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200
FAM/SOCHX
non-contributory.
Doctor: Do you have a family history of neurological conditions that I should know about? Patient: What exactly do you mean by that, doctor? Doctor: Well, it could be anything from A D H D, to epilepsy, to Alzheimer's. Patient: Oh, no.
201
MEDICATIONS
Abilify.
Doctor: Are you on any medications? Patient: Yeah. I take Abilify to help with my mood. Doctor: Do you find that it's helping? Patient: A little, yeah.
202
ASSESSMENT
Upper respiratory infection.
Doctor: Your culture results came back positive for Streptococcus pneumoniae. This is a bacterial infection. I would like to take a course of antibiotics. This should start to improve your symptoms with in three to four days. Patient: Okay. Doctor: Please let me know if your symptoms have not improved or becomes ...
203
PASTMEDICALHX
Significant for history of pulmonary fibrosis and atrial fibrillation. He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.
Patient: I had a lung transplant in two thousand and four because of Pulmonary Fibrosis. Doctor: Okay, how are you now? It was, was that for both lungs? Patient: Yes, both sides. Doctor: You do have irregular heart rhythm, right? Patient: Yes, I do.
204
ASSESSMENT
Foreign body of the left fifth fingernail (wooden splinter).
Doctor: How are you? Patient: Look at this fifth fingernail on my left hand, doctor. Doctor: Oh what is stuck here? Patient: I think it's wood splinter. Doctor: Oh, must be painful! Patient: Yes a lot.
205
EXAM
MSK: The head and neck by inspection showed no obvious deformity. Again, the extremities showed no obvious deformity. Range of motion appeared to be normal for the upper and lower extremities.
Doctor: Can you move your arms? I would like to see how your range of motion is. Patient: Sure, see. Like that? Doctor: Yes, yes, looks good for both arms and legs. Patient: Great. Doctor: I do not see any obvious deformities in head neck or in extremities. Patient: Yes, no problems. Doctor: Okay? Patient: Okay.
206
ALLERGY
Eggs and peanuts.
Doctor: Are you allergic to anything? Patient: Yes, I am allergic to eggs and peanuts. Doctor: Oh, okay. Doctor: Anything else? Any medication? Patient: No, nothing else. Doctor: Alright.
207
FAM/SOCHX
He is a nonsmoker. He occasionally has a beer. He is married. He works as a flooring installer.
Doctor: Do you smoke, sir? Patient: No. Doctor: Do you drink? Patient: Sometimes I take a beer or two. Doctor: Are you married? Patient: For last ten years. Doctor: What do you do for living? Patient: I install floor. I am associated with a construction company and my main work is flooring installation.
208
GENHX
The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age. Since that time, the patient has developed significant calcaneal valgus deformity with significant pain. Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot. Given the patient's symp...
Doctor: Good morning, young lady. Is this your mother? Patient: Yes, this is my mommy. Doctor: Good morning, mom. Can you tell me more about your daughter, please? Guest_family: Good morning, doctor. Well, she's thirteen now, but she's had feet problems all her life. Doctor: What's been the problem with her feet...
209
GENHX
The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007. The patient was seen in the emergency room. The patient had a complete fracture of both bones with shortening bayonet apposition. Treatment options were offered to the family including casting versus closed reduction and pi...
Doctor: Good morning, young man. Are these your parents? Patient: Yes. Doctor: Good, can you tell me more about your son, please? Guest_family_1: Well, he's five now, and he fell onto his right arm on December fifth two thousand seven. Doctor: After he fell, how was he treated? Guest_family_1: We went to the E ...
210
PASTMEDICALHX
Negative for chronic medical problems. No local physician. Has had previous back surgery and appendectomy, otherwise generally healthy.
Doctor: Hello. Are you a new patient? Patient: I am. I've been traveling a lot, so I don't have a local doctor I usually see. Doctor: That's fine. What is the reason for your visit? Patient: I've had this dark spot on my leg for a long time. Doctor: I see. Do you know if your family has any chronic medical prob...
