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Doctor: Any other allergies besides Penicillin?
Patient: Um no.
Doctor: I see here that you've previously tolerated Cephalosporins without any problems. Do you remember when you were last prescribed a Penicillin like antibiotic? | Section header: ALLERGY Section text: PCN, but has tolerated cephalosporins in the past. |
Doctor: Where are you having pain?
Patient: My left elbow. I hit it against a railing when I was trying to do a new trick on my skateboard.
Doctor: Did the pain come on gradually?
Patient: Yeah. I even tried icing it, but I think it's only gotten worse.
Doctor: Did you injure any other parts of your body?
Patient... | Section header: CC Section text: Left elbow pain. |
Doctor: Do you drink?
Patient: No, doc.
Doctor: How about smoke?
Patient: That I do.
Doctor: How long have you been smoking?
Patient: I long time.
Doctor: Have you tried to quit or reduce how much you smoke?
Patient: Truly, I have no interest in doing that with my age.
Doctor: I see. I'd recommend you consider n... | Section header: FAM/SOCHX Section text: She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use. |
Doctor: How about any surgeries?
Patient: No, I have not had any surgeries.
Doctor: Are you sure?
Patient: Yes. | Section header: PASTSURGICAL Section text: No prior surgeries. |
Doctor: Welcome to the clinic.
Patient: Thank you.
Doctor: It looks like you were referred to us by Doctor Jones.
Patient: Yes I was.
Doctor: Great! The chart notes that Doctor Jones sent over says you are currently twenty weeks pregnant. Is that correct?
Patient: Yes, I am.
Doctor: Do you have any other children... | Section header: GYNHX Section text: G3, P1. She is currently 5 months' pregnant. |
Doctor: Are you married?
Patient: Yes.
Doctor: Who do you have in your family?
Patient: Me, my spouse and three happy kids. One of them is ready to go to college.
Doctor: Are you working?
Patient: Yes and no.
Doctor: What does that mean?
Patient: I was an attorney but retired from my official post two years back. I ... | Section header: FAM/SOCHX Section text: Married. 3 children who are alive and well. Semi-retired Attorney. Denied h/o tobacco/ETOH/illicit drug use. |
Doctor: When did you stop smoking?
Patient: About thirty years back.
Doctor: Okay. How about any alcohol or drugs?
Patient: No never.
Guest_family: Mom, please let the doctor know about the time when you had it in the past.
Doctor: Yes, please tell me son.
Guest_family: She used to drink a long time back and used to t... | Section header: FAM/SOCHX Section text: The patient used to smoke, but quit approximately 30 years ago. The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son. |
Doctor: Have you ever had surgery, ma'am?
Patient: No, not that I can remember, and I have a good memory.
Doctor: Not even a C section when you had your son?
Patient: No, I had all my children naturally. | Section header: PASTSURGICAL Section text: Unremarkable. |
Doctor: Any sudden weight gain or loss?
Patient: No.
Doctor: Any headaches, nose bleeds, coarse voice, blurry vision or loss or change of vision?
Patient: No, not at all.
Doctor: No fever or chills, right?
Patient: Yeah, no fever or anything.
Doctor: Any chest pain, shortness of breath or shortness of breath while slee... | Section header: ROS Section text: CONSTITUTIONAL: Denies weight loss/gain, fever or chills. ENMT: Denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision. CV: See history of present illness. Denies chest pain, SOB supine, palpitations, edema, varicose veins or leg pains. RESPIRATOR... |
Doctor: Do you or have you used tobacco products,sir?
Patient: No. I have never been a smoker.
Doctor: Do you have any history of alcohol or recreational drugs use?
Patient: I have never been a drug user, but I used to drink a little, but it was never a problem. I don't drink any more.
Doctor: What do you do for a ... | Section header: FAM/SOCHX Section text: Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present. |
Doctor: Any old or new medications I should know about?
Patient: Nope. | Section header: MEDICATIONS Section text: None. |
Doctor: Good afternoon, sir. My nurse has it written down here that that you're a thirty three year old black male, is that correct?
Patient: Yes, doctor, that's correct.
Doctor: Great, what seems to be the problem today, sir?
Patient: Well, I think I'm having some sexual dysfunction. I was wondering if Cialis would... | Section header: GENHX Section text: The patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction. Patient reports that he would like to try Cialis to see if it will improve his erectile performance. Patient states that he did a quiz on-line at the Cialis web site and... |
Doctor: We were not able to find the cause of your pain right now, but in the future, we will do a few more tests and then we can have a diagnosis.
Patient: Will you give me some medicine for my stomach pain? And what about that feeling to throw up all of the time?
Doctor: Yes, I will write a prescription. It will help... | Section header: DIAGNOSIS Section text: Nausea and abdominal pain of uncertain etiology. |
Doctor: You had a bad acidity problem?
