Split (2)

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Doctor: Good morning, sir. Can you confirm your age for me, please? Patient: Good morning, doctor. I'm fifty nine years old. Doctor: Great, and which hand is your dominant hand? Patient: Um, I use my right hand for everything. Doctor: Great, thank you. So, what seems to be the problem today? Patient: I have had th...	Section Header: HISTORY of PRESENT ILLNESS Summary: This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower ext...
Doctor: Do you have any known allergies to medications? Patient: No.	Section Header: ALLERGY Summary: None.
Doctor: Good evening, and welcome to A B C D General Hospital E D. Patient: Thank you, Doctor, I've really messed up this ankle. Doctor: Before we begin, how old are you? And which gender do you identify? Patient: Thank you for asking, Doctor, I'm a fifty year old man. Doctor: Thank you, what happened? Patient: I f...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement. There was no open injury. The patient fell approximately 10 feet off his liner, landing on his left foot. There was evidenc...
Doctor: What medications are you currently taking? Patient: Augmentin, Detroal LA and lisinopril.	Section Header: MEDICATIONS Summary: Augmentin; Detrol LA; lisinopril.
Doctor: Did you ever have any surgery? Patient: No.	Section Header: PAST SURGICAL HISTORY Summary: Negative.
Doctor: Hello, miss. How are you doing today? Patient: I have this massive headache. Doctor: I see. Do migraines usually run in your family? Patient: They do. Everyone has it. We've been having it for many years. Doctor: Oh, wow. I'm looking at your blood reports, and it shows you have high blood sugar. Does diabet...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: There is family history of migraine and diabetes in her siblings.
Doctor: What's bringing you in today? Patient: I've had a terrible toothache. I can't stand the pain anymore. I have never experienced this pain in fifty eight years. Doctor: Where are you experiencing the most pain? And when did this pain start? Patient: It started about three weeks ago. It's mostly on the left side...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, bu...
Doctor: How long has your finger been in pain, sir? Patient: Well, at this point, it's been more than a few months. Doctor: Have you seen another doctor for this pain? Patient: Yeah, I saw another guy a little while ago. Doctor: Do you have the records from the visit? Patient: Yeah, actually, they're right here. Doct...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient has been followed elsewhere, and we reviewed his records. Essentially, he has had a trigger finger and a mucocyst, and he has had injections. This has been going on for several months. He is now here for active treatment because the injections were not...
Doctor: Hello, I am Doctor James. Guest_family: Hi Doctor, this is my daughter Miya, and I am Jena. Doctor: Nice to meet you ladies. So, Miya how old are you? Patient: I am fifteen. Doctor: Okay, so tell me what is going on with you? Patient: Well, I am having a severe headache. Guest_family: She has been complainin...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 15-year-old girl presenting with occipital headache for the last six hours. She denies trauma. She has been intermittently nauseated but has not vomited and has some photophobia. Denies fever or change in vision. She has no past history of headaches.
Doctor: And you said you're right handed, correct? Patient: Yep. Right handed. Doctor: Okay, great. I've made note of it in your chart. I have one more question to ask regarding tobacco and alcohol. Do you smoke or drink? Patient: I don't do either. I can't even think of the last time I took a sip of alcohol.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is right-handed. She does not smoke and does not drink alcohol.
Guest_clinician: What brings him in today? Doctor: He's here for sepsis and I suspect he may have spontaneous bacterial peritonitis. Guest_clinician: Let me pull up his chart.	Section Header: CHIEF COMPLAINT Summary: Sepsis, possible SBP.
Doctor: Let's check your throat. Okay, I don't see any swelling or any mass. Is there any pain when I touch you? Patient: No pain. Doctor: I don't feel any kind of lump in your throat. That is a good sign. It looks very flexible and symmetric.	Section Header: EXAM Summary: NECK: Supple and symmetric. There was no thyroid enlargement, and no tenderness, or masses were felt.