211
PASTSURGICAL
Significant for a chest port placement.
Doctor: It's surgery day! How are you feeling? Patient: Not as excited as you. Doctor: Have you had a surgery before? Patient: Yeah. It was something with my chest. Guest_family: Hi Doctor. I'm the mother. He had a chest port placement. Doctor: I see. Thank you for letting me know.
212
FAM/SOCHX
Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.
Doctor: What is your living status? Do you live alone or with family? Patient: I live with my boyfriend. Doctor: Do you smoke? Patient: Yes. Doctor: For how long you are smoking? Patient: Around ten years. Doctor: How many cigarettes do you take? Patient: Well, one pack of cigarettes lasts for around thre...
213
PASTMEDICALHX
Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.
Doctor: I want to talk to you about your reproductive history, okay? Patient: Okay. Doctor: Do you take birth control pills? Patient: Yes, I do. Doctor: Do you have any kind of medical history that I should be aware of? Patient: I had both chickenpox and measles when I was a kid.
214
ROS
Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.
Doctor: Just want to ask you few questions. Patient: Okay shoot. Doctor: Do you have any nausea, vomiting? Patient: Yes to both. Doctor: How about fever? Patient: Yes, I do. Doctor: Any blood in sputum or chest pain? Patient: Yes, I do.
215
DIAGNOSIS
Hypothermia.
Doctor: Well, this is a case of hypothermia. Guest_family: Will he survive? Doctor: Don't worry, we will take care of him.
216
FAM/SOCHX
He has a history of tobacco use, which he quit at the age of 37. He has one alcoholic drink per day. He is married. He is a retired lab manager.
Doctor: Do you take any tobacco related products? Patient: I used to chew tobacco, but I quit when I was thirty seven. Doctor: What about alcohol consumption? Do you drink? Patient: I take one glass of wine every day. Doctor: Are you married? Patient: Yes, sir. I'm married to a wonderful woman for last thirty...
217
CC
Please evaluate stomatitis, possibly methotrexate related.
Doctor: Hello! What brings you back into the clinic today? Patient: I came back because I increased my methothrexate as we discussed the last time I was here. A few days later I started getting multiple canker sores in my mouth. They hurt. Doctor: I am sorry. It is likely that the increased dosage of your methothre...
218
FAM/SOCHX
Otherwise noncontributory.
Doctor: Are you aware of any medical issues in your family? Patient: No. Doctor: How about any known heart disorder or diabetes in the family. Patient: No, I'm not aware of anything like that.
219
IMAGING
X-rays shows no open fracture or bony abnormality.
Doctor: So, I am looking at his x ray and it does not show any open fracture or any kind of bone abnormality. Guest_family: Okay, I was really worried about my son. Doctor: I understand, but like I said, I didn't see any open fracture in his x ray report nor any abnormality. Guest_family: Okay.
220
FAM/SOCHX
2-4 Beers/day. 1-2 packs of cigarettes per day.
Doctor: Do you drink? Patient: Yes, I do take two or four beers in a day. Doctor: Do you smoke? Patient: Oh yeah, I'm a smoker. I take around one to two packs of cigarettes each day.
221
FAM/SOCHX
The patient lives by herself and has three pet cats. She is an ex-smoker, quit smoking about five years ago. She occasionally drinks a glass of wine. She denies any other recreational drugs use. She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.
Doctor: Do you live alone? Patient: I wouldn't say I live alone. I have three cats and they always keep me company. Doctor: Aw, what kind of cats? Patient: Two Persian cats and one Chartreux. Doctor: Are you currently working? Patient: I retired a few months ago. I used to work as a psych aide for the State ...
222
CC
Possible exposure to ant bait.
Doctor: Hi there! What brings you in today? Guest_family: I think my baby got into the ant bait. I am not sure if he consumed any of it but he was under the counter and it was in his hands. Doctor: What kind ant bait did he get into? Guest_family: It was the one with Borax in it. Doctor: Do you have a picture of ...
223
GENHX
The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity. This has not got...