Patient: Yes I was vomiting too.
Doctor: What came out in the vomit?
Patient: It was all brown colored things like coffee.
Doctor: But nothing anymore, right?
Patient: Yes I am all better.
Doctor: Great!
Patient: They told me I can go home.
Doctor: Yes your blood count looks good,... | Section header: ASSESSMENT Section text: Coffee-ground emesis secondary to severe gastritis, resolved and stable. Hemoglobin at the time of discharge was stable and the patient to continue on Nexium 40 mg once daily. |
Doctor: How long have you been feeling weakness and fatigue?
Patient: Well, I'd say it's been a lot worse this week. I haven't had much of an appetite either.
Doctor: Have you lost weight as a result?
Patient: I've lost about eight pounds, which is the most I've ever lost in a week's time.
Doctor: Wow, that's conce... | Section header: ROS Section text: The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as ... |
Doctor: I see here that you have no surgical history. Is this correct?
Patient: Yes, indeed. At least for now. Who knows what the future will bring. | Section header: PASTSURGICAL Section text: None. |
Doctor: So, sir, tell me about your knees, how long have they been bothering you?
Patient: Well, I'm sixty nine years old now, so I'm not as young as I used to be. But, these old knees have been bothering me for a couple years now.
Doctor: What kind of symptoms do you notice in these knees?
Patient: I hear clicking ... | Section header: GENHX Section text: The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years. The patient complained of clicking noises and stiffness, which affected his daily activities of living. |
Doctor: You smoke or drink?
Patient: Nope, I never did any such thing.
Doctor: Any drugs?
Patient: Never.
Doctor: Are you still working?
Patient: I'm retired. I used to work. I used to work in Morse chain. I also used to deliver newspapers. But now I'm retired, and I enjoy life.
Doctor: Are you married?
Patient: I... | Section header: FAM/SOCHX Section text: She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it. |
Doctor: As far as you know, is there any family history of cancer?
Patient: Yes, actually, my mom told me that someone had cervical cancer.
Doctor: What about heart disease, does that sound familiar?
Patient: Yes, I know someone had heart disease, and another person had heart failure.
Doctor: Good to know, what abou... | Section header: FAM/SOCHX Section text: Remarkable for cervical cancer, heart disease, COPD, dementia, diabetes, and CHF. |
Doctor: Can you give me a quick run down of her medical history?
Guest_family: Sure. It's a bit long, sadly.
Doctor: I'm sorry to hear that.
Guest_family: She was recently diagnosed with dementia. She's also suffered from high blood pressure for some time now.
Doctor: When was she diagnosed with dementia?
Guest_... | Section header: PASTMEDICALHX Section text: Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine. No history of diabetes, stroke or coronary artery disease. |
Doctor: Hi, there. How are you both doing? What brings you two to the Emergency Department?
Guest_family: Hi, Doctor. We're both doing fine. I brought my daughter in today because she's been feeling sick.
Doctor: I see. Let me ask your daughter a few questions before we start. Hi, ma'am. I understand you feel sick. Be... | Section header: FAM/SOCHX Section text: Lives at home, here in the ED with the mother and there is no smoking in the home. |
Doctor: Are you married, sir?
Patient: Yes, I'm lucky to have, and live with my lovely wife.
Doctor: That's very nice. Did you speak with the nurse before I came in here?
Patient: Yes, she was lovely as well, I hope you're paying them well.
Doctor: We take good care of them. They'll be happy to hear that. Let me look... | Section header: FAM/SOCHX Section text: The patient is married and lives with his wife. Nursing notes were reviewed with which I agree. |
Doctor: Hi. How are you doing, sir?
Patient: Hi. I am doing fine.
Doctor: The nurse told me that you are on disability from work now. What happened?
Patient: I got hurt at work and now I am on disability.
Doctor: What did you do for work? How long ago was your injury?
Patient: I worked on the pipeline. The acciden... | Section header: FAM/SOCHX Section text: He previously worked with pipeline work, but has been on disability for five years. He is unsure which symptoms led him to go on disability. He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago. He denies alcohol or illicit d... |
Doctor: How're you doing today?
Patient: Overall, pretty good.
Doctor: Any plans for the weekend?
Patient: No, not really. Just dog sitting my friend's golden.
Doctor: Gotcha. That's still nice. We used to have a golden when I was a kid. They're the sweetest dogs.
Patient: They are very sweet.
Doctor: Okay, so yo... | Section header: GENHX Section text: Followup evaluation and management of chronic medical conditions. |
Doctor: Let's see. Are you taking any medications?
Patient: No, none right now. | Section header: MEDICATIONS Section text: None. |
Doctor: Do you smoke cigarettes?
Patient: Yes. I smoke.