Patient: Good afternoon, doctor. Doctor: Remind me, please, how old are you? Patient: I'm sixty nine years old, doctor. Doctor: Thank you, what seems to be the problem today? Patient: Oh, I've had pain in these knees for years, but it's been getting a lot worse over the last few months. Doctor: Is the pain messing w...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living. He attempted conservative treatment, which includes anti-inflammatory medicat...
Doctor: How's this little guy doing today? Guest_family: I think he might have another ear infection. Doctor: Oh, I'm sorry to hear that. Let's have a look see. Guest_family: He's been telling me over and over again that his left ear is hurting him. He was here on April fourteenth and prescribed Amoxicillin. Doc...	Section Header: HISTORY of PRESENT ILLNESS Summary: Mom brings the patient in today for possible ear infection. He is complaining of left ear pain today. He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today. He ...
Doctor: How are you feeling today, sir? Patient: I'm doing much better today, doctor. Doctor: How is your strength and muscular pain? Patient: They're both improving. Doctor: Do you have any other complaints today? Patient: No, I'm doing quite well, honestly.	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient was seen and examined. He feels much better today, improved weakness and decreased muscular pain. No other complaints.
Doctor: You have cholesterol issues, right? Patient: Yes. Doctor: Okay. I see. Gemfibrozil? That sounds familiar? Do you take that? Patient: Yes, I think that one. But I am not sure. Doctor: Okay. Do you remember taking them at all as an outpatient? Patient: I mean I don't remember. Doctor: Okay don't worry I can look...	Section Header: PAST MEDICAL HISTORY Summary: The only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil. The patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient.
Doctor: Are you taking any medicine? Patient: No.	Section Header: MEDICATIONS Summary: None.
Doctor: So it looks like you're here today for a noticeable foreign body sensation in your eye. Patient: Yeah, my left eye. Never had this happen to me in my forty one years. Doctor: First time for everything I guess! When did you first notice the sensation? Patient: Um when I was at work this morning. It felt like s...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye. He states that he was doing his normal job when he felt a foreign body sensation. He attempted to flush this at work, but has had persistent pain which has pro...
Doctor: What brings you in today? Patient: I've had a lot of discomfort in my private area. Doctor: When did it start? Patient: It's been going on for about two weeks now. Doctor: Have you noticed any abnormal discharge? Patient: Not really, no. But it's been super itchy down there. Doctor: Any abdominal pain, n...	Section Header: CHIEF COMPLAINT Summary: 1. Infection. 2. Pelvic pain. 3. Mood swings. 4. Painful sex.
Doctor: Do you have any allergies? Patient: No, I do not have any allergies. Doctor: Okay so no medically relevant allergies then. Nothing? Patient: Nope.	Section Header: ALLERGY Summary: She has no known medical allergies.
Doctor: I don't think we need to do any major procedure right now. Patient: Okay.	Section Header: PROCEDURES Summary: None.
Doctor: Did you have any medical issues? Patient: Nope.	Section Header: PAST MEDICAL HISTORY Summary: Otherwise negative.
Doctor: Any known allergies? Patient: Oh yes, I cannot take Sulfa drugs. Doctor: Let me add that to your record.	Section Header: ALLERGY Summary: She is allergic to Sulfa.
Doctor: So how are you feeling? Patient: I am feeling well. Doctor: Any illness or fever? Patient: No, nothing like that. Doctor: Any headache or nausea? Patient: No. Doctor: Any vomiting or stomach upset? Patient: No. Doctor: Okay, any numbness tingling or loss of sensation in the hand? Patient: No, not at all. Doc...	Section Header: REVIEW OF SYSTEMS Summary: Otherwise well. No febrile illness. No motor or sensory complaints of any sort or paresthesias in the hand.
Doctor: Welcome to the clinic. I am Doctor Frank. Patient: Thank you. It is nice to meet you. Doctor: What brings you into see me today? Patient: I think I may have had a stroke. Doctor: What happened to make you think that you had a stroke? Patient: This morning, I felt like something in my throat. It was a stran...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 75-year-old female who comes in today with concerns of having a stroke. She states she feels like she has something in her throat. She started with some dizziness this morning and some left hand and left jaw numbness. She said that she apparently ...
