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Doctor: Any specific family medical history that I should be aware of? Patient: No. Doctor: Anyone in your family, even grandparents, if you know them, did they have diabetes or high blood pressure? Patient: No. Doctor: Anyone else sick at home? Patient: No.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory. No one else at home is sick.
Doctor: What is your family medical history? Patient: My mother has high blood pressure, and she had a stroke last year. Doctor: Is your mother still with us after the stroke? Patient: Yeah. She is doing well. Doctor: Good. What about your father's medical history? Patient: My father died in a car accident, when he ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 years.
Doctor: Anyone in your family have a history of drug or alcohol abuse? Patient: No. Doctor: Any other medical conditions that might run in your family? Patient: Nope.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Doctor: Do you drink? Patient: Like, every day? Doctor: No, just in general. Patient: No, I don't drink at all. Doctor: Do you smoke? Patient: No, I don't do that at all, either.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient does not smoke nor drink alcohol.
Doctor: Any drug allergies? Patient: Ah yes, I am allergic to... what's the name of the drug? It's called Napro- Doctor: Naprosyn? Patient: Yes, Naprosyn.	Section Header: ALLERGY Summary: Naprosyn.
Doctor: Hi, how old are you madam? Patient: I am ninety three. I am a super duper old Swedish woman. Doctor: Ha! Not so old okay! Patient: I had vomiting episodes and I am feeling very nauseous. Doctor: Oh I am so sorry to hear that. Patient: I have pain in urination too, I think I might have the U T I? Doctor: Let's s...	Section Header: PLAN Summary: The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.
Doctor: Do you drink? Patient: No, never! Doctor: Did you ever smoke? Patient: No. Doctor: How about drugs? Marijuana or anything? Patient: Well, I always stayed away from drugs. Doctor: Good. And what is your living arrangement? Do you stay with your kids? Patient: I live at my place. My kids visit me but mostly I l...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No history of smoking, alcohol, or drug use. She lives at home.
Doctor: Good afternoon, how old are you? Patient: Hello Doctor, I'm fifty four years old. Doctor: What gender do you identify with? Patient: I identify as a female. Doctor: Thank you. What symptoms are you experiencing in your right hand? Patient: I have numbness and tingling in my right hand. Doctor: Are there a...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.
Guest_family: Congestion and cough. Doctor: Oh, how long? Guest_family: It's been three weeks now. Doctor: Okay. Guest_family: He has been like this for so long, but nothing else. Doctor: How about fever nausea vomiting diarrhea? Guest_family: No fever, no vomiting, nothing else. Doctor: Okay great.	Section Header: REVIEW OF SYSTEMS Summary: He has been congested for about three weeks ago. Coughing now but no fevers. No vomiting. Review of systems is otherwise negative.
Doctor: What do you do? Are you working or in school? Patient: I am in school. Doctor: Good. Patient: Thanks.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is currently in school.
Doctor: Do you have any children, ma'am? Patient: Yes, I have a wonderful baby girl at home. Doctor: Wonderful, were there any complications with your pregnancy or delivery? Patient: Nope, everything went very smooth. I'm thankful. Doctor: Good, have you ever been hospitalized for any issue? Patient: No, thankfully...	Section Header: HISTORY of PRESENT ILLNESS Summary: Pregnancy and delivery with no complications. He has no history of hospitalizations or surgeries.
Doctor: Any past surgeries that I should know of? Patient: I had a hip replacement years ago. Doctor: Both hips? Patient: My left. Doctor: Total? Patient: Yeah. Doctor: Got it. Patient: I also had my uterus and appendix removed. I was young when I had my appendix taken out. Doctor: Do you happen to remember who did you...	Section Header: PAST SURGICAL HISTORY Summary: Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.
Doctor: Where do you live? Patient: I live with my mother around the corner where the Whole Foods is. I have been there for a few years now. Doctor: Are you the mother of the patient? Guest_family: Yes, I'm the mother. Doctor: How are you dealing with everything? Guest_family: We just want what is best for him. We...	Section Header: REVIEW OF SYSTEMS Summary: PSYCHIATRIC: The patient lives with his mother and has been staying with her for a few years now. We have talked to her. She is very supportive. His only sister is also very supportive of him. He has lived in the ABCD houses in the past. He has done poorly in some of the...