Doctor: Good morning, ma'am. I just need to confirm some information about you before we begin today. Patient: Good morning, doctor. Sure, that's no problem. Doctor: Great, so you're sixty seven years old, and White, correct? Patient: Yes, that's right doctor. Doctor: Thank you. Do you remember how many cycles ...
224
DIAGNOSIS
Symptomatic thyroid goiter.
Doctor: How long has she had difficulty swallowing? Guest_family: A while now. We scheduled her to see an endocrinologist, but she's not able to get in until Monday. I wanted to see if we could get to the bottom of it now. Doctor: It does appear that her thyroids are fairly enlarged. I believe that's where most of ...
225
FAM/SOCHX
Includes coronary artery disease, hypertension. Nobody in the family was diagnosed with any type of colon cancer or any type of other cancer.
Doctor: Do you have any significant medical conditions that run in your family that I should be aware of? Patient: Yes, um, I know some of my relatives have had coronary artery disease, and, um, high blood pressure. Doctor: What about cancer? Does anyone in your family have a history of cancer? Patient: No, that ...
226
GENHX
This patient was injured on November 20, 2008. He works at the Purdy Correctional Facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back. The patient said he primarily landed on the left side. After t...
Doctor: When was your injury, sir? Patient: Um, if I recall, it was on November twentieth two thousand eight. Doctor: What do you do for a living, sir? Patient: I work at the Purdy Correctional Facility, doctor. Doctor: How did you get hurt? Patient: Well, an inmate broke some of the overhead sprinklers, and I...
227
PASTMEDICALHX
There is no significant past medical history noted today.
Doctor: Any past medical problems or surgeries that I should know of? Patient: Nope, none that I can think of.
228
PASTMEDICALHX
Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear.
Doctor: So, I see here in your reports you have arthritis in you both knees. Patient: Yes. Doctor: And you got a tear in your eye in the past, right? Patient: Ah yes, I got a tear in my retina. Doctor: Right. Also, it's mentioned here that you have atrial fibrillation. Patient: That's correct. Doctor: Are you ...
229
PROCEDURES
None.
Doctor: Have you had any procedures in the past? Patient: No.
230
FAM/SOCHX
Her father had prostate cancer. Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer.
Doctor: Do you have any medical conditions that run in your family that I should know about, ma'am? Patient: Um, yeah, my dad had prostate cancer. Doctor: What about your mother, or the rest of your family? Patient: Um, my mom's brother had Hodgkin's disease, melanoma, and prostate cancer.
231
FAM/SOCHX
No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.
Doctor: Do you drink? Patient: Not really, no. Doctor: Any drugs? Patient: No. Doctor: Do you get a chance to exercise during the week? Patient: I like to go on walks with my dog every day. I'm also eating a lot healthier these days. Doctor: That's wonderful. How's work going for you? Patient: I actuall...
232
ALLERGY
No known drug allergies.
Doctor: Are you allergic to anything? Patient: No, I do not have any allergies. Doctor: Great.
233
GENHX
The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserting a needle using the right hand. He did have a protective clothing including us...
Doctor: What do you do in the hospital? Patient: I work as a phlebotomist and respiratory therapist. Doctor: Ok, how old are you? Patient: I am fifty four. Doctor: You are very young. Patient: Thank you! Patient: So, as you remember I was trying to measure blood gas as I was working with a patient and I accident...
234
EDCOURSE
In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1...
Doctor: They took some fluid out of your back remember? Patient: Yes actually. Doctor: We got the results back for that and it looks like it was clear then it turned bloody. Patient: They checked my urine and blood too. Doctor: Yes, they did. I see the orders for urine culture, B M P, C B C, C R P, and blood cult...
235
GENHX
He had tonsillectomy at the age of 8. He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure. He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.
Doctor: Tell me about your medical history. Did you have any surgeries? Any medical issues in the past? Patient: I had my tonsils removed when I was a kid, maybe around eight. I was hospitalized for the heart attack in ninety six. They did some surgery to check how my heart is functioning and then they did a bypass I...