Doctor: How much do you smoke per day?
Patient: About a pack or two a day.
Doctor: Do you drink alcohol?
Patient: No. It is very rare that I will have a drink.
Doctor: What is your family medical history?
Patient: Well, I don't know very much about my dad's ... | Section header: FAM/SOCHX Section text: 1-2 ppd cigarettes. rare ETOH use. Father died of renal CA. |
Doctor: So, ma'am, what do you do for a living?
Patient: Actually, I'm retired, I don't work at all anymore.
Doctor: Congratulations on your retirement. Where did you go to college?
Patient: Oh, I didn't go to college, I stopped after high school.
Doctor: That's understandable. Do you have children?
Patient: Yes, my... | Section header: FAM/SOCHX Section text: The patient is retired. She is married with three grown children. Has a high school level education. Does not smoke, drink, or utilize any illicit substances. |
Doctor: You are five feet four inches.
Patient: Yes.
Doctor: Weight one ninety seven.
Patient: Okay.
Doctor: Your blood pressure is one twenty five over seventy five.
Patient: Okay. | Section header: EXAM Section text: VITAL SIGNS: Blood pressure is 125/75. His weight is 197 with height 5 feet 4 inches. |
Doctor: Do you smoke or drink?
Patient: Never smoked a cigarette a day in my life. As for alcohol, I'll drink socially with friends and family. | Section header: FAM/SOCHX Section text: Non-smoker. Social drinker. |
Doctor: How's he feeling today?
Guest_family: I think this is the worst he's been feeling all week.
Doctor: I'm sorry to hear that he hasn't been feeling well. What symptoms has he been having?
Guest_family: He's been very congested as of late and seems to be coughing a lot more than usual. He was also running a fev... | Section header: DIAGNOSIS Section text: Upper respiratory illness with apnea, possible pertussis. |
Doctor: Okay, let me quickly examine him. Mom do you give the permission? I will quickly check his genitalia. Can you pull his pants down?
Guest_family: Sure, you can check.
Doctor: Well, everything looks fine, his penis and testes are normal shape and size for his age. No fluid accumulation or swelling in the scrotum... | Section header: EXAM Section text: EXTERNAL GENITALIA: Normal for age. Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele. |
Doctor: We can release you from the hospital today if we have a safe place for you to go. Is there a parent or guardian we can release you to?
Patient: I am in foster care. My foster mom is going out of town on the nineteenth to the twenty third.
Doctor: In that case, we will have to keep you in the hospital until ... | Section header: FAM/SOCHX Section text: As mentioned, she is in foster care. Foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient. Biological Mom and Gra... |
Doctor: Do you know about any medical issues running in your family?
Patient: Yeah, almost everyone had diabetes. | Section header: FAM/SOCHX Section text: Multiple family members have diabetes mellitus. |
Doctor: Do you have any past or present medical conditions?
Patient: No. | Section header: PASTMEDICALHX Section text: None. |
Doctor: Do you have any family history of lung disease, thromboembolism, pulmonary embolism, stroke, or heart disease.
Patient: No. My parents are healthy with no medical issues.
Doctor: How many children do you have?
Patient: I have five kids.
Doctor: Do your children have any health condition?
Patient: My chi... | Section header: FAM/SOCHX Section text: She reported that her parents were healthy with no known medical problems. She had five healthy children with no medical problems. There was no family history of lung disease, thromboembolism, pulmonary embolism, stroke, or heart disease. |
Doctor: Do you smoke or drink alcohol?
Patient: Nope. | Section header: FAM/SOCHX Section text: No tobacco or alcohol. |
Doctor: Do you know of any medical problems that run in your family?
Patient: I have no idea to be quite honest with you. My parents never shared their medical history with me and neither did their parents with them. I don't think they want any of us to worry.
Doctor: Oh wow, I understand. It can be hard for many peo... | Section header: FAM/SOCHX Section text: Unknown. |
Doctor: Hello again, how are you doing, miss?
Patient: I'm good. Thank you. How about you?
Doctor: All good here too. I know you are an established patient of dermatology here and was last seen in our office on July thirteenth, two thousand and four. I will be asking you a few questions just to check whether the ent... | Section header: GENHX Section text: 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, increased moisturizin... |
Doctor: You have been diagnosed with allergic rhinitis, right? For how many years?
Patient: Um, I would say around four years now. Oh my God it has been so, so many medications that I had to take for this.
Doctor: Yeah, it's hard to control. Are you diabetic?
Patient: No, I don't have any such conditions.
Doctor: So ... | Section header: PASTMEDICALHX Section text: Allergic rhinitis, which she has had for many years and treated with numerous medications. No history of diabetes, hypertension, or renal disease. No history tuberculosis, asthma, or upper airway disease. |
Doctor: Hm how would you describe her diet?