Doctor: What is your family medical history? Patient: My mom was healthy all her life. She died of old age. She was eighty nine years old. My dad died of a stroke. He was eighty nine as well. Doctor: Do you have siblings? Patient: Yes I had a brother and a sister. My sister died way too young. She was only thirty whe...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother died age 89 of "old age." Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of cancer.
Doctor: Do you have any known drug allergies? Patient: No.	Section Header: ALLERGY Summary: None.
Doctor: Any history of heart attack? Patient: No. Doctor: Any chest pain, palpitations or shortness of breath on exertion? Patient: No. Doctor: How about your blood pressure? Patient: It's normal. Doctor: Any swelling? Patient: No. Doctor: Any history of irregular heartbeats? Patient: No.	Section Header: REVIEW OF SYSTEMS Summary: CARDIOVASCULAR: Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. No history of heart attack, no history of arrhythmias, no history of hypertension.
Doctor: Hi, do you smoke? Patient: No, sir, I don't. Doctor: Do you take any drugs? Patient: No. Doctor: What about drinks? Do you take alcohol in any form? Patient: No, none of those.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Denies Tobacco/ETOH/illicit drug use.
Doctor: Hi there, so you are here for your follow up? Patient: Yes, I had a surgical removal of multiple abscesses on my right thigh. Doctor: Okay, let me quickly check your discharge sheet. Patient: Sure. Doctor: It says you had multiple extensive subcutaneous abscesses on your right thigh and there was a massive op...	Section Header: DIAGNOSIS Summary: 1. Multiple extensive subcutaneous abscesses, right thigh. 2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh.
Doctor: Hi Gina, how are you? Patient: I wish, I was in better state but yeah, I am okay. Doctor: I understand. So, you are here for your follow up post your surgeries, right? Patient: Yes, I am. Doctor: Alright, I see you recently had your left breast removed due to cancer. Patient: Correct. Doctor: And then you also...	Section Header: PAST SURGICAL HISTORY Summary: Status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis.
Doctor: Hello. How are you all doing today? Guest_family: We're doing fine. I'm the mother of my four year old boy. Doctor: Hello, ma'am. What seems to be the problem? Gest_family: We just wanted to follow up after my son's E R visit. Doctor: Oh, no. What happened? Guest_family: He was playing at the park and thought...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 4-year-old white male, apparently dominantly right-handed who suffered a severe injury to his left distal humerus after jumping off of a swing. He apparently had not had previous problems with his left arm. He was seen in the Emergency with a grossly defo...
Doctor: You had a heart procedure done couple months back right? Patient: Yes, they had to do a cardioversion on me because of my heart rhythm disorder. Doctor: Okay. Patient: And I am taking a blood thinner right now. Doctor: Yes, I saw, you are on Coumadin. Do you know other medications you are on? Patient: Yes, I ha...	Section Header: HISTORY of PRESENT ILLNESS Summary: He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation. He also lists some other medications. I do have his medications list. He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other ...
Doctor: What is your family medical history? Patient: My uncle on my dad's side of the family had kidney failure. I lot of my family members have diabetes and asthma.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family.
Doctor: What is your family medical history? Patient: My dad passed away from a heart attack. He was fifty nine. My mom died from complications with her diabetes. Doctor: Do you have any siblings? Patient: Yes. My brother had a bypass with a graft in August of ninety five.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.
Doctor: Hello, how are you? Patient: What? Doctor: How are you related to the patient? Guest_family: Hello doctor, I am his son. Doctor: Hello. How old is he? Guest_family: He is eighty years old. He is suffering from dementia. Doctor: I see. Do you think he will be able to provide me with his medical history? Gue...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain. In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstructi...
Doctor: What is your family medical history? Patient: My mother had cancer. She had multiple myeloma. She passed away at age eighty three. My dad died when he was eighty one.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father passed away at 81; mother of multiple myeloma at 83.