Doctor: Are you taking any medications? Patient: Yes, I am taking Accutane for my acne issues. Doctor: Okay, any other medicines? Patient: No, just that. Doctor: Okay.	Section Header: MEDICATIONS Summary: Accutane and takes no other medications.
Doctor: Do you have any history of surgeries, sir? Patient: The most recent was seven years ago. I had a craniotomy. I had a brain hemorrhage and there was bleed inside and outside the brain that they had to fix. Doctor: How was the recovery for that? Patient: I took a while but the doctors said I had a normal recov...	Section Header: PAST SURGICAL HISTORY Summary: 1. He has a surgery on his stomach as a child. He does not know the type. 2. Surgery for a leg fracture. 3. Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.
Doctor: Do you have any past medical problems that I should know about? Patient: Well, what exactly do you mean by that, doctor? Doctor: Well, it could be anything from A D H D to depression to epilepsy. Patient: Oh, no. I don't have anything like that.	Section Header: PAST MEDICAL HISTORY Summary: No significant past medical problems.
Doctor: So, lets talk about your family, anybody in your family have any neurological problems? Patient: No, I don't think so, my parents did experience some memory loss but that was when they were in their nineties. And I am assuming it was mostly from the old age rather than any neuro problem. Doctor: Yeah, that is ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.
Doctor: Do you have any family history of heart disease? Patient: My mother has coronary artery disease.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother with history of coronary artery disease.
Doctor: Hello, miss X Y Z. Dr. X and I will go over your report with you to make sure everything is correct. Then, I will ask you a few questions. Patient: Sounds good to me. Doctor_2: Hi, ma'am. Could you confirm your age for me, please? Patient: I'm seventy six years old. I'm also a resident of A S D F if that mat...	Section Header: HISTORY of PRESENT ILLNESS Summary: Ms. XYZ is a 76-year-old resident of ASDF. She is seen at the request of Dr. ABC. She carries a diagnosis of hyperlipidemia, hypertension, and atherosclerotic cerebrovascular disease. She underwent an L3-4 decompression in Month DD, YYYY by Dr. Stanley Gertzbein f...
Patient: Um, do I have to follow some special or soft diet? Doctor: No, nothing like that. You can have a normal diet. Whatever you like to eat. Patient: At this age, my diet is very limited. I am going to be eighty-two next month. Doctor: Well, I don't think you need to restrict your diet. You can follow your regular...	Section Header: PLAN Summary: Regular for age.
Doctor: Do migraine headaches run in the family? Patient: My mother gets migraines and she told me that it runs on her side of the family. Doctor: Any family history of blood clots? Patient: No.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Migraine headaches on maternal side, including her mother. No family history of thrombosis.
Doctor: Are you married? Patient: I was, but my husband died thirty years ago. Doctor: Are you working? Patient: Nope. Doctor: What is your highest degree? Patient: I did high school. I was living alone for fifteen years until December of ninety four. Doctor: How is your living situation now? Who is taking care o...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use.
Doctor: Do you smoke, or have you smoked in the past? Patient: Yeah, I quit two years ago. But before that I used to smoke two packs per day. I first started smoking as a teenager. Doctor: Do you drink at all? Patient: I used to drink six packs of beer plus two additional drinks a day for many years. Good news is t...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: 2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use.
Doctor: Hello, miss. How are you doing today? It looks like we are evaluating C O P D and emphysema. Patient: Yes, the last time I was seen in Pulmonary Medicine Clinic was March two thousand and four. Doctor: It has been quite some time. How are you feeling? Patient: I have actually been hospitalized for psychiatric ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very fru...
Doctor: You can continue working, I just want you to be careful. Patient: Thanks Doctor. I will be. Doctor: Great.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He was released to regular work.
Doctor: Can you confirm your age for me, ma'am? Patient: Sure, I'm fifty six years old. Doctor: Great, so what brings you in to see me today? Patient: Um, I'm peeing a lot, and I'm having a little bit blood in that urine as well. Doctor: Have you ever had a cystoscopy? Patient: Yes, it was unremarkable, that's wh...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night. No gross hematu...
