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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. |
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