Doctor: How are your parents doing? Patient: Unfortunately, they both passed away. Doctor: Oh no, I'm so sorry to hear that. Patient: Thank you, its okay, I manage.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient's parents are deceased.
Doctor: What's going on? Patient: I am having a bellyache. Doctor: Since when? Patient: Oh, it's been a while now. Doctor: Okay. Patient: Yeah.	Section Header: CHIEF COMPLAINT Summary: Chronic abdominal pain.
Doctor: So, you are following up for your high blood pressure and high cholesterol? Patient: Yes.	Section Header: CHIEF COMPLAINT Summary: Followup on hypertension and hypercholesterolemia.
Doctor: Hey, what's going on with you today? Patient: Oh, I have a chest pain. Doctor: You have fever too? Patient: Yes, I did.	Section Header: CHIEF COMPLAINT Summary: Chest pain and fever.
Doctor: Hi, how are you? Patient: I am feeling not so good. Doctor: What happened and how long since it started? Patient: Oh, I don't remember it. Just my head is hurting so much. Guest_family: Hi doctor, she is my mother. Her dementia has progressed and most of the time she does not remember anything. Doctor: Oh, I s...	Section Header: REVIEW OF SYSTEMS Summary: She has moderate-to-severe dementia and is unable to give any information about history or review of systems.
Doctor: Any past medical history I should be aware of? Patient: Nope.	Section Header: PAST MEDICAL HISTORY Summary: None.
Doctor: Do you have allergies to any medications? Patient: Um I'm allergic to Clonidine and Medifast. Doctor: What happens when you take Clonidine? Patient: I get a really bad rash. Doctor: And how about with Medifast? Patient: I get very tired after taking it. The last time I took it, I had trouble getting out of ...	Section Header: ALLERGY Summary: He has known history of allergy to clonidine, Medifast does fatigue.
Doctor: Good morning, ma'am. My nurses tell me that you're thirty nine years old, is that correct? Patient: Good morning, Doctor. Yes, that's correct. Doctor: So, what seems to be the problem today, ma'am? Patient: I hurt my knee while on the trampoline back in late August. Doctor: Do you remember the mechanism of i...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August. She was diagnosed per MRI. An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear. She states she has had multiple episodes of inst...
Doctor: Can you tell me more about your family history, ma'am? How is your father doing? Patient: Well, doctor, my father passed away from leukemia a while back. Doctor: I'm so sorry to hear that. What about your mother? How is she doing? Patient: She died too. She had kidney and heart failure. Doctor: I'm sorry, ma'...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Her father died from leukemia. Her mother died from kidney and heart failure. She has two brothers; five sisters, one with breast cancer; two sons; and a daughter. She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depr...
Doctor: Anyone sick at home? Patient: No, fortunately. Everyone else is feeling fine.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Everyone else is healthy at home.
Doctor: Hi there! What brings you in today? Patient: I have not been feeling well. I am tired and feel weak. Doctor: Have you had any other symptoms? Patient: I noticed after I went to the bathroom this morning, that my urine was dark. Doctor: Have you been staying hydrated? Patient: Yes. Doctor: Lets get a urine...	Section Header: CHIEF COMPLAINT Summary: Dark urine and generalized weakness.
Doctor: Good afternoon, sir. Patient: Good afternoon, doctor. Doctor: You're forty four, correct? Patient: Yes sir. Doctor: Great, what seems to be the problem today, sir? Patient: Well, doctor, I've had lower back pain for a while now. Doctor: Does the pain go into your legs? Patient: Yeah, I have pain in my ri...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. He attributes this to an incident in which he was injured in 1994. I do not have any paperwork authenticating his claim that there is an open claim. Most recently he was...
Doctor: Did you have an allergic reactions to any medication? Patient: Nope. Doctor: Okay.	Section Header: ALLERGY Summary: No known drug allergies.
Doctor: Hello, how are you? Patient: I am doing well. Just here for a follow up visit. Doctor: Are there any changes from the last visit in your social history or medical history? Patient: No. Whatever you wrote last time should be correct. I was here just three months ago. I was here December third of two thousand an...	Section Header: OTHER_HISTORY Summary: Reviewed and unchanged from the dictation on 12/03/2003.