Doctor: Any health issues on your mom or dad's side? Patient: No, we're a pretty healthy family.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Doctor: Hello sir, how are you? Patient: I don't know, I don't know whether I am good, or my problem is getting worse and that is the reason I got myself to your clinic for a neurological consult. Doctor: Hm, don't worry! We will take care of you, let me start by taking some details. Patient: Sure! Doctor: So were y...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social f...
Doctor: All right, you can go home now. Patient: Thank you doctor. Doctor: You can stay at your friend's place and make sure to take good care of yourself. Patient: Yes. Doctor: Make sure you follow up with Doctor X on Monday or Tuesday. I know that Doctor Y already discussed his plans. Continue taking your medicines e...	Section Header: DISPOSITION Summary: She is being discharged to home. She will stay with a friend for a couple of days. She will be following up with Dr. X on Monday or Tuesday. Apparently Dr. Y has already discussed the situation and the plan with her. She will continue on her usual medications except for discont...
Doctor: Do you smoke or drink? Patient: Nope, I've never touched a cigarette nor do I plan on ever doing so. Same goes for alcohol.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She does not drink or smoke.
Doctor: Hi there! Welcome to the Neurology clinic, sir. Patient: Hi! Thank you. Doctor: What brings you in to the clinic today? Patient: I was diagnosed with binocular diplopia twenty five years ago but I haven't had much of an issue with it until about a year ago. Doctor: What did you notice as far as symptoms? Pa...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details ...
Doctor: How old is your son? Guest_family: He is almost five and a half years old now. Doctor: What seems to be the problem? Guest_family: He has a lot of pain about both feet, and if you look at it, it looks like his feet rotate inwards. Doctor: Okay, let me see, okay, um, he has rocker bottom feet. Guest_family...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 5-year-4-month-old male who presents for evaluation of feet. He has been having significant feet pain with significant planovalgus deformity. The patient was noted to have flexible vertical talus. It was decided that the patient would benefit by s...
Doctor: Welcome back to the clinic. Patient: Thank you. Doctor: I understand that we are doing an impairment rating exam today. Patient: Yes, that's correct. Doctor: And we are evaluating your right shoulder injury. Correct? Patient: Yes. Doctor: Was this a workrelated injury? Patient: Yes. I was working as a C...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02. She formerly worked for Veteran's Home as a CNA. She has had a long drawn out course of treatment for this shoulder. She trie...
Doctor: Are you up to date on your vaccines? Patient: I've actually never been vaccinated before. My parents don't believe in vaccines.	Section Header: IMMUNIZATIONS Summary: None.
Doctor: Hi there! Welcome in, sir. Patient: Hi! Thank you. Doctor: What is your past medical history? Patient: No. I don't have any health problems. Doctor: Do you have a primary care doctor? Patient: No. I don't have health insurance right now.	Section Header: PAST MEDICAL HISTORY Summary: The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured.
Doctor: Are you married, ma'am? Patient: Yes. Doctor: Do you smoke, use alcohol or use recreational drugs? Patient: No.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is married. She does not smoke, use alcohol or use illicit drugs.
Patient: In the past I was very very fat! Actually, I was morbidly obese. I also had high blood pressure, but after my surgery it got resolved. Doctor: So, everything is okay now? Patient: Yeah.	Section Header: PAST MEDICAL HISTORY Summary: Significant for hypertension and morbid obesity, now resolved.
Doctor: So, you were referred by Doctor X. Patient: Yeah. Doctor: According to him, I see no changes or correction to your present illness, right? Patient: Yeah, I think so.	Section Header: HISTORY of PRESENT ILLNESS Summary: As per Dr. X without any changes or corrections.
Doctor: Do you have any related family history? Patient: You mean like heart issues in the family? Doctor: Yeah, something like that. Patient: My brother died of heart attack. It was sudden everyone was shocked. Doctor: How old was he? Patient: He was not that old; he was just in his fifties.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She states her brother died of an MI suddenly in his 50s.