Doctor: Does she eat solid food?
Guest_family: Mostly thin liquids and ground meat.
Doctor: I see. | Section header: PLAN Section text: Regular with regular consistency with thin liquids and ground meat. |
Doctor: Hello there, I am Doctor Nathan.
Patient: Hello.
Doctor: How old are you?
Patient: I am forty eight?
Doctor: Do you get regular periods?
Patient: No, I didn't get any periods for the last year after my surgery.
Doctor: Any hot flashes?
Patient: Yes, it's been happening for the last several months. Sometime... | Section header: ASSESSMENT Section text: 1. Postsurgical menopause. 2. Mood swings. |
Doctor: Any change in appetite?
Patient: Um, no.
Doctor: Any stomach pain or change in bowel movement?
Patient: No.
Doctor: Any history of bowel issues?
Patient: No, not really.
Doctor: Any hernia problem?
Patient: No.
Doctor: Any history of stomach ulcer?
Patient: No.
Doctor: Did you notice any rectal bleeding?
Pa... | Section header: ROS Section text: GASTROINTESTINAL: No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems. |
Doctor: Do you drink alcohol?
Patient: Nope! I use to occasionally, very long time ago. But not anymore.
Doctor: Okay and how bout cigarettes? Do you smoke or vape?
Patient: No, none of those.
Doctor: And no drugs and stuff, right? No snorting, I V or anything right?
Patient: Right, I don't do drugs either, never did.... | Section header: FAM/SOCHX Section text: Denied Tobacco/ETOH/illicit drug use. |
Doctor: Let me check your neck, it looks nice and symmetrical. Your thyroid looks normal it is not enlarged.
Doctor: Does it hurt you when I press on your neck?
Patient: No.
Doctor: Neck is nontender.
Doctor: Okay, I don't see any bulging of external jugular vein.
Patient: These medical terms I don't understand.
Doc... | Section header: EXAM Section text: NECK: Supple and symmetric. No masses. Thyroid midline, non enlarged. No JVD. Neck is nontender. Full range of motion without pain. |
Doctor: Hello, miss. It looks like you are here for your yearly physical. How is everything going?
Patient: Great, I think. I just got a mammogram and nothing showed up. I still am taking my multivitamin and low dose aspirin.
Doctor: Great to hear. Has there been any changes in drinking and smoking?
Patient: No chang... | Section header: GENHX Section text: She is not exercising. She does not do self breast examinations. She has recently had her mammogram and it was unremarkable. She does take her low-dose aspirin daily as well as her multivitamin. She does wear her seatbelt. As previously noted, she does not smoke or drink alcoh... |
Doctor: Hello. How are you doing today?
Patient: I want to get surgery on my leg.
Doctor: Have you ever had a surgery.
Patient: I did. Here's a list of them.
Doctor: Looks like you had eye surgery, cataract surgery, and lumbar decompression, correct?
Patient: Yeah. So, what options do I have for surgery?
Doctor: ... | Section header: PASTSURGICAL Section text: Eye surgery, cataract surgery and lumbar decompression. |
Doctor: Hi you guys, how are you?
Patient: I am good, he is my stepdad.
Guest_family: Hi Doctor, how are you?
Doctor: I am fine, thank you. So, she gets seizures?
Guest_family: Yes.
Doctor: And when did it start?
Guest_family: She was fourteen or thirteen. I think fourteen.
Patient: Dad I was fourteen, when it start... | Section header: FAM/SOCHX Section text: Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently. The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia. The maternal grandmother is notable for hypertension and diabetes. There are no other children i... |
Doctor: Do you have any known allergies to medications?
Patient: None whatsoever. | Section header: ALLERGY Section text: None. |
Doctor: Did you have your vaccines?
Patient: Yeah.
Doctor: Did you skip any?
Patient: No, I had all of them and am up to date with my immunizations. | Section header: IMMUNIZATIONS Section text: Also up-to-date. |
Doctor: Hi, how can I help you, ma'am?
Patient: I have no complaints.
Doctor: Okay but tell me what is going on and we can figure this out.
Patient: Okay so my right hand and left foot was very swollen and very painful, and that's why I came to emergency room.
Doctor: Do you have urine bag?
Patient: Yes, I could not ... | Section header: ROS Section text: The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room. Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out. Also they started her on steroids and colchicine... |
Doctor: Does low blood pressure run in your family?
Patient: No. As far as I know, no one else has it.
Doctor: Okay. | Section header: FAM/SOCHX Section text: Noncontributory. |
Doctor: Were you ever diagnosed with any kind of cancer in the past?
Patient: No.
Doctor: Did you ever had any rashes? Was there any change in your moles?
Patient: No.
Doctor: Any sudden weight loss history?
Patient: No.
