Dialogue,Target "Doctor: What brings you back into the clinic today, miss? Patient: I came in for a refill of my blood pressure medicine. Doctor: It looks like Doctor Kumar followed up with you last time regarding your hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Have you noticed any changes or do you have any concerns regarding these issues? Patient: No. Doctor: Have you had any fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure? Patient: No. Doctor: Great. Also, for our records, how old are you and what race do you identify yourself as? Patient: I am seventy six years old and identify as a white female.","Section header: GENHX Section text: The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check. She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Since her last visit she has been followed by Dr. Kumar. Those issues are stable. She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure." "Doctor: How're you feeling today? Patient: Terrible. I'm having the worst headache of my life. Doctor: I'm so sorry. Well you are only twenty five, so let's hope this is the last of the worst. Let's see how we can best help you. When did it start? Patient: Around eleven in the morning. Doctor: Today? Patient: Um no yesterday. July thirty first. Doctor: July thirty first O eight. Got it. Did it come on suddenly? Patient: Yeah. Doctor: Are you having any symptoms with it, such as blurry vision, light sensitivity, dizziness, lightheadedness, or nausea? Patient: I'm having blurry vision and lightheadedness. I also can't seem to write well. It looks so messy. I am naturally right handed but my writing looks like I am trying with my left. Doctor: How would you describe the lightheadedness? Patient: Like there are blind spots. Doctor: Okay. How about any vomiting? Patient: Um no. I feel like my face is pretty swollen though. I don't know if it's related to the headache but it started around the same time. Doctor: Here in the E R, we'll do a thorough exam and eval to make sure nothing serious is going on. While we're waiting for your C T results, I'm going to order a migraine cocktail and some Morphine. Patient: Thank. Will the nurse be in soon? Doctor: Yes, she'll be right in as soon as the order is placed. It shouldn't be more than a few minutes. If it takes longer, then please ring the call bell.","Section header: GENHX Section text: The patient is a 25-year-old right-handed Caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the July 31, 2008. She described the headache as worse in her life and it was also accompanied by blurry vision and scotoma. The patient also perceived some swelling in her face. Once in the Emergency Department, the patient underwent a very thorough evaluation and examination. She was given the migraine cocktail. Also was given morphine a total of 8 mg while in the Emergency Department. For full details on the history of present illness, please see the previous history and physical." "Doctor: Hello, miss. What is the reason for your visit today? Patient: I think I have some warts on my back end where the poop comes out. Doctor: I see. When did you start noticing them? Patient: I think like three to four weeks ago. Doctor: Do you feel any pain or discomfort? Patient: It itches a little, but I haven't felt any pain yet. Is this normal for a twenty two year old? Doctor: I'll have to take a look, but you'll be fine. Are there any other symptoms that you are aware of? Patient: Nope. Just the warts and itchiness.","Section header: GENHX Section text: This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region. She has noticed approximately three to four weeks ago. She denies any pain but does state that there is some itching. No other symptoms associated." "Doctor: Are you taking any over the counter medicines? Patient: No, only the ones which were prescribed. Doctor: No alternative medicine, naturopathy or anything? Patient: No, only whatever is here in this prescription. Doctor: Okay let me take a look...so you were prescribed Salmeterol inhaler- Patient: On as needed basis. Doctor: Okay and the other one is Fluticasone inhaler, which is- Patient: Which is a nasal inhaler. Doctor: Right.","Section header: MEDICATIONS Section text: Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines." "Doctor: Hi, how are you? Patient: I burned my hand. Doctor: Oh, I am sorry. Wow! Patient: Yeah. Doctor: Is it only right arm? Patient: Yes.","Section header: CC Section text: Burn, right arm." "Doctor: How's your asthma since you started using your inhaler again? Patient: Much better. I don't know why I didn't take it with me everywhere I went. Doctor: It's important to carry it with you, especially during times where you're exercising or walking more than usual. Patient: Yeah. I think I've learned my lesson. Doctor: Besides asthma, do you have any other medical problems?",Section header: PASTMEDICALHX Section text: Asthma. "Doctor: Do you smoke? Patient: No, I quit before I had my daughter. Doctor: Are you currently pregnant? Patient: No, I'm not. Doctor: Did you have any complications with the birth of your daughter? Patient: I actually had a C section. Doctor: Have you had any other surgeries in the past? Patient: I got my appendix out a few years ago. Doctor: Do you have any other issues, like high blood pressure or heart disease? Patient: No. Doctor: Do you have diabetes? Patient: No. Doctor: Are there any problems with the lungs, thyroid, kidney, or bladder? Patient: No. Doctor: So, how long ago did you hurt your lower back? Patient: It was about four or five years ago now, when I was in a car crash. Doctor: What kind of treatments were recommended? Patient: They didn't recommend P T, and I didn't really have any increased back pain after the accident.","Section header: PASTMEDICALHX Section text: The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions. The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant. The patient has had a C-section and also an appendectomy. The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident." "Doctor: Any know drug allergies? Patient: No.",Section header: ALLERGY Section text: No known drug allergies. "Doctor: Hi there, sir! How are you today? Patient: Hello! I am good. Doctor: I would like to start with your family medical history today. What do you know about their medical history? Patient: My mother and father both had heart disease. Well, my mother had complication from her heart disease and that is how she passed. My father was only in his forty's when he died. Doctor: I am so sorry the hear that. Patient: Thank you. I have two brothers, one whom I don't speak to very much anymore. I don't know if he has any health problems. My other brother is healthy with no issues. Both my uncles on my mother's side had polio, I think. Doctor: Tell me more about your uncles with polio. They both had polio? Patient: One of them had to wear crutches due to how bad his leg deformans were and then the other had leg deformities in only one leg. I am fairly certain that they had polio. Doctor: Do you know of any other family member with neurological conditions? Patient: No. None that I know of. Doctor: Do you have any children? Patient: Yes. I have one child. Doctor: Is your child healthy and well? Patient: Yes.","Section header: FAM/SOCHX Section text: His mother died of complications from heart disease. His father died of heart disease in his 40s. He has two living brothers. One of them he does not speak too much with and does not know about his medical history. The other is apparently healthy. He has one healthy child. His maternal uncles apparently had polio. When I asked him to tell me further details about this, he states that one of them had to wear crutches due to severe leg deformans and then the other had leg deformities in only one leg. He is fairly certain that they had polio. He is unaware of any other family members with neurological conditions." "Doctor: Can you tell me about any diseases that run in your family? Patient: Sure, my brother has a prostate cancer. Doctor: Okay, brother. Patient: My father had brain cancer. Doctor: Okay, dad. Patient: Then on both sides of my family there are many heart related issues. Doctor: Okay. Patient: And my brother and sister both have diabetes. Doctor: Okay. Patient: Yes, that's it.",Section header: FAM/SOCHX Section text: His brothers had prostate cancer. Father had brain cancer. Heart disease in both sides of the family. Has diabetes in his brother and sister. "Doctor: Good afternoon, ma'am. Welcome to A B C D General Hospital. Before we begin, I just need to confirm some background information on you. Patient: Good afternoon, doctor. Absolutely, that's no problem. Doctor: First, how old are you? Patient: I'm nineteen, sir. Doctor: Good, and your chart says you identify as Caucasian. Is that correct? Patient: Yes, sir, that's correct. Doctor: Great, what seems to be problem today, ma'am? Patient: I've had this bunion on my foot for such a long time. Doctor: How long has this bunion been present? Patient: At this point, um, I don't even remember how long it's been. Doctor: Do you have any other conditions that I should be aware of? Patient: Actually, yes. I have a history of, um, Charcot Marie tooth disease. Doctor: That's good to know, thank you. Patient: I would like to have surgery to cut this bunion off, I can't take it anymore.",Section header: GENHX Section text: This 19-year-old Caucasian female presents to ABCD General Hospital. The patient states she has had worsening bunion deformity for as long as she could not remember. She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time. "Doctor: I hear someone has a birthday coming up, how old are you turning, ma'am? Patient: I'll be ninety later this month, doctor. Doctor: You're here for a follow up not very long after your first visit. What seems to be the problem today? Patient: Well, actually, my high blood pressure and right arm symptoms are basically gone. Doctor: Great, I saw your blood pressure reading for today, and it's much better. Are you taking the higher dose of Mavik we recommended? Patient: No, I'm not taking that right now. Doctor: How did you tolerate the higher dose? Patient: I didn't feel well at all, so I just went back to the old dose. Doctor: That was one M G per day, correct? Patient: Yes, doctor. I do think I could have some white coat high blood pressure. Doctors' offices make me nervous. Doctor: That does happen. Here, try this sample of Tarka, please. Patient: What is this for, doctor? Doctor: Well, since you're taking the Mavik plus verapamil, you can switch over to Tarka, which is the combined version of the two drugs. Patient: I can't take these, doctor. They're too big. Guest_family: Hello doctor, I'm her daughter. Just so you know, we check her blood pressure at home periodically and it's always similar to that reading. Doctor: Good, so back to that right arm, how is that doing today? Patient: Well, that pain is basically gone now, I think it had to do with that muscle problem back in my right shoulder blade. Doctor: Did you have x rays taken today? Patient: Yes, the tech brought me back right before you came in. Doctor: Good, I have the images right here. Patient: What do they show, doctor? Doctor: Well, these x rays of the neck and right shoulder show some degenerative changes, and possibly some kind of rotator cuff injury. Patient: What makes you think there's an injury? Doctor: Well, look right here. The humeral head is pretty high in the glenoid in the right shoulder, but do you have any pain here? Patient: No, none. Doctor: Then we won't worry about it. Patient: I am having this stomach pain though, doctor. Doctor: How has this pain developed and progressed recently? Patient: Well, it's improved somewhat with me not taking Aleve anymore. Doctor: What medicines are you taking right now, then? Patient: Right know, I'm just taking Tylenol as needed. That seems to be enough for me. Doctor: Do you think this could be acid reflux, or heartburn? Patient: No, but I take Tums, um, three times a day, and Mylanta at night. Oh yeah, I have these sores in my mouth, can you take a look? Doctor: I see. How long have you worn dentures? Patient: Oh I couldn't even tell you, it's been many, many years. Doctor: Do they come and go, the sores? Patient: Yes, one will come, then it'll heal up, then another. Doctor: Okay, we'll keep an eye on it. Patient: And doctor, since I've been taking the Lexapro, I have some tremors on basically my whole body, at least the upper body, like my torso and arms. Doctor: It's hard to tell if you have a tremor today, ma'am, but do you think the Lexapro is helping otherwise? Patient: Yes, we think so.","Section header: GENHX Section text: The patient is an 89-year-old lady. She actually turns 90 later this month, seen today for a short-term followup. Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved. Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended. She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily. She thinks, she also has an element of office hypertension. Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka. However, when we gave her samples of that she thought they were too big for her to swallow. Basically, she is just back on her previous blood pressure regimen. However, her blood pressure seems to be better today. Her daughter says that they do check it periodically and it is similar to today's reading. Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade. We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems. She has some vague 'stomach problems', although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve. She takes Tylenol p.r.n., which seems to be enough for her. She does not think she has any acid reflux symptoms or heartburn. She does take Tums t.i.d. and also Mylanta at night. She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth. They do heal up, but then she will get another one. She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor. They do think the Lexapro has helped to some extent." "Doctor: Are you talking any medications? Patient: No, I don't believe in meds. Doctor: Oh really, let me check your list. Patient: Yeah never. Doctor: Wow amazing.",Section header: MEDICATIONS Section text: None. "Doctor: Any past medical history? Guest_family: She has a history of peptic ulcer disease and we think she may have had a possible stroke three or four years ago. I would have to double check. Doctor: Let me see if I can find it in her records. Doctor: Does she see a neurologist? Guest_family: Um I'm not sure. I can call her son? Doctor: Yes, if you could find out that'd be great. Guest_family: She's also experiencing some memory loss as of one to two years ago. I think that's it for medical history.","Section header: PASTMEDICALHX Section text: PUD, ?stroke and memory difficulty in the past 1-2 years." "Doctor: How old are you? Patient: I am forty four. Doctor: Are you right handed or left handed? Patient: I'm right handed. Doctor: Tell me what happened. Patient: I don't know. I woke up over this numbness on my left side of the body. I remember it was on July twenty nineth. Doctor: Was there any sensation like having pins and needles? Was there any weakness? Is there any change in your visual or mental status? Were you able to walk? Patient: I was able to walk and there was no weakness or any other thing you mentioned. Doctor: When did you first start noticing these symptoms? Patient: There was nothing around Independence Day. It all started after that. At first, I felt that my right hand is very clumsy, and it is kind of stiff. Then I noticed leaning towards the right when walking. It was strange. Happened around July seventh. Doctor: Did you recently have any cold or flu like symptoms? Patient: No. Doctor: Were diagnosed with a thing called multiple sclerosis? Patient: No. Doctor: Did you ever have a feeling where you felt like there's an electric is going up or down your spine? Patient: No. Doctor: How about any fatigue or pain? Any frequency in your urination? Any urgency in that? Patient: No.","Section header: GENHX Section text: This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena." "Doctor: You had a heart surgery, right? Patient: Yes, that is right. Doctor: Pacemaker? Patient: Yes, they did that. Doctor: What else? What other surgeries? Patient: I have had a hysterectomy. Doctor: Okay. Patient: Yeah.",Section header: PASTSURGICAL Section text: Placement of pacemaker and hysterectomy. "Doctor: How old are you, young boy? Patient: I am twenty nine. Doctor: And you got right side shoulder pain? Is this something new? Patient: Yes. That is right. Doctor: What were you doing when this happened? Patient: I think I was picking up a stack of cardboard, then putting it down on the ground and twisting to the right side. And sometimes I was throwing them a little bit as well. Doctor: Okay, and how far you were lifting them or bending? Patient: Around here, till waist level. Doctor: Okay. Patient: I heard a pop and since then there is pain in this area. I can't lift heavy items. Basically I have no strength. Doctor: Okay. And this all started from June thirty two thousand and four? Patient: Yes, that's right. The pain is in the lateral part of the back of my shoulder. Doctor: How did you lose your arm if I may ask? Patient: Motorcycle accident.","Section header: GENHX Section text: This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level. Sometimes he has to throw the stacks a little bit as well. He states he felt a popping sensation on 06/30/04. Since that time, he has had persistent shoulder pain with lifting activities. He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder. He has no upper extremity ." "Doctor: When did the nausea and vomiting start? Patient: About a few hours ago. I can't seem to stomach anything. Doctor: How many episodes of vomiting have you had? Patient: At least four. Doctor: Any abdominal pain, fever, chill, or other symptoms? Patient: Just nausea and vomiting. It's been so terrible. Doctor: I'll order you some Zofran to help bring the nausea to bay. One moment while I put the order in.",Section header: CC Section text: Intractable nausea and vomiting. "Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: Is this your assistant, ma'am? Patient: Yes, she helps me out all day. Doctor: Great, do you have your food diary sheets? Patient: Yes, can you give them to her, please? Doctor: Thank you. What are you doing for exercise? Patient: Um, right now, I walk around at the mall to get my steps in every day.",Section header: GENHX Section text: The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall. "Doctor: Is he currently taking any medication? Guest_family: No.",Section header: MEDICATIONS Section text: None. "Doctor: Hello, sir. I see your last visit was on July two thousand and seven. What was the reason for that visit? Patient: My asthma was acting up, and it felt like I couldn't breathe. Doctor: Do you have a history of asthma? Patient: Not that I know of, but I know I always get this really bad cough where I cough up some nasty phlegm. Doctor: I see. I'm looking at your report and it says you have a history of pneumonia.",Section header: PASTMEDICALHX Section text: Asthma with his last admission in 07/2007. Also inclusive of frequent pneumonia by report. "Doctor: Do you know about any medical traits in your family? Patient: No, everyone in my family is quite healthy. I'm not aware of any medical problems. Doctor: Are you sexually active? Patient: Yes, I am with my boyfriend. Doctor: Do you take any drugs or alcohol or smoke? Patient: No, none of them.",Section header: OTHER_HISTORY Section text: completely unremarkable FHx. Has boyfriend and is sexually active. Denied drug/ETOH/Tobacco use. "Doctor: Any past medical history? Patient: Um there were a couple times where I noticed my blood pressure was high but that's improved as of late. Doctor: When did these episodes occur? Patient: About a year ago. Doctor: Did you follow up with your previous doctor? Patient: Yeah, my old doctor knows. Doctor: Okay then. Let's see. Have you been checking your own blood pressure as a result? Patient: No not really. Doctor: It looks like your blood pressure was normal today, which is a good sign. Patient: Great. Doctor: Hm any allergies to medications? Patient: None that I know of. Doctor: And it looks like you have gained about fourteen pounds since last year. Any new diet changes or stressors? Patient: I lost my job last January and it took a pretty big toll on me. Doctor: I'm sorry to hear that. How have you been coping? Patient: I'm doing better now but I need to watch what I eat. I tend to eat a lot more when I'm stressed. It's something I'm working on.","Section header: PASTMEDICALHX Section text: Unremarkable. There is no history of allergies. He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year." "Doctor: Are you allergic to anything? Patient: Yes, I am allergic to Penicillin. Doctor: Any other drugs that you could be allergic to? Patient: Nope that is all. Doctor: Okay.",Section header: ALLERGY Section text: Penicillin. "Guest_clinician: What brought them in today? Doctor: Poor renal sufficiency, possibly due to dehydration or diabetic nephropathy. She also has high blood pressure and low blood sugar as a result of missing meals regularly.","Section header: ASSESSMENT Section text: 1. Hypoglycemia due to not eating her meals on a regular basis. 2. Hypertension. 3. Renal insufficiency, may be dehydration, or diabetic nephropathy." "Patient: Doc what are you going to diagnose me as? Doctor: We are looking at blood born pathogen exposure secondary to needlestick. Patient: Yes, I was also thinking around contamination.",Section header: ASSESSMENT Section text: Blood-borne pathogen exposure secondary to contaminated needlestick. "Guest_clinician: She was in a car crash, correct? Doctor: Correct. About two days ago. I believe it was a head on collision.",Section header: CC Section text: Motor vehicle accident. "Doctor: Any allergies I should know about? Patient: Nope, no allergies for me.",Section header: ALLERGY Section text: No allergies. "Doctor: Hello sir. Let me first start by asking your age. How old are you? Patient: I'm twenty four. Doctor: So, what brought you here? How can I help you? Patient: I was out for fishing this weekend, I think I got into some poison ivy and I have these rashes all over my chest, legs, arms and also some are on my back. Doctor: You seem so confident of it being poison ivy has it happened before? Patient: Oh yes, it has happened several times before. It usually takes some time to get over. Last time I was here Doctor Blackman gave me a steroid injection. Doctor: Okay, let me check my records. It looks like he gave you eighty milligrams of depomedrol. How was it last time after the injection? Patient: It worked fine. It did take us some time to get rid of it. Doctor: Did you take any medicine or anything else this time? Patient: I took over the counter Benadryl. Also, I'm applying cortisone cream on the rashes. Doctor: Did they help you? Patient: I saw a little bit of improvement. But this weekend it seemed to have been worst. Doctor: No worries, let's set you up for another injection.","Section header: GENHX Section text: He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing. He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg. He said that it worked fairly well, although it seemed to still take awhile to get rid of it. He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back." "Doctor: You had mentioned that cancer runs in your family. What type of cancer? Patient: Skin cancer. Doctor: Any other health problems in the family? Patient: High blood pressure.","Section header: FAM/SOCHX Section text: Cancer, hypertension." "Doctor: Hi, what brings you here today? Patient: I feel this lump on the upper side of my breast. Doctor: Both sides? Patient: No, only on the left side. Doctor: Do you feel it deep inside or on the outer side? Patient: Only on the outer side.","Section header: CC Section text: Suspicious calcifications upper outer quadrant, left breast." "Doctor: I understand that you are new to the clinic. Welcome. Patient: Yes, I am new here. I have lived in Arizona for the last four years. I am from Maine. That is where I grow up and most of my family still lives there. Doctor: What line of work are you in? Patient: I am a homemaker. I used to clean house, a while back. Doctor: Do you have children? Patient: I have two children but only one of them is still with us. My oldest son passed away from ulcerative colitis complications three years ago. Doctor: I am so sorry to hear that!","Section header: FAM/SOCHX Section text: The patient is originally from Maine. She has lived in Arizona for 4 years. She has had 2 children; however, only one is living. She had one child died from complications of ulcerative colitis. She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past." "Doctor: You okay there? Patient: Uh yeah, sorry. I'm just trying to adjust the stretcher. Doctor: Want some help? Patient: No, thank you. I think I got it. Doctor: So how're you doing? Patient: Fine, but I have this weird lump in my chest. Doctor: When did you first notice it? Patient: It's been there for a while. I'd say almost half a year. Doctor: Have you seen anyone for it? Patient: No, not until now. Doctor: Is it causing you pain? And has it changed in size at all? Patient: Not really. It's just noticeable when I run my fingers over it. Doctor: Have you spotted any swelling or redness to the area? Any drainage? Patient: No. Doctor: I see. Okay. Let me take a look and then I'll have you walk down the hall to get an Xray so we can see what's going on.",Section header: CC Section text: Lump in the chest wall. "Doctor: Hello, so you are here for follow up today. Patient: Yes, very much. Doctor: I will ask you some regular questions, okay? Patient: Sure. Doctor: Any pain in urination? Patient: Nope. Doctor: Any fever or chills? Patient: Neither of them. Doctor: Have you noticed any blood while urinating? Any blood in your urine? Patient: Nope. I do leak, especially when I'm changing my positions like from sitting to standing so I do feel there is some involuntary urination. It's more like a urge. I'm loading data in like every one hour in the morning, especially when I take that Lasix. Doctor: Does it taper off in the afternoon or night? Patient: It tapers off in the afternoon. And by the night I don't do not feel anything. Doctor: Any leakage in the night? Patient: Nope. Doctor: Do you apply a lot of force to urinate? Patient: Nope. Doctor: How about this stream? Is it good or less? Are you emptying well? And what about the bowel movement? Patient: The stream is good. It does feel like all is out in one go. I do not have any kind of bowel issues. I'm using my vaginal cream. Sometimes I feel difficulty in doing so because I feel that there is still something coming out from the vagina and I'm afraid that there might be a prolapse. Doctor: Don't worry, I will look into it.","Section header: GENHX Section text: The patient presents today for followup. No dysuria, gross hematuria, fever, chills. She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence. She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0. No incontinence. No straining to urinate. Good stream, emptying well. No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse." "Doctor: Have you lost weight? Patient: No, I haven't, you can ask my daughter. Doctor: How about anything like fever, nausea, vomiting, pain? Patient: No. Doctor: And as we discussed you have problem talking and comprehending. Patient: Yes. Doctor: And you get urine infections too? Patient: Yes. Doctor: And as discussed, your drainage is similar to past episodes when you had such infection? Patient: Yes.","Section header: ROS Section text: As in HPI. Patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. She has had some difficulty expressing herself, but seems to comprehend speech as above. The patient has had a history of chronic urinary tract infections and her drainage is similar to past episodes when she has had such infection." "Doctor: Do you use tobacco products? Cigarettes, chewing tobacco or vaping? Patient: I used to smoke a pack a day. I quit that awful habit in nineteen eighty five. Doctor: Do you work? Patient: I am retired. Doctor: Wonderful. Is your husband retired with you? Patient: Yes. We