Doctor: So, tell me what's going on? What brings you to the emergency? Patient: I felt like my heart will explode. I have never felt palpitations like this. I am feeling so weak. Doctor: When did it start? Patient: This afternoon. Doctor: Hm, so your blood pressure is one ninety five by eighty three and your heart rate...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 66-year-old patient has history of hypertension and has not taken medication for several months. She is a smoker and she drinks alcohol regularly. She drinks about 5 glasses of wine every day. Last drink was yesterday evening. This afternoon, the patient fel...
Doctor: Hello, how are you today? Patient: I am here for a breast cancer screening. Doctor: Have you gotten a mammogram before? Patient: Yes, I have. I also try to keep up with my self examinations every few weeks. Doctor: That is great. I am happy to see you on top of your preventative healthcare. Patient: I try ...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Her sister had breast cancer.
Doctor: Good morning, sir. Patient: Good morning, doctor. Doctor: So, what seems to be the problem today, sir? Patient: Well, I've had toe problems in the past. Doctor: I see, what about the rest of the lower body, any problems there? Patient: Actually, yes, I've had left knee issues in the past, too.	Section Header: PAST MEDICAL HISTORY Summary: He has had toe problems and left knee pain in the past.
Doctor: Do you have a history of any health conditions that I should be aware of, ma'am? Patient: Um, yeah, I had a mastectomy, and chest tube placement. Doctor: Oh, wow. Do you have any chronic conditions? Patient: Yeah, I have chronic A F I B.	Section Header: PAST MEDICAL HISTORY Summary: History of mastectomy, chest tube placement, and atrial fibrillation; chronic.
Doctor: How have you been handing erectile dysfunction since your last visit, sir? Patient: Well, I've been taking the Cialis, it's the, um, ten M G version. Doctor: Have you seen any improvement? Patient: Yes, I've had some, which is good. Doctor: Have you had any side effects? Patient: No, none yet. Doctor: Good...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg. He indicates that he has noticed some mild improvement of his symptoms, with no side effect. On this dose, he is having firm erection, able to penetrate, l...
Doctor: I am afraid, I don't have better news for you, your reports confirm cancer. Patient: We were suspecting it all along, but now since it is confirmed it's just hard to accept. Doctor: I am sorry, I totally understand. Do you want some time? Patient: No, I am okay. Doctor: Hm, you also have hypertension and diabet...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Positive for hypertension, diabetes, and cancer. Negative for heart disease, obesity or stroke.
Doctor: Are you married? Patient: Yes. I am happily living together with my husband and my four kids. Doctor: Oh, do you smoke? Patient: Nope. Doctor: What about alcohol or any other kind of drug use? Patient: Nope.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use.
Doctor: Anyone in the family had any medical issues? Patient: Oh yes. Doctor: Can you please elaborate? Patient: So, my mother's side family had heart issues. My dad's sister had sugar problem.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: There was a history of coronary artery disease and diabetes mellitus in the family.
Doctor: And you are not allergic to anything right? Patient: That's right. Doctor: Any drugs or pollens or anything? Patient: Nope nothing. Doctor: Good.	Section Header: ALLERGY Summary: No known allergies.
Doctor: Has the redness worsened over the last few days? Guest_clinician: I think so. Her right big toe looks worse to me. Doctor: Is she otherwise healthy? Guest_clinician: Um besides her toe and some nasal congestion, she's doing fine.	Section Header: REVIEW OF SYSTEMS Summary: She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness. Review of systems is otherwise negative.
Doctor: You had a surgery on your breasts? Patient: Yes, they removed lump from my left breast. Doctor: Okay, and what other surgeries have you had? Patient: I do not have a gall bladder, then I had a breast augmentation, I have had heart surgeries three times and they have removed half of my pancreas. Doctor: Okay. P...	Section Header: PAST SURGICAL HISTORY Summary: Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.
Doctor: What happened? Guest_clinician: She was brought to emergency by her son. Apparently, she is doing fine, no distress. She is alert, and I was able to communicate with her and take her history, she was cooperative and calmy responded to all my questions. Doctor: Okay, that's good.	Section Header: EXAM Summary: GENERAL: Alert and in no apparent distress, calm, cooperative, and communicative.
Doctor: What is your family medical history? Patient: My family has high blood pressure and diabetes. Doctor: Do you have any family history of nervous system disorder or disease such as multiple sclerosis, Alzheimer's disease, Parkinson's disease, epilepsy, or stroke? Patient: No. Doctor: Do you have any children,...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008.