Doctor: How about your energy level how do you feel?
Patient: I feel great, my energy level is qu... | Section header: ROS Section text: ONCOLOGIC: No history of any cancer, change in moles or rashes. No history of weight loss. The patient has a good energy level. |
Doctor: What medications are you currently taking?
Patient: I am a diabetic, so I take Insulin.
Doctor: How much Insulin do you take?
Patient: It varies from day to day. | Section header: MEDICATIONS Section text: Insulin (unknown dosage) |
Doctor: Anything else that is going on?
Patient: Just some pain in the buttock.
Doctor: Okay.
Patient: I do not have anything else.
Doctor: Okay no fever, nausea, anything of that sort?
Patient: Nope. | Section header: ROS Section text: Significant for pain in the buttock. Otherwise negative. |
Doctor: You recently turned sixty seven, correct?
Patient: Yes. Sixty seven years young.
Doctor: Are you right or left handed?
Patient: Right.
Doctor: When were you first diagnosed with Parkinson's?
Patient: September first of nineteen ninety five.
Doctor: Do you remember who diagnosed you?
Patient: A local doctor I ... | Section header: GENHX Section text: This 67y/o RHF was diagnosed with Parkinson's Disease in 9/1/95, by a local physician. For one year prior to the diagnosis, the patient experienced staggering gait, falls and episodes of lightheadedness. She also noticed that she was slowly "losing" her voice, and that her handwrit... |
Doctor: Hi there! How are the both of you doing today?
Guest_family: I am doing well but my son is sick. He is two and a half years old.
Doctor: What are his symptoms?
Guest_family: He has a bad cough. He's been sick for the last three or four days. It sounds like there is phlegm rattling around in there when he cou... | Section header: GENHX Section text: The patient is a two-and-a-half-month-old male who has been sick for the past three to four days. His mother has described congested sounds with cough and decreased appetite. He has had no fever. He has had no rhinorrhea. Nobody else at home is currently ill. He has no cigaret... |
Doctor: Any medical diseases in the family?
Patient: Yeah, mainly heart issues. My father died from heart attack.
Doctor: What about your mother?
Patient: She had the second type of diabetes. | Section header: FAM/SOCHX Section text: Father died of an MI, Mother had DM type II. |
Doctor: So just to double check. No past medical history?
Patient: Yes, sir. None. | Section header: PASTMEDICALHX Section text: None. |
Doctor: Do you drink or smoke, ma'am?
Patient: No, I don't do any of that.
Doctor: Good, what about harder drugs?
Patient: No, none of that either.
Doctor: Very good. Do you have any history of S T D that you know about?
Patient: No, there's no history of any of that there. | Section header: FAM/SOCHX Section text: Patient denies smoking, alcohol abuse, illicit drug use and STDs. |
Doctor: What medications are you taking?
Patient: I take Prilosec and Tramadol when I have back pain. | Section header: MEDICATIONS Section text: 1. Prilosec. 2. Tramadol p.r.n. |
Doctor: Any drug allergies?
Patient: No. | Section header: ALLERGY Section text: No known drug allergies. |
Doctor: How often are you vomiting?
Patient: At least three times until my stomach is empty.
Doctor: Can you think of something this is related to?
Patient: Just when I eat raw carrots and celery.
Doctor: Do you get belly pain?
Patient: Yes. | Section header: ASSESSMENT Section text: Report of vomiting and abdominal pain after eating raw carrots and celery. Etiology of this is unknown. |
Doctor: Good morning, ma'am. Can you confirm your age for me?
Patient: Well, doctor, I'm sixty six years old now.
Doctor: Thank you, so, how is your knee doing today? Hope the osteoarthritis is getting better.
Patient: It's so bad, doctor.
Doctor: Have you had any improvement with the rest and antiinflammatories we... | Section header: GENHX Section text: A 66-year-old female with knee osteoarthrosis. Failed conservative management. Risks and benefits of different treatment options were explained. Informed consent was obtained. |
Doctor: How old are you?
Patient: I am twenty four.
Doctor: What brings you in today?
Patient: I have been having this back pain for a long time. I thought I should come and get it checked out because it has not gotten any better. | Section header: GENHX Section text: A 24-year-old female with chronic back pain. |
Doctor: Any medical issues running in your family?
Patient: I don't know anything about that.
Doctor: You know anyone in your family or relatives who ever had diseases like diabetes or any heart issues?
Patient: Nope. | Section header: FAM/SOCHX Section text: unremarkable. |
Doctor: Hello, miss. Could you verify your age, please?
Patient: I'm fifty five years old.
Doctor: Great. What is the reason for your visit today?
Patient: I've been having a lot of problems recently, so I decided to come get it checked out by you.
Doctor: I see. What kind of problems are you experiencing?
