thousand four, correct? Patient: Yes, that's right. Doctor: Has there been any change since your last visit? Patient: Well, I'm having some increased paranoia. Doctor: Have you been treated, and are you taking medicine for thi...	Section Header: PAST MEDICAL HISTORY Summary: Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications.
Doctor: I just met with one of my patients whom I believe has pertussis. Guest_clinician: Second case of the day. What's their name and date of birth? Doctor: Hm give me a second to pull up their information.	Section Header: CHIEF COMPLAINT Summary: Public Health Department was notified of a case of suspected pertussis.
Doctor: Have you ever had psychiatric or psychological treatment? Patient: Uh no, no treatments whatsoever. I mean I do find myself in low moods every now and again when I'm dealing with certain stressors, but the decreased moods rarely ever long lasting.	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient denied any history of psychological or psychiatric treatment. He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.
Doctor: Do you remember when your last flu vaccine was? Patient: I don't remember what month, but it was in nineteen ninety nine. Doctor: Good, and do you remember your last pneumonia vaccine? Patient: Let me look at my notes here, um, it was in nineteen ninety six. Doctor: Thank you, now, tell me more about your pa...	Section Header: IMMUNIZATIONS Summary: Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996. Family Medical History: Father age 79, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 74. No brothers and sisters.
Doctor: How are you doing today, ma'am? Patient: I'm doing just fine. Doctor: Any kind of alcohol consumption? Patient: Nope. Doctor: Have you ever taken any kind of illegal drugs? Patient: Nope. Doctor: What about smoking? Patient: No. Doctor: Are you still working? Patient: No, sir. I had issues with my knees, and ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is retired on disability due to her knee replacements. She does not smoke, drink or use any illicit drugs.
Doctor: Do you have any chest pain? Patient: No, I don't. Doctor: Any breathlessness? Patient: Yes, I do get breathless only when I have to do some form of exertion like walking a long time or running. Doctor: Okay. How about any bowel issues? Patient: No, I don't have any stomach problems except I have to go frequentl...	Section Header: REVIEW OF SYSTEMS Summary: He denies any chest pain. He admits to exertional shortness of breath. He denies any GI problems as noted. Has frequent urination as noted. He denies any bleeding disorders or bleeding history.
Doctor: Does she lives with anyone? Guest_family: Yes, we all stay together, so just the immediate family. My parents, me and my sister. Doctor: Okay.	Section Header: HISTORY of PRESENT ILLNESS Summary: She lives with her parents.
Doctor: Hi, the weather outside is beautiful, did you get some sunshine? Patient: Yes in fact I came in walking. Doctor: Great way to get some exercise in. Doctor: ok so what's going on? Patient: I am having a bellyache. Doctor: Since when? Patient: Oh, it's been a while now. Doctor: Can you tell me more about your pai...	Section Header: HISTORY of PRESENT ILLNESS Summary: 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unr...

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