Doctor: Have you ever had any heart problems in the past? Patient: I remember I did have something heart related but I don't know what that was. I do not understand any medical terms. Doctor: Okay that's fine, I completely understand. We will try to look for your past medical history. Patient: I do have hypertension a...	Section Header: PAST MEDICAL HISTORY Summary: She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history. She states that she has underlying history of heart disease but is not able to elaborate to any significant extent. She also has a his...
Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: So, are you married? Patient: Yes, happily to my husband. Doctor: That's wonderful, um, what do you do for a living? Patient: I work as an office manager right now. Doctor: Do you smoke? Patient: Yes, I do. I've smoked a pack a day for the la...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics....
Doctor: I'm going to run down a list of symptoms and I'd like you to tell me if you've experienced any. Patient: Okay. Doctor: Headache? Patient: No headaches. Doctor: Are you coughing at all? And if yes, then are you bringing up any blood with your cough? Patient: No cough. Doctor: Any chest pain or shortness of...	Section Header: REVIEW OF SYSTEMS Summary: No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND, orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI.
Doctor: Looking at your medical history now. Any changes since your last visit? Patient: No changes.	Section Header: PAST MEDICAL HISTORY Summary: Otherwise reviewed and noted.
Doctor: Hello, sir. Looks like we are here for a general wellness check? Patient: Yes, sir. In my seventy eight years on this Earth, I have learned to take my health more seriously. I need to start catching things before they come, not after. Doctor: I could not agree more. From your last checkup notes, it looks like ...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has, and he just got back from a cruise...
Doctor: And when did you had your last tetanus shot? Patient: Um, I don't remember correctly, but it should be in my reports. I did have one sometime back, just don't remember when exactly. Doctor: Ah, no problem. I see it here in your reports and it's up to date. So that's good. Patient: Cool.	Section Header: IMMUNIZATIONS Summary: Up-to-date.
Doctor: So where do you stay? Patient: I stay nearby in my apartment. Doctor: Alone? Patient: No, I stay with my boyfriend. Doctor: Okay, and do you smoke and drink? Patient: Both. Doctor: And how much would say you smoke per day? Patient: Well, I smoke a lot. Seven to eight packs per day. Doctor: Oh! And for how ma...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She lives with her boyfriend. The patient has a history of heavy tobacco and alcohol abuse for many years.
Doctor: How are you, sir? Patient: One less than sixty. Doctor: So, what happened? Patient: I was visiting my son in Cheyenne, Wyoming, then I on October tenth when I was taking a shower, I felt a pop in my head. I don't know what happened after that. Guest_family: We thought he was having a long shower that day. Th...	Section Header: HISTORY of PRESENT ILLNESS Summary: 59y/o male experienced a "pop" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headac...
Doctor: Is this your first surgery or have you had other surgeries in the past? Patient: This will be my second. I had a hernia repair back in O ten.	Section Header: PAST SURGICAL HISTORY Summary: Hernia repair.
Doctor: Where do you work? Patient: I work at the Hilton as a head chef. Doctor: Do you smoke or consume any form of tobacco? Patient: Nope. Doctor: Do you drink or have ever used any illegal drug? Patient: No, none of that.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Employed cook. Denied ETOH/Tobacco/illicit drug use.
Doctor: Where do you feel the most pain? Patient: I'd have to say at the heels of my feet. I spend a lot of time on my feet at work. Doctor: I see. What kind of shoes do you normally wear to work? Patient: Regular tennis shoes. Doctor: Are they cushioned? Patient: Eh not really, but they're pretty durable. Doctor...	Section Header: REVIEW OF SYSTEMS Summary: Positive findings of the foot that have been recorded. All other systems reviewed were negative.
Doctor: I'm here to take your social history. So, tell me about yourself. Patient: I was taking drugs. I tried all the methods, mainly I was using inhalation and I V drugs. Doctor: Right now, you are on methadone, right? Patient: Yes. I'm also going to the psychiatry department for my depression and these drug issue...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient has a history of inhalation on intravenous drug abuse. She is currently on methadone maintenance. She is being followed in Psychiatry for depression and substance abuse issues. She lives with a room-mate.