Patient... | Section header: GENHX Section text: A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies. Please refer to ... |
Doctor: Are you a smoker?
Patient: Yes.
Doctor: Do you use alcohol or any recreational drugs?
Patient: I have been in treatment for heroin and alcohol in the past.
Doctor: Any current use of drugs or alcohol?
Patient: I did do a little bit of coke today.
Doctor: Okay. | Section header: FAM/SOCHX Section text: The patient is a smoker. Admits to heroin use, alcohol abuse as well. Also admits today using cocaine. |
Doctor: Do you take any-
Patient: Meds?
Doctor: Yes.
Patient: I do. I take Allegra for seasonal allergies. I also take something that starts with a P. I'm blanking on the name. My other doctor prescribed it to me for exercise induced asthma.
Doctor: Oh, do you mean Proventil?
Patient: Yes, that's it! I keep that o... | Section header: MEDICATIONS Section text: Proventil and Allegra. |
Doctor: Welcome into the office.
Patient: Thank you.
Doctor: Let us start with your family medical history.
Patient: That is going to be a hard one. I was adopted and I do not know any family medical history.
Doctor: Okay. That is alright. | Section header: FAM/SOCHX Section text: Unobtainable. |
Doctor: So, you are here to review your sleep study results, right?
Patient: That's right.
Doctor: First let's go back to your medical history a little bit and then we will continue with the result. Patient: Sure.
Doctor: So, you first came to our Pulmonary Clinic, and you were suffering with dyspnea even on minimal... | Section header: GENHX Section text: The patient presented initially to the Pulmonary Clinic with dyspnea on minimal exertion. At that time, she was evaluated and found to have evidence for sleep disruption and daytime fatigue. She also complained of nocturnal choking episodes that have since abated over the past se... |
Doctor: So, I see you were diagnosed with an acid reflux problem and high blood pressure twenty years back?
Patient: Yes.
Doctor: And then you also have arthritis and Parkinson's.
Patient: Yes, both.
Doctor: Also, you had a brain stroke?
Patient: Yes, mini stroke!
Doctor: Ah, yes. We also call it as T I A.
Patient: ... | Section header: PASTMEDICALHX Section text: GERD, hypertension times 20 years, arthritis, Parkinson's, TIA, chronic atrial fibrillation, on Coumadin three years. |
Doctor: Good morning, ma'am.
Patient: Good morning, doctor.
Doctor: How are you feeling today?
Patient: Honestly, I'm feeling a little bit better.
Doctor: That's good to hear, ma'am. | Section header: GENHX Section text: The patient states she is feeling a bit better. |
Guest_clinician: I see here that he may need antibiotic therapy for possible cellulitis of his lower extremities.
Doctor: According to the patient, his symptoms started getting progressively worse over the past two days.
Guest_clinician: Does he have a history of cellulitis?
Doctor: No. | Section header: CC Section text: Questionable need for antibiotic therapy for possible lower extremity cellulitis. |
Doctor: Welcome to the clinic.
Patient: Thank you.
Doctor: Are you from the area?
Patient: No. I was born and raised in North Carolina. I am the sixth of nine siblings.
Doctor: Tell me about you family medical history.
Patient: My family has significant amount of diabetes, heart disease, high blood pressure, thyroi... | Section header: FAM/SOCHX Section text: The patient was born and raised in North Carolina. She was the sixth of nine siblings. Her father was a chef. He completed third grade and died at 60 due to complications of diabetes. Her mother is 93 years old. Her last job was as a janitor. She completed fourth grade. ... |
Doctor: Good afternoon, young man.
Patient: Good afternoon, doctor.
Doctor: How old are you, sir?
Patient: I'm thirteen.
Doctor: So, what brings you in today?
Guest_family: Well, at first, we went to Sierra Pacific Orthopedic Group, and he had an M R I that showed, um, O C D in the left knee.
Doctor: Yes, I see tha... | Section header: GENHX Section text: The patient is 13-year-old male with persistent left knee pain. He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee. The patient presented here for a second opinion. Surgery was recommended grossly due to the in... |
Doctor: Good afternoon, young lady.
Patient: Good afternoon, doctor.
Doctor: Let's get the personal questions out of the way to begin, shall we?
Patient: Sure.
Doctor: Have you had any S T D s recently?
Patient: No, not that I know of.
Doctor: Are you sexually active?
Patient: No, I'm not.
Doctor: I'm looking h... | Section header: FAM/SOCHX Section text: She has had no recent STDs and she is not currently sexually active. PPD status was negative in the past. PPD will be placed again today. Treatment adherence counseling was performed by both nursing staff and myself. Again, the patient is a 100% compliant with her meds. Las... |
Doctor: Hi, I would like to physically examine your rectal area, ok?