236
FAM/SOCHX
Mother, father and siblings were alive and well.
Doctor: How's everyone in your family? Patient: My mom, dad and siblings are good. Doctor: They are well, that is good. That's what we want. Patient: Yes.
237
FAM/SOCHX
Works at ABC. Social alcohol and he does smoke.
Doctor: So, what do you do for a living, sir? Patient: I work at A B C store, doctor. Doctor: That's great, do you smoke? Patient: No, I don't smoke at all. Doctor: How about alcohol? Do you drink? Patient: I'd say I drink socially, like if I'm at a party, or something.
238
MEDICATIONS
None.
Doctor: Do you take any daily medications or supplements? Patient: Nope.
239
GENHX
The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are negotiated 1 at a time. His problems with bilateral knee DJD have been well doc...
Doctor: Good afternoon, sir, how are you today? Patient: Good afternoon, Doctor, my knees are in a lot of pain today. Doctor: Is the pain equal? Or is one knee worse than the other? Patient: Um, the left knee hurts more than the right, but there's pretty significant pain with both. Doctor: Is it interfering with ...
240
FAM/SOCHX
Tobacco use, averages two cigarettes per day. Alcohol use, denies.
Doctor: Do you smoke? Patient: Yes. Doctor: How much? Patient: Two cigarettes per day. Doctor: Okay that is not bad, but try quitting. Patient: Okay. Doctor: Alcohol? Patient: No, I don't drink.
241
GENHX
The patient is in with several medical problems. He complains his mouth being sore since last week and also some "trouble with my eyes." He states that they feel "funny" but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eating is okay. He...
Doctor: Hi Ryan, what brings you here today? Patient: Well, you told me to follow up if my cough doesn't get better. Also, I started having several other issues. Doctor: Oh really! Patient: Yeah. Doctor: Okay, so tell me about your cough, is it getting worse than before? Patient: It's about the same but not gett...
242
FAM/SOCHX
He is a petroleum engineer for Chevron. Drinks socially. Does not use tobacco.
Doctor: So, sir, what do you do for a living? Patient: Right now, I'm working with Chevron as a petroleum engineer. Doctor: That's fantastic. So, do you drink? Patient: Um, I'd say I drink socially, like if I'm at a party or something. Doctor: Sure, me too. Do you smoke? Patient: No sir, I don't do that.
243
FAM/SOCHX
Noncontributory. No one else at home is sick.
Doctor: Is anyone else at home sick? Patient: No. My husband and daughter seem to be doing okay. They haven't complained of anything yet.
244
GENHX
The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having compli...
Doctor: Hi, how are you doing, ma'am? What brings you here today? Patient: I'm good, thank you. I'm having this weakness on my left side after the brain, I mean, after they removed my tumor from the brain. Doctor: Remind me when did you have your surgery for brain tumor? Patient: It was on October twenty fourth la...
245
MEDICATIONS
Nexium.
Doctor: What medication have you tried? Patient: I took Nexium. Doctor: Pain? Patient: Yes.
246
GENHX
Overall, the patient has been doing reasonably well. She is being treated for some hemorrhoids, which are not painful for her. There has been a note that she is constipated. Her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188. I see a couple in ...
Doctor: Well, I am looking at your test reports and your blood sugars have been running up and down but nothing to be worried about but yeah, we need to keep monitoring. This morning it was perhaps a bit high at one hundred eighty-eight. Last time it was one hundred fifty and in one report it's around one hundred twent...
247
GENHX
She has been followed for her hydrocephalus since 2002. She also had an anterior cervical corpectomy and fusion from C3 though C5 in March 2007. She was last seen by us in clinic in March 2008 and she was experiencing little bit of head fullness and ringing in the ears at that time; however, we decided to leave her s...
Doctor: The next patient we have is Miss Dey, we have been regularly following up with her for her hydrocephalus since two thousand and two. Guest_clinician: Oh, okay. Doctor: She also had anterior cervical corpectomy, we removed her front part of the vertebra followed by fusion from C three to C five in March two th...