both are. I cannot imagine working a full time job at seventy six years old.",Section header: FAM/SOCHX Section text: She is married. A 76-year-old who used to smoke a pack a day and quit in 1985. She is retired. "Doctor: Hi there, how are you? Patient: I am okay. Doctor: So, I see you turned eighty-eight yesterday, happy birthday! Patient: Thank you! Doctor: And you are referred by Doctor X, he is your primary physician, right? Patient: Correct! I am also seeing Doctor Y for my leukemia. Doctor: Hm he mentioned that it's chronic lymphocytic leukemia. Patient: Yes. Doctor: Okay. Doctor: And you are also seeing Doctor Z for your heart related problems. Patient: That is correct. Doctor: So, tell me what is happening with you? Patient: For the past one week I am having this increased shortness of breath and having difficulty breathing from past few nights while sleeping. Doctor: Okay. Patient: And this morning I was having difficulty catching my breath. I am also having wheezing since morning. Doctor: Let me examine you, can you come forward and sit-up here? Any chest discomfort or acute chest pain or anything of that sort? Any pain of the left arm? Patient: No. Doctor: Any dizziness, feeling like fainting or light headedness or losing control? Patient: No. Doctor: Well, I don't think there is any sign of cardiovascular accident or heart attack, so that's that. You do have mild peripheral edema. We need to treat that. Patient: Okay.","Section header: GENHX Section text: The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues. He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning. He reports no clear-cut chest discomfort or difficulty with angina. He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication." "Doctor: Ready to go home? Patient: I just can't wait. Doctor: Sure. I can understand. Patient: Bye Doctor. Doctor: Yes. See you soon.",Section header: DISPOSITION Section text: The patient will be going home. "Doctor: Hello, sir. How are you today? Can you confirm your age? Patient: Fifty eight. I feel like my balance is off, and I've been feeling tired and weak. Doctor: How long have you been experiencing this? Patient: It's been going on for six to eight weeks. Doctor: I see. Did you feel any other symptoms? Patient: I haven't, but this might not be related. I had pneumonia ten days before this all started. Doctor: Interesting. Did you take any medication for that? Patient: I did, but I don't know how to pronounce it. I wrote it down for you to read. Here it is. Doctor: Let me take a look. I see you took a full course of amoxicillin, right? Patient: Yeah, that's right. Doctor: How did you feel after you finished the antibiotics? Patient: Terrible. I felt like I couldn't control my body. My balance got even worse, and I felt even more tired and weak. Doctor: Oh, wow. Do you know why your balance and coordination worsened? Patient: I did fall recently, but I know for a fact my balance was off before my fall. Doctor: How high were you when you fell? Patient: I think I was three or five feet high when I fell. Doctor: Did you fall on your back? Patient: No, I fell on my feet. Just kidding, I fell on my back. Doctor: Funny. Did anything hurt after your fall? Patient: Not really, but I've been having some back pain in my lower and mid back. Doctor: Did you always have that pain? Patient: No, I haven't. It comes and goes. Doctor: Have you done anything to treat it? Patient: I started to see a chiropractor like five days ago. He adjusts my neck and lower back. Doctor: I see. Did you start having problems with your balance after this? Patient: No. I was still having problems with that before I saw the chiropractor. Doctor: Okay. So, it wasn't the result of the adjustments. Is there anything else that may have caused it? Patient: I was taking this other medicine for ten days, but I don't remember what it was for. Here is the name of the medication. I wrote it on another paper. Doctor: It looks like you took Cipro. This is usually used to treat a U T I. Were you aware you had a U T I? Patient: Oh, yeah. I forgot about that. I thought I had one, so I went to another doctor to get some medication. Doctor: I see. I have one more question. Do you have any trouble controlling your bowel movements or attempting to go to the bathroom? Patient: Nope. I feel like I'm able to go to the bathroom whenever I want.","Section header: GENHX Section text: This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this. He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding." "Doctor: Have you had any illnesses in the past? Patient: Nope. Doctor: Anything that is worth mentioning? Patient: Nope. Doctor: Sure? Patient: Yes.",Section header: PASTMEDICALHX Section text: Noncontributory. "Doctor: Good afternoon, sir. My nurse tells me you're twenty eight years old, is that correct? Patient: Good morning, doctor. Yes, that's correct. Doctor: So, what happened? Patient: Well, I punched a wall about three days ago. Doctor: Which hand is it? Patient: It's my right hand. Doctor: Is this your dominant hand? Patient: Unfortunately, yes, it is. Doctor: Where does it hurt? Patient: Um, it's right here on the outside of my hand. Doctor: What kind of treatments have you had? Patient: I went to the E D, and they pushed some of the joints in my hand back, and they put me in a splint, so I've been wearing that ever since. Doctor: How is your pain today? Patient: Compared to when it started, it's much better today. Doctor: How would you describe your pain today? Patient: Today, I'd say it's minimal pain. Doctor: Good, do you have any numbness or tingling today? Patient: No, thankfully not.","Section header: GENHX Section text: The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation. He complained of ulnar-sided right hand pain and was seen in the emergency room. Reportedly, he had some joints in his hand pushed back and placed by somebody in emergency room. Today, he admits that his pain is much better. Currently, since that time he has been in the splint with minimal pain. He has had no numbness, tingling or other concerning symptoms." "Doctor: Hello there, how are you? Patient: I am good, thank you. Doctor: He is my colleague Doctor Mason, and he will be assisting me today and taking down notes. Guest_clinician: Hi there. Patient: Hello. Doctor: Is it okay with you if he can join us? Patient: Sure, no problem. Doctor: Great, thank you Doctor: Doctor Mason can you take down the notes. Guest_clinician: Sure. Doctor: Patient looks well developed and well nourished. He is alert with not acute distress. Guest_clinician: Got it. Doctor: Patient had a head injury, but he is fully conscious. G C S is fifty and nontoxic. Guest_clinician: Okay.","Section header: EXAM Section text: GENERAL: Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic." "Doctor: Anyone sick in your family? Patient: No. Doctor: How about anyone with the same disorders? Patient: No, I don't know. Doctor: Okay don't you worry.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: How did the patient do on the activity test? Guest_clinician: Patient was good. I have advised him to continue with his normal activities as long as he is feeling fine.",Section header: PLAN Section text: As tolerated. "Doctor: How old was he when he were first evaluated in the other hospital? Guest_family: He was seven. Doctor: Which hospital was that again? Guest_family: It was at U I H C. Doctor: So what exactly happened? Guest_family: He was doing all good like seven months before his evaluation, then he started having some dizzy spells, which like stayed for several seconds to a minute. They were not regular, but he was able to continue his activity immediately after these dizzy spells. Doctor: Did the intensity change? Guest_family: Oh yes. This, these spells, they became more frequent, and they were now for longer periods. By the time we came for the first evaluation, they were like two to three times per day. Doctor: How long were they in the duration? Guest_family: They lasted for like two to three minutes. Doctor: Was there any other associated disorder or anything? Guest_family: Yeah, around three months before his evaluation his hands, they started becoming stressed, like stiffer and felt tighter during these spells. He also felt very weak and tired after these episodes.","Section header: GENHX Section text: The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as ""dizzy spells"" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue." "Doctor: Do you have major illnesses in the family like diabetes or high B P? Patient: No nothing. No major illnesses. Doctor: Okay. Patient: Yes.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Good morning, sir. Patient: Good morning, doctor. Doctor: I just need some background information before we begin today. Patient: Sure. Doctor: Good, have you ever had surgery, sir? Patient: Yeah, actually I've had it on my knee, a nose job, and, um, carotid sinus surgery.","Section header: PASTSURGICAL Section text: Right knee surgery, cosmetic surgery, and carotid sinus surgery." "Doctor: Are you still working? Patient: No, I am retired now. I used to work for the U S postal service as an electronic technician but took retirement one year earlier due to my disability. Doctor: Ah okay. And who is in your family? Patient: Well, I stay with my wife and daughter in our apartment. Doctor: Okay. Do you smoke? Patient: No. Doctor: How about alcohol? Patient: I use to drink occasionally, that too very rare, but after my symptoms stated I stopped completely. Doctor: Any use of recreational or illegal drugs? Patient: Nope. Doctor: Did you travel anywhere recently? Patient: No, it's been really long since I traveled anywhere.",Section header: FAM/SOCHX Section text: The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history. "Doctor: Good afternoon, how are you today? Patient: I am good Doctor, thanks for asking. Doctor: This is my colleague Doctor White, and she will be taking the notes. Is it okay if she joins us? Patient: Oh sure, no problem. Doctor: Thank you. Guest_clinician: Hello, I am Doctor White, nice to meet you. Patient: Nice to meet you too. Doctor: Okay, can you breathe in and out for me? Deep breaths please. Patient: Okay. Doctor: Okay breath sounds are clear. Lung function looks good. Symmetrical rise and fall in chest as patient breathes. I am going to palpate your chest, it's just a routine exam. Patient: Sure. Doctor: Doctor White can you make a note, no egophony or tactile fremitus. Guest_clinician: Sure.",Section header: EXAM Section text: RESPIRATORY: Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus. "Doctor: Where do you live? Patient: I live in a board and care. It is a nice small care home with some very nice and supportive people. It is just next to the Safeway on Village Drive. Doctor: Nice. It looks like you love living there. Patient: Oh yes. I feel very relaxed there. Doctor: Did you consume alcohol in any way? Patient: No Sir. Doctor: Any tobacco consumption? Patient: Never in my life. Doctor: Did you ever try any kind of illicit drugs? Any I V drugs? Patient: No. I have always kept myself away from all those things.","Section header: FAM/SOCHX Section text: The patient lives in a board and care. No tobacco, alcohol or IV drug use." "Doctor: Have you had any surgeries in the past? Patient: Actually, yes, I had my gallbladder removed in nineteen ninety two. Doctor: Great, any other surgeries? Think back a little further? Patient: Oh yeah, I had my appendix out in nineteen eighty eight.",Section header: PASTSURGICAL Section text: Appendectomy 1988. Cholecystectomy. 1992 "Doctor: How are feeling now after the treatment? Patient: I am feeling pretty fair, improving slowly. Doctor: Okay? Patient: Okay.","Section header: DISPOSITION Section text: Fair, but improved." "Doctor: Sir? Can you hear me? Are you Mister Smith's wife? Guest_family: Yes. I am his wife. Doctor: How old is he? Can you tell me a little bit of how your husband's condition has come to this point? His level of consciousness is concerning. Guest_family: He is eighty five. He took the entire M G of Xanax. He is only supposed to take point one twenty five M G of Xanax. That is why he is like this. Doctor: It looks like your husband was admitted to the emergency room the night before. How did these injuries to his face happen? Guest_family: He fell off his wheelchair. Doctor: The Adult Protective Services said they found your husband in the home barley conscious. How long had he been that way? Guest_family: All day. Doctor: Do you know what other medications your husband has taken other than the Xanax? Guest_family: He didn't take his regular medications for two days.","Section header: GENHX Section text: The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness. The patient apparently lives with his wife and was found to have a decreased status since the last one day. The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse. When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife. Actually the night before, he fell off his wheelchair and had lacerations on the face. As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then. The patient's wife is not able to give a history. The patient has not been getting Sinemet and his other home medications in the last 2 days." "Doctor: How have you been feeling? Is the Wellbutrin keeping your mood stabilized? Patient: I have been feeling good. The Wellbutrin is working well for me. Doctor: It is important to not consume any alcohol or recreational drugs while taking Wellbutrin. Patient: I don't drink or do drugs.",Section header: FAM/SOCHX Section text: The patient has a history of depression. No history of substance abuse. "Doctor: Tell me a little bit about your family history. Patient: My dad and grandpa both had type two diabetes. My son is struggling with type one diabetes at the moment. Doctor: I'm sorry to hear that. Does anyone in your family have heart problems? Patient: No. Doctor: How about cancer? Patient: Two of my cousins had breast cancer.",Section header: FAM/SOCHX Section text: As far as heart disease there is none in the family. As far as cancer two cousins had breast cancer. As far as diabetes father and grandfather had type II diabetes. Son has type I diabetes and is struggling with that at the moment. "Doctor: Where do you work, miss? Patient: Well, you see, I am a civil engineer. Right now, due to pandemic like everyone else I am working from home. Doctor: Are you working full time or is your disability affecting that? Patient: No, I can only work on half time. This disability does not let me work full time. I need to go to physical therapy quite frequently on and off and I also have a baby who consumes a lot of my time. Doctor: Do you smoke or drink? Patient: No, I've never done any of them.","Section header: FAM/SOCHX Section text: The patient is a civil engineer, who currently works from home. She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. She does not smoke and does not drink and has never done either." "Doctor: Do you know any familiar diseases in your family? Patient: Do you mean like B P, high sugar? Doctor: Yes. Patient: No, no one in my family has anything like that. Doctor: Great.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Have you had any anxiety attacks lately? Patient: No. Doctor: Have you felt depressed or had any mood swing problems? Patient: No. Doctor: Any phobias? Patient: No, not really. Doctor: Okay.","Section header: ROS Section text: PSYCHIATRIC: Normal; Negative for anxiety, depression, or phobias." "Doctor: Do you have a history of mental illness or psychological disease? Patient: No.",Section header: PASTSURGICAL Section text: None Past Psychological History: None "Doctor: Hello sir. How are you doing today? You still look a little uncomfortable. Is there still pain? Patient: Yeah. Still a good amount of pain. I did not take my pain medication this morning though. Not sure if that will make a huge difference. Doctor: That is possibly why you are still in pain. How is movement? Can you get out of the house and get around? Patient: Yes. I am quite happy that I can do my daily activities. I can get up with minimal assistance and do many activities out of the house. I think I am gaining muscle from moving around more too. Doctor: How is the home exercise program going? Patient: I am loving pool therapy. I really feel like that is helping. I do the home exercises sometimes twice a day. I really want to get back to normal.","Section header: GENHX Section text: The patient states pain still significant, primarily 1st seen in the morning. The patient was evaluated 1st thing in the morning and did not take his pain medications, so objective findings may reflect that. The patient states overall functionally he is improving where he is able to get out in the house and visit and do activities outside the house more. The patient does feel like he is putting on more muscle girth as well. The patient states he is doing well with his current home exercise program and feels like pool therapy is also helping as well." "Doctor: Have you had any surgeries in the past? Patient: Yes, I had knee surgery. Doctor: Which knee? Patient: Right.",Section header: PASTSURGICAL Section text: Right knee surgery. "Doctor: Are you sexually active? Patient: Yes. Doctor: How many partners do you have? Patient: Just one. Doctor: Is this a monogamous relationship? Patient: Yes. Doctor: What gender is you partner? Patient: He is a male. We have been together for three years. He is H I V positive.","Section header: FAM/SOCHX Section text: Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years." "Doctor: I remember you mentioned that you had one operation done in the past. Patient: I had a lymph node biopsy back in September of O three. Doctor: Did it come back negative? Patient: Fortunately, yes.",Section header: PASTSURGICAL Section text: Excisional lymph node biopsy (9/03). "Doctor: It looks like you have an extensive medical history. Patient: I blame my heart. It's caused me the most trouble. I had coronary artery bypass surgery in twenty ten along with an angioplasty. Doctor: I'm sorry that your heart has been giving you so much trouble. I'm happy that you're here with us today and taking the right measures to keep yourself healthy. Patient: Oh, and I forgot to mention that I've had prostate biopsies in the past. Doctor: When did you have the biopsies done? Patient: Last year. Doctor: Did they come back negative? Patient: Yes, fortunately. I guess my prostate isn't as troublesome as my heart. Doctor: I understand.",Section header: PASTSURGICAL Section text: Coronary artery bypass surgery and a prior angioplasty and prostate biopsies. "Doctor: Do you have any medical problems? Patient: Let's see. I have diabetes, high blood pressure, high cholesterol, and osteoporosis. Doctor: And any surgeries? Patient: Several. Doctor: Which ones? Patient: I had my tonsils taken out when I was a kid. I also had my uterus removed along with my ovaries and fallopian tubes. The list goes on. I had my appendix removed and two or three of my parathyroids taken out. Despite getting some of my parathyroids removed, I still have borderline high calcium levels according to my endocrinologist. Doctor: Did you experience any complications during or after surgery? Patient: No. I forgot to mention that I had two carpel tunnel releases as well.","Section header: PASTSURGICAL Section text: She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases. She also has had a parathyroidectomy but still has had some borderline elevated calcium. Also, hypertension, hyperlipidemia, as well as diabetes. She also has osteoporosis." "Doctor: What is your family medical history? Patient: My mother passed away from complications with Huntington Disease. She was diagnosed and had been having treatments at U I H C. My grandmother and two of my aunts also passed away from Huntington as well. Doctor: I am so sorry. Do you have siblings? Patient: Yes! I have one sister. She is thirty eight. She has a lot of metal issues. She has attempted suicide two times. Doctor: Are you close with her? Patient: No. Not really. Doctor: Are you married? Patient: Yes. Doctor: Do you have children? Patient: Yes. We have two adopted kids.",Section header: FAM/SOCHX Section text: Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice. He and his wife have 2 adopted children. "Doctor: Any medical problems on your mom or dad's side? Patient: My dad has lupus and his brother has Addison's disease. High blood pressure also runs in the family. Doctor: Is your dad being treated for lupus? Patient: Yes, he follows up with his rheumatologist pretty regularly.","Section header: FAM/SOCHX Section text: HTN, father with SLE, uncle with Addison's Disease." "Doctor: I will do a quick exam on you. Patient: What kind of exam? Doctor: I'm just checking for lymph nodes. Whenever there is an infection those guys are the first ones to be noticed with swelling. Doctor: Okay, so let's first check your neck area. It looks good. I don't feel any inflamed lymph node. Your armpits look good too and the last place to check is your groin area. It is all good. No sign of infection.","Section header: EXAM Section text: LYMPH: No neck, axillary or groin adenopathy was noted." "Doctor: What are some medications you are on? Patient: I am on pain pills. Doctor: Do you know their names? Patient: Yes. Oxycontin and Vicodin. Doctor: Okay that helps.",Section header: MEDICATIONS Section text: OxyContin and Vicodin. "Doctor: I am looking at the list of your medication. Patient: Okay. Doctor: All I can see is Risperdal and Invega. Patient: I think that is correct. Doctor: Are you not taking anything else? Patient: Yes, I take some multivitamins, but do I need to mention it? Doctor: Yes, you should. We need to know everything. Patient: Okay.",Section header: MEDICATIONS Section text: Listed as Invega and Risperdal. "Doctor: Good morning, ma'am. Patient: Oh, good morning, doctor. Doctor: Please, tell me about your living situation. Patient: Well, right now, I live at home with my kids and my dad. Doctor: I see here that you're not able to go up the stairs well, can you tell me more about that? Patient: Yeah, I can't use the stairs without holding the rail the entire time. Doctor: Holding the rail makes navigating the stairs easier? Patient: Yeah, but I still move very slow. Doctor: I see. Do you smoke? Patient: Yeah, I smoke about a pack to a pack and a half a day. Doctor: What about exercise? Do you workout? Patient: No, I don't regularly workout, I've never been good at it.","Section header: FAM/SOCHX Section text: The patient lives in a private home with children and her father. The patient states that she does have stairs to negotiate without the use of a railing. She states that she is able to manage the stairs, however, is very slow with her movement. The patient smokes 1-1/2 packs of cigarettes a day and does not have a history of regular exercise routine." "Patient: My physician did a blood test. My potassium is high. He recommended me to meet you. Doctor: Okay. I did not get the blood report yet. I am waiting for your doctor's office to send it to me. Is it only your potassium that is elevated? Patient: Yes, that's what they told me.","Section header: CC Section text: ""My potassium is high""" "Guest_family: He was going to buy me a surprise but met with this car accident. Doctor: I am sorry! He does have multiple trauma due to the accident, and he will require aftercare. Guest_family: Yeah.",Section header: DIAGNOSIS Section text: Aftercare of multiple trauma from an motor vehicle accident. "Doctor: So, what is your family's living situation at home? Guest_family: Um, he lives at home with me, and his father. Doctor: May I assume that you are his biological parents? Guest_family: Yes, that's correct. Doctor: Great, does he have any siblings? Guest_family: No, right now, he's an only child. Doctor: What grade is he in? Guest_family: He's in the third grade. Doctor: Great, and is he doing well in school? Guest_family: Yes, he's doing quite well.",Section header: FAM/SOCHX Section text: lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools. "Doctor: Good afternoon, what gender do you identify with? Patient: Thank you for asking, I identify as a female. Doctor: Thank you. Do you know of any chronic illnesses? Patient: No, but can you give me some examples of what you mean? Doctor: Well, high blood pressure, osteoarthritis, diabetes, depression, anything like that ring any bells? Patient: Oh, no, I don't have anything like that.",Section header: PASTMEDICALHX Section text: She claims no chronic illnesses. "Doctor: Do you have any major medical conditions that I should know about? Patient: What, like cancer? Doctor: It doesn't have to be that serious, but is there anything you take medicine for? Patient: Oh, I have allergies and asthma.",Section header: PASTMEDICALHX Section text: Asthma and allergies. "Doctor: Can you tell me something about your mom and dad? Like any diseases they have had? Patient: Sure, my dad died of heart attack when he was sixty five and my mom died of stroke when she was seventy. Doctor: How's about siblings, miss? Any health issues? Patient: No, my brother is healthy.","Section header: FAM/SOCHX Section text: Basically unchanged. Her father died of an MI at 65, mother died of a stroke at 70. She has a brother, healthy." "Doctor: Does anyone in your family suffer from any health problems? Patient: No one comes to mind. Doctor: Great.",Section header: FAM/SOCHX Section text: Negative. "Doctor: Tell me, what's going on? Guest_family: She is complaining of weakness on the right side of her face. Patient: And I feel the right side is drooping. Doctor: Okay, let me look at it.",Section header: CC Section text: Right-sided facial droop and right-sided weakness. "Doctor: My chart here says that you're eighty three years old, is that correct, ma'am? Patient: Yes doctor, that's correct, I just had my birthday. Doctor: Happy belated birthday! How have you been doing since your last visit? Patient: Well, my cancer hasn't needed phlebotomies for several months now, which is good. Doctor: That's great, you have been treated for polycythemia vera, correct? Patient: Yes, that's the one. Doctor: I also see you're unassisted today, which is also great. Patient: Yeah, having some independence is nice.",Section header: GENHX Section text: The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied. "Doctor: So, do you have any family history of cancer? Patient: Well, yes, but I can't remember who had what kind. Doctor: Still, that's helpful, thank you. What about heart disease? Patient: That too, there's some history of heart disease, but I can't remember who.",Section header: FAM/SOCHX Section text: 1. Cancer. 2. Coronary artery disease. "Doctor: As far as you know, are there any major health conditions that you know about? Patient: What do you mean by that? Doctor: Anything like cancer, or arthritis, do those sound familiar? Patient: Oh, um, no nothing like that.","Section header: PASTMEDICALHX Section text: Otherwise, negative." "Doctor: Do you have any medical history that we should be aware of? Patient: I have type two diabetes. My numbers always come high. Doctor: Okay, anything else? Patient: I also have high cholesterol. Doctor: Okay.","Section header: PASTMEDICALHX Section text: Diabetes type II, poorly controlled, high cholesterol." "Doctor: Hello. How are you feeling today? Patient: Great. I'm just here for my yearly physical. Doctor: Oh, good. I see your past medical history is missing. Do you, by chance, know if you've had any health related problems before? Patient: Uhm. Let me check my notes on my phone. I knew this question would pop up, but I always forget. Oh, perfect. You can take a look at them. Doctor: Thank you. I just want to verify the information with you. You had asthma, nasal inflammation, and some abnormal growth on you neck, correct? Patient: If it's on there, then it's true. I usually don't remember these kinds of things. My wife is usually here with me. She knows all about my health.","Section header: PASTMEDICALHX Section text: Significant for asthma, allergic rhinitis and cervical dysplasia." "Doctor: How's the little one doing? Guest_family: She is doing okay. Doctor: How long was your pregnancy? Guest_family: Thirty six weeks. Doctor: Was your delivery normal or C section? Guest_family: It was a C section. Doctor: How much did she weigh? Guest_family: She was eight pounds and three ounces. Doctor: Tell me what's the issue? Guest_family: Yeah, she has a history of seizures. It looks like she is having pain in her tummy and is throwing up. Doctor: What else did you notice? Guest_family: It looks like she is having some rashes on her skin. There is vomiting for sure. She also feels bloated. She also complains of pain in her tummy. Sometimes she does scratch her mouth. We also noticed some swelling around her lips, eyes and face. Doctor: It looks like she's having some food intolerance.","Section header: PASTMEDICALHX Section text: Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces. She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue." "Doctor: What medications are you taking right now? Patient: I am taking Advair and Allegra. Doctor: Okay is it helping you? Patient: I don't know, I am not sure the Allegra is helping. But I do take them regularly. Doctor: But is it like better than Claritin? Patient: Yes, I think so. Doctor: Okay that's good. Patient: Shall I continue?",Section header: MEDICATIONS Section text: Advair and Allegra. He has been taking these regularly. He is not sure the Allegra is working for him anymore. He does think though better than Claritin. "Doctor: Anybody sick in family? Patient: No one. Doctor: How about any illnesses that run in your family? Patient: No, everyone is healthy.