Doctor: Do you take any meds? Patient: No. Doctor: Are you sure? Patient: Yes.	Section Header: MEDICATIONS Summary: He is on no medications.
Doctor: Did you have any surgeries in the past? Patient: No.	Section Header: PAST SURGICAL HISTORY Summary: Negative.
Doctor: Welcome to the clinic. Patient: Thank you. Doctor: I would like to start with your medical history. Do you have any medical problems or conditions? Patient: I don't have any medical conditions other then the one I was sent to you for. Doctor: Yes. Doctor Hanine sent over your recent blood test results and c...	Section Header: PAST MEDICAL HISTORY Summary: History of IgG subtype multiple myeloma.
Doctor: So, how are feeling? Doctor: You came here last time with C V A right? Patient: Yeah, I am recovering well. You asked me to follow-up for high sugar. Doctor: Oh yeah, you have diabetes mellitus. Did you happen to get a blood test done before this visit? Patient: Yes, I did here is the report.	Section Header: CHIEF COMPLAINT Summary: Followup on diabetes mellitus, status post cerebrovascular accident.
Doctor: What is your family medical history? Patient: I don't know of any family health problems.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: noncontributory.
Doctor: What brings you here today? Patient: I have a queasy tummy and the feeling that I am about to throw up all the time. Doctor: Anything else? Patient: I'm actually throwing up a lot.	Section Header: CHIEF COMPLAINT Summary: Vomiting and nausea.
Doctor: Do you smoke? Patient: Yeah, here and there. Doctor: On average, how many cigarettes would you say you smoke? Patient: Probably three or four if I had to guess. Doctor: Any medical problems that run in the family? Patient: Yeah, my brother had a heart attack when he was pretty young. Doctor: How old was h...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Her father has type I diabetes and heart disease. She has a brother who had heart attack at the age of 52. He is a smoker.
Doctor: Hello, miss. How are you doing? Patient: I am fine. I just have a few questions about diet and exercise. I want to get my health in order. Doctor: Okay, great. That's something we can handle today. Can you tell me about your familial history? This will help me see any possible ailments that we should watch out...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Reviewed. Mother died from congestive heart failure. Father died from myocardial infarction at the age of 56. Family history is positive for ischemic cardiac disease. Brother died from lymphoma. She has one brother living who has had angioplasties x 2. She h...
Doctor: Smoke or drink? Patient: No and no.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is a nonsmoker. He denies use of alcohol.
Doctor: Are you allergic to anything? Patient: No, I am not. Doctor: How about food allergies. Patient: No, I am fine. Doctor: Okay.	Section Header: ALLERGY Summary: None.
Doctor: Do you have any food allergies? Patient: Nope. Doctor: Any drug allergies? Patient: No.	Section Header: ALLERGY Summary: None.
Doctor: Do you smoke? Patient: Yeah, I smoke weed every now and again. It helps with my anxiety. Doctor: How about cigarettes? Patient: No, not the least bit interested in cigs. Doctor: Good to keep it that way.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient smokes marijuana. The patient does not smoke cigarettes.
Doctor: Hello! Who do we have here today? Guest_family: Hello, this is our son, A B C. Doctor: How old is he? What is the issue? Guest_family: He is two. He is continuously complaining of pain in his belly and back. He is active otherwise. Doctor: Did you notice any change in his toilet habits or routine? Guest_famil...	Section Header: HISTORY of PRESENT ILLNESS Summary: Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any feve...
Doctor: Can you tell me about the medications that you are currently using? Patient: I am taking Alesse twenty eight. Doctor: Do you know its strength? Um, like how many milligrams? Patient: Oh yes, it is twenty M C G and I take point ten milligrams of it. Doctor: When did you start it? Patient: On seventh August in...	Section Header: MEDICATIONS Summary: Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.