Doctor: I will ask you a few questions about your family history, sir. Patient: That's okay. Doctor: Does anyone in your family ever have any medical problems? Patient: Both of my parents had diabetes.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: His father and mother had diabetes.
Doctor: Are you aware of any medical issues in your family? Patient: I don't know. Doctor: What about your paternal family? Patient: I don't know my father. No idea about his family. Doctor: What about your mom? Maternal family? Patient: I have no idea. I'm not in contact with her.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She did not know her father and was not in contact with her mother.
Doctor: Good morning, sir. Before we begin, how old are you? Patient: Good morning, doctor. I'm forty one. Doctor: Thank you, and how long have you had this left knee pain? Patient: It's been about two years now. Doctor: Is there an injury? Patient: Yeah, I sprained my MCL while playing hockey back then. Doctor: Wha...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain. He has had a positive symptomology of locking and pain since then. He had no frank instability to it, however.
Doctor: I see here that you've been feeling more short of breath. Patient: Yes, for three days now. Doctor: Is it worse when you exert yourself? Patient: Um no, not really. I've had a terrible cough along with frequent headaches and chest congestion. I have also had a low fever. Doctor: Did these symptoms start aro...	Section Header: HISTORY of PRESENT ILLNESS Summary: 69-year-old Caucasian male complaining of difficulty breathing for 3 days. He also states that he has been coughing accompanying with low-grade type fever. He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extre...
Doctor: Are you aware of any medical problems in your family? Patient: No. Doctor: Anyone with any heart disease or diabetes? Patient: No.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.
Doctor: Besides pain in your left eye, are you having any other problems? Patient: No. Doctor: Do you happen to have a history of eye problems? Patient: None.	Section Header: REVIEW OF SYSTEMS Summary: Focal left eye pain without any changes in visual acuity or photophobia. He has no prior ophthalmologic problems. Review of systems for cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine, immunologic systems is negative.
Doctor: Hello, sir how can I help you? Looks like we are talking about snoring today. Patient: Yeah, I need to get this loud and obnoxious snoring under control. I keep waking up my partner. I have a C P A P right now because I was told I have almost severe sleep apnea. Doctor: Yes, I see on your chart that you were ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure. He has been on CPAP now f...
Doctor: How are you feeling today? Patient: I have a lot of anxiety. Doctor: Anything else? Patient: I have a lot of pain in my chest as well. Doctor: Do you drink? Patient: Yes, I cannot stop myself. I have tried many times but it's hard to control.	Section Header: CHIEF COMPLAINT Summary: Anxiety, alcohol abuse, and chest pain.
Doctor: So, do you smoke? Patient: No. Doctor: How about alcohol? Patient: I drink, but just normal. I don't have any alcohol problem. Doctor: Okay. So, no history of any drug or alcohol abuse, right? Patient: No, not at all. Doctor: Okay.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He is a nonsmoker. He has been drinking alcohol today, but has no history of alcohol or drug abuse.
Doctor: Hi, how can I help you? Patient: I am here for a follow up on my heart rhythm problem. I think it is atrial fibrillation. Doctor: Oh yes. You are not on Cardizem and your heart rate is up just a little bit today. Patient: That's right. I misplaced it. Doctor: Okay. Let me see. What symptoms are you experienci...	Section Header: HISTORY of PRESENT ILLNESS Summary: ABC is in today for a followup of her atrial fibrillation. They have misplaced the Cardizem. She is not on this and her heart rate is up just a little bit today. She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to...
Doctor: Good morning, young man. Patient: Good morning, doctor. Doctor: Who is this young lady, is this your grandmother, or sister? Guest_family: Oh doctor, yes, I am his grandmother. Doctor: Good, my chart says that you're fourteen years old. Is that correct? Patient: Yes sir. Doctor: Good, so what seems to be th...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 14-year-old male who reported having knee pain for 1 month. Apparently while he was playing basketball on 12/22/2007 when he had gone up for a jump, he felt a pop in his knee. The patient was seen at an outside facility where he was splinted and su...