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Hi again! How has your acne been since you started the spironolactone? Patient: It has been improving. Doctor: Have you experienced any increased thirst, mood changes or unusual fatigue? Patient: No.",Section header: CC Section text: The patient comes for a routine followup appointment. "Doctor: Well, I don't think you need any restraints as you are doing fine. I do want to make sure you have a chair and bed monitor since you have a history of multiple falls. They can help detect fall. Patient: I don't want that, I will manage. Doctor: Are you sure? Patient: Yes!",Section header: EDCOURSE Section text: RESTRAINTS: None. The patient has declined use of chair check and bed check. "Doctor: Do you know when was the last time you got a tetanus shot? Patient: No I don't remember. Doctor: Okay.",Section header: IMMUNIZATIONS Section text: Not sure. "Doctor: Hi there! How are you today? Patient: Hi! I am good. Doctor: Welcome in! Patient: Thank you. Doctor: Lets start with a little social history. Are you a tobacco or alcohol user? Patient: No. Doctor: Are you married? Do you have children? Patient: I am not married but I do have a two year old son. Doctor: Do you currently see a gynecologist? Patient: Yes. She is in Bartow. Doctor: Great.",Section header: FAM/SOCHX Section text: She is followed by a gynecologist in Bartow. She is not an alcohol or tobacco user. She is not married. She has a 2-year-old child. "Doctor: Tell me about your family medical history. Patient: My family is pretty healthy. I don't know of any health problems.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Welcome in. Patient: Thank you. Doctor: Do you smoke? Patient: No, I don't. Smoking is gross. Doctor: I agree. Do you drink alcohol? Patient: Yes. Doctor: How much do you drink per day or week? Patient: When I get off work usually have a glass of wine. I don't ever have more then one glass. Doctor: Okay.",Section header: FAM/SOCHX Section text: She does not smoke. She takes one glass of wine per day. "Doctor: The nurse applied antibiotic ointment and a bandage to your foot. Did she go over how to change the bandage at home? Patient: Yes.",Section header: EDCOURSE Section text: The patient had antibiotic ointment and a bandage applied to his foot. "Doctor: Hello. Before we begin, I need you to confirm some information for me. Patient: What kind of information? Doctor: About your family. Do you know if you have certain medical conditions that run in your family? Patient: Nope. My family is very healthy.",Section header: FAM/SOCHX Section text: Negative. "Doctor: How about any breathing issues or asthma? Patient: Actually, I have a history of asthma. Doctor: Oh okay, and was it severe or mild? Patient: Well, it was not severe but still remarkable. Doctor: Hm, alright. Anything else? Patient: Yes, I also struggled with a serious acne problem. Doctor: Got it.",Section header: MEDICATIONS Section text: Significant for asthma and acne. "Doctor: How's she doing? Guest_family: She's had better days. Doctor: Aw and why's that? Guest_family: She's been really congested recently. Snorting a lot more, too. She's onlt eleven and I think it is odd she snores so much. I took her to see the allergist and he said it's not her allergies so we stopped giving her Allegra. Doctor: Does she happen to snore at night? Guest_family: No, not really. Doctor: Hm. Guest_family: And while we're here, I also wanted you to check out her toe. The right big toe appears a bit red to me. The skin around it has been peeling for the last week and a half. Doctor: Lemme take a look. Have you applied anything to the area?","Section header: GENHX Section text: This is an 11-year-old female who comes in for two different things. 1. She was seen by the allergist. No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting. They do not notice a lot of snoring at night though, but she seems to be always like that. 2. On her right great toe, she has got some redness and erythema. Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now." "Doctor: Why are you holding your face? Patient: Ah! Have pain in my tooth. Doctor: Oh, how bad is it? Patient: Oh, awfully bad. Doctor: I am so sorry.",Section header: CC Section text: Toothache. "Doctor: Have you had similar symptoms before? Patient: No never like this. Doctor: Any other complaints you have had in the past? Patient: Just some knee pain issues. Doctor: Okay, so chronic knee pain. Patient: Yes.",Section header: PASTMEDICALHX Section text: Chronic knee pain. "Doctor: Can you tell me about any cancers in your family? Patient: Yes, my sister has ovarian cancer, and my father has liver cancer. Doctor: Oh I am so sorry. Patient: That is okay. Doctor: Any heart conditions? Patient: My mom and dad both have heart disease. My dad has diabetes too.","Section header: FAM/SOCHX Section text: Consistent with a sister of his has ovarian cancer and his father had liver cancer. Heart disease in the patient's mother and father, and father also has diabetes." "Doctor: Can you tell me what problems you have had in the past. Or what medical issues are currently going on? Patient: You mean my heart problem and things? Doctor: Yes. Patient: Okay, I have hypertension and kidney problems since many years. Doctor: Okay. Patient: I get frequent urinary infections. Doctor: Your urine creatinine is normal. Patient: Okay. I also have severe aortic stenosis.","Section header: PASTMEDICALHX Section text: Significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal)." "Doctor: Does anyone else in your family have aneurysm problem? Patient: Well, my grandmother had it. She actually passed away due to brain aneurysm. Doctor: Oh, okay.",Section header: FAM/SOCHX Section text: Grandmother died of cerebral aneurysm. "Doctor: What is wrong with your back honey? Patient: Oh, it all started off with a little pimple on the buttock. I was soaking it at home with hot water and stuff, but it did not improve. I hope this is not cancer. I am only twenty four. Doctor: Okay what exactly are you experiencing? Patient: I have pain. Doctor: So you came to the hospital on the first and they did an I and D in E D? Patient: Yes I was admitted to the hospitalist service with high blood sugars. My African American father was so scared. Doctor: Okay sugars high. Do you know the number? How high? Patient: No, I do not know that but they found positive bacteria or some sort of thing in my blood culture. Doctor: So today we are evaluating you for surgery? Patient: Yes.",Section header: GENHX Section text: This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation. "Doctor: Hi there! I have the results from your ultrasound. You have kidney stones in the ureter close to the bladder. Patient: Oh no. Doctor: This explains the pain you have been having on your left side. Are you still experiencing nausea and vomiting? Patient: Yes, I have been. Doctor: I would like to set you up with a consult with a consult with a surgeon. Patient: Okay.",Section header: ASSESSMENT Section text: 1. Left flank pain. 2. Left ureteral stone. 3. Nausea and vomiting. "Doctor: Any known drug allergies? Patient: No.",Section header: ALLERGY Section text: No known drug allergies. "Doctor: Your daughter had an exposure to the ant bait but we are not sure if she actually ingested any of it. Poison Control confirmed that even if she did ingest the small amount that she was found with, it is likely nontoxic. Do you have any questions? Guest_family: No.",Section header: ASSESSMENT Section text: Exposure to ant bait. "Doctor: Hello, sir. How are you today? Patient: I am alright. I am here for a check up since I am feeling kind of dizzy lately. Doctor: That is not good. How long has this been happening? Patient: A few months. This happened to my sister too. I think she is still dealing with it. Doctor: Is there any other family medical history I should know about? Migraines or cancer? Patient: No. Not that I know of. The rest of my family seems pretty healthy.",Section header: FAM/SOCHX Section text: Sister is dizzy but no other acute illnesses. "Doctor: Do you know anyone in your family whose had cancer? Patient: No one that I know.",Section header: FAM/SOCHX Section text: Negative for cancer. "Doctor: Okay so your blood report is back and the cardiac enzyme we were looking for are negative. Patient: Okay. Doctor: Your blood urea nitrogen, also known as B U N, is within normal limits and hydrogen is stable. Creatinine is also within the normal range. Patient: Great!",Section header: LABS Section text: First set of cardiac enzyme profile negative. H&H stable. BUN and creatinine within normal limits. "Doctor: Are you on any medications? Patient: No, not taking any medications.",Section header: MEDICATIONS Section text: None. "Doctor: Hi, how are you doing today? Patient: I've been better. Thank you. Doctor: So, you are here for your follow up right? Remind me how often are you coming here? Patient: That's right. I'm coming around between a month or two. Doctor: Yeah, it's every four to eight weeks. Patient: I'm not taking any medicine now. I just wanted to let you know. Doctor: Yeah, I can see it in your record. It says that you are off of all the immunosuppression. So, just let me check. It says here that you do have mild chronic G V H D. It is not that bad that I should be worried about any therapy or anything else. How long ago did you get that transplant? Patient: I think it was around four and a half years ago. I'm feeling much better after that. I do have complaints of blood in my stool. But after you sent me to that doctor, that gastro doctor, I feel good. I know they said that they removed something, but I'm not sure, but after that it has been improved a lot. Doctor: Okay, let me see in my chart. You had some rectal bleeding issues because of which I referred you to the gastroenterologist. A complete endoscopy was performed, which was both on the upper and the lower side. There was no evidence of ulcers or any other abnormality. That's good news, right? Patient: Yeah, I agree. That was a relief. Doctor: They did find some polyps and they removed it. They turned out to be benign, so nothing to worry about there. Patient: Yeah, I remember this said they removed something, but I forgot the name. Doctor: Is there any other issue that I can help you with? Patient: I don't know. I feel a lot of fatigue and like I'm not able to do things like I used to do before. I get tired very easily. I don't know if it is related to something or not, but things have been weird. I'm not able to do even the minor things like I lift two boxes and I'm done for the day. Is it something that I should be worried about? Doctor: It looks like you have a mild iron deficiency. I will work on that with you, don't worry.","Section header: GENHX Section text: The patient comes to the clinic today for followup. I am seeing him once every 4 to 8 weeks. He is off of all immunosuppression. He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant. He has multiple complaints. He has had hematochezia. I referred him to gastroenterology. They did an upper and lower endoscopy. No evidence of ulcers or any abnormality was found. Some polyps were removed. They were benign. He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity." "Doctor: Are you feeling any pain? Patient: No, I feel great. Doctor: Is there any other medical issue that we should be worried about? Patient: No, it feels like I'm young again. I'm able to do all my activities.",Section header: EDCOURSE Section text: COMPLICATIONS: None. "Doctor: Thank you for coming in to see us at A B C D General Hospital today. Patient: I wish I wasn't here right now. Doctor: I understand, before we begin, how old are you? Patient: I'm seventy seven years young. Doctor: Which race, and gender do you identify with? Patient: I'm an African American woman. Doctor: What's seems to be causing you pain today? Patient: I've had this bunion on my foot for as long as I can remember. Doctor: Is the pain worsening? Patient: Yes, it is so painful, I've tried to avoid surgery for so long, but I want this bunion gone. Doctor: How have you managed this bunion in the past? Patient: I've used antiinflammatories, rested, changed my activities, I've done everything, but this pain is getting worse and worse. I need it gone.",Section header: GENHX Section text: This 77-year-old African-American female presents to ABCD General Hospital. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment. "Doctor: Do you have diabetes or blood pressure problems? Patient: Yes, I have hypertension but no diabetes. Doctor: Alright.",Section header: PASTMEDICALHX Section text: Hypertension. "Doctor: How are you dealing with your pain now? Patient: Oh no, I have no issues with my pain. Today I'm here for a different cause. I'm having this weakness all around on my left side, especially in my arm. I feel like I cannot lift anything like even a glass of water. It's hard for me to lift it up. I'm not able to walk properly, let alone the balancing and everything else. It's just that my whole left side seems to be weak.",Section header: GENHX Section text: The patient reports that the pain is not an issue at this time. The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness. "Doctor: Did you have any medical disorders previously, sir? Patient: I have diabetes. Also, I was quite overweight. Doctor: Are you taking any medications for that? Patient: Yes, I was still taking something called Zyprexa, but I stopped it after my last regular weight check. Also, I never took anything for diabetes. I also have chronic bronchitis for… I don't know… many years. Doctor: Do you smoke? Patient: Oh yes, I am a smoker. Doctor: How many cigarettes do you take in a day? Patient: Maybe up to sixty a day.","Section header: PASTMEDICALHX Section text: He has a history of obesity and also of diabetes mellitus. However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa. The patient has chronic bronchitis. He smokes cigarettes constantly up to 60 a day." "Doctor: Lets talk about your ears. Any continuous ringing or thumping noises you may hear? Patient: No, nothing like that. Doctor: Any hearing problems? Patient: Um, no. Doctor: Any dizziness or spinning sensation? Patient: Nope.","Section header: ROS Section text: EARS: Negative tinnitus, negative vertigo, negative hearing impairment." "Doctor: Good morning, ma'am. You're eighty two years old, is that correct? Patient: Good morning, doctor. Yes, that's correct. Doctor: Good, and just one more piece of background information, which hand do you write with? Patient: I use my right hand for everything. Doctor: Good, so what seems to be the problem today? Patient: Doctor, I've had years of pain in this shoulder. Doctor: What kind of treatments have you had? Patient: Well, um, I've had antiinflammatories, and rested, and none of it has helped so far. Doctor: Can I assume the pain is impacting your daily life? Patient: Yes, it certainly is. The pain is unbearable now.",Section header: GENHX Section text: The patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment. "Doctor: Have you ever had surgery? Patient: What, like a joint replacement? Doctor: Well, anything from joint replacements, to appendix removal, or C sections? Patient: Yeah, I've had an appendectomy and hysterectomy, actually.",Section header: PASTSURGICAL Section text: The patient has a past surgical history of appendectomy and hysterectomy. "Doctor: Can you confirm your age for me, ma'am? Patient: Absolutely, I'm sixty six now. Doctor: Good, so it's been about five months since you last evaluation for type two diabetes and high blood pressure. Patient: Yes, and I have a few other problems today, too. Doctor: Sure, we can treat all of them. What seems to be the problem today? Patient: I'm having some right shoulder pain. Doctor: Can you remember an injury to this shoulder? Patient: No, not that I can remember. Doctor: What aggravates your symptoms? Patient: It hurts when I move the shoulder. Doctor: Do you have any weakness, numbness, or tingling? Patient: No, I don't have any of that. Doctor: Okay, back to diabetes, how has that been progressing? Patient: Well, I can only check it in the morning, and it's usually less than one hundred. Doctor: Have you been checking your blood sugar two hours after meals? Patient: No, doctor, I haven't been. When I check them, it's normal though. Doctor: Do you have any records to prove that? Patient: No, I don't have that with me today. Doctor: That's important, do you have any other issues or concerns today? Patient: No, I can't think of anything. Doctor: Okay. I'm looking at your charts, and I see you had a benign breast biopsy done on June eleventh two thousand four. Did you have a repeat done after six months like they asked? Patient: No, I never had that done, I need to.","Section header: GENHX Section text: The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension. While here she had a couple of other issues as well. She stated that she has been having some right shoulder pain. She denies any injury but certain range of motion does cause it to hurt. No weakness, numbness or tingling. As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100. She has not been checking any two hours after meals. Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her. No other issues or concerns. Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well." "Doctor: What is your family medical history? Patient: None, that I know of.",Section header: FAM/SOCHX Section text: Unremarkable. "Doctor: Do you mind giving me a run down of his past medical history? I want to make sure it's all in his chart. Guest_family: Sure. I'll start with his surgeries. If I remember correctly, he had back surgery, a couple knee surgeries, and coronary artery bypass surgery with angioplasty. Doctor: I see. When did he have these done? Guest_family: I'd have to check, but I know he had back surgery in O nine. He has a history of high blood pressure and high cholesterol. He was recently diagnosed with B P H potentially linked to cancer. It's B P H, right? Or is it B H P? Doctor: If it's his prostate, then B P H is correct. Guest_family: Oh, he has high P S A levels, too. I think that's related to the prostate. Doctor: Is he currently experiencing any symptoms? Guest_family: He was complaining of pain earlier. He does have a history of fatigue, tiredness, and shortness of breath though. So far, he hasn't complained about the usual.","Section header: PASTMEDICALHX Section text: Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer. Symptoms of shortness of breath, fatigue, and tiredness." "Doctor: How long have you been living with diabetes, sir? Patient: Oh, it's been about thirty five years now. Doctor: How long have you been taking insulin for this? Patient: Well, um, I've been taking insulin for about twenty years now. Doctor: Do you have any major medical conditions that I should know about? Patient: Yeah, um, prostate cancer. Doctor: How were you treated for this? Patient: I've had radiation. Oh, my P S A is zero point zero one, by the way.","Section header: PASTMEDICALHX Section text: The patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years. He also has a history of prostate cancer, which was treated by radiation. He says his PSA is at 0.01." "Doctor: So, what stomach symptoms are you experiencing? Patient: I feel an intense burning in my throat. Doctor: When do you feel this? Patient: It really hurts after eating food, especially junk food. Doctor: That's pretty consistent with reflux disease. Patient: Ah, yes. Doctor: I got your survey results back as well, let's discuss them. Patient: Absolutely, please, what does it show. Doctor: According to your answers, it looks like you have depression as well.",Section header: PASTMEDICALHX Section text: Significant for depression and reflux disease. "Doctor: Any difficulty in swallowing? Patient: No. Doctor: Any nausea, vomiting or blood in your vomit? Patient: No, no vomit at all. No problem there. Doctor: Okay, any stomach pain? Patient: No. Doctor: Okay.","Section header: ROS Section text: GASTROINTESTINAL: Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain." "Doctor: Hello, ma'am. How are you feeling today? Patient: I'm sad and depressed. Doctor: I'm sorry to hear that. Why do you feel that way? Patient: My cancer came back.",Section header: PASTMEDICALHX Section text: Significant for cancer. She also has a depression. "Doctor: What's going on with you? What brings you here today? Patient: I am having loose watery stools for more than two weeks now. I feel very lethargic. I also have pain in my tummy.",Section header: DIAGNOSIS Section text: Diarrhea. "Doctor: Are you allergic to anything? Patient: No.",Section header: ALLERGY Section text: He has no known drug allergies. "Doctor: Are you a smoker? Patient: I used to smoke. I quit in nineteen sixty eight. Doctor: Excellent! Have you weighed your self recently? Patient: I weighed myself this morning. I am at one hundred and eighty three pounds. Doctor: And how tall are you? Patient: I used to be five foot ten but I think I have been shrinking. Doctor: That is definitely a possibility. We do shrink as we go through life. I can have the nurse get your height after we do your exam. Patient: Okay.",Section header: FAM/SOCHX Section text: He quit smoking in 1968. His current weight is 183 pounds. His tallest height is 5 feet 10 inches. "Doctor: Do you smoke? Patient: No, I have never smoked in my entire life.",Section header: FAM/SOCHX Section text: She is a nonsmoker. "Doctor: Welcome to the clinic, sir. Patient: Thank you. Doctor: Let us start with your medical history. Patient: I used to have seizures, but they have stopped now. Doctor: Was there a cause of the seizures? Patient: About seven years ago I had a traumatic stroke. They told me I had bleeding in the brain. After the stroke I was left with this weakness on my right side. Doctor: What part of your body is affected by the weakness? Patient: My arm, hand, and my face. Doctor: Do you have any other health problems? Patient: My liver is falling. It is because of all the alcohol that I have consumed over the years. I am not drinking anymore. Doctor: Are you being treated for your liver disfunctions? Patient: No. I just stopped drinking. I think I have diabetes. Doctor: What makes you feel like you have diabetes? Patient: I have been really thirsty, and I have been having numbness and tingling in my feet. Doctor: Oh okay. We can definitely do some test today to find out if you are diabetic or not.","Section header: PASTMEDICALHX Section text: 1. Liver cirrhosis caused by alcohol. This is per the patient. 2. He thinks he is diabetic. 3. History of intracranial hemorrhage. He said it was subdural hematoma. This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis. 4. He said he had a seizure back then, but he does not have seizures now." "Doctor: Hi miss. How old are you? Patient: I am sixteen. Doctor: What race do you identify as? Patient: White. Doctor: Are you okay? You have a headache? Patient: No I have a really bad migraine. Doctor: Okay can you point to where you are feeling it the most? Patient: Here, since Monday. Doctor: Okay so mostly on the right frontal side and it's been forty eight hours now? Patient: Yes, I am feeling a lot of pressure. Doctor: I can understand the discomfort. Is it continuous or throbbing? Patient: It is throbbing. Doctor: On the scale of one to ten, ten being the worst, how would you rate it? Patient: Nine or more. Doctor: Have you ever experienced similar symptoms in the past? Patient: No I haven't. Doctor: Did you hit your head buy any chance? Patient: No no. Doctor: Okay can you tell me if you have any fever or chills, congestion, cough cold like symptoms? Patient: No. Doctor: Any nausea, vomiting, diarrhea or trauma anywhere? Patient: No nothing like that. Doctor: Anything from head to toe? Patient: No everything else is fine.","Section header: GENHX Section text: This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache. She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago. Indicates pressure type of discomfort with throbbing component. It is as high as a 9 on a 0 to 10 scale of intensity. She denies having had similar discomfort in the past. Denies any trauma. Review of systems: No fever or chills. No sinus congestion or nasal drainage. No cough or cold symptoms. No head trauma. Mild nausea. No vomiting or diarrhea. Other systems reviewed and are negative." "Doctor: Has the patient signed a do not resuscitate order? Guest_family: Yes, she has. Doctor: Does she have a healthcare proxy or durable power of attorney? Guest_family: Yes, she has both.","Section header: EXAM Section text: CODE STATUS: DNR, healthcare proxy, durable power of attorney." "Doctor: How are you doing today? Patient: I have a long history of lung disease. COPD to be exact. Recently, I was experiencing a lot of coughing and shortness of breath even on walking from one room to another. All the time I felt sleepy, tired, or confused. Doctor: How is it now? Patient: It is getting better. Doctor: What else? Patient: I was also diagnosed with pneumonia; I was on trip and there they found it. It is also getting a lot better now, but doctor said to continue taking oxygen for some more time. Doctor: Oh wow! Patient: With everything going on, I felt weak and tired and it looks like I have lost all my strength and muscle. Patient: I also felt very instable and had a fall. I did not call for any assistance but now I think I should have called someone. Everyone including my family and nurses all tell me all the time to call for assistance. I was just being stubborn and hurt myself. Doctor: Did you use a wheelchair? Patient: No. Doctor: You know I would agree with everyone else; you should call for assistance if you need help like getting out of bed or need to use the restroom.","Section header: ASSESSMENT Section text: 1. Acute on chronic COPD exacerbation. 