Doctor: What type of surgeries have you had in the past? Patient: I don't know what surgery they did today. I mean I don't know the name of it. Doctor: It's okay, I know. It is Lap Band. Patient: And I have had right side foot surgery done in the past. Doctor: Okay great. Patient: Sure.	Section Header: PAST SURGICAL HISTORY Summary: 1. Lap-Band done today. 2. Right foot surgery.
Doctor: Please, tell me a little more about your son. Guest_family: Well, he's twelve years old now, but he was born at about a month and a half early. Doctor: Were there any other complications with the pregnancy? Guest_family: He was exposed to drugs in the womb while I was pregnant, and he has been diagnosed with...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 12-year-old boy born at a 32-week gestation and with drug exposure in utero. The patient has diagnosis of autism as well. The patient presented with bilateral knee flexion contractures, initially worse on right than left. He had right distal media...
Patient: Oh doc, I've had a lot of trouble breathing lately. Doctor: I'm sorry to hear that. We'll get to the bottom of it. Patient: Yeah, I lose my breath so quickly with just one to two flights of stairs. Doctor: When did you first start noticing this? Patient: I believe two weeks ago. Doctor: Any chest pain or ti...	Section Header: REVIEW OF SYSTEMS Summary: Dyspnea on exertion. No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.
Doctor: Can you tell me more about your family medical history, sir? How's your dad doing? Patient: Well, doctor, he passed away. He had mesothelioma. Doctor: I'm so sorry to hear that, sir. How is your mother? Patient: It's okay, thank you. I lost her too. She had A L S. Doctor: I'm sorry, that must be so hard. Pat...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: His father died of mesothelioma and his mother died of Lou Gehrig's disease.
Doctor: Good afternoon, who's the victim today, sir? Is it you, or your daughter? Guest_family: Good afternoon, doctor. It's my daughter today. Doctor: Remind me, how old is she? Patient: I'm thirteen, sir. Doctor: So, what happened? My nurses tell me she fell today. Patient: Yeah, I fell off the swing at school ea...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today. The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow...
Doctor: So, tell me did anyone in your family have Idiopathic pulmonary fibrosis? Patient: Actually, my father passed away due to this disease. Doctor: Oh, sorry to hear that. Patient: Yeah. Doctor: Anything else that he or any other family member might have. Patient: Oh, he also had this spastic colon problem and ir...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Significant for his father who died of IPF and irritable bowel syndrome.
Doctor: How are you today? Patient: I am doing okay. Doctor: Do you have any medical conditions? Patient: I have diabetes. Doctor: When were you diagnosed with diabetes? Patient: It was two thousand and three, I think. I also have high blood pressure, asthma and high cholesterol. Doctor: Okay.	Section Header: PAST MEDICAL HISTORY Summary: He has had diabetes since 2003. He also has asthma, hypertension, and hypercholesterolemia.
Doctor: I do not feel any swellings in your neck or groin area. Patient: Oh yeah, I don't notice anything either. Doctor: Okay yeah, I was just trying to look for any lymph nodes. Patient: Okay. Doctor: Let me check. Patient: Sure.	Section Header: EXAM Summary: LYMPH: There was no appreciated node that I could feel in the groin or neck area.
Doctor: Your bloodwork came back from the Coumadin sensitivity test. The results showed a high level of sensitivity. I am going to adjust your dosage of Coumadin to a much lower dose. This will help reduce the bruising and the bleeding episodes. Do you have any questions? Patient: No.	Section Header: ASSESSMENT Summary: Hypersensitivity to Coumadin.
Doctor: Hello. You must be his mom. Guest_family: Yeah, he started having a sore throat last night. And that's why we are here. His eyes have been really puffy. Uh, we gave him some Benadryl. Doctor: Hm. Patient: I had a stuffy nose and it was hard to breathe. Doctor: When did it all start? Guest_family: It started ...	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 use tobacco, alcohol, or recreational drugs? Patient: No.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Denied Tobacco/ETOH/illicit drug use.