Patient: No, I am not comfortable with that. I don't want you to do that. | Section header: EXAM Section text: RECTAL: Examination was deferred. |
Doctor: Hello, what brings you here today?
Patient: I fell four times on third of this month because my leg suddenly gave out.
Doctor: How old are you?
Patient: You don't ask age of a lady. She will never tell you the truth.
Doctor: I know I'm in the wrong profession. I have to do that every time I meet someone. So... | Section header: GENHX Section text: This 51y/o RHF fell four times on 1/3/93, because her "legs suddenly gave out." She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her h... |
Doctor: Any medical traits in the family?
Patient: Oh yeah. Diabetes and high blood pressure runs in my family.
Doctor: Anything else?
Patient: Yeah, my mom suffered with a stroke when she was in her seventies. | Section header: FAM/SOCHX Section text: Mother suffered stroke in her 70's. DM and Htn in family. |
Doctor: Are you married, ma'am?
Patient: No, I'm divorced.
Doctor: Do you live alone?
Patient: Yes, so I have no support at home, it's difficult.
Doctor: Do you drink or smoke?
Patient: No, I never have.
Doctor: What about more illicit substances?
Patient: No, absolutely not. | Section header: FAM/SOCHX Section text: She is divorced. She does not have support at home. She denies tobacco, alcohol, and illicit drug use. |
Doctor: What is your family medical history, sir?
Patient: We have some heart issues in my family. My sister died during heart surgery two years ago.
Doctor: I am so sorry.
Patient: Thank you. My mom died of a heart attack.
Doctor: How old was she when she passed?
Patient: She was in her seventies? My dad died from... | Section header: FAM/SOCHX Section text: His father died of a cerebral hemorrhage at age 49. His mother died in her 70s from complications of congestive heart failure. He has one sister who died during a cardiac surgery two years ago. He has another sister with diabetes. He has one daughter with hypercholesterolem... |
Doctor: Do you have any known allergies?
Patient: Not that I know.
Doctor: Any allergies to any drug?
Patient: Nope. | Section header: ALLERGY Section text: No known drug allergies. |
Doctor: Are you married?
Patient: Yes, I am.
Doctor: Is the baby your first kid?
Patient: You see, I am a missionary. I have four kids. My eldest is seven years old. Then the other ones are five and three and this one is the youngest. She is just six weeks old. | Section header: FAM/SOCHX Section text: Missionary. Married. 4 children ( ages 7,5,3,6 weeks). |
Doctor: Welcome to A B C D General Hospital. Before we get started, ma'am, how old are you?
Patient: I'm thirty nine, doctor.
Doctor: Great, and what seems to be the problem today?
Patient: I've had this bunion for a good few months now.
Doctor: Is the pain getting worse?
Patient: Absolutely, I can't take it anymore... | Section header: GENHX Section text: This 39-year-old female presents to ABCD General Hospital with the above chief complaint. The patient states that she has had bunion for many months. It has been progressively getting more painful at this time. The patient attempted conservative treatment including wider shoe ge... |
Doctor: How old are you?
Patient: I'm twenty eight.
Doctor: So, you are here for the dietary consultation. Is this your first pregnancy?
Patient: No, this is my second pregnancy. I had gestational diabetes with my first one as well.
Doctor: Were you taking any insulin at that time?
Patient: Yes, I used insulin las... | Section header: GENHX Section text: This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy. Patient reports that she had gestational diabetes with her first pregnancy. She did use insulin at that time as well. She does not fully understand what ketones are. She walks her dau... |
Doctor: Do you know of any family history of kyphosis?
Patient: I'm sorry, what's that?
Doctor: It has to do with rounding of the spine. Does anyone in your family have a rounded posture?
Patient: Actually, yeah, my great grandmother had that, and my mom would talk about my second cousin, he had it too. | Section header: FAM/SOCHX Section text: Of kyphosis in great grandmother and second cousin. |
Doctor: When did you retire from your job?
Patient: About eleven years ago. It's definitely been nice. I'm able to spend more time with my grandkids.
Doctor: Aw, how many grandkids do you have? And do you live alone?
Patient: I have four grandkids between the ages of two and eleven. I live in the county with my wife... | Section header: FAM/SOCHX Section text: The patient is married and retired. |
Doctor: Good afternoon, young lady.
Patient: Good afternoon, doctor.
Doctor: How has your weight been since your last visit, with the phentermine?
Patient: Well, since the last visit I've gained about a pound.
Doctor: Well, it could be worse, but we're at a plateau, I'd like to see you lose some more per month.
Pa... | Section header: GENHX Section text: She is here for a followup on her weight loss on phentermine. She has gained another pound since she was here last. We talked at length about the continued plateau she has had with her weight. She gained a pound the month before and really has not been able to get her weight any... |
Doctor: Anyone in the family had a stroke?