2. Community acquired pneumonia both resolving. However, she may need home O2 for a short period of time. 3. Generalized weakness and deconditioning secondary to the above. Also sustained a fall secondary to instability and not using her walker or calling for assistance. The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed." "Doctor: Were there any medical issues in the past? Patient: Oh, I have a list. I have asthma and sinus issues. I also had hives at some point and psoriasis. Doctor: How about allergies? Patient: I don't know of any.","Section header: ALLERGY Section text: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies." "Doctor: Do you use tobacco products, alcohol, or recreational drugs, miss? Patient: I have a drink every once and a while. Doctor: How many drinks do you consume in a week? Patient: I don't even drink that often. I probably have one drink per month. Doctor: Are you married? Patient: I was engaged but that is not happening anymore. It is a long story. Doctor: I am sorry the hear that. What do you do for work? Patient: I am a metal grinder.",Section header: FAM/SOCHX Section text: works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month. "Doctor: Now that you're eighteen, I have a big question to ask you. Do you smoke? Patient: Never have, never will. Doctor: That's what I like to hear. You have a good head on your shoulders, bud. Patient: Thanks. I'd like to think so, too. I have some friends who smoke weed, but stay clear of tobacco.",Section header: FAM/SOCHX Section text: None. "Doctor: Have you ever been diagnosed with any illnesses? Patient: No, I do not have any diseases. Doctor: How about any issues with B P, thyroid, diabetes? Patient: Nope none.",Section header: PASTMEDICALHX Section text: No significant past medical history. "Guest_clinician: Any history of drug or alcohol use? Doctor: He was a former smoker and tested positive for cocaine during his last visit in January O eight.","Section header: FAM/SOCHX Section text: He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08." "Doctor: I just quickly wanted to check few things, let's go over them together? Patient: Sure. Doctor: Any heart condition like heart failure or anything? Patient: No. Doctor: Any heart catheterization? Patient: Um, no. Doctor: Any history of chest pain, palpitation, or irregular heartbeat? Patient: No. Doctor: Do you have high blood pressure? Patient: No. Doctor: Any history of high cholesterol? Patient: No. Doctor: Any excessive or abnormal sweating? Patient: Not really, no. Doctor: Any stress test or heart tests done recently? Patient: No. Doctor: Okay, thank you for answering these questions. Patient: No problem.","Section header: ROS Section text: CARDIOVASCULAR: No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests." "Doctor: Hello Miss Sherry, how are you doing today? Patient: I have seen worse days. Doctor: Ha, I will take that as a positive answer then. I have my resident here with me, Doctor Helm, she will be representing your case today. Guest_clinician: Hello. Patient: Hello Doctor Helm. Doctor: Doctor Helm. Guest_clinician: The patient is a sixty one year old female. She was diagnosed with non small cell lung cancer stage one A in the upper right lobe. She was treated with CyberKnife and the treatment was completed one month ago. This is her first visit after the CyberKnife treatment. Doctor: Thank you Doctor Helm. So, Miss Sherry, how are you doing after the treatment? Patient: I feel nauseous. Doctor: How would you define it mild, moderate, or severe? Patient: I would say mild. Doctor: What about vomiting? Patient: No, only nausea is there. If I try to take deep breaths, then I still have pain. Doctor: How is your dysphagia? Are you able to swallow and eat your food and drink now? Patient: It has been better now. I won't say I am all good but as I said I have seen the worst days. Doctor: Is there any heartburn or rash? Patient: No. Doctor: Are you coughing up blood, or just cough? Patient: No, none of them. Doctor: Let me exam for any rib pain, okay? Patient: Okay. Doctor: Any pain if I touch you here or here? Patient: No.","Section header: GENHX Section text: The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit. Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting. She continues to have pain with deep inspiration and resolving dysphagia. She has no heartburn, cough, hemoptysis, rash, or palpable rib pain." "Doctor: Around what time did the car crash take place? Patient: About forty five minutes ago. I think someone called nine one one shortly after it happened. Doctor: Do you happen to remember how fast you were driving at the time of the crash? Patient: I was driving about forty miles an hour. Doctor: What kind of car were you driving? Patient: A minivan. The car in front of me stopped suddenly and I hit them right from behind. The front of my car is pretty wrecked. Doctor: Were you wearing a seatbelt? And did the airbag deploy? Patient: Yes and yes. Doctor: Any passengers in the car with you? Patient: No, just me. Doctor: Did you hit your head anywhere? Patient: No, but I do have some pain on the left side of my neck. Doctor: Do you think you lost consciousness at any point in time? Patient: Actually, I do. Right after the crash. Doctor: Any pain elsewhere? Patient: Um I'm having some pain in my lower stomach area. I think it could be due to slamming into the airbag or steering wheel. Doctor: How would you rate this pain, ten being the worst pain ever? Patient: Um I'd give it a five out of ten right now. Doctor: Any knee, ankle, or foot pain? Patient: No. Doctor: How about pain in your shoulders, elbows, or wrists? Patient: Uh no, but I guess I do have a little bit of pain in my pelvic area. Doctor: Do you remember walking before or after the ambulance arrived? Patient: I don't think so. Someone told me that I was placed on the stretcher after they got me out of the car. Doctor: Just to confirm, no chest pain or difficulty breathing? Patient: No. Doctor: Have you noticed any cuts on your skin? Patient: No. Doctor: Any headache, nausea, or vomiting? Patient: No. Doctor: Fever or chills? Patient: No. Doctor: Any chance of pregnancy? Patient: No, I've been good at taking my birth control and I also have an I U D. Doctor: When was your last period? Patient: Um end of May I believe. Doctor: Are you taking anything besides birth control? Patient: Accutane for my pimples.","Section header: GENHX Section text: This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance. The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago. The patient states that she was driving her vehicle at approximately 40 miles per hour. The patient was driving a minivan. The patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her. The patient states that she was wearing her seatbelt. She was driving. There were no other passengers in the van. The patient states that she was restrained by the seatbelt and that her airbag deployed. The patient denies hitting her head. She states that she does have some mild pain on the left aspect of her neck. The patient states that she believes she may have passed out shortly after the accident. The patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag. The patient denies any pain in her knees, ankles, or feet. She denies any pain in her shoulders, elbows, and wrists. The patient does state that she is somewhat painful throughout the bones of her pelvis as well. The patient did not walk after this accident. She was removed from her car and placed on a backboard and immobilized. The patient denies any chest pain or difficulty breathing. She denies any open lacerations or abrasions. The patient has not had any headache, nausea or vomiting. She has not felt feverish or chilled. The patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan. There were no oblique vectors or force placed on this accident. The patient had straight rear-ending of the vehicle in front of her. The pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10. The patient states that her last menstrual cycle was at the end of May. She does not believe that she could be pregnant. She is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on Accutane." "Doctor: Any known allergies? Patient: No. Doctor: Any allergy to any drug? Patient: No.",Section header: ALLERGY Section text: She has no known drug allergies. "Doctor: Let's talk about your family history. Did anyone in your family have any medical issues that you were aware of? Patient: I don't think so. My family has been pretty healthy. Both my parents died of old age. Doctor: What about your siblings? Any kind of thyroid issue or diabetes or blood pressure issue there? Patient: I have one older brother. He's into weightlifting and all. I would say he's pretty healthy.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Can you tell me more about your parents, please? How are they doing? Patient: Thank you for asking, they're both doing very well. They're very healthy. Doctor: That's great to hear. How old are they? Patient: My mom is fifty, and my dad is forty. Doctor: Wonderful, do you have any siblings? Patient: Yeah, I have two sisters, one is a half sister, and the other we have the same mom and dad. Doctor: How old are they? Patient: My half sister and I have the same mom, and she's thirty four. My other sister is ten. Doctor: Do they have any history of medical conditions that you know about? Patient: My half sister, um, no. My other sister has had some yeast infections.","Section header: FAM/SOCHX Section text: Mother is 50 and healthy. Dad is 40 and healthy. Half-sister, age 34, is healthy. She has a sister who is age 10 who has some yeast infections." "Doctor: Hello sir, what brings you here today? Also, please confirm your age for the records. Patient: I am seventy years old. I am here for nothing particular but I just have discomfort on the right side. Doctor: We did electromyography study. This was to assess the health of muscles and the nerves in your body. When did you first notice this discomfort? Patient: About five years ago. After my stroke. I've been to a neurologist before. Doctor: Yeah, I can see that you have taken different kinds of medications, but nothing seems to help you. Patient: That sounds right. Nothing seems to help me to get rid of this discomfort. Doctor: How often do you check your sugar levels? Patient: I do it at home. Mainly two to three times a day. I increase or decrease the amount of insulin that I take based on my numbers. Doctor: Don't you consult anyone before doing that? Patient: It's been so many years now. I do it all by myself. Doctor: We did reevaluations of your symptoms. It turned out to be all negative. Do you smoke? Patient: I used to chew tobacco a lot and then there were drinks. I used to drink at least half a bottle of single malt in one night. I quit everything five years ago after my stroke.",Section header: GENHX Section text: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage. "Doctor: It is nice to see you again, miss. We are following up on a few things today. How is your arm feeling? Patient: My arm is all better. It is not in pain at all anymore. Doctor: How has your mood been? Are you feeling any relief from your symptoms since you have been on the Lexapro? Patient: It's helping a little bit. Doctor: How much Lexapro are you taking now? Patient: I am taking ten M G. Doctor: How long have you been taking the full dosage? Patient: About a week ago. I don't take it every day. I don't feel like I need it some days. Doctor: I want you to take the full dosage every day. This might be why you have not had much relief with your symptoms yet. Patient: Okay. Doctor: Your hands are a little shaky. Is this a normal occurrence for you? Patient: I didn't even notice. Doctor: It is very subtle. We will keep an eye on it for now. Your blood pressure is a little better today. Have you experienced any worsening joint or bone pain? I want to check on your osteoporosis and osteoarthritis. Patient: No.","Section header: ASSESSMENT Section text: 1. Hypertension, better reading today. 2. Right arm symptoms, resolved. 3. Depression probably somewhat improved with Lexapro and she will just continue that. She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it. 4. Perhaps a very subtle tremor. I will just watch that. 5. Osteoporosis. 6. Osteoarthritis." "Doctor: Do you have any past medical history? Patient: No.",Section header: PASTMEDICALHX Section text: Negative. "Doctor: How long it has been since these psychotic periods are going off and on? Patient: It has been around twenty years. Doctor: So, you were taking Clozaril and some other medications? Patient: Yes. Doctor: Were you feeling better with them, sir? Patient: Yes. It was better for some years. Doctor: These antipsychotics, they were good on you, right? Patient: They were at times, but eventually there was a new episode.","Section header: GENHX Section text: As mentioned before, this patient has been psychotic off and on for about 20 years now. He has had years in which he did better on Clozaril and also his other medications. With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout." "Doctor: Does anyone in your family ever have any neurological disorder? Patient: Not anything specific but, many of my family members had lazy eyes. Doctor: Who is in your family? Patient: My parents and my two little sisters. Doctor: How old are your sisters? Patient: One is nine, another one is five. Doctor: How are they both health wise? Patient: They both are healthy.","Section header: FAM/SOCHX Section text: Many family members with ""lazy eye."" No other neurologic diseases declared. 9 and 5 year old sisters who are healthy." "Doctor: I have their surgical history if you'd like to go over it. Guest_clinician: Go ahead. Doctor: So they had an exploratory laparotomy in nineteen sixty seven. Guest_clinician: Okay. Doctor: They had a number of surgeries in nineteen seventy five, which include an L five S one lumbar laminectomy, anal fissure surgery, tonsillectomy, and adenoidectomy. Guest_clinician: Got it. Any complications that you know of? Doctor: None were mentioned by the patient or their spouse.","Section header: PASTSURGICAL Section text: L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975." "Doctor: How is your foot feeling? Patient: It feels good. Doctor: Any pain or discomfort when you walk around on it? Patient: No. I am good doc.",Section header: DISPOSITION Section text: Stable. "Doctor: Are you married? Patient: Yes, for almost twenty two years now. Doctor: That is amazing! And are you working? Patient: Ah yes, I drive a delivery truck in the town. Doctor: Okay. So, tell me do you smoke or drink? Yes, I do both. Doctor: And how much would you say you smoke per day? Patient: I smoke about two packs a day. Doctor: Hm, how much do you drink? Patient: I drink three, oh wait, I drink two beers every day. Doctor: And do you do any drugs like coke or anything? Patient: No.","Section header: FAM/SOCHX Section text: The patient is married. He works as a truck driver and he drives in town. He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs." "Doctor: Are you married? Patient: No sir, I'm happily single. Doctor: Where do you work? Patient: I am a press worker, I work in a newspaper printing. Doctor: Do you smoke? Have you ever taken any Illicit drug? Patient: No, none of them. Doctor: What about alcohol? Patient: I don't take any now. I was a heavy drinker, but I quit in the seventies.","Section header: FAM/SOCHX Section text: Single. Works as a newpaper printing press worker. Denies tobacco, ETOH or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit." "Doctor: Ever reacted poorly to any medications taken in the past? Patient: Hm I don't think so. No reactions so far.",Section header: ALLERGY Section text: No known medical allergies. "Doctor: Are you taking any medications? Patient: Yes I am taking thyroid meds and Lipitor.",Section header: MEDICATIONS Section text: Synthroid and Lipitor. "Doctor: Any past medical history like any diabetes or high blood pressure or any heart disease? Patient: No, I don't remember any such thing. Doctor: How about any surgeries in the past? Patient: No. No surgeries at all.",Section header: PASTMEDICALHX Section text: Otherwise nondescript as is the past surgical history. "Doctor: Good morning, young lady, how old are you? Patient: Good morning, doctor. I'm thirteen. Doctor: Good, and what seems to be the problem today? Mom, can you explain for me? Guest_family: Well, if you look, doctor, her back posture is very rounded. Doctor: I think, it's rounding about the thoracic spine. Is there a family history of this problem? Guest_family: Yes, on my side, my aunt and grandfather had, um, kyphosis. Doctor: Yes, that's what this is. This is thoracic kyphosis to be specific. Has she seen another doctor for this? Guest_family: Yes, we saw another orthopedist. Doctor: What did they recommend? Guest_family: They recommended we come in for further observation, so we're here for a second opinion. Doctor: Good, is there any back pain, numbness or tingling? Patient: No, I don't have any of that. Doctor: Is there any weakness, numbness or tingling in your legs and arms, my dear? Patient: No, I'm very strong, especially for my age. Doctor: Are you going to the bathroom with no problem? Patient: Yes, doctor, everything is regular there.","Section header: GENHX Section text: The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis. The patient has a family history in a maternal aunt and grandfather of kyphosis. She was noted by her parents to have round back posture. They have previously seen another orthopedist who recommended observation at this time. She is here for a second opinion in regards to kyphosis. The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities. No problems with her bowels or bladder." "Doctor: Are you allergic to anything? Patient: No, I am not allergic to anything. Doctor: Okay so no drug allergies. Patient: Yeah.",Section header: ALLERGY Section text: No known drug allergies. "Doctor: Are you married, ma'am. Patient: Yes, to my husband, I can't even remember how long my husband and I have been married. Doctor: That's wonderful. Do you drink or smoke? Patient: Absolutely not, I've never have used that stuff.","Section header: FAM/SOCHX Section text: She is married, retired. Denies tobacco or ethanol use." "Doctor: Uh let's see here. Are there any diseases that run in your- Patient: Family? Doctor: Yes. Patient: Nope.",Section header: FAM/SOCHX Section text: unremarkable. "Doctor: What happened to you? How did you get involved in this accident? Patient: I was just trying to adjust cable that my brother's dog was tied to. All of a sudden, he attacked me out of nowhere. The injury to my leg is V shaped and the V is pointing towards my foot. Doctor: What kind of dog? Patient: German shepherd. But he is up to date on his shots, and he is completely healthy. Patient: He bit me on my foot, and it looks like his teeth went into my skin. I went to my P C P. Doctor: What did you do there? Patient: They cleaned the wound and did some bandage along with it he gave me a tetanus shot. Doctor: And he sent you to us? Patient: Yes. Doctor: Okay let me examine your wound. Patient: Sure! Doctor: It looks like there is a flap injury developed after puncture wound. It seems like a centimeter long and viable. How old are you sir? And what ethnicity do you identify with? Patient: White male. I am fifty years old. Is my right leg going to be okay? Doctor: The skin looks viable. We can save the tissue.","Section header: GENHX Section text: This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him. He sustained a bite to his right lower leg. Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that. The dog has given no prior history of any reason to believe he is not a healthy dog. The patient himself developed a puncture wound with a flap injury. The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot. It appears to be viable. The wound is open about may be roughly a centimeter in the inside of the flap. He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment." "Doctor: Are you aware of any family medical history? Patient: Nope. Both of my parents, they died of old age. They were in their eighties. I cannot remember of any other medical issue in any of my relatives. Doctor: What about memory loss or stroke or high blood pressure, diabetes, or any other kind of mental illness? Patient: Nope. Doctor: Anyone sick in your family out of these things? Patient: Nope. Doctor: Do you have kids? Patient: Yeah, I have five children and they all are doing well in their life.","Section header: FAM/SOCHX Section text: Father and mother died in their 80's of ""old age."" There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well." "Doctor: Do you have any significant medical conditions in your history that I should know about? Patient: What, like high blood pressure? Doctor: Well, it could be anything from high blood pressure, to depression, to something as serious as cancer. Patient: Oh, no, I don't have anything like that, at least not that I know if.",Section header: PASTMEDICALHX Section text: None. "Doctor: Hi! How are you two doing today? Guest_family: We are doing good. I am tired today. Doctor: Our records show that he is up to date on all of his two month old immunizations. Guest_family: That is right! He had his shots the last time we were here. Doctor: Does he have any health conditions or difficulties during childbirth? Guest_family: Nope. He is healthy.",Section header: PASTMEDICALHX Section text: Unremarkable. He has had his two-month immunizations. "Doctor: Hello! How are you all today? Guest_family: Not good. We are really worried about our daughter. Doctor: What happened? Guest_family: I turned my back for one second and I saw her under the counter in the cabinet. We have childproofing on that cabinet. I don't know how she got it open. I pulled her out from the cabinet, and she had the bottle of ant bait in her hands. She had spilled the entire bottle all over her. She had the liquid on her hands. I don't know if she drank any of it or put her hands in her mouth. Doctor: Do you know what the ant bait was called? Guest_family: No. I know it was the kind with Borax in it. Doctor: Do you know how big the container was? Guest_family: It was an eleven M L bottle. I am not sure if that stuff is toxic or not? Doctor: How old is she? Guest_family: She is fourteen months. Doctor: Have you noticed and strange behavior or vomiting? Guest_family: No.","Section header: GENHX Section text: This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not sure whether she ingested any of it. So, they brought her in for evaluation. They did not note any symptoms of any type." "Doctor: Hello. Are you ready for your surgery today? Patient: I'm ready as can be. This isn't my first rodeo. Doctor: I see. Have you had surgeries before? Patient: Yeah, I have. I think it's in my report that you have with you. Doctor: You're right. It says here you've had some stripping of veins in your legs, a tonsillectomy, and a adenoidectomy.","Section header: PASTSURGICAL Section text: Lower extremity vein stripping, tonsillectomy and adenoidectomy." "Doctor: Is she married? Guest_family: Um no, she's divorced. Doctor: Any history of tobacco, alcohol or drug use? Guest_family: I think she used to drink? But I'm not positive.",Section header: FAM/SOCHX Section text: divorced. unknown history of tobacco/ETOH/illicit drug use. "Doctor: And tell me, are you allergic to any medications? Patient: No. Not that I know of. Doctor: Okay.",Section header: ALLERGY Section text: There were no known drug allergies. "Doctor: I'd like to get her in to see you sometime next week for her enlarged thyroid. Guest_clinician: Is she symptomatic? Doctor: Yes, she's experiencing increased difficulty swallowing. She's also reporting throat tightness on an off. Guest_clinician: What's her medical record number?",Section header: DIAGNOSIS Section text: Symptomatic thyroid goiter. "Doctor: Hi! How are you today? Patient: I am doing well. I start a new job on Monday. I have been unemployed for about a year now. It is going to be nice to get back to work. Doctor: Congratulations. Do you use tobacco products, drink alcohol or recreational drugs? Patient: I used to smoke a little bit, but I quit ten years ago. Doctor: Great! Patient: I don't drink or do drugs.","Section header: FAM/SOCHX Section text: He was unemployed and denied any alcohol or drug use. He was a prior 'mild' smoker, but quit 10 years previous." "Doctor: So, tell me about your family's medical history. Patient: Hm, my mother passed away due to cancer. Doctor: Oh, what type? Patient: Actually, I don't know that. Doctor: Okay. Patient: And my dad died due to heart attack. Doctor: Oh. Patient: Yeah. Doctor: Okay, I don't see your vaccination record here, do you have it? Patient: No, I don't have it. I moved here from a different country a long time ago with barely anything. I don't have any medical records from my past. Doctor: I see.","Section header: FAM/SOCHX Section text: Mother died of cancer, unknown type. Dad died of an MI. VACCINATION STATUS: Unknown." "Doctor: Welcome back to the clinic, Miss A B C. Patient: Thank you. Doctor: It looks like we last saw you June twenty first, this year. Doctor X and Y referred you for the evaluation of your pinched nerve in the C six regain on the left side. I also see that we are following up on the significant rotator cuff tear on the left side. Did you get scheduled for the surgery with Doctor Yen yet? Patient: Yes. I believe the surgery is scheduled for July twentieth. Doctor: How is your shoulder feeling? Patient: My shoulder is the same. I am still in a significant amount of pain. Doctor: I am sorry to hear that. Your surgery is coming up soon and that should help. Patient: I hope so. Doctor: We are also following up the pinched nerve in your upper left extremity C six. How are you feeling? Patient: I have had some pain starting in that same spot, and it goes down the left arm into my wrist. Doctor: Have you had any weakness associated with your upper extremities on the left side? Patient: It is mild and it is about the same as the last time. Doctor: Is it about the same as the last time you were here? We have it noted in the last note that it was mild as well. Patient: Yes. It has been the same. Doctor: Any weakness or symptoms on the right side? Patient: No, not really. Doctor: Any difficulty with mobility or moving around on either side? Patient: No. Doctor: Have you been experiencing any bowel or, bladder dysfunction. Patient: No. Doctor: I see in the chart for our last visit, I only had a report of a prior cervical spine M R I. I don't have any recent images. I going to refer you for a cervical spine M R I. Are you able to get the imaging done today and I will have you return to the clinic at the end of today? Patient: Yes. I can do that. I took the whole day off of work today. Doctor: Great! I will put the order in right now.","Section header: GENHX Section text: Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07. At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy. She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07. At our last visit, I only had a report of her prior cervical spine MRI. I did not have any recent images. I referred her for cervical spine MRI and she returns today. She states that her symptoms are unchanged. She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y. She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist. She has some associated minimal weakness described in detail in our prior office note. No significant right upper extremity symptoms. No bowel, bladder dysfunction. No difficulty with ambulation." "Doctor: Are you on any medications at this time? Patient: None whatsoever. Doctor: Got it.",Section header: MEDICATIONS Section text: None. "Doctor: Hey, how is the patient doing? Guest_clinician: I actually don't know, I was not able to examine him. He is having special procedures done for the past two hours for some medical management. Doctor: Oh, I see.",Section header: CC Section text: Medical management. The patient has been in special procedures now for over 2 hours and I am unable to examine. "Guest_family: So, you mean it is something simple? Doctor: Yes, it is probably sinus infection and then cough secondary to that infection. Guest_family: Will that be treatable? Doctor: Yes, it is. Guest_family: Okay nice.",Section header: ASSESSMENT Section text: Clinical sinusitis and secondary cough. "Doctor: You have an infection that has become septic. We are going to have to start you on intravenous antibiotics. Patient: Okay. Doctor: We also need to address the blood clotting. I am going to give you an anticoagulant to prevent any further clotting issues. Do you have any questions? Patient: No.",Section header: DIAGNOSIS Section text: 1. Disseminated intravascular coagulation. 