Doctor: What's a young thirty one year old like you doing in my office today, ma'am? Patient: Well, I got referred to P T after I had a fall. Doctor: When was your fall? Patient: Um, it was on October third two thousand eight. Doctor: What happened when you fell? Patient: I tripped over my dog's toy. Doctor: Did you...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs tha...
Doctor: Do you smoke cigarettes? Patient: No, that never really appealed to me, doctor. Doctor: Good, what about more illicit substances? Patient: Oh, most certainly not. Doctor: What about alcohol, do you drink? Patient: Well, I'd say I'm an occasional drinker.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is a nonsmoker and does not use illegal drugs. Occasionally drinks.
Doctor: Do you mind elaborating more on your family history? Did either of your parents suffer from any medical problems? Patient: Sure. My dad had heart disease. He passed at seventy five. He had a sister with diabetes and I think my mom may have had diabetes as well. Doctor: Got it. Patient: As for my mom, she ha...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85. In addition, his father had a history of heart disea...
Doctor: Any muscular pain? Patient: No, not really. Doctor: Any problem in walking? Patient: No, it's normal. Doctor: Let me check your toes and fingers. Can you move them for me? Patient: Yeah. Doctor: Everything looks fine. Nails looks fine too. No bluish discoloration no sign of any infection. Can you push your l...	Section Header: EXAM Summary: MSK: Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable.
Doctor: Do you have a known- Patient: Drug allergy? Doctor: Oh no, I meant family history of disease.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Doctor: Have you experienced any headaches or blackouts recently? Patient: No. Doctor: Dizziness or seizure? Patient: Nope. Doctor: Any history of stroke? Patient: No. Doctor: Okay, good.	Section Header: REVIEW OF SYSTEMS Summary: NEUROLOGIC: Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.
Doctor: Hi there! I am Doctor Kim. Nice to meet you, miss. Patient: Hi! Nice to meet you. Doctor: How are you feeling today? Patient: I am feeling much better today. Doctor: How old are you? Patient: I am forty six. Doctor: How is your pain in the left side? Patient: It is much better. It is more like a dull pai...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. Details are in the history and physical. She does have a vague history of a bruised left kidney in a motor vehicle accident. She feels much bette...
Patient: Well, I have a long family history of heart problems. My mom died quite young at the age of fifty due to heart attack and my father was detected with heart failure, he has a pacemaker. Doctor: Oh, I am sorry to hear about your mom. Patient: Yeah. Also, high blood pressure runs in my family. Doctor: Okay.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed.
Doctor: Where are you experiencing the most pain? Patient: All over my belly. Doctor: How long has this been going on? Patient: Two to three weeks. Doctor: Does the pain come and go? Patient: It does. Doctor: And how would you describe- Patient: The pain? Doctor: Yes. Patient: Hm I'd describe it as a gnawing ...	Section Header: CHIEF COMPLAINT Summary: Abdominal pain.
Doctor: Hi, there. Patient: Hi. Guest_family: Hi! It is nice to meet you. Doctor: It is nice to meet you as well. You are the husband, correct? Guest_family: Yes. I am the husband. Doctor: How long have you two been married? Guest_family: We have been married for forty eight years. Doctor: Do you live in the sam...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient lives with her husband of 48 years. She used to be employed as a registered nurse. Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medicati...
Doctor: Do you have a history of surgeries? Patient: I had a bone fragment removed from my right arm. I had a D and C done a long time ago. It was a treatment for H P V. More recently I had an ovarian cancer staging biopsy done. I have not heard back with the results yet. I only had it done less then a week ago. Doct...	Section Header: PAST SURGICAL HISTORY Summary: 1. A D and C. 2. Bone fragment removed from her right arm. 3. Ovarian cancer staging.
Doctor: Anybody else in your family suffers from this condition? Patient: No. Doctor: Okay.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Doctor: Hello Miss Jane, how are you? Patient: I am good, thank you for asking. Doctor: So, tell me what brings you here? Patient: I have so many issues and problems, where do I start? Doctor: Start by telling the one troubling you the most. Patient: I have this pain in my toes on the right side and I also feel this n...	Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is in with several medical problems. She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain. She initially describes it as a sharp quality pain, but is unable to characterize it more fully. ...