Patient: No, no one had a stroke in my family.
Doctor: How about someone in the family with heart disease?
Patient: No one that I can remember.
Doctor: Okay. | Section header: FAM/SOCHX Section text: Negative for cerebrovascular accident or cardiac disease. |
Patient: You know doctor, I was born in Munich, Germany.
Doctor: Wow, I cannot tell, you speak English so well, no German accent.
Patient: Yeah, I always knew how to speak English even before I was a teen. So, when I moved to America I did not have any language problem.
Doctor: Okay and did you move with your family?... | Section header: FAM/SOCHX Section text: Significant for her being without a companion at this point. She was born in Munich, Germany. She immigrated to of America in 1957 after her family had to move to Eastern Germany, which was under Russian occupation at that time. She is divorced. She used to work as a secret... |
Doctor: What brings you in today? Can you also please state your age?
Patient: Yeah. I am forty five. I've had really bad stomach pain on my right side since last week.
Doctor: On a scale of one to ten, how bad is the pain at its worst?
Patient: I'd have to say a seven.
Doctor: How would you rate it now?
Patient: O... | Section header: GENHX Section text: The patient is a 45-year-old male complaining of abdominal pain. The patient also has a long-standing history of diabetes which is treated with Micronase daily. |
Doctor: Your cholesterol appears to be elevated today. Is this the first time you've been told that your cholesterol levels are high?
Patient: No, unfortunately. I suffer from a few medical problems so maybe that's to blame.
Doctor: I see here that you have diabetes and high blood pressure.
Patient: Right.
Doctor:... | Section header: GENHX Section text: CORONARY RISK FACTORS: History of hypertension, history of diabetes mellitus, nonsmoker. Cholesterol elevated. History of established coronary artery disease in the family and family history positive. |
Doctor: How was the sleep study?
Patient: Not bad. Although I hafta admit it was difficult staying up in preparation for it.
Doctor: I can imagine. That's always tough. It looks like the eval of your daytime fatigue and insomnia was sent over. Let me print out a copy and we can go over it together. How old are you ag... | Section header: GENHX Section text: This 48-year-old woman returns in followup after a full-night sleep study performed to evaluate her for daytime fatigue and insomnia. |
Doctor: So what brings you in today?
Patient: Ugh.
Doctor: I'm guessing you're not feeling too great.
Patient: You got that right. I've had a fever on and off for the past few days.
Doctor: When was the last time you took your temperature?
Patient: Right before I drove here.
Doctor: I see. Did the nurse take you... | Section header: CC Section text: Fever of unknown origin. |
Doctor: Anything that has been going on?
Patient: No. What do you mean?
Doctor: I mean anything wrong from head to toe that you would like to add?
Patient: No everything is well. No other problems.
Doctor: Okay. Good. | Section header: ROS Section text: He otherwise has a negative review of systems. |
Doctor: How was the procedure?
Patient: It was okay. I was nervous to go under the knife at first, but it turned out better than I expected. Do you know others who've gotten hysterectomies that are near my age?
Doctor: I do, actually. It's a pretty common procedure. I'm glad to hear that you didn't experience any com... | Section header: GYNHX Section text: Status post hysterectomy. |
Doctor: Hello and welcome to our dermatology office. What is the reason for your visit?
Patient: I have these rashes on my arms.
Doctor: Let me take a look. Do you have prior reports about your history?
Patient: Yeah, I do. I gave it to the nurse.
Doctor: Let me go get it really quick. I'm reading the report and it... | Section header: ALLERGY Section text: The patient has eczema and a positive atopic family history. No psoriasis. No known drug allergies. |
Doctor: Do you drink?
Patient: Well, I will call myself a social drinker. I would admit that I am addicted to caffeine.
Doctor: How much coffee do you consume each day?
Patient: I would say three to five cups.
Doctor: Any history of sexually transmitted disease?
Patient: Nope.
Doctor: How're your eating habits?
P... | Section header: FAM/SOCHX Section text: Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history. |
Doctor: Good afternoon Sir. Do you know how you got here?
Patient: Yes, I passed out and the paramedics brought me to the hospital.
Doctor: Do you have any recollection of the incidences leading up to your loss of consciousness?
Patient: I think I had a seizure and then I passed out.
Doctor: Prior to the episode d... | Section header: GENHX Section text: The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest... |
Doctor: Hello Miss Lee how are you?
Patient: I am okay, my arms are troubling me so much.
Doctor: Yeah, I know it's been a longstanding pain in both your arms.
Patient: Yeah, and hands too
Doctor: Can you pinpoint where exactly is the pain?
Patient: Yeah, it's right here in the middle part of arm and my palm.
Doct... | Section header: GENHX Section text: The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand. She denies any weakness. No s... |
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