2. Streptococcal pneumonia with sepsis. "Doctor: So, what do you do for a living, sir? Patient: Right now, I'm a truck driver, sir. Doctor: Wow, that's hard work. Are you working right now? Patient: No, I can't right now, I'm on sick leave. Doctor: Are you married? Patient: Yes, to my wonderful wife. She's helping to take care of me. Doctor: Do you two have any children? Patient: Yes, we have three. We all live together, and for that I'm very thankful. Doctor: Do you smoke, sir? Patient: Yeah, I smoke about two packs a day. Doctor: How about alcohol? Do you drink? Patient: No, just smoking for me. Doctor: How about more illicit substances, have you used illegal or prescription drugs inappropriately? Patient: Oh, absolutely not. Doctor: That's good. Do you have any other medical conditions that run in your family that I should know about? Patient: No, not that I know of.",Section header: FAM/SOCHX Section text: Occupation: truck driver. Work status: on sick leave. Marital status: married. Children: three. The patient lives at home with family. Tobacco history: smokes two packs of cigarettes per day. The patient denies the use of any alcoholic beverages. The patient denies any current or past history of illegal / recreational drug or prescription drug abuse or addiction. Family History: There are no known significant medical illnesses in the immediate and past family history. "Doctor: Hello there, how are you? Patient: I am good, thank you for asking. Doctor: So, what brings you in today? Patient: Well, I think I am suffering from memory loss, like short term memory loss. Doctor: Okay, and why do you say so? Patient: I have been under tremendous stress for the last five to ten years. I am currently working for T mobile customer service and my work is really hectic. It requires a lot of technical knowledge with project deadlines which is adding to my stress. Patient: Sometimes I have trouble absorbing all the technical knowledge and computer skills or customer issues. Doctor: Hm. Patient: I did my M B A in business for a reason, I wanted to make a good career, but this job is very demanding and stressful. I previously worked at a bank in Conway Springs, Norwich. I have worked many jobs around accounting and management services, but my current job is a high stress one. Doctor: I see, are you married? Patient: I have been widowed for past eleven years. My husband died in a car accident, he was hit by drunk driver. It was not the time for my husband to go! After he left, I had to take care of everything and that's another reason for my stress from the past several years. Doctor: I am so sorry to hear that. Patient: Yeah. Doctor: Okay, so tell me any weakness or dizziness or lethargy in the past or now? Patient: No. Doctor: Any history of stroke? Patient: No.","Section header: CC Section text: Here with a concern of possibly issues of short-term memory loss. She is under exceeding amount of stress over the last 5 to 10 years. She has been a widow over the last 11 years. Her husband died in an MVA from a drunk driver accident. She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services. She does have an MBA in business. Currently, she works at T-Mobile Customer Service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well. She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc. She describes the job is very demanding and high stress. She denies any history of weakness, lethargy, or dizziness. No history of stroke." "Doctor: Hi there! Welcome to the clinic. Patient: Thank you. Doctor: Doctor Murphy sent your records over. I reviewed the ultrasound, and we did find a kidney stone that has become stuck in the ureter on the left side. The stone is large enough to block the flow of urine from the kidney to the bladder. How much pain are you having and where is the pain located? Patient: I am in a great deal of pain. It is coming from my left side right here. Doctor: Okay. Let use discuss your treatment options. Patient: Okay.","Section header: CC Section text: Left flank pain, ureteral stone." "Doctor: Any allergies? Patient: What do you mean? Doctor: Are you allergic to anything? Patient: No no, oh no.",Section header: ALLERGY Section text: He has no known medicine allergies. "Doctor: You have type two Diabetes? Patient: Yes. Doctor: And High Cholesterol? Patient: Yes. Doctor: Your diabetes is poorly controlled. Patient: I will keep an eye on it.","Section header: PASTMEDICALHX Section text: Diabetes type II, poorly controlled, high cholesterol." "Doctor: Can you tell me more about your daughter's injury? Guest_family: Well, we came in in November, and she was diagnosed with an acute on chronic right slipped capital femoral epiphysis. Doctor: Did she have surgery on this? Guest_family: Yes, let me look at my notes, I have it written down here, um, a situ pinning. Doctor: Remind me, how old are you, dear? Patient: I'm thirteen now. Doctor: Okay, thank you. So, um, if you look her at the x rays, it appears that the screw is now going into the hip joint. Guest_family: They didn't see that before. What can we do about this? Doctor: We'll need to do another operation in order to remove this screw and put a shorter one in. We need to do the surgery because this can cause further joint damage. Guest_family: Are there any risks of infection from this surgery? Doctor: Overall, the risk of infection is very low, honestly its less than one percent. Guest_family: That's good to hear, will she go to sleep during surgery? Doctor: Yes, we'll use anesthesia the entire time. She won't feel a thing. Guest_family: What does recovery look like for this surgery? Doctor: I expect her to heal up very well, but there's always a risk of some changes in sensation and motion, and she may be stiff for some time following everything. Other risks include bleeding, but I would not worry about these things. Guest_family: Okay, how does that sound, honey? Would you like to do this? Patient: Yeah, I want to get back to playing sports with my friends. Guest_family: I agree, Doctor, we'll do the surgery.","Section header: GENHX Section text: The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis. She underwent in situ pinning. The patient on followup; however, noted to have intraarticular protrusion of her screw. This was not noted intraoperatively on previous fluoroscopic views. Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one. Risks and benefits of surgery were discussed. Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage. All questions were answered and parents agreed to above plan." "Doctor: What brings you in today? Patient: Um a number of different things. I don't even know where to start to be honest. Doctor: I understand. What's bothering you the most? Patient: Lemme think. I'm uh having really bad pain. Doctor: Where's the pain located? Patient: Hm. It's in a tricky spot. Guest_family: Hi. Husband here. Let me help explain. She's been having severe lower back pain. It started off mild and got worse over the course of a few days. She's also a lot more sluggish as a result. Doctor: Any recent injuries or falls? Guest_family: None. She spends most of her time in bed.",Section header: CC Section text: Severe back pain and sleepiness. The patient is not a good historian and history was obtained from the patient's husband at bedside. "Doctor: Hello, I want you to meet my assistant. She will be helping me out with your case today. Doctor: Please represent the patient's case. Guest_clinician: Patient is a seventy six year old male. He complains of generalized weakness and malaise for several months. He has a two week history of worsening orthostatic dizziness. He denies any recent symptoms of fever or shortness of breath, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes. Doctor: You said you are feeling dizziness, so what makes it worse? Patient: It's bad whenever I try to stand straight. I also have these intermittent headaches where it feels like somebody is hammering inside. Doctor: Do these headaches change with changing the positions or standing straight? Patient: No. Doctor: Does the patient have any known medical history? Guest_clinician: Yes, he has a history of sinusitis. Doctor: So, your headaches-- how long has this been going on? Patient: Many weeks now. Doctor: Do you smoke? Patient: I used to smoke a hundred and even more packs per year. Now it's just one to two packs each day. Doctor: Has there been any weight loss? Patient: I lost forty pounds.","Section header: GENHX Section text: This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes. He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis." "Doctor: Have you ever had jaundice? Patient: Um, no. Doctor: Any rash or anything? Patient: Nope.","Section header: ROS Section text: INTEGUMENTARY: Negative rash, negative jaundice." "Doctor: Good morning, ma'am, before we begin, how old are you? Patient: Good morning, doctor, I'm twenty five. Doctor: Good, thank you. So, how are you feeling today? Patient: I'm okay, but I have this rash and itching over my right arm. It's so itchy and I scratch all the time. Doctor: Is this your dominant hand? Patient: Yes, so this had especially been bothering me. Doctor: When did you first notice these symptoms? Patient: Um, I think it was in October of nineteen ninety two. I think it was the twenty third. Doctor: Have you had any symptoms in any other parts of your body? Patient: Um, yeah, I've had tingling in both my legs, like in the front, and then it goes into my toes too. Doctor: Did this tingling sensation go away? Patient: Yes, it went away the next day without me doing anything. Doctor: Have these symptoms returned at any point? Patient: Well, two days later, so that'd be the twenty fifth, I noticed that my legs felt like they were asleep. I really couldn't feel anything. Doctor: Have these symptoms spread to any other part of the body? Patient: Yeah, I couldn't really feel anything in the middle of my chest. I also have started having pain in my right shoulder blade. Doctor: Do these symptoms interfere with your ability to move? Patient: Yes, I don't really feel comfortable standing on my own, and I can't walk very well. Doctor: Do you have any cold or flu like symptoms? Patient: No, heat and cold don't bother me Doctor: Do you feel any significant fatigue? Patient: No, not really. Doctor: Have you had any significant weight loss? Patient: No.","Section header: GENHX Section text: 25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt ""asleep"" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss." "Doctor: How's it going? Patient: Good, can't complain. Doctor: Glad to hear. So today we're going to do a comprehensive eval. It'll be a bit different than our usual visits together. Would you like your mom to step in the room, too? Patient: Yeah, that's not a problem. Doctor: Alright. I'll grab her from the waiting room. I'll be right back.",Section header: GENHX Section text: The patient comes in today for a comprehensive evaluation. She is well-known to me. I have seen her in the past multiple times. "Guest_clinician: I was not able to get her complete history and review of systems. But she is scheduled for a bladder distension surgery. Doctor: Okay. Guest_clinician: Also, I am not sure if she is off Coumadin because of the surgery. Doctor: Oh yeah, she has chronic AFib and she is on Coumadin. Not sure if she has stopped the medicine due to upcoming surgery. Guest_clinician: The only thing she could tell was that she was having tremors for the past three to four years and was diagnosed with early Parkinson's disease. Doctor: Alright.","Section header: ROS Section text: Complete review of systems is unobtainable at present. From what I can tell, is that she is scheduled for an upcoming bladder distension surgery and I do not know if this is why she is off Coumadin for chronic AFib or what, at this point. Tremor for 3-4 years, diagnosed as early Parkinson's." "Doctor: Hello. What is the reason for your visit today? Patient: I keep having this dry cough and it gets hard to breathe at times. Doctor: Were you exposed to anything recently? Patient: Here's a note from a contractor that worked on my house recently. I wasn't sure what it meant. Doctor: I see. It looks like you may have been exposed to asbestos. Patient: Oh, no! Am I going to be fine? Doctor: I'll take a look, but I want to ask you a quick question. Did you have any family living with you at the time? Patient: Nope. I live alone, so my family wasn't there to be exposed.",Section header: FAM/SOCHX Section text: No noted exposures. "Doctor: How are you feeling today, ma'am? Patient: Honestly, overall, I'm feeling a lot better. Doctor: Are you still having the diarrhea and decreased appetite? Patient: Yes, but I'm still feeling better though. Doctor: Have you been peeing a normal amount? Patient: Yeah, no problems there. I measured it like you told me to—six hundred M L. Doctor: When was the last time you peed? Patient: Um, it was about seven this morning. Doctor: Are you having any fever symptoms? Patient: No, I feel pretty well.","Section header: GENHX Section text: The patient seen and examined feels better today. Still having diarrhea, decreased appetite. Good urine output 600 mL since 7 o'clock in the morning. Afebrile." "Doctor: Do you smoke, sir? Patient: No. Doctor: Do you drink? Patient: No. I was a boxer before so that's why I was always stayed away from these things. Doctor: How is your living condition? Are you living alone or with family? Patient: Mostly I'm by myself during the daytime. Family comes to help with me on and off. I just love it that way. I wasn't to be in an independent home setting soon.",Section header: FAM/SOCHX Section text: He is a nonsmoker and nondrinker. Prior boxer. He lives in a home where he would need to be independent during the day. Family relatives intermittently available. Goal is to return home to an independent fashion to that home setting. "Doctor: Do you smoke cigarettes? Patient: Yes. Doctor: Do you drink alcohol or use recreational drugs? Patient: Yes, I have been in and out of treatment. I am not doing so well with staying clean. Doctor: What substances do you use? Patient: I drink, and I did some coke today. I have been in treatment for heroin and alcohol.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Hello how are you? Doctor Mina is an intern working with me. She will be taking notes and discussing your case today. Patient: That's okay. Doctor: So, tell me Doctor Mina, what brings this young man today here? Guest_clinician: This is a sixteen year old right handed boy. He is studying in eleventh grade. He is having some difficulties with vision like blurring and focusing. He was diagnosed with a suprasellar tumor. Later on, January fourth, he underwent a surgery for his tumor. Biopsy reports said that it was craniopharyngioma. Even after the surgery, there was some residual disease left and his visual apparatus was decompressed. Doctor: Thank you Doctor. Tell me how are you doing young man? Are there any difficulties going back to school? Patient: I am doing fine. I do get some headaches and it feels like somebody is ringing bells in my ears. My eyesight has improved a lot.","Section header: GENHX Section text: Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor. Histology returned as craniopharyngioma. There is some residual disease; however, the visual apparatus was decompressed. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved." "Doctor: Remind me, please, when was your surgery? Patient: Well, it's been about two and a half months now. Doctor: Great, we repaired that slipped capital femoral epiphysis on both sides, we call it S C F E. Patient: Thank you for reminding me, I forgot the names of everything.","Section header: GENHX Section text: This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally." "Doctor: Any medications I should know about? Patient: Nah, no daily meds.",Section header: MEDICATIONS Section text: None. "Doctor: Is your husband still around, ma'am? Patient: No, he passed away a few years ago. Doctor: I'm so sorry to hear that. Patient: Oh, it's quite all right. Doctor: Do you drink or smoke? Patient: No, I don't do either of those. Doctor: Good, so where are you living now? Patient: I'm living at Kansas Christian Home. Doctor: Do you live independently there? Patient: Yes, thankfully. But, I can't do a lot of things. I have to be sure to take my medicines. Doctor: Did you drive yourself today? Patient: No, I had a driver today. Can we speed this up, I need to get to the noon meal.","Section header: FAM/SOCHX Section text: The patient is widow. She is a nonsmoker, nondrinker. She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal." "Doctor: Welcome in, Miss A! Patient: Thank you. Doctor: How have you been doing? Patient: I am good today! Doctor: Have you not been feeling good other days? Patient: I have been feeling nervous and having some anxiety lately. Doctor: Is your feelings of nervousness or anxiousness triggered by anything specific? Patient: It varies. I feel anxious when I think about retuning to work or this upcoming trip that I have planned. Doctor: How often do you feel this way? Patient: It comes and goes. Doctor: Have you ever had any treatment or history of depression, anxiety, or mood disorders? Patient: No.","Section header: GENHX Section text: Ms. A did not report a history of psychological or psychiatric treatment. She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events. She reported that this only ""comes and goes.""" "Doctor: Who lives with you, miss? Patient: I live with my boyfriend. Doctor: Do you smoke cigarettes? Patient: Yes, I do. Doctor: How about drugs? Patient: Sometimes, but I don't want to talk about it. Doctor: Okay. Anything else you want to talk about? Patient: Pardon?",Section header: FAM/SOCHX Section text: She lives with her boyfriend. The patient has history of tobacco abuse as well as multiple illicit drug abuse. "Doctor: Good afternoon, sir. Patient: Good afternoon, doctor. Doctor: Refresh my memory, please, how old are you, sir? Patient: I'm forty nine. Doctor: Also, I need you to remind me, when was your lower back surgery? Patient: It was in January of two thousand five. What was the name of the surgery, again? Doctor: It was a lumbar disc replacement. So, how are you feeling today? Patient: Truthfully doctor, the surgery did nothing. I'm still in a lot of pain. Doctor: Besides the surgery, what other interventions have you tried? Patient: I have them written down, let me look. Um, I did acupuncture, T E N S unit at P T, and I've been to the chiropractor too. Doctor: Have you taken any medicines? Patient: Yeah, I have those written down here. I've taken Elavil, Topamax, Cymbalta, Neurontin, and Lexapro. Doctor: Are you still taking any of these? Patient: No, I had bad side effects to some, and the others just didn't do anything. Doctor: Have you had any injections for this pain? Patient: I've had a few into the, um, piriformis. Doctor: Did that do anything? Patient: Um, it provided some brief relief, I guess. I had a Botox procedure done on March eighth two thousand six. Doctor: How did this work? Patient: Honestly, it did nothing. Doctor: Where is your pain, exactly? Patient: I'd say its seventy five percent in my butt and leg, and twenty five percent in my lower back. Doctor: Are you able to workout, or exercise, anything like that? Patient: I've tried to increase how much I walk, but when I do I get spasms in my lower back. Doctor: I see, with ten being the worst pain of all time, how would you rate your pain today? Patient: I'd say it's a six out of ten today. Doctor: What adjectives would you use to describe the pain? Patient: Um, I'd say its shooting, sharp, and, um, aching. Doctor: Specifically, what activities make the pain worse? Patient: Well, lifting, standing for a long time, or, um, squatting. I can't do that anymore. Doctor: Does anything make the pain better? Patient: Um, sitting back, ice, and I guess there's some improvement with the pain medication. Doctor: Is the pain constant, or does it come and go? Patient: It's constant now, but, um, the intensity of it comes and goes. Doctor: Are you able to sleep at night? Patient: Not really, it is affecting my sleep, which in turn affects my mood. Doctor: So, overall, I can summarize and say you're not happy with your pain relief so far? Patient: Yes, doctor, that's correct.","Section header: GENHX Section text: This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005. Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain. He has also tried acupuncture, TENS unit, physical therapy, chiropractic treatment and multiple neuropathic medications including Elavil, Topamax, Cymbalta, Neurontin, and Lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain. Most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the Botox procedure that was done on March 8, 2006 has not given him any relief from his buttock pain. He states that approximately 75% of his pain is in his buttock and leg and 25% in his back. He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back. He rated his pain today as 6/10, describing it is shooting, sharp and aching. It is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication. It is constant but variable in degree. It continues to affect activities and sleep at night as well as mood at times. He is currently not satisfied completely with his level of pain relief." "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.",Section header: FAM/SOCHX Section text: non-contributory. "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.",Section header: MEDICATIONS Section text: Abilify. "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 worse. Patient: I will. Thank you.",Section header: ASSESSMENT Section text: Upper respiratory infection. "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.",Section header: PASTMEDICALHX Section text: Significant for history of pulmonary fibrosis and atrial fibrillation. He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis. "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.",Section header: ASSESSMENT Section text: Foreign body of the left fifth fingernail (wooden splinter). "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.","Section header: EXAM Section text: 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: 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.",Section header: ALLERGY Section text: Eggs and peanuts. "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.",Section header: FAM/SOCHX Section text: He is a nonsmoker. He occasionally has a beer. He is married. He works as a flooring installer. "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? Guest_family: Well, she had bilateral feet corrections when she was a year old. Doctor: Okay, how has she been since that procedure? Guest_family: Well, just look at her heel, doctor. Doctor: Yes, I see. She has pretty significant calcaneal valgus deformity. Patient: What does that mean, doctor? Doctor: Your heel is out of alignment, sweetie. Do you have pain? Patient: Yes, I have a lot of pain, doctor. Guest_family: What can we do about this, doctor? Doctor: Well, given all of her symptoms, I think we should do a calcaneal osteotomy and Achilles lengthening procedure. Guest_family: What does that procedure entail? Doctor: Well, in short, we'll go in there and straighten everything out, and get everything lined back up. Guest_family: What's the risk of infection with the surgery, sir? Doctor: Actually, it's less than one percent, so it's extremely low. Guest_family: How is this possible, doctor? Doctor: We use antibiotics to control for infection the entire time. Guest_family: That's great. Will she be asleep for this procedure? Doctor: Yes, we'll use anesthesia the entire time. She won't feel a thing. Guest_family: Okay, that's good too. What about after the procedure? What's the protocol? Doctor: Well, I'll need your help. We have to be strict about her being nonweightbearing for six weeks at minimum. Guest_family: Will she need a brace too? Doctor: Yes, at least for six months, but if she does everything I ask of her, it will be only six months. Guest_family: Okay, yes, I think we should do the procedure. What do you think, honey? Patient: Yes, I want to get back to playing sports with my friends. Doctor: The other risks include bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures. I would not worry about these issues, though. It is quite rare. So, looking at her radiographs, the spinal arch is definitely collapsed. I think you guys are making the right decision.","Section header: GENHX Section text: 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 symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening. Risks and benefits of surgery were discussed with the mother. Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures. The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months. All questions were answered and parents agreed to the above surgical plan." "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 D right after he fell, and they said he had complete fractures of both bones in the arm. Doctor: Yes, I see that here, he also has shortening bayonet apposition. Guest_family_1: What can we do for this? Doctor: There's actually a few options here. First we can cast it and see how he heals, generally, children heal up very well from fractures. Guest_family_1: That's good, we like that option more than any kind of surgery. Doctor: However, surgery is also an option here as well. Guest_family_1: Yeah, to be completely sure we fix this, I think we should opt for the surgery, what do you think, honey? Guest_family_2: Yes, I agree. What are the risks of infection for this surgery? Doctor: The risk of infection is very low, generally less than one percent. We use antibiotics to control for infection. Guest_family_1: Will he be asleep for the surgery? Doctor: Absolutely, he won't feel a thing. Other risks include bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, and cast tightness. I would not worry about these risks. We have great results with these surgeries. Guest_family_1: Then yes, we'd like to do the surgery.","Section header: GENHX Section text: 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 pinning. The parents opted for the latter. Risks and benefits of surgery were discussed. Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness. All questions were answered, and the parents agreed to the above plan." "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 problems? Patient: Not that I know of. Doctor: That's good. I think I'll be able to remove it surgically. Before I go over the procedures, have you had a surgery before? Patient: Yeah, I have. I had surgery on my back and to remove my appendix. Doctor: Sounds good. Other than that dark spot, you seem to be very healthy.","Section header: PASTMEDICALHX Section text: Negative for chronic medical problems. No local physician. Has had previous back surgery and appendectomy, otherwise generally healthy." "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.",Section header: PASTSURGICAL Section text: Significant for a chest port placement. "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 three days. Doctor: Do you drink? Patient: I do take beer. Doctor: How many do you drink a day? Patient: I take around six bottles once a week. Doctor: Are you working somewhere? Patient: I was working in a herbicide plant. There were so many layoffs because of this pandemic. I lost my job too.","Section header: FAM/SOCHX Section text: 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: 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.","Section header: PASTMEDICALHX Section text: Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles." "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.","Section header: ROS Section text: Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain." "Doctor: Well, this is a case of hypothermia. Guest_family: Will he survive? Doctor: Don't worry, we will take care of him.",Section header: DIAGNOSIS Section text: Hypothermia. "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 five years. Doctor: Are you still working? Patient: I used to. Now I'm retired, I was a lab manager before.","Section header: FAM/SOCHX Section text: 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: 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 methothrexate is the cause of the mouth sores. Have you experienced a decreased appetite, nausea, abdominal discomfort or diarrhea? Patient: No. It is painful to eat with the sores, but I still have an appetite. Doctor: Have you had any new rashes, or hair loss? Patient: No. Doctor: I would like to get some bloodwork done. I would also recommend we decrease your dosage back to your previous amount. I would also like to see you back in two weeks to see how you are doing. Patient: Okay.","Section header: CC Section text: Please evaluate stomatitis, possibly methotrexate related." "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.",Section header: FAM/SOCHX Section text: Otherwise noncontributory. "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.",Section header: IMAGING Section text: X-rays shows no open fracture or bony abnormality. "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.",Section header: FAM/SOCHX Section text: 2-4 Beers/day. 1-2 packs of cigarettes per day. "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 of Pennsylvania. Doctor: Congratulations on your retirement. Patient: Thank you. Doctor: How long did you work as a psych aide? Patient: Thirty two years. Doctor: Incredible. One more question. Do you smoke, drink, or use drugs recreationally? Patient: I drink wine every now and then. I used to smoke back in the day, but I'm five years smoke free. I do not do drugs. Doctor: Always great to hear.","Section header: FAM/SOCHX Section text: 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: 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 it? Guest_family: Yes. It is in my phone.",Section header: CC Section text: Possible exposure to ant bait. "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 of carboplatin and Taxol you've had for your cancer, ma'am? Patient: Um, I've had six, I'm here for a follow up today. Doctor: Yes, I see here that your last chemo treatment on January eighteenth two thousand eight. Patient: Yes, I remember that. Can you remind me the full name of my cancer? Doctor: It's a uterine papillary serous carcinoma. Patient: Thank you, doctor. Doctor: Sure, do you have any problems today? Patient: Well, I just have some numbness in my right upper arm today. Doctor: Has this gotten worse recently? Patient: Well, no, not really. Doctor: That's good. Do you feel this in your toes at all? Patient: No, there's no numbness there. Doctor: Good, do you have any tingling or burning to speak of? Patient: No, thankfully no.","Section header: GENHX Section text: 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 gotten worse recently and there is no numbness in her toes. She denies any tingling or burning." "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 her symptoms, if not all, are stemming from. Guest_family: Does that mean she'll need surgery? Doctor: We'll have to see, but chances are higher since she's experiencing symptoms due to her thyroid. Guest_family: When will we find out? Doctor: I'd like to get some imaging done and see if we can get a consult in first.",Section header: DIAGNOSIS Section text: Symptomatic thyroid goiter. "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 doesn't ring any bells.","Section header: FAM/SOCHX Section text: Includes coronary artery disease, hypertension. Nobody in the family was diagnosed with any type of colon cancer or any type of other cancer." "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 slipped on all the water and I landed on the back of my head, and then onto my back. Doctor: Which side took most of the hit? Patient: It was mostly on my left side. Doctor: How were you after the fall? Patient: Well, I was pretty stunned, mostly. I didn't want to come in, but my employers asked me to just to be sure. Doctor: Who has evaluated you to date? Patient: Um, I went to Gig Harbor Urgent Care, and then they sent me to Tacoma General Hospital. At Tacoma they said I have a whiplash and concussion. Doctor: What did they do at the hospital? Patient: Um, they did a C T scan, and they found a dark spot on my brain. Doctor: What did they recommend about the spot? Patient: They said I should have another M R I and they diagnosed an, um, recurrent acoustic neuroma. Doctor: So, you've had this before? How did they know you had it? Patient: I used to see a chiropractor, and they suggested that I get a scan and that's how they found it before. Doctor: When was this? Patient: Um, it was in October of two thousand five. Doctor: Did you have surgery on this? Patient: Yes, I'm recovering now. Doctor: Are they still considering radiation? Patient: Yes, it's under consideration but there's no final decision yet. Doctor: Okay, what does the chiropractor do for you? Patient: You know, the usual, adjustments and massages, stuff like that. Doctor: Has there been any improvement? Patient: Overall, my spine pain has improved a lot. Doctor: That's good. Okay, so after your fall, what other treatments did you have? Patient: I went to Prompt Care in Bremerton, and saw Doctor X Y Z. She's an osteopathic doctor. Doctor: How did she treat you? Patient: She ordered an M R I of my neck, I have the report right here. Doctor: Okay, this shows some mild disc bulge at C four C five. Did she let you go back to work? Patient: Yes, she released me back to full duty. I was doing fine after the neurosurgical treatment. Doctor: Do you have any other treatment planned? Patient: Some radiation. Doctor: What else has she treated you for? Patient: Oh, you know, just general aches and pains on my back and neck. I have been seeing her since two thousand and two.","Section header: GENHX Section text: 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 the accident he states that he was generally stun and someone at the institute advised him to be evaluated. He went to a Gig Harbor urgent care facility and they sent him on to Tacoma General Hospital. At the Tacoma General, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a CT scan. The patient describes that he had a brain CT and a dark spot was found. It was recommended that he have a followup MRI and this was done locally and showed a recurrent acoustic neuroma. Before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in October 2005. The patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments. Overall his spine complaints have improved substantially. After the fall, he also saw at Prompt Care in the general Bremerton area, XYZ, an Osteopathic Physician and she examined him and released him full duty and also got an orthopedic consult from XYZ. She ordered an MRI of his neck. Cervically this showed that he had a mild disc bulge at C4-C5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned. Since 2002 the patient has been seeing the chiropractor, XYZ for general aches and pain and this has included some treatments on his back and neck." "Doctor: Any past medical problems or surgeries that I should know of? Patient: Nope, none that I can think of.",Section header: PASTMEDICALHX Section text: There is no significant past medical history noted today. "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 taking any medications? Patient: Yes, I am on anticoagulants. Doctor: Okay.","Section header: PASTMEDICALHX Section text: Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear." "Doctor: Have you had any procedures in the past? Patient: No.",Section header: PROCEDURES Section text: None. "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.","Section header: FAM/SOCHX Section text: Her father had prostate cancer. Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer." "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 actually got promoted last month so it's been going well. I've had a lot more time to spend with my family as a result. Doctor: That's great to hear. Congratulations! Patient: Thank you so much.","Section header: FAM/SOCHX Section text: No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits." "Doctor: Are you allergic to anything? Patient: No, I do not have any allergies. Doctor: Great.",Section header: ALLERGY Section text: No known drug allergies. "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 accidently jammed that needle inside my right hand index finger. Patient: I am coming for regular screening. Doctor: Were you wearing gloves? Patient: Yes, I had gloves and protective clothing. Doctor: Yes, thank you for that. Did they screen patient? Patient: Yes, he got negative HIV but positive Hep C. Doctor: Ok. Patient: I am scared.","Section header: GENHX Section text: 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 use of gloves at the time of the incident. As he advanced the needle, the patient jerked away, this caused him to pull out of the arm and inadvertently pricked the tip of his index finger. The patient was seen and evaluated at the emergency department at the time of incident and had baseline studies drawn, and has been followed by employee health for his injury. The source patient was tested for signs of disease and was found to be negative for HIV, but was found to be a carrier for hepatitis C. The patient has had periodic screening including a blood tests and returns now for his final exam." "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 culture as well. Patient: I got albuterol nebulizer treatment too. Doctor: That is good. but did that help you? Patient: No, it did not. Doctor: Oh I am sorry. Patient: It is okay. Doctor: I see that they gave you some antibiotics in E R? Patient: Yes, Ampicillin and Cefotaxime.","Section header: EDCOURSE Section text: 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 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each." "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 guess. Doctor: Do you have some record of those surgeries? Patient: Oh yes, I got it with me. Here it is. Doctor: That is awesome. Let me have a look. So, according to this you had L I M A to L A D coronary bypass graft. You also had had three saphenous vein grafts performed. Patient: Yes I had so many surgeries, it's hard to keep a track of all those complex names. That's why I keep those papers with me all the time if I go to any new doctor. Doctor: I will add all these surgeries into my record. Thank you.",Section header: GENHX Section text: 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: 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.","Section header: FAM/SOCHX Section text: Mother, father and siblings were alive and well." "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.",Section header: FAM/SOCHX Section text: Works at ABC. Social alcohol and he does smoke. "Doctor: Do you take any daily medications or supplements? Patient: Nope.",Section header: MEDICATIONS Section text: None. "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 your ability to walk? Patient: Yes, I can walk like, maybe a half a mile a day, then the pain gets too bad. Doctor: Are you able to go up and down stairs? Patient: I have to take them one at a time. Doctor: I see you have degenerative joint disease of both knees, does that ring any bells? Patient: Yes, but what does that mean? Doctor: You have arthritis in both of your knees, sir. Patient: Ah, yes. Doctor: Have you had surgery on these knees? Patient: Um, I had surgery on both of these knees, let me check my notes. It was an, um, arthroscopy. Doctor: When were these surgeries? Patient: They were in the nineteen ninety one nineteen ninety two time frame, somewhere in there. Doctor: How have you managed this since the surgeries? Patient: I've taken antiinflammatories, had injections, and I've even used narcotics. Doctor: I see. If those haven't helped, I think you'd be a good candidate for knee replacements. Patient: Can we do both at the same time? Doctor: No, let's do the left since that one hurts more. Do you have any other conditions I should know about? Patient: I've had a lot of back surgeries, I have spinal stenosis. Doctor: Do you know what surgeries you've had? Patient: Let me check my notes, um, I've had a spinal decompression and epidural steroids injection. Doctor: Who has prescribed you narcotics for this pain? Patient: The pain is so bad, but Doctor X has handled those.","Section header: GENHX Section text: 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 documented. He had arthroscopy in the 1991/199two time frame for both of these. He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections. At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side. He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids. Significant pain is handled by narcotic medication. His attending physician is Dr. X." "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.","Section header: FAM/SOCHX Section text: Tobacco use, averages two cigarettes per day. Alcohol use, denies." "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 getting better. Doctor: Hm. And what about your diarrhea and stomach pain? Patient: No more diarrhea and no pian. Doctor: Bowel movement? Patient: Normal. Doctor: Any pain while peeing? Are you able to empty your bladder completely? Patient: No pain and no problem emptying my bladder. Doctor: Okay good. Any nausea or vomiting? Patient: Nope, but I have developed this weird sore taste in my mouth. Doctor: Oh okay. How long? Patient: Since last week. Doctor: I see. Any loss of appetite? Patient: No, not really. Doctor: Okay and what other issues were you talking about? Patient: Yeah, I am also having some trouble with my eyes, I am able see fine, but it feels kind of funny. Doctor: Okay. Patient: And then my back is hurting so much, and last week my right shoulder and neck started to hurt. Doctor: Did you injure it or had a fall or anything? Patient: No. Doctor: Okay.","Section header: GENHX Section text: 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 is emptying his bladder okay. He denies dysuria. His back is hurting worse. He complains of right shoulder pain and neck pain over the last week but denies any injury. He reports that his cough is about the same." "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.",Section header: FAM/SOCHX Section text: He is a petroleum engineer for Chevron. Drinks socially. Does not use tobacco. "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.",Section header: FAM/SOCHX Section text: Noncontributory. No one else at home is sick. "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 last year. Doctor: How old are you now? Patient: I'm sixty four. Patient: He is my husband, Al. Doctor: Hi, nice to meet you. Doctor: Tell me what happened. Patient: They asked me to go to the physical therapy for all the problems I was having after my brain surgery. I went from November fifth to the fourteenth of last year. I did therapy for around two weeks starting on November fifth. My problems were not solved so I went to the hospital and then they did some tests and they found out something was wrong. They said there is swelling in my brain so they admitted me there and then I had my second surgery. Doctor: When was the second surgery? When did you get admitted? Patient: It was on December fifth. I was there in the rehab the whole time and then I was discharged for home one month after my second surgery. Doctor: Was there any other issue? Guest_family: Yeah. When she was in the rehab she developed something which they called D V T in her left calf. She did not have any such problem again after that.","Section header: GENHX Section text: 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 complications. The patient reports that she was admitted to Hospital on 12/05/08. At that time, they found massive swelling on the brain and a second surgery was performed. The patient then remained in acute rehab until she was discharged to home on 01/05/09. The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved." "Doctor: What medication have you tried? Patient: I took Nexium. Doctor: Pain? Patient: Yes.",Section header: MEDICATIONS Section text: Nexium. "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 twenty and in lower teens too which is good. So, tell me how are you feeling? Patient: Well, I am doing okay. I am getting treated for hemorrhoids. I am also having some constipation from the past few weeks and I have recently developed this cough which is okay as I kind of get it often. Doctor: Oh boy, that's a lot going on! Patient: Yeah. Doctor: So, tell me are your hemorrhoids painful? Patient: No, it's fine. Doctor: And are you taking anything for constipation? Patient: Well, just prune juice. Doctor: Okay, let me write you an order for a laxative that should help. How bout cough? Any pain in the ribs while coughing? Patient: Nah, I am not bothered by it. Doctor: Any headache or nerve pain or body pain? Patient: Um, no I am fine. Doctor: Any fall or imbalance problem? Patient: No. Doctor: Any agitation or any other issues? Patient: Well, I am doing okay! Sometimes if I have pain, I take Tylenol and usually it works for me. Doctor: That's good! Patient: Yeah. Doctor: So, you have been seeking psychiatric help from Doctor Hudyncia right? Patient: Yes. Doctor: She mentioned in her report that you are responding well to her treatment and that your depression is under control and the medicine is working for you. That's good news. Oh, what medicine has she prescribed? Um let me see here in the report, oh okay, got it! It's Cymbalta. Patient: Right. Doctor: And no side effects, right? Patient: No. Doctor: And looks like the plan is to treat you for a minimum one year. Patient: Yeah. Doctor: Lastly, any breathing issues? Patient: No.","Section header: GENHX Section text: 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 the 150s. However, I also see one that is in the one teens and a couple in the 120s range. She is not bothered by cough or rib pain. These are complaints, which I often hear about. Today, I reviewed Dr. Hudyncia's note from psychiatry. Depression responded very well to Cymbalta, and the plan is to continue it probably for a minimum of 1 year. She is not having problems with breathing. No neurologic complaints or troubles. Pain is generally well managed just with Tylenol." "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 thousand and seven. Guest_clinician: Oh wow! Doctor: Yeah. We last saw her in March two thousand and eight at that time she was experiencing some head fullness and ringing in the ears, however we decided to leave her shunt setting at one point zero. Guest_clinician: Okay, then you asked her to follow up doctor X Y Z regarding her cervical spine M R I. Doctor: Yes exactly! Let's go see her. Hello Miss Dey, how are you? This is my colleague doctor Jen, and she will be accompanying me today if that is okay with you? Patient: Of course, Hello doctors. Guest_clinician: Hi Miss Dey. Doctor: So, tell me what is going on? Patient: Well, last week I had some urine issue, like had to pee frequently. I had few episodes of urgency. Doctor: Okay and how do you feel this week? Patient: This week it's much better I am not feeling like how I was feeling last week. Doctor: Okay good. Patient: I feel no urgency or inconsistency and I am able to empty my bladder completely. Doctor: That's good. Patient: However, I do leak some pee when I cough. I wear pads daily. Doctor: And did you notice any changes regarding your bladder, do you think it is better than before or worse since the last time I saw you? Patient: I don't think it changed much, it feels almost the same. Doctor: Okay. Let's talk about your memory, any problem there, are you able to remember stuff and think about stuff? Patient: Yes, all good there, no issues. Doctor: Any headache? Patient: Nope! Doctor: Any changes in your walk or balance? Patient: Yes, I feel both have worsened. I am able to walk on uneven surface most of the time. But I feel I have become very slow. Doctor: And are you able to climb up and down the stairs? Patient: Yes. Doctor: Are you able to climb in and out of the car normally without any fuss? Patient: Yes. Doctor: Are you using cane at this point of time? Patient: No, no cane. Doctor: Okay good. Anything else you want to tell me? Patient: Ah yes, in the beginning of May, I got a spell of severe cough and because of continuous coughing I think I developed pain in my hip which travels down to my legs. Doctor: Oh okay, do you feel any tingling or numbness. Patient: Yes! I feel constant tingling sensation and a feeling that something is pinching my never. Sometimes it's just so painful. Doctor: Okay. Patient: Often I feel like my legs have become like elastic. I feel this tingling sensation is the reason my walking has become slower. Doctor: Doctor Jen did you take the notes of what she said? Guest_clinician: I did. Doctor: Okay great, anything else Miss Dey? Patient: No, I think I told you everything. Doctor: Alright you take care. I will see you next time. Patient: Bye! Doctor: Bye. Guest_clinician: Take care Miss Dey, Bye!","Section header: GENHX Section text: 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 shunt setting at 1.0. We wanted her to followup with Dr. XYZ regarding the MRI of the cervical spine. Today, she tells me that with respect to her bladder last week she had some episodes of urinary frequency, however, this week she is not experiencing the same type of episodes. She reports no urgency, incontinence, and feels that she completely empties her bladder when she goes. She does experience some leakage with coughing. She wears the pad on a daily basis. She does not think that her bladder has changed much since we saw her last. With respect to her thinking and memory, she reports no problems at this time. She reports no headaches at this time. With respect to her walking and balance, she says that it feels worse. In the beginning of May, she had a coughing spell and at that time she developed buttock pain, which travels down the legs. She states that her leg often feel like elastic and she experiences a tingling radiculopathy. She says that this tingling is constant and at times painful. She feels that she is walking slower for this reason. She does not use the cane at this time. Most of the time, she is able to walk over uneven surfaces. She is able to walk up and down stairs and has no trouble getting in and out of a car." "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 here is the phone number. You should book the appointment. Patient: Okay I will do that. Doctor: Also, I would like to follow up with your endocrinologist that is Doctor A for adjustments that is needed in your insulin pump. Patient: And you want me to see my gastro doc too? Doctor: Yes, please follow up with Doctor B for issues with your J tube. Patient: Sure thing. Doctor: Lastly, I want you to see Doctor Y if your condition changes regarding colon cancer.","Section header: PLAN Section text: 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 up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube." "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.","Section header: PASTMEDICALHX Section text: 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: 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.",Section header: PASTMEDICALHX Section text: Diabetes. "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. Patient: Yeah.","Section header: EXAM Section text: MSK: No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength." "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.",Section header: CC Section text: Nausea. "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.","Section header: ROS Section text: Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath." "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 pneumonia. Patient: Yeah. Started around age twenty and stuck with me ever since. Doctor: How often have you had pneumonia? Patient: Once every five years or so. Doctor: Have you ever been hospitalized due to pneumonia? Patient: Uh I'm usually given antibiotics and then discharged. Doctor: I see. Patient: Unfortunately, I've had more episodes in the past year than ever before. Doctor: Any history of inherited lung disease, bronchiectasis, or other chronic pulmonary cause for repeated pneumonia? Patient: Not to my knowledge. Doctor: And you recently saw the urologist, correct? Patient: Yes. I had a catheter placed for urinary retention. He told me he thinks it's due to an enlarged prostate. Doctor: Do you have a history of diabetes or other medical problems? Patient: Uh no. I've lost about eighteen pounds in the last month but other than that everything else seems to be fine.","Section header: PASTMEDICALHX Section text: 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 with antibiotics and then discharged. There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia. 2. He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement. The patient does not have any history of diabetes and does not report any other medical problems. He has lost approximately 18 pounds in the past month. 3. He had an appendectomy in the 1940s. 4. He had an ankle resection in 1975." "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 you have a history of any seizure disorder? Patient: No.","Section header: ROS Section text: 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: Tell me about your family medical history. Patient: No one in my family has any health problems.",Section header: FAM/SOCHX Section text: Noncontributory. "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 was quite smooth otherwise. Guest_family: What's phimosis? Doctor: That's tightness of the foreskin. It sometimes makes the procedure more difficult, but everything went smoothly. Guest_family: Oh, that's good to hear. Doctor: He also had a little bit of bleeding when he woke up in the recovery room, so we had to put in some additional sutures. Guest_family: Okay, thank you for taking care of him. Doctor: It's my pleasure. Has he been taking his pain medicine? Guest_family: He took them for a couple days, but he really seems back to normal now. He doesn't seem to be in any pain. Doctor: Great, does he have any difficulty urinating? Guest_family: No, that's normal. Doctor: Bowel movements? How are they? Guest_family: That's normal too, doctor.","Section header: GENHX Section text: 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 has been complete. His mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now. He is having no difficulty urinating, and his bowel function remains normal." "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.","Section header: CC Section text: A 54-year-old patient, here for evaluation of new-onset swelling of the tongue." "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.",Section header: CC Section text: Antibiotic management for a right foot ulcer and possible osteomyelitis. "Doctor: Your condition is improved, and you look pretty stable. Patient: Yeah, I feel much better.",Section header: DISPOSITION Section text: Improved and stable. "Doctor: Do you have any allergies to medications? Patient: Yes. Penicillin.",Section header: ALLERGY Section text: To penicillin. "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 quite a few. I always carry the list of my medications, let me tell you the names. Yeah, so I take Dilantin for my seizures, Toprol for my high blood pressure and Pravachol for my cholesterol. Doctor: Pravachol for my cholesterol. Wow, thank you for that, it helps a lot. Let me make a note of it. Patient: Sure.","Section header: MEDICATIONS Section text: Pravachol, Dilantin, Toprol, and Macrobid." "Doctor: Have you had any operations in the- Patient: Nope. No surgeries. Doctor: How about any past injuries or illnesses? Patient: Nope.","Section header: PASTMEDICALHX Section text: Otherwise noncontributory. There is no operation, serious illness or injury." "Doctor: What is going on? Patient: I have pain in my jaw since the morning. Doctor: How bad is it? Patient: Not that bad.",Section header: CC Section text: Jaw pain this morning. "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.",Section header: MEDICATIONS Section text: None. "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.",Section header: PLAN Section text: ADA 1800-calorie diet. "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 still undergoing treatment? Patient: Yes. Doctor: Do you have any other medical conditions? Patient: Have a heart murmur. It has not been an issue. I also have acid reflux. Doctor: Do you take medication for the G E R D? Patient: Yes. I take omeprazole.",Section header: PASTMEDICALHX Section text: 1. Gastroesophageal reflux disease. 2. Mitral valve prolapse. 