248
PLAN
The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow ...
Doctor: So, you saw Doctor X? Patient: Yes, seven days back. I went to get my blood work done and then I followed up with Doctor Y. Doctor: Yes, I will look at C B C diff and C M P profile. Patient: I will follow up with my oncologist, Doctor Z, for my swellings. Doctor: Yeah, I couldn't get hold of Doctor Z but h...
249
PASTMEDICALHX
Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.
Doctor: I see here that you were in for afib last month. Patient: Yep. Doctor: How're you doing? Patient: It's all under control for now. Doctor: That's good to hear. Are you still taking Metoprolol and Premarin? Patient: Yeah.
250
PASTMEDICALHX
Diabetes.
Doctor: Any health problems I should note? Patient: Diabetes. Doctor: Type one or two? Patient: Type two. Doctor: Are you on insulin? Patient: Yeah. I'm also trying to manage it with exercise.
251
EXAM
MSK: No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength.
Doctor: Let me examine your leg. Well your x ray looks fine. No defect there, I don't see any mass or swelling. Are you able to walk or use that leg at all? Patient: Oh yes, I am using it. I have also started going back on my regular walk. Doctor: Good, so your muscle strength is good, no loss of muscle tone there. ...
252
CC
Nausea.
Doctor: Hello, how are you? Patient: Hi Doctor, I am good. Doctor: So, what is going on with you? Patient: Well, I am having nausea and I just want to get it checked. Doctor: Okay.
253
ROS
Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.
Doctor: How long have you had this cough? Patient: Past three weeks, doc. Doctor: Are you bringing anything up when you cough? Patient: Nah. Doctor: Any shortness of breath or chest pain? Patient: Nah. Doctor: How about fevers or chills? Patient: None of that.
254
PASTMEDICALHX
1. Pneumonia. He has had recurrent episodes of pneumonia, which started at approximately age 20. These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year. He is usually treated wit...
Doctor: Let's go over your history. Patient: Okay. Doctor: I see that you had an appendectomy. Patient: Back in the nineteen forties. I also had an ankle resection in nineteen seventy five. Doctor: Any complications with either surgery? Patient: Uh nope. Doctor: I also see that you have a recurring history of pne...
255
ROS
Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time. The patient does have a history of nausea and vomiting, but is doing better.
Doctor: Hi again! How are you feeling today? Patient: I am feeling okay. Doctor: Are you still experiencing any nausea or vomiting? Patient: No. I feel better now. Doctor: Have you had any shortness of breath or chest pain? Patient: No. Doctor: Any painful or burning urination? Patient: No. Doctor: Do yo...
256
FAM/SOCHX
Noncontributory.
Doctor: Tell me about your family medical history. Patient: No one in my family has any health problems.
257
GENHX
The patient had his circumcision performed on 09/16/2007 here at Children's Hospital. The patient had a pretty significant phimosis and his operative course was smooth. He did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery...
Doctor: Your son had his circumcision performed here at Children's Hospital, correct? Guest_family: Yes, doctor. Doctor: Do you remember the date of that procedure? Guest_family: Um, it was on September sixteenth two thousand seven. Doctor: Good, the procedure went well. He had some phimosis, but the operation ...
258
CC
A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.
Doctor: Is this something new? Or have you had it before? Patient: No doctor, this is new. Doctor: What exactly are you feeling? Patient: I feel like my tongue is swollen. Doctor: Okay. How old are you? Patient: I am fifty four years old. Doctor: Okay let me see how we can evaluate that.
259
CC
Antibiotic management for a right foot ulcer and possible osteomyelitis.
Doctor: So, I think we need to start you on antibiotics for that ulcer on your right foot and possible osteomyelitis. I will send a prescription to your pharmacy. Patient: Sure.
260
DISPOSITION
Improved and stable.
Doctor: Your condition is improved, and you look pretty stable. Patient: Yeah, I feel much better.
261
ALLERGY
To penicillin.
Doctor: Do you have any allergies to medications? Patient: Yes. Penicillin.