Doctor: Good afternoon, ma'am. Can you confirm your age for me, please? Patient: Sure, good afternoon, doctor. I'm sixty one years old. Doctor: Great, what brings you in for a visit today? Patient: I have some notes here with me, but I have a history of polyarteritis nodosa mononeuritis multiplex. Doctor: Is this i...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating ...
Doctor: Hi there, what's going on? Guest_family: I am her daughter. I brought her to the emergency. She lives in a skilled nursing home. Today, when I went to meet her, I found her with the right side of her face drooping. I immediately rushed her here. Doctor: Oh, you did the right thing. Ma'am, how are you feeling? ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation...
Doctor: Hello, are you translating for the patient today? I am sorry, but I do not speak Spanish. Guest_family: Yes doctor. Doctor: My chart says this man is fifty two years old, is all of that correct? Guest_family: Yes doctor, that's correct. Doctor: Good, so, what seems to be the problem today? Guest_family: He ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the ...
Doctor: Do you smoke cigarettes? Patient: I smoke about three packs in a month. Doctor: Do you drink alcohol or use recreational drugs? Patient: No. Doctor: What do you do for work? Patient: I am an editorial assistant at the local newspaper.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.
Doctor: Have you had any adverse reactions to medications you've taken in the past? Patient: No, thankfully.	Section Header: ALLERGY Summary: He has no allergies.
Doctor: Are you okay? Patient: Yeah, yeah, I am fine. Doctor: I am asking this as you look a little pale. Patient: No I am okay. I have always been healthy my whole life. Just a little fatigued now. Doctor: Okay that won't be something we can't fix. Patient: Yeah, but I am okay. Doctor: Yes, I do not see any issues wit...	Section Header: PAST MEDICAL HISTORY Summary: Otherwise, reviewed. Fairly healthy.
Doctor: Hello today I have my assistant with me, and she will be representing your case. Tell me who do we have today? Guest_clinician: Patient has been cared by Doctor X since two thousand and two. She had a Codman Hakim shunt set at ninety M M H two O. She last came to our clinic in January two thousand and eight. A...	Section Header: HISTORY of PRESENT ILLNESS Summary: Dr. X has cared for her since 2002. She has a Codman-Hakim shunt set at 90 mmH2O. She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches. We also recommended that the p...
Doctor: Tell me about the medical issues you had in the past or still do. Patient: Well, I have asthma, sinus. I also have hives and there is a history of psoriasis. Doctor: Wow, okay. Any known allergies? Patient: Nothing that I have known.	Section Header: ALLERGY Summary: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies.
Doctor: Any known allergies? Patient: No.	Section Header: ALLERGY Summary: None.
Doctor: Hello there, how are you doing? Patient: Sorry, I'm just not feeling well. Something is wrong. Doctor: Don't worry, I will check you up. We will figure it out. Do you remember when you had your last physical? Patient: It was sometime in early May in two thousand and eight. Doctor: Okay, I'm going through yo...	Section Header: HISTORY of PRESENT ILLNESS Summary: This patient presents to the office today because he has not been feeling well. He was in for a complete physical on 05/02/2008. According to the chart, the patient gives a history of feeling bad for about two weeks. At first he thought it was stress and anxiety a...
Doctor: So just to double check, you're not on any medications? Patient: You got it. Nothing since last year.	Section Header: MEDICATIONS Summary: None.
Doctor: What brings you in today? Patient: I have this nasty cough and my nose has been super stuffy. Doctor: Are you bringing anything up when you cough? Patient: Not really, no. Doctor: Are you having any other symptoms, such as chest pain, headaches, nausea, or vomiting? Patient: No. I did have a slight headach...	Section Header: ASSESSMENT Summary: Upper respiratory infection.
Doctor: How are you feeling today, sir? Patient: I feel pretty weak right now, but I am doing okay at the moment. Doctor: I reviewed the chart notes that was sent to me by the nursing home. They also sent me your medical history. You have been going through a lot recently. Patient: Yes, I have. They moved me into th...	Section Header: HISTORY of PRESENT ILLNESS Summary: He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07. He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. He is unable to stand at the moment. He is ...