Doctor: Do you have any known allergies to medications? Patient: No.	Section Header: ALLERGY Summary: No known drug allergies.
Guest_family: He is coughing for one week now. Doctor: How about any congestion? Is it one week or more? Guest_family: No did I say that? I meant two to three weeks. I am so worried. He is just one year. Doctor: Don't worry let me see, can you tell me everything from the beginning? Guest_family: Sure. It started off ...	Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks. Started off as a congestion but then he started coughing about a week ago. Cough has gotten worsen. Mother was also worried. He had Pop Can just three days ago and...
Doctor: Hi, how are you? Patient: I am good, Doctor. Doctor: So, I see you recently moved to U S A from Brazil, right? Patient: Yes, about one year back. I was an engineer manager back there, but my job was so stressful that when I got admitted in the M B A program here in the states, I took it. Doctor: Wow, that's qu...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was "very stressful". He had recently ...
Doctor: Do you drink, sir? Patient: No, I don't drink at all. Doctor: How about tobacco? Do you smoke? Patient: Well, yes. Doctor: How much do you smoke, sir? Patient: I smoke about a half a pack of cigarettes a day.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He does admit to one half pack of cigarette consumption per day. He denies any alcohol consumption.
Doctor: How are you feeling? You have been sick? Patient: Yes, I am not feeling well for the last three days. I have bad body aches, cough and a sore throat. Doctor: Do you get wet cough or it's dry? What color sputum comes out? Patient: It is wet and green colored stuff comes out. Doctor: Okay we will need to send ...	Section Header: HISTORY of PRESENT ILLNESS Summary: XYZ is in today not feeling well for the last three days. She is a bit sick with bodyaches. She is coughing. She has a sore throat, especially when she coughs. Her cough is productive of green colored sputum. She has had some chills. No vomiting. No diarrhea. ...
Doctor: Hi there, what's going on with you? Patient: Well, I am having this weird jerky movement in my arm and leg. Doctor: Oh okay, let me take a look.	Section Header: CHIEF COMPLAINT Summary: Arm and leg jerking.
Doctor: Good afternoon, sir. Is this your mother? Patient: Good afternoon, doctor. Yes, this is my mom. Doctor: Great, please, give me some background information on your history. Patient: Well, I used to live here in the city when I went to college, but I wanted to get away from a bad crowd, so I came back to live ...	Section Header: HISTORY of PRESENT ILLNESS Summary: This patient presents to the office today with his mom for checkup. He used to live in the city. He used to go to college down in the city. He got addicted to drugs. He decided it would be a good idea to get away from the "bad crowd" and come up and live with his...
Doctor: Hi there, how is it going? Guest_family: Hi doctor, I am his son Ethan. Doctor: Nice to meet you. Doctor: So, I see your father has a history of drug abuse, right? Guest_family: Yes. Patient: Not abuse, I just used to do drugs. The last time I really made a big mistake I injected the heroine directly into both...	Section Header: CHIEF COMPLAINT Summary: The patient is a 62-year-old male with a history of drug use. He had a history of injection of heroin into his bilateral thighs. Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. Decision was made to do...
Doctor: Do you smoke cigarettes or use any tobacco products, miss? Patient: No. Doctor: Do you drink alcohol and if so, how many drinks do you consume in a typical week? Patient: I don't drink. Doctor: Do you use any recreational drug or other substances? Patient: No. Doctor: Do you have children? Patient: Yes. I...	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Married, 3 children who are healthy. She denied any Tobacco/ETOH/Illicit drug use.
Doctor: How is your family doing? Patient: They all are good. Doctor: Are you aware of any medical issues in your family? Patient: No, not to my knowledge.	Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.
Doctor: Have you ever had spine problems before? Patient: What, like an injury? Doctor: Well, it's broad. It could be an injury, or just any kind of pain. Patient: Oh, no. I've never had any problems.	Section Header: PAST MEDICAL HISTORY Summary: Unremarkable.

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