262
MEDICATIONS
Pravachol, Dilantin, Toprol, and Macrobid.
Doctor: Looks like you have a U T I and I need to give you some antibiotics to treat it. Patient: Okay. Doctor: I will write you a prescription for Macrobid. Are you still using the Walgreens pharmacy at Thrashers Corner? Patient: Yes. Doctor: Are you taking any other medications? Patient: Yes, I am taking qui...
263
PASTMEDICALHX
Otherwise noncontributory. There is no operation, serious illness or injury.
Doctor: Have you had any operations in the- Patient: Nope. No surgeries. Doctor: How about any past injuries or illnesses? Patient: Nope.
264
CC
Jaw pain this morning.
Doctor: What is going on? Patient: I have pain in my jaw since the morning. Doctor: How bad is it? Patient: Not that bad.
265
MEDICATIONS
None.
Doctor: Have you taken any medications in the past? Patient: Do you mean prescription, or over the counter? Doctor: Either of those. Patient: Oh, I haven't taken anything in the past.
266
PLAN
ADA 1800-calorie diet.
Doctor: Any changes to your diet? Patient: I've been following the A D A diet online and maxing out at around eighteen hundred calories per day. Doctor: How're you feeling since starting this diet? Patient: A lot better actually. My blood sugar isn't as high as it used to be.
267
PASTMEDICALHX
1. Gastroesophageal reflux disease. 2. Mitral valve prolapse. 3. Stage IIIC papillary serous adenocarcinoma of the ovaries.
Doctor: Hello! How are you doing? Patient: I am doing okay. Doctor: Tell me about your past medical history. Patient: I was diagnosed with stage three ovarian cancer two years ago. They found a tumor in my upper abdomen. I had surgery and they removed everything. Doctor King is my oncologist. Doctor: Are you st...
268
GENHX
This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma. She says her asthma has been worse over the last three months. She has been using her inhaler daily. Her allergies seem to be a little bit worse as well. Her husband has been hauling corn and this seems to aggrava...
Doctor: Hello, miss. Before we begin your physical, could you verify your age and ethnicity for me, please? Patient: I'm forty two years old and identify as white. Doctor: Thank you. I also see that you're here for a follow up for your asthma, correct? How is your asthma? Patient: That's right. Oh, man. My asthma...
269
FAM/SOCHX
His parents are deceased. He has two brothers ages 68 and 77 years old, who are healthy. He has siblings, a brother and a sister who were twins who died at birth. He has two sons 54 and 57 years old who are healthy. He describes history of diabetes and heart attack in his family.
Doctor: How are your parents doing, sir? Patient: Well, doctor, I've lost both of them now. Doctor: I'm so sorry to hear that, sir. How about your brothers? Patient: Thank you, doctor. Both of my brothers are doing very well. Doctor: Remind me, please, how old are they? Patient: One of them is sixty eight, an...
270
GENHX
I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis. As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and pos...
Doctor: Hello, ma'am. What is the reason for your visit today? Patient: I was referred by a doctor to come see you so that you could check up on my nasal problems. Here is my report from my previous doctor who referred me to you. Doctor: Thank you. Let me take a look. I see here it says you had severe sinusitis tw...
271
FAM/SOCHX
The patient lives with his wife.
Doctor: Is there anyone that lives with you at home? You are going to need someone to help you care for your wound. Patient: My wife lives at home with me. She can help me change my bandages.
272
PASTSURGICAL
PermCath insertion times 3 and peritoneal dialysis.
Doctor: Hello. Looks like you're having surgery today. Patient: Yeah, I am. I forgot what the surgery was, but it says it in my report. Doctor: I'm looking at it right now. Looks like you had a PermCath inserted three times and received peritoneal dialysis
273
PASTMEDICALHX
He has had bilateral knee replacement three years ago and experiences some pain in his knees with this.
Doctor: So, what is happening with you? Patient: I had knee replacement for both my knees three years ago and now I am having some pain. Doctor: Okay and in one or both knees? Patient: Both. Doctor: Okay.