Doctor: How is your sleep? Are you sleeping well? Patient: Yes, without any disturbance. I sleep like a log! Doctor: Good. Any mood swings or did you feel your emotions are out of control? Patient: Nah, just the normal mood swings around my periods otherwise no problem at all. Doctor: Any depression like feeling, sud...	Section Header: REVIEW OF SYSTEMS Summary: PSYCHIATRIC: No history of emotional lability, depression or sleep disturbances.
Doctor: How's he doing today? Guest_family: I think he might have fifth disease with sinusitis. It's been running rampant at his school. Doctor: Oh, wow. Let's see what we can do.	Section Header: ASSESSMENT Summary: Fifth disease with sinusitis.
Patient: Help! I need help! I need to see the doctor! Doctor: Yes, what's wrong? Where's your pain? Patient: My stomach! It hurts so much! I've never had this type of pain before! Doctor: When did it start? Patient: At ten! I don't know. It started hurting out of nowhere. One second I'm driving home and the next t...	Section Header: CHIEF COMPLAINT Summary: Abdominal pain.
Doctor: Just want to ask you few routine questions, let me know if any of this is positive. Patient: Sure, go ahead. Doctor: Do you have any problems like headache, fever, rash, oral ulcer? Patient: None. Doctor: Any problem with vision? Like unable to see or double vision? Patient: Um no, I can see everything. Doctor:...	Section Header: REVIEW OF SYSTEMS Summary: No rashes, headache, photophobia, diplopia, or oral ulcers. No palpitations, orthopnea or PND. No diarrhea, constipation, melena, bright red blood per rectum, or pale stool. No jaundice. Decreased appetite, but no weight loss.
Doctor: Good morning, ma'am. What seems to be the problem with your knee? Patient: I've had pain in this knee since I tripped on some ice on March tenth two thousand three. Doctor: How old are you now? Patient: I'm forty seven. Doctor: What kind of symptoms have you had since the fall? Patient: It's hard for me to...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice. The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative proce...
Doctor: How're you doing today, sir? Patient: Uh I'm hanging in there. Doctor: I see that you've recently celebrated your seventy second birthday. Patient: Yep. My kids and grandkids threw me a surprise party. It was really nice. Doctor: Aw surprises are always fun. However, I'm sorry to hear that you're not doing...	Section Header: HISTORY of PRESENT ILLNESS Summary: On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for t...
Doctor: And where do you live? Patient: Well, I live in this small town called Fayetteville in Tennessee. Doctor: Ah, I see. And do you have lot of friends there? Patient: I have few. Doctor: Okay, and do you drink? Patient: No. Doctor: How about smoking? Patient: Never did!	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She does not drink or smoke. Lives in Fayetteville, Tennessee.
Doctor: How are you feeling? Patient: I am feeling better now. Doctor: What happened last night? Guest_family: She went out to a party last night. She came home drunk and high. Doctor: What did you take? Patient: I took Ecstasy. I only had two drinks. Doctor: How much Ecstasy did you take? Patient: I didn't take...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecsasy tablets. The patient upon returning to home was energetic an...
Doctor: Do you have any support system? Patient: No, I am single. Doctor: Okay so live alone at home? Patient: Yes. Doctor: Do you smoke or drink? Patient: Nope I do not.	Section Header: PAST SURGICAL HISTORY Summary: The patient is single. Living at home. No smoking or alcohol.
Doctor: So, are you married? Patient: No, my wife and I got divorced a while ago. We have three children together, though. Doctor: Okay, and do you have someone who is managing your case? Patient: Yes, I have an lawyer handling everything. Doctor: Do you smoke or drink? Patient: No, I never really smoke or drink.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney.
Doctor: Have you ever had surgery? Patient: No, not that I can remember. Doctor: No gallbladder or appendix removal, c sections, or joint replacements? Patient: Nope, never had anything done.	Section Header: PAST SURGICAL HISTORY Summary: Otherwise, negative.
Doctor: I just need to confirm a few pieces of information from my nurse before we begin today, sir. Patient: Sure, no problem, doctor. Doctor: Great, so it says here that you are forty five years old, and you identify as Caucasian. Is that correct? Patient: Yes, that's correct. Doctor: Thank you, so, what seems to ...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain. He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.

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