274
EDCOURSE
PROGNOSIS: Improved.
Doctor: Hi! Patient: Hello! Doctor: How are you feeling now? Patient: I am feeling okay. Doctor: Yeah, looks like your condition is improving. Patient: Yes, I think so too.
275
DIAGNOSIS
1. Gastroenteritis. 2. Autism.
Doctor: And who are we seeing today? Guest_family: Hi Doctor, this my son J and that's my wife. Guest_family_2: Hi there Doctor: Well, hello young man how are you feeling today? Guest_family_2: He has been complaining of severe tummy pain and was crying the whole time. We are worried as he is a special child. He ...
276
FAM/SOCHX
She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired.
Doctor: Hello, nice to meet you, miss. I will be taking care of you today. Before we start, can I get to know you a bit? I like to know who I am treating. Patient: Hello, nice to meet you. Of course. Um, what can I say? I am a recent widow. My husband passed when we were married for only eight years. I am also retire...
277
MEDICATIONS
Albuterol.
Doctor: What do you use to treat your asthma? Patient: I use my Albuterol inhaler.
278
GENHX
The patient eats regular diet and eats 3 meals a day.
Doctor: Do you eat three meals a day? Patient: Yes. Doctor: Do you think those meals add up to about two thousand calories a day? Patient: I would say yes.
279
MEDICATIONS
Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.
Doctor: Are you still taking Micronase every morning? Patient: Yes, I take um two point five M G once a day. Doctor: Great. Continue taking Micronase by mouth every day. As for your infection, I want you to start taking Bactrim twice daily. I'll be prescribing you thirty pills. It'll be Bactrim four hundred M G and...
280
FAM/SOCHX
She does not smoke or drink alcohol.
Doctor: Do you consume any kind of tobacco? Patient: No. Doctor: What about smoking? Patient: No, I've never done it. Doctor: Any kind of alcohol consumption? Patient: Nope.
281
GENHX
The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and...
Doctor: What seems to be the problem today? Patient: I've been having headaches for a while now. Doctor: How long have you been having these headaches? Patient: Um, I had my first one about two months ago. Doctor: Did you suddenly start having them, or was it more gradual? Patient: Um, I'd say it was more gra...
282
PASTMEDICALHX
Negative.
Doctor: Do you have any medical conditions that I should know about? Patient: No, not that I know of. Doctor: So, there's no history of depression, or cancer, or high blood pressure? Patient: No, it's not ringing any bells.
283
CC
Abdominal pain, nausea and vomiting.
Patient: I am having stomach pain. Doctor: Hm, any nausea or vomiting? Patient: Yes, both.
284
ROS
No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.
Doctor: Have you been experiencing any mental difficulties or confusion? Patient: No. Doctor: Any hallucinations? Are you seeing hearing thing that is not real? Patient: No.
285
PASTSURGICAL
She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008. She has also had arm surgery when she was 6 years old.
Doctor: Good afternoon, which gender do you identify with? Patient: Good afternoon, doctor, thank you for asking, I identify as a female. Doctor: Great, thank you. Have you ever had surgery on this knee? Patient: Yes, I actually had an A C L reconstruction done in March of two thousand eight. Um, it didn't go well...
286
GENHX
Negative for use of alcohol or tobacco. He is a professor at College and teaches history and bible.
Doctor: Welcome in, sir. Patient: Thank you. Doctor: What do you do for work? Patient: I am professor at the college up on the hill. Doctor: What do you teach? Patient: I teach history and the bible. Doctor: Do you drink alcohol or use tobacco products? Patient: No. I do not partake in either of those acti...
287
PASTMEDICALHX
Past medical history is significant for allergies and thyroid problems.
Doctor: Do you have any major medical conditions that I should know about? Patient: Yeah, I have a history of thyroid problems, actually. Doctor: I'm seeing here that you have a history of allergies too, is that correct? Patient: Oh yes, that's right too.
288
DISPOSITION
Stable.
Guest_clinician: How's the patient? Doctor: He's stable. Heart rate sixty five. Normal rhythm. Oxygen ninety seven percent on room air.
289
PASTMEDICALHX
Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection. She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place. She has had right-sided CVA. She has had atr...
Doctor: Tell me about your past problems. Patient: Sure. I just came into the hospital I think about three weeks back for recurrent urine infections. Doctor: Yes it says here that you have bladder problems from a long time, mostly related to tone and capacity. Patient: Yes that is why they put catheter in me. Doct...
290
FAM/SOCHX
Noncontributory.
Doctor: Do you have any major medical conditions running in your family history that you know about? Patient: No, there's nothing of note. Doctor: So, there's no history of arthritis, or cancer that you're aware of? Patient: No, not that I know of.
291
FAM/SOCHX
Noncontributory to the present condition and review of his previous charts.
Doctor: So, does high blood pressure run in your family? Patient: Um, no it's just me. Doctor: Okay and this was your first time? Patient: Yes. Doctor: Because I am looking at your previous charts and I don't see it mentioned before. Patient: Oh yeah first time it shot up this high. I never had a high blood pres...
292
FAM/SOCHX
Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.
Doctor: Now, let's talk about your family history. Have any of them had cancer? Patient: Actually, yes, I know a few family members have, but I can't remember who had what kind. Doctor: That's okay. What about heart disease? Can you remember anyone having that? Patient: Yes, that rings some bells. Doctor: Thank...
293
CC
Pressure decubitus, right hip.
Doctor: Hi, how are you? Patient: I am good, how about you? Doctor: Well, I am good too, thank you for asking. So, what brings you here? Patient: Um, I have developed this painful ulcer on my hip. Doctor: Oh, let me take a look. Which side? Patient: On my right hip. Doctor: Okay, I see it. Looks like you have ...
294
GENHX
A 14-day-old was seen by private doctor because of blister. On Friday, she was noted to have a small blister near her umbilicus. They went to their doctor on Saturday, culture was drawn. It came back today, growing MRSA. She has been doing well. They put her on bacitracin ointment near the umbilicus. That has abo...
Doctor: Okay, tell me what's going on and what's brought you here. Guest_family: I am her mother. She has this blister on the side of her head right above her ear, here. I was just worried and concerned about my baby. Doctor: How old is the baby? When did you first notice it? Guest_family: She is just fourteen day...
295
DIAGNOSIS
Migraine headache.
Patient: I am in pain. I get these frequent episodes of pain and discomfort in my head. Doctor: Is it in any side of head or is it overall? Patient: Sometimes it is overall and other times just on any one side. Doctor: This sounds like it is a migraine headache.
296
GENHX
This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing i...
Doctor: Good afternoon, young man. Is this your mother? Patient: Hi, doctor. Yes, this is my mom. Doctor: Good, can you tell me more about your son, ma'am? Guest_family: Sure, well, he's six years old now, and we're here to follow up his A D H D medicines. Doctor: He's been taking Adderall, correct? How long has...
297
GENHX
The patient is a 52-year-old male who is here for independent medical evaluation. The patient states that he works for ABC ABC as a temporary worker. He worked for ABCD too. The patient's main job was loading and unloading furniture and appliances for the home. The patient was approximately there for about two and ...
Doctor: Good afternoon, sir. Welcome in. Let's get started, how old are you? Patient: Good afternoon, doctor. I'm fifty two years old. Doctor: My nurse says that you're here for an independent evaluation, is that correct? Patient: Yes sir, that is. Doctor: Good, what do you do for a living? Patient: Right now,...
298
FAM/SOCHX
Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.
Doctor: Is there any family medical history? Patient: I have a whole list. See, my grand aunt had a stroke. My M G had heart issues same as my mom, who died of a heart attack at sixty three. My father had some sort of cancer. I don't know what exactly. And my sisters have blood pressure issues. Doctor: Wow, that su...
299
ALLERGY
He has no known drug allergies.
Doctor: Does he have any known drug allergies? Guest_family: No.