3. Stage IIIC papillary serous adenocarcinoma of the ovaries. "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 has been getting worse over the last three months. My allergies are also acting up again. Doctor: Oh, no. Has anything changed that may have made your allergies worse? Patient: Well, my husband has been hauling more corn in since it's busy season. I think that might have made it worse. Doctor: Are you taking any medications to alleviate your asthma and allergies? Patient: I'm using my inhaler every day for my asthma. Here are the other medications and treatments I've been using. I know I wouldn't have remembered, so I put them on a paper for you to see. Doctor: Let me take a look. I see you have been taking Allegra for your allergies. Has that been helping? Patient: Eh. It kind of helps when I do take it. Doctor: You don't take it every day then? Patient: Nope. Only when I feel like I need to. Doctor: I see. What about the Flonase? Has that been helping? Patient: I'm not taking that right now, but it helped me in the past. Doctor: I also see you took Advair in the past, correct? Do you still take it? Patient: I did, but I stopped taking it because it started to annoy my private area. Doctor: I understand. Speaking more on this. Let's begin your physical. Do you have anything you'd like to add that you're starting to notice more? Patient: Oh, yeah. I feel like I'm easily annoyed right before my period. It could also be my husband, but he likes to say it's because I'm about to start my period. Doctor: I see. Do you see any other increased symptoms right before your menstrual cycle? Patient: Yeah. I feel like I've seen an increase in all the signs before my period. I'm also getting more impatient around that time, but when I'm not on my period, I feel like my mood is better. Doctor: When do you see your mood change? Patient: My husband says it's bad the week before I start my period, but I think it gets better a day after I start. Doctor: Have you seen any bleeding during your cycle? Patient: Not as much anymore. Just some spots here and there. Doctor: I see. What about hot flashes or night sweats? Patient: Nope. I feel fine most of the time. Doctor: That's good. I'm looking at your chart right now and it says you showed a U T I present, correct? Your test showed blood in your urine. Patient: Yeah, that's correct. Doctor: Has your urine been checked since then? Patient: Nope. Doctor: I see. I'll order another urine test along with additional lab tests so that we can complete your physical. Patient: I actually just had some lab work done because it was required for a life insurance application. Crazy, right? Here's the form with all the details for the lab work. Doctor: Oh, perfect. I see they looked at your cholesterol and other areas. Could you send that to me when you get the results? Patient: Of course. I'll get that sent to you A S A P.","Section header: GENHX Section text: 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 aggravate things. She has not been taking Allegra daily but when she does take it, it seems to help somewhat. She has not been taking her Flonase which has helped her in the past. She also notes that in the past she was on Advair but she got some vaginal irritation with that. She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle. She has been more impatient around that time. Says otherwise her mood is normal during the rest of the month. It usually is worse the week before her cycle and improves the day her menstrual cycle starts. Menses have been regular but somewhat shorter than in the past. Occasionally she will get some spotting after her cycles. She denies any hot flashes or night sweats with this. In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously. Her urine has not been rechecked. She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available." "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, and the other is seventy seven. I'm in the middle. Doctor: That's great. Do you have any medical conditions that run in your family? Patient: Well, I'm not sure if it counts, but I had a brother and sister, they were twins, they died at birth. Doctor: Oh no, thank you for telling me. Patient: Yes, I thought it would be important. Doctor: Do you have any children, sir? Patient: Yes, I have two sons, they're both doing very well. Doctor: How old are your sons? Patient: One of them is fifty four, and the other is fifty seven. Doctor: In addition to the neonatal deaths, do you have any other conditions that I should know about? Patient: Yeah, um, a lot of my family has diabetes, and a lot of them have had heart attacks as well.","Section header: FAM/SOCHX Section text: 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: 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 two to three months ago, correct? Patient: Is that what they're calling my nasal problems? Doctor: Yeah, it is. Sinusitis is the inflammation of your nasal airways. Patient: I see. Thank you for describing it to me. Doctor: No problem. Would you be able to describe to me what you had been feeling two to three months ago? Patient: Yeah, I can. My face would feel uncomfortable, my nose was stuffy, my eyes hurt, and I felt something dropping in the back of my throat. Doctor: Have you ever been prescribed any medication? Patient: Here's the list of medicine I was taking. Doctor: I see you were given antibiotics, correct? Patient: I was, but I don't know what those are. Could you explain them to me? Doctor: Antibiotics are usually used to fight infections. Patient: I had an infection? I thought I just had some nasal problems. Doctor: Your report states you had a severe infection. Do you remember if the antibiotics helped? Patient: Not really. I felt like my symptoms were the same. Doctor: I see. Did your doctor order any advanced imaging's? Patient: Yeah. They did a C T scan of my nose. Here is the report from my C T scan. Doctor: Let me take a look. It looks like you had some thickening of the mucosal layer in your right paranasal sinus. You also had some obstruction in your right ostiomeatal complex and excess growing of some of the bones in your nose. Uhm. Oh, one more thing. I see your nasal septum was shifted to the left. Patient: Oh, wow. Thank you for explaining everything to me. Doctor: No problem. Going back to your list of medications, I know you took antibiotics for your infection, but did you take any medication for your sinuses? Patient: No, I haven't. I did try this cream for my nose, but that didn't work either. Nothing worked! Doctor: I see. Looks like the cream you used was a topical nasal corticosteroid. Are there any other symptoms that you have been experiencing? Patient: I've had some trouble with my balance, and I feel like I've lost some of my hearing. I thought this was odd since I'm only fifty years old. I think my ears felt plugged or full of air, so they just needed to pop. Doctor: I see. Let's perform an audiogram test to check your ears. Patient: Sounds good. Doctor: I'm seeing that you have some mild high frequency sensorineural hearing loss. Your tympanometry seems to be normal. Your speech discrimination was also normal. Patient: That's reassuring. Doctor: I want to ask a few more questions about your ears. Do you feel any fullness or pressure? Patient: No, I don't feel anything like that right now. Doctor: Do you hear any humming, buzzing, or roaring sounds? Patient: Nope. I don't hear anything like that. Doctor: We checked your ears and now understand more about the problem, but I wonder why your balance is affected. When did you start noticing your balance was affected? Patient: I think it could have been to this one medicine that starts with an A. I forgot the name, but it didn't really help my nasal problems. It just made my balance worse. Doctor: Was the medicine called Allegra? Patient: Oh, yeah. That's what it was called. I thought I had some sort of allergy, so I thought it would help. Doctor: I see. Did you ever feel any dizziness too? Patient: Yeah, I did. Doctor: I will have you do some movements to see if your dizziness occurs. Patient: Sounds good. Doctor: Could you look to the left and then look to the right. Patient: Oh, wow. That made me very dizzy. Doctor: Looks like sudden movements and head turning make your dizziness worse.","Section header: GENHX Section text: 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 postnasal drip symptoms. She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics. She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left. She currently is not taking any medication for her sinuses. She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness. Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination. She has tried topical nasal corticosteroid therapy without much improvement. She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen. She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears. She denies any previous history of sinus surgery or nasal injury. She believes she has some degree of allergy symptoms." "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.",Section header: FAM/SOCHX Section text: The patient lives with his wife. "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",Section header: PASTSURGICAL Section text: PermCath insertion times 3 and peritoneal dialysis. "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.",Section header: PASTMEDICALHX Section text: He has had bilateral knee replacement three years ago and experiences some pain in his knees with this. "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.",Section header: EDCOURSE Section text: PROGNOSIS: Improved. "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 has autism. Doctor: For how long now? Guest_family_2: Autism? Doctor: No, I mean when did he start complaining of stomach pain? Guest_family_2: It started last night. Doctor: Oh okay, let me check him. Did he have any nausea or vomiting? Guest_family: Yes, he threw up a lot and is refusing to eat or drink anything. Doctor: And then he is complaining of tummy pain? Guest_family_2: Yes. Doctor: Well, the good part is he is not dehydrated. Doctor: Any diarrhea? Guest_family_2: Yes, he went three to four times. Doctor: Hm, but no blood or anything in the stools or vomit? Guest_family: No, nothing like that, we did not notice anything. Doctor: Okay good. Doctor: Well, let me run some tests but the signs and symptoms sound like he might have a stomach flu, also called as gastroenteritis in medical terms. I will start him on some medicines and hopefully that should help.",Section header: DIAGNOSIS Section text: 1. Gastroenteritis. 2. Autism. "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 retired and loving every minute of it. Doctor: I am sorry to hear that, but I am glad you are happy after retirement. Do you celebrate your infinite days off with a drink or a cigarette? Patient: No, I do not smoke. I drink occasionally, but it is very rare. Doctor: Do you have any children that you spend your time with? Patient: I have three wonderful children.",Section header: FAM/SOCHX Section text: 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: What do you use to treat your asthma? Patient: I use my Albuterol inhaler.",Section header: MEDICATIONS Section text: Albuterol. "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.",Section header: GENHX Section text: The patient eats regular diet and eats 3 meals a day. "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 eighty M G tablets.",Section header: MEDICATIONS Section text: Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30. "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.",Section header: FAM/SOCHX Section text: She does not smoke or drink alcohol. "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 gradual. Doctor: Where do you feel your headaches? Patient: Right here, between my eyes. Doctor: How would you describe your symptoms? Patient: I'd say it feels like a pressure sensation. Doctor: What's the intensity of these headaches? Patient: Um, they're about moderately severe, I guess. Doctor: Do these headaches interfere with your ability to do your activities? Patient: Yes, they do. My regular activities are significantly more difficult now. Doctor: Do you have any sinus congestion? Patient: Yeah, I do. I also have some light sensitivity. Doctor: Are you stressed out at work? Patient: Yes, I have a very stressful job, doctor. Doctor: Are you sleeping well? Patient: Well, no not at all. I even try to have a little drink before bed, and it doesn't help. Doctor: Do you have any oral symptoms, like vomiting or pain in your jaw? Patient: No, nothing like that.","Section header: GENHX Section text: 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 photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain." "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.",Section header: PASTMEDICALHX Section text: Negative. "Patient: I am having stomach pain. Doctor: Hm, any nausea or vomiting? Patient: Yes, both.","Section header: CC Section text: Abdominal pain, nausea and vomiting." "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.","Section header: ROS Section text: No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits." "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, so they did a revision at the end of that year, in December. Doctor: I see, thank you. What about your upper body? Is there any history of surgery there? Patient: Actually, yes, I had surgery on my arm when I was six.","Section header: PASTSURGICAL Section text: 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: 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 activities. Doctor: Okay.",Section header: GENHX Section text: Negative for use of alcohol or tobacco. He is a professor at College and teaches history and bible. "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.",Section header: PASTMEDICALHX Section text: Past medical history is significant for allergies and thyroid problems. "Guest_clinician: How's the patient? Doctor: He's stable. Heart rate sixty five. Normal rhythm. Oxygen ninety seven percent on room air.",Section header: DISPOSITION Section text: Stable. "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. Doctor: Okay and you have recently had right side C V A? Patient: Yes, because of my heart problems they had to put pacemaker in. Doctor: Okay. Good. Patient: I have hereditary diabetes. Doctor: Okay and your neural problem is associated to that as well. Patient: That's right. Doctor: You have pain on the right side now? Patient: Yes, because of my stroke. Doctor: And you take thyroid medications too? Patient: Yes, for my hypothyroidism. Doctor: Okay. Patient: Yeah. Doctor: What surgeries have you had in the past? Patient: I have had many surgeries. They took out my gall bladder, then colon cancer surgery was in nineteen ninety eight. Doctor: And now pacemaker placement, right? Patient: Yes, that is correct.","Section header: PASTMEDICALHX Section text: 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 atrial fibrillation status post pacemaker. She is a type 2 diabetic with significant neuropathy. She has also had significant pain on the right side from her stroke. She has a history of hypothyroidism. Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998. She has had a pacemaker placement." "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.",Section header: FAM/SOCHX Section text: Noncontributory. "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 pressure problem before.",Section header: FAM/SOCHX Section text: Noncontributory to the present condition and review of his previous charts. "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 you, has anyone in your family had a joint replacement? Patient: I know that a lot of my family has had arthritis in the past, but I can't remember whether or not they had joint replacements, honestly.",Section header: FAM/SOCHX Section text: Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis. "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 developed pressure ulcer.","Section header: CC Section text: Pressure decubitus, right hip." "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 days old. Let me tell you from the beginning. On Friday, when I was taking her for a bath, I noticed a blister near her umbilicus area. We went to our doctor on Saturday, and they did a test. Doctor: Did you get the test result? Guest_family: I got it today. Here is the report. Doctor: Okay, let me have a look. It says she is having a growing M R S A. Guest_family: Yeah, I've been diagnosed with that too. And I am on medications. I had it on my buttock area. Doctor: Okay, so you know about it, and I don't have to explain it more. Guest_family: Yeah. Doctor: So how is the blister on the umbilicus now? Guest_family: She has been doing good. We put on some bacitracin ointment, and it almost healed up. But today I noticed that another small blister on her head. It really scared me, and I did not want to take any chance. That's why I reached out to the Infectious Disease center. I know it is private. But still, I don't want to take any chance with my baby's health. I called the center directly and they asked me to come to the hospital. Doctor: You did good. I will start the treatment. How are her eating and sleeping habits? Guest_family: She hasn't missed any of her meals. She is taking around two ounces of milk in every feed. I don't think I have any issues with her eating or sleeping. Doctor: Did she have any fever? Guest_family: Not that I noticed. Doctor: Has she been lethargic or crying more than normal? Guest_family: No. Doctor: Any other changes in her daily routine that you might have noticed? Guest_family: No, I didn't notice any changes.","Section header: GENHX Section text: 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 about healed up. However today, they noticed a small blister on her left temporal area. They called the private doctor. They direct called the Infectious Disease doctor here and was asked that they come into the hospital. Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications. The child has not had any fever. She has not been lethargic or irritable. She has been eating well up to 2 ounces every feed. Eating well and sleeping well. No other changes have been noted." "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.",Section header: DIAGNOSIS Section text: Migraine headache. "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 he been taking this? Guest_family: It's been about a month now. Doctor: How has he responded to the Adderall? Guest_family: The first day he took it, truthfully, he was wonderful. There's been a lot of improvement in his behavior, and he's really been doing well, so far. Doctor: That's great! Guest_family: Yes, but I have two concerns. When he takes the medicine first thing in the morning it seems to take a while to kick in, and then it wears off at about two P M and he has problems in the evening. Doctor: Has he had problems with his appetite? Guest_family: Um, he did at first, but it's been coming back. It's more of a problem in the morning when he first takes the medicine in the morning, not so much in the afternoon after it wears off. Doctor: Have you gotten any reports from his teachers? Guest_family: They have seen a dramatic improvement with it. Doctor: Has he taken every dose? Guest_family: Well, I missed one last weekend, and he was just horrible. Patient: Yeah, mommy, I thought I needed it, but you didn't give it to me.","Section header: GENHX Section text: 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 in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication." "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, I'm a temporary employee for A B C A B C, I've worked for A B C D, too. Doctor: What do you do there? Patient: Mainly, I handle the loading and unloading of furniture and appliances for people's houses. Doctor: That's hard work. When did you get hurt? Patient: It was about two and a half weeks ago now, back in October. Doctor: Do you have a history of back problems, like before this injury? Patient: Yeah, I've had back pain for a long time. Doctor: What happened when you got hurt this time? Patient: I was unloading one of the A B C eighteen wheelers, when I bent down to pick up some boxes, and I felt the pain. Doctor: What kind of pain did you feel? Patient: I felt a sharp pain in my lower back right away when I tried to lift those boxes. Doctor: Does your pain go down your legs? Patient: Yes, it goes into the right side of my butt, and then all the way down the outside of my right leg, like into the knee. Doctor: How have your symptoms progressed since they began? Patient: Doctor, they've only gotten worse. Doctor: Do you have any pain in your left leg? Patient: A little, not as bad as the right. Doctor: What other symptoms are you having besides the pain down your leg? Patient: The muscles in my butt are spazzing, and it's happening more and more. Doctor: Have you seen another doctor for this? Patient: Yes, I saw Doctor Z at first. Doctor: What did they do for you? Patient: He gave me some muscle relaxers, and some, um, Lidocaine patches. Doctor: Did this help at all? Patient: No, not at all. Doctor: Who else have you seen? Patient: I saw doctor X Y Z too, through worker's comp. Doctor: When did you see them? Patient: That was back in April. Doctor: What did they recommend? Patient: Um, he sent me for an M R I, and I have the report for that right here. Doctor: Okay, this M R I report is basically negative, which is good. Did he give you any medications? Patient: Yes, he gave me some opioids. Doctor: Wow, that's strong stuff. What is your work status right now? Patient: Doctor X Y Z put me on restricted duty status, doctor. Doctor: I'm reading your notes from doctor X Y Z, he says he released you in June, and that you have reached maximum medical improvement. Patient: He told me that, but I still have pain, so I went back to see him. Doctor: When you went for follow up, did you still have that pain down your legs? Patient: Yes, I did. Doctor: What did doctor X Y Z recommend at that time? Patient: He referred me to a Pain Clinic, and he recommended I have, um, epidural injections with doctor A B C. Doctor: Did you have this done? Patient: Yes, I did. Doctor: Did this help at all? Patient: No, it did absolutely nothing. Doctor: Okay, so after that, what treatment did you have? Patient: I had an M R I, um, E M G, and nerve conduction study with doctor A B C D. Doctor: Do you have the results of that as well? Patient: Yes, doctor, they're right here. Doctor: Okay, sir, these tests are essentially normal, which is more good news. What aggravates your pain? Patient: Well, anything like sitting for a long time. When I do that, I feel it in my legs. Doctor: When you sit for a long time, is it in both legs? Patient: It's really on my right. Doctor: Are you able to sleep at night? Patient: No, sir, I'm not able to sleep at all. Doctor: Have you been able to return to work? Patient: Well, I went back to work in June, after doctor X said I'd reached the maximum medical improvement we talked about. Doctor: Finally, have you seen a chiropractor for this pain? Patient: Yeah, I saw doctor X about eight or nine times. Doctor: Did they do anything to help you feel better? Patient: Really, no, it did not. I still have the pain down my legs today.","Section header: GENHX Section text: 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 a half weeks. Date of injury occurred back in October. The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load. Unfortunately at this particular event, the patient had sharp pain in his lower back. Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee. This became progressively worse. He also states that some of his radiating pain went down to his left leg as well. He noticed increase in buttock spasm and also noticed spasm in his buttocks. He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe. The patient states that after this treatment, his symptoms still persisted. At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April. After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids. He was put on restricted duty. The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement. Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral. The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief. The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD. The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping. He has difficulty sleeping at nighttime because of increase in pain. Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June. The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side. The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms." "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 sure is a list. Anyone with diabetes? Patient: No. Well, that is one thing that skipped my family.","Section header: FAM/SOCHX Section text: Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives." "Doctor: Does he have any known drug allergies? Guest_family: No.",Section header: ALLERGY Section text: He has no known drug allergies. "Doctor: Good morning, can you tell me more about your son, ma'am. Guest_family: Sure, he's forty six, White, and he has Down syndrome. Doctor: Great, thank you. Is he still having problems with his hypothyroidism and onychomycosis? Guest_family: Yes, that's correct doctor. Doctor: Has he remained complaint with his Lamisil? Guest_family: Yes, he's taken six weeks of it with no problems. Doctor: Good, so we'll do an A L T blood test today. Guest_family: Why is that doctor? Doctor: Well, at his last appointment in April, he had an elevated T S H level. So, we should recheck that today. Guest_family: Yes, I remember that. Doctor: Has he been taking his Levothroid daily as well? Guest_family: Yes, he has, he doesn't like it, but I help him with it, and he eventually takes it. Doctor: Good, thanks for taking care of him, Mom. Guest_family: Oh, it's my job. Doctor: Does he take any other medications? Guest_family: He has some medicated eye drops for his cornea.","Section header: GENHX Section text: This 46-year-old white male with Down's syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis. He has finished six weeks of Lamisil without any problems. He is due to have an ALT check today. At his appointment in April, I also found that he was hypothyroid with elevated TSH. He was started on Levothroid 0.1 mg and has been taking that daily. We will recheck a TSH today as well. His mother notes that although he does not like to take the medications, he is taking it with encouragement. His only other medications are some eyedrops for his cornea." "Doctor: Do you have any questions regarding your surgery? Patient: Yes, I do, multiple. Doctor: Go ahead shoot. Patient: I have them all written down on this.",Section header: CC Section text: Surgery. "Doctor: How about any drugs, alcohol, or tobacco? Patient: No, no, and no.","Section header: FAM/SOCHX Section text: Negative for illicit drugs, alcohol, and tobacco." "Doctor: Hey, how are you? Patient: I think I am better. Doctor: So you do not have any more nausea or vomiting? Patient: No I don't. Doctor: How about any acidity? Patient: I think it's all better. Doctor: Great.","Section header: ASSESSMENT Section text: Severe nausea and vomiting likely secondary gastroenteritis, resolved." "Doctor: How are you? Patient: I am good. Doctor: That's great. You are stable. Patient: Can I go home now? Doctor: Yes, you can. Patient: Thank you!",Section header: DISPOSITION Section text: Stable. "Doctor: Good afternoon, young man, are these your parents? Patient: Yes, doctor. Doctor: Can you tell me more about your son, please? Guest_family: Well, he is seven years old, and he has had diarrhea for four days, and he's been throwing up for three days. Patient: Yeah, my brother has been doing this too. Guest_family: We had some chicken one day, and then we had more of it the next day. After they ate it they started to feel bad and still feel bad. Doctor: How many times has he had diarrhea per day since this began? Guest_family: Well, it's been about five or six times a day for the last four days. Doctor: How many times has he thrown up per day? Guest_family: Um, it has been frequent. Doctor: Has he been throwing up today? Patient: No, I haven't today. Doctor: Has he gone to the bathroom today? Patient: Yes, I peed this morning. Doctor: Has he had any fever symptoms? Guest_family: Yes, he had a fever of one hundred three last night. Doctor: Has he eaten any solid food? Patient: Yeah, I had half a hamburger and some milk last night. Doctor: Was he able to keep the food down? Guest_family: No, he threw it up. Doctor: What has he drank? Guest_family: Um, Pedialyte, Gatorade, white grape juice, and seven up, the soda.","Section header: GENHX Section text: The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea. Apparently, his brother had similar symptoms. They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened. But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad. The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days. He has not had any emesis today. He has urinated this morning. His parents are both concerned because he had a fever of 103 last night. Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis. He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything." "Doctor: Welcome into the clinic! I would like to start with your past medical history. Patient: I have high blood pressure and macular deterioration. Last year I caught pneumonia but that has cleared up. Doctor: Okay. What brings you in today? Patient: I have had this cough and pain on the right side of my abdomen. Doctor: How long has this been going on? Patient: Two days. I have had body aches and have been feeling nauseous too. Doctor: Have you had a fever? Patient: I think so. I was chilled and my forehead was warm. The cough is a dry sounding cough. Doctor: Does the abdominal pain come during one of these coughing episodes? Patient: Yes.","Section header: GENHX Section text: This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient stated that the abdominal pain was only associated with coughing. The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home." "Doctor: Good afternoon, dear, how old are you? Patient: I'm fourteen years old. Doctor: Good, and what brings you in for a visit today? Patient: My left knee hurts really bad. Doctor: Oh no, how long has this knee been hurting you? Patient: Well, since the fall of two thousand seven. Doctor: Have you seen another doctor for this? Patient: Mom, can you tell the doctor? Guest_family: Yes, actually, we went to another orthopedist in November of two thousand seven. Doctor: I see, and what did this doctor recommend? Guest_family: We got an MRI, I have a disc with the images, and the report as well right here, if you want to take a look at it. Doctor: Thank you, yes, so this shows left patellar chondromalacia. Has she been to P T? Guest_family: We got a referral for P T, but they only wanted to do, um, let me look at my notes, patellar tracking exercises. Doctor: I see, has she been wearing her brace? Guest_family: Yes, she has been. I've been making sure of it. Doctor: That's good, and how is your pain today, dear? Patient: P T only made the pain much worse, it hurts so much. Guest_family: Yes, she's in a lot of pain, is there anything else we can do, besides P T? Doctor: Well, we're in a pretty difficult spot here. The majority of my patients get significantly better by just going to P T. Guest_family: Is there any surgery to fix this? Doctor: Usually, we manage this for six months without surgery, and she hasn't reached that milestone yet. But, because her pain is getting so severe, I can do a lateral capsular release on this knee. Guest_family: What is that? Doctor: It's a small procedure, minimally invasive, and we can do it outpatient. Her kneecap is partially dislocating, so this surgery will get everything back into alignment. Guest_family: Okay, what is the risk of infection? Doctor: The risk of infection is actually less than one percent. We use antibiotics to control for infection. Patient: Will I be asleep for this? Doctor: Yes, you won't feel a thing. Patient: Will I need to go back to P T? Doctor: Yes, you'll need to go some after the surgery to make sure everything heals up okay. The other risks include bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling. Guest_family: I think we'd like to do the surgery. What do you think, honey? Patient: Yeah, I think so too, I want to get back to playing soccer. Sp 3","Section header: GENHX Section text: The patient is a 14-year-old girl who started having left knee pain in the fall of 2007. She was not seen in Orthopedic Clinic until November 2007. The patient had an outside MRI performed that demonstrated left patellar chondromalacia only. The patient was referred to physical therapy for patellar tracking exercises. She was also given a brace. The patient reported increasing pain with physical therapy and mother strongly desired other treatment. It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy. Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered. Risk and benefits of surgery were discussed. Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling. All questions were answered, and mother and daughter agreed to the above plans." "Doctor: What brings you here today? Patient: I have pain in my tummy. Doctor: When did you first notice it? Patient: It started suddenly around noon.",Section header: CC Section text: Abdominal pain. "Doctor: Welcome to the clinic., ma'am Patient: Thank you. Doctor: What brings you into see me? Patient: I have been struggling with pain and stiffness in my right neck and shoulder. Doctor: How long has this been going on for? Patient: Maybe for about four months. Doctor: In these past four months have your symptoms becomes worse or has it improved at all? Patient: It has been getting worse. The pain is worse at night. It wakes me up at night. I haven't had a good night sleep in four months. Doctor: Have you experienced any pain or numbness in your arm, wrist, or hand? Patient: Yes! About two weeks after the pain started, I was having some numbness and painful cramping in these two fingers here. Doctor: The right hand and the first and second finger? Patient: Yes. Doctor: How old are you? Patient: I am forty six. Doctor: Are you left or right handed? Patient: Right. It was a throbbing pain in my hand. Doctor: Have you had any other pain anywhere else in your body? Patient: I few times I had some numbness in both of my legs. It started with a pinching from my tailbone area. Doctor: Did you experience any trauma neck, head or back? Patient: No. I don't know where this pain came from. Oh, every once and a while I have this electric shock like sensation shooting down my spine when move my neck certain way. Doctor: Any pain or symptoms in your left arm or shoulder? Patient: No. Doctor: Have you had any visual changes or disturbances? Patient: No. Doctor: Any difficulties with your bowels or your bladder? Patient: No. Doctor: Have you been taking any thing for the pain? Patient: I have been taking Naprosyn. Doctor: Has the Naprosyn help relieve your pain? Patient: Only a little bit. Doctor: Okay.","Section header: GENHX Section text: This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma. She had been taking Naprosyn with little relief." "Doctor: Is this baby number two? Patient: Yes, this is baby number two. Doctor: How many times have you been pregnant, including miscarriages or abortions if any? Patient: I've been pregnant two times in total. No miscarriages or abortions. Doctor: When was your last period? Patient: About a month ago. Doctor: And how would you describe your periods? Light, normal, heavy? Patient: Pretty normal. Doctor: Any abnormal pap smears? Patient: No, fortunately they've all been normal. Doctor: That's wonderful to hear. And my last question for you is if you've ever gotten a mammogram? Patient: I haven't gotten one before. Do I need to get one? I just turned thirty nine. What's the recommended age again? Doctor: It depends. For example, the recommended age would be younger for someone who has a family history of breast cancer. Given that you don't have a positive family history of breast cancer, I'd advise getting one in a few years at the age of forty five.","Section header: GYNHX Section text: Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal." "Doctor: Okay, I want you to follow up with our hand therapist Doctor X at her A B C D office in one to two weeks. Patient: Okay, I will make an appointment today.",Section header: DISPOSITION Section text: Follow up with Dr. X in ABC Office in 1 to 2 weeks. "Doctor: So we're here to follow up on a few things. I'd like to know how you're keeping up with your blood sugar checks. Patient: I've been checking my blood sugar one to two times a day. Doctor: Have you been keeping a log? Patient: Uh yeah, but I need to be better at it. Doctor: Do you have the log with you today? Patient: Yep, in fact it's right here. Let me grab it for you. Doctor: Great. Patient: Here ya go. Doctor: Thank you. And have you been watching your cholesterol intake since getting blood work done? Your labs show your cholesterol levels are a bit elevated. I'd like for you to monitor your cholesterol and go in for another set of labs before our next visit. Patient: Do I need to fast for it again? Doctor: Yes, you'll need to fast. I'd recommend going in early in the morning before eating any breakfast. Patient: That sounds like a good plan. Doctor: And as for your sinusitis, how have you been feeling since finishing your course of antibiotics? Patient: Much better. No more headaches and a stuffy nose.","Section header: CC Section text: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis." "Doctor: What brings you in today? Patient: My back started hurting last night. I have a stomachache. I have had pain with urination for the last two days. Doctor: Do you have any other symptoms? Patient: I just started coughing and now I have a fever. Doctor: Do you have any history of kidney stones? Patient: Yes. I had kidney stones less than a year ago. I had a urinary tract infection at the same time. It was awful.","Section header: GENHX Section text: The patient complains of backache, stomachache, and dysuria for the last two days. Fever just started today and cough. She has history of kidney stones less than a year ago and had a urinary tract infection at that time. Her back started hurting last night." "Guest_clinician: When did she have lumbar discitis? Doctor: A little over a year ago. She received antibiotic therapy and ended up having debridement and instrumentation with Doctor XYZ. Guest_clinician: How's she doing today? Doctor: Really quite well. Guest_clinician: She also had a P E with that prior hospitalization, correct? Doctor: Yes.","Section header: PASTMEDICALHX Section text: Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well. She had a pulmonary embolus with that hospitalization." "Doctor: Do you have sugar or blood pressure problems? Patient: Oh, I have high blood pressure but it's well under control. I make sure to keep it under normal range. Doctor: Good. Any other health issues? Patient: Yeah, I have history of high triglycerides. But otherwise, I am pretty healthy. Doctor: Okay. Do you smoke? Patient: No.",Section header: GENHX Section text: She has had hypertension very well controlled and history of elevated triglycerides. She has otherwise been generally healthy. Nonsmoker. "Doctor: Hello, miss. The nurse who seated you tells me you are here for a second opinion on surgery. Patient: Hello, doctor. Yes, I have been told that both eyes need cataract extraction. I came for a second opinion because I will only have surgery if necessary. I am nervous. Doctor: What is the reason for the extraction? Patient: I am not exactly sure because the other doctors said a bunch of medical terms. I have had laser in my eyes though. That was for macular degeneration. Doctor X said I had neurovascular age-related macular degeneration. Doctor: Do you know what laser you had on your eyes? Patient: No. I just know laser was done by Doctor X four times to the macula on the right and two times on the left.","Section header: GENHX Section text: The patient seeks evaluation for a second opinion concerning cataract extraction. She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery. Past ocular surgery history is significant for neurovascular age-related macular degeneration. She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this." "Doctor: Any allergies? Patient: Um yeah. I'm trying to remember the name. It's a pain killer that starts with an L. Oh Lortab. Doctor: What happens when you take Lortab? Patient: Really bad hives. I've only ever taken it once. Doctor: I'll make note of that in your chart so we have it in your records.",Section header: ALLERGY Section text: She is allergic to Lortab. "Doctor: Do you have any known drug allergies? Patient: No, none that I know of.",Section header: ALLERGY Section text: None. "Doctor: Welcome in. Patient: Thank you. Doctor: What do you do for work? Patient: I work in Human Resources for the State of Maryland. Doctor: Do you live alone or with others? Patient: I live alone. Doctor: Do you smoke cigarettes? Patient: I used to smoke like a chimney. I quit smoking a while back. I had been smoking for about sixteen years. Doctor: That's great! When did you quit? Patient: I quit in nineteen eighty four. That is also the year I quit drinking. Doctor: What was the reason behind quitting drinking? Patient: I had a drinking problem. I am in A A. I have been in A A since I quit. Doctor: That's great. Keep up the hard work. Patient: Thank you. Doctor: Do you have any history of recreational or I V drug use? Patient: Yes. I used to take pills, but I never got into needle drugs. Thank God. I went through treatment, all those years back. I started going to A A and got my life together. Doctor: Do you have any other risk factors for H I V? Like multiple sex partners? Patient: No. I had my last H I V test over two years ago. I have been with the same guy for over two years. Doctor: Okay.","Section header: FAM/SOCHX Section text: He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use. He denies any HIV risk factors and states that his last HIV test was over two years ago." "Doctor: Hi, tell me about your family? Did anyone have any medical diseases? Patient: Both of my parents were healthy, but my maternal grandfather had a stroke. Doctor: Did anyone in your family ever have migraines? Patient: No, not that I know.",Section header: FAM/SOCHX Section text: MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family. "Doctor: Do you have any chronic medical conditions that I should know about? Patient: What do you mean by that, doctor? Doctor: Well, it could be anything from high blood pressure, to depression, to cancer. Do any of those sound familiar? Patient: Oh, yeah, I have a few things like that. I have anemia, high cholesterol, and, um, hypothyroidism.","Section header: PASTMEDICALHX Section text: Anemia, high cholesterol, and hypothyroidism. PAST" "Doctor: How old are you? Patient: Oh, I am fifty eight now. Doctor: So, you are here today because you are having some vision difficulties? Tell me about what has been going on, ma'am. Patient: Yeah. Okay. It all started a year ago. It started with losing the color in my vision. Doctor: Was the loss sudden or gradual? Patient: Gradual. And now I am starting to have blurry vision. Doctor: When did that start happening? Patient: I noticed it two months ago. Doctor: Is the blurred vision an all blur or is there a blind spot of blurred vision. Patient: It is an all over vision blur and then I have on blind spot in my right eye. Doctor: Have you had any fluctuations in your symptoms in the last year? Have you gained any vision back? Patient: Some days I feel like things are a little better but not much. I have basically been the same. Doctor: Have you experienced any weakness, dizziness, vertigo, nausea or vomiting? Patient: No. Doctor: Any double vision or headaches? Patient: No. Doctor: Any pain in or behind the eye at all? Patient: No. Doctor: Any other health concerns or complains? Patient: No. Just the vision problems. Doctor: Alright! Let me take a look here.","Section header: GENHX Section text: 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There have been mild fluctuations of her symptoms, but her vision has never returned to its baseline prior to symptom onset one year ago." "Doctor: How are you feeling today? Patient: I have been having some trouble breathing. I had tightness in my chest after walking up stairs. Doctor: Let me listen to your lungs.","Section header: CC Section text: ""Trouble breathing.""" "Doctor: Good afternoon, ma'am. Before we begin, can you confirm your age for me, please? Patient: Sure, I'm fifty six years old. Doctor: Great, thank you. What seems to be the problem today? Patient: Well, I have a history of systemic lupus erythematosus. Doctor: How have you been treated for this in the past? Patient: Um, I went to a rheumatologist about four months ago, I had discomfort in both of my hands. Doctor: Which hand was worse? Patient: My left was worse than my right at that time. Doctor: Have you seen anyone else for this? Patient: Um, I came in on October thirtieth two thousand seven. I was having the same problem. Doctor: What did they do for you at that time? Patient: They have me a trial of Elavil because they thought it was, um, ulnar or radial neuropathy. Doctor: Did they give you any topical creams? Patient: Yeah, they gave me a prescription for Zostrix but I couldn't fill it because of my insurance. Doctor: I see, have your symptoms gotten worse since they began? Patient: Yeah, especially here, at the base of my left hand, like around my wrist. Doctor: Which fingers do you feel it in? If any? Patient: Right here, doctor. Doctor: Okay, these are your second, third, and fourth fingers. Do you have any other symptoms of note? Patient: Um, actually yeah, I've been having some respiratory problems for the last three days or so. Doctor: What symptoms have you been experiencing? Patient: Um, I've had a dry cough and I feel like I've had a fever but I haven't taken my temperature. Doctor: Have you had any night sweats or chills? Patient: No, not that I can remember. Doctor: Have you had any chest pain or discomfort? Patient: No. Doctor: What about shortness of breath, or G I problems? Patient: Thankfully, no.","Section header: GENHX Section text: The patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater than right. The patient was seen on 10/30/07. She had the same complaint. She was given a trial of Elavil at bedtime because the thought was to see that represented ulnar or radial neuropathy. She was also given a prescription for Zostrix cream but was unable to get it filled because of insurance coverage. The patient reports some worsening of the symptoms especially involving at the dorsum of the left hand, and she points to the area that actually involves the dorsal aspect of the second, third, and fourth digits. The patient recently has developed what sounds like an upper respiratory problem with a nonproductive cough for 3 days, although she reports that she has had subjective fevers for the past 3 or 4 days, but has not actually taken the temperature. She has not had any night sweats or chills. She has had no recent problems with chest pain, chest discomfort, shortness of breath or problems with GU or GI complaints. She is returning today for routine followup evaluation." "Doctor: Do you remember the name of the medication you are taking? Patient: I have two, but I do not remember their name or why I am taking it. Doctor: That is fine, we will figure it out.","Section header: MEDICATIONS Section text: She is on two different medications, neither of which she can remember the name and why she is taking it." "Doctor: I wanted to talk to you about your family medical history. Patient: Okay, how this will be helpful? Doctor: Family history plays an invaluable role in your health. It provides us with important clues and insight to predict and detect diseases before obvious symptoms appear. Patient: My mom dealt a long time with anxiety and stress disorder.","Section header: FAM/SOCHX Section text: Patient admits a family history of anxiety, stress disorder associated with mother." "Doctor: Okay, let's review your family history. Patient: Ready when you are. Doctor: Does anyone in your family have high blood pressure or high cholesterol? Patient: Both my parents have high blood pressure. Doctor: Are they being treated for it? Patient: Um yes. Oh they also have E T. Doctor: Do any of your siblings have it as well? Patient: No. Doctor: Does anyone in your family have an autoimmune disorder. Patient: Hm. Give me a second to think. Does lupus count? Doctor: Yes. Who do you know that has lupus? Patient: My cousin. Doctor: On your mom or dad's side? Patient: Uh mom.",Section header: FAM/SOCHX Section text: Both parents have ET and hypertension. Maternal cousin with lupus. "Doctor: What are you taking as a maintenance treatment? Patient: Oh, I take Flonase. Doctor: And do you have a lot of issues after taking that? Patient: No I do not. Doctor: That is good.",Section header: MEDICATIONS Section text: He is maintained on Flonase and denies much in the way of nasal symptoms. "Doctor: Hello. Looks like we are here for a six months follow up. How are we doing? Patient: I have stayed relatively the same. My main complaint is that I feel tired throughout the day. The C P A P is doing fine and I wake up refreshed, but I don't like how I crash. Doctor: Alright. How are the thyroid issues? Patient: I seem to be fine. My thyroid gland does not seem enlarged and I can breathe like normal. No fever or anything. Doctor: Have you experienced any of the following: temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, or diarrhea? Patient: Nothing of the kind. Doctor: How has you weight been? Patient: It has been stable. Doctor: Any muscle weakness closest to the body's center? Patient: No, nothing like that. Not bad for forty five.","Section header: GENHX Section text: This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 years old. Her last visit was about 6 months ago. Since that time, the patient states her health has remained unchanged. Currently, primary complaint is one of fatigue that she feels throughout the day. She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day. In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism. She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea. Her weight has been stable. She is not reporting proximal muscle weakness." "Doctor: So I understand you had a fainting episode yesterday? Patient: Yes, I did. Doctor: Has this happened to you before? Patient: Yes. It happens whenever needles are involved. Doctor: You had a Vasovagal Syncope. How are you feeling today? Patient: I feel normal today.",Section header: CC Section text: Syncope. "Doctor: Hello, how are you? Patient: I am not so good. Doctor: Oh, what is going on with you? Patient: Well, I have lot of swelling in my legs. Doctor: Hm, okay.",Section header: CC Section text: I have a lot of swelling in my legs. "Doctor: Hi there, sir! I am Doctor Frankland. Patient: Hi! It's nice to meet you. Doctor: What brings you into see me today? Patient: I have had this pain in my finger and wrist for about a month. I have had some numbness too. The numbness started in the finger and is now in the wrist too. Doctor: Which wrist and finger is it that is hurting? Patient: The left one and the middle finger, here. Doctor: What was to time frame of the procreation of the numbness from the finger to the wrist? Patient: It started when I woke up and then by the end of the day my wrist was numb too. Doctor: When did you start experiencing pain in the wrist area? Patient: A few days after the numbness started. Doctor: Which hand is your dominate hand? Patient: I am left handed. Doctor: What do you do for work? Patient: I am a cook. I also cut the fish for the whole restaurant. I cut fish for hours in the mornings and it has been a struggle and it is aggravating my finger and wrist. Doctor: How old are you? Patient: I am forty four. Doctor: Do you have any history of injuring a neck injury? Patient: No. Doctor: Any neck pain or weakness? Patient: No. Doctor: Any difficulties with bowel movements or urination? Patient: No.","Section header: GENHX Section text: This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury." "Doctor: Good morning. How are you feeling today? Patient: I feel good, considering. I slept well last night. Doctor: Are you expensing any pain or discomfort? Patient: No. I feel fine.","Section header: EXAM Section text: GENERAL: The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted." "Doctor: How are you doing with everything? Patient: I'm good. It's hard when you are in quarantine. I hope things will get back to normal soon. Doctor: So, you are here for your breast examination. Patient: Yes, it was due for so long. Doctor: I'm going to touch both of your breasts one by one to check for any lump or kind of mass. Okay? Patient: Yeah. Doctor: Okay, so both looks good. Are you feeling any pain while I'm touching? Patient: No, I don't feel any pain. Doctor: That's good, no masses, no pain and I do not feel anything in your armpit area.",Section header: EXAM Section text: BREASTS: The breasts show no masses or tenderness. No axillary adenopathy. "Doctor: How's your wife doing? I think the last time I saw her was two weeks ago. She was telling me about the remodeling you've been doing around the house. Patient: She's doing well, thanks for asking. Oh yeah, the remodeling has been a lot. I didn't think it'd take as long as it has. Doctor: Yeah, it can take some time. We remodeled our kitchen three years ago and it turned our lives upside down. So tell me, how's training going for you? I believe you were telling me that you have a five k coming up. Patient: Yeah, it's two weeks away. I've been jogging and doing cross country track about five times a week. I also lift twice a week on my better days. Doctor: That's great! And no smoking or drinking, correct? Patient: Nope. Doctor: How's work been treating ya? Patient: Pretty darn well actually. I go into the allergy and immunology clinic four days outta the week. I like that my hours are flexible. My patients also haven't run away from me yet, which is always a good sign.","Section header: FAM/SOCHX Section text: The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology." "Doctor: My nurse tells me you're thirty four years old, is that correct? Patient: Yes, I just had my birthday, doctor. Doctor: You identify as African American, correct? Patient: Yes, that's right, sir. Doctor: You're here for a follow up? What brings you back in today? Patient: Well, I don't really have a single acute complaint, but I have a muscle sprain in my upper back. Doctor: Is there an injury associated with this pain, ma'am? Patient: I think it has to do with me lifting weights. Doctor: Yes, that's common. Is this messing with your ability to work? Patient: No, it's not really. Doctor: What do you do for a living? Patient: I'm a housekeeper, it's my profession. Doctor: Are you having trouble sleeping at night? Patient: Yes, it's not severe, but I'm having some trouble. Doctor: With ten being the worst pain imaginable, how would you rate your pain today? Patient: I'd say it's usually a two out of ten. Doctor: When it's the worst, how would you rate it? Patient: When that happens, I'd say it's a three or a four. Doctor: Do you take any medicines for this pain? Patient: Over the counter medications usually help the pain go away. Doctor: Do you have any other complaints? Patient: No, just this muscle pain. Doctor: Do you have any loss of balance when you hold something with this arm? Patient: No, my strength and everything is normal there. Doctor: Do you have any signs of infection? That'd be anything like fever or chills, anything like that? Patient: No, I don't have anything like that.","Section header: GENHX Section text: This is a 34-year-old African American female who comes today for routine followup. She has no acute complaints. She reports that she has a muscle sprain on her upper back from lifting. The patient is a housekeeper by profession. It does not impede her work in anyway. She just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication. No other associated complaints. No neurological deficits or other specific problems. The patient denies any symptoms associated with opportunistic infection." "Doctor: How can I help you today. Patient: I have been having irregular periods. Doctor: When was your last menstrual period? Patient: My last period was on June first two thousand and four. Doctor: Are you currently sexually active? Is there a possibility of pregnancy? Patient: No! There is no possibility that I am pregnant. I have not had sex in two years. Doctor: How old where you when you had your first menstrual period? Patient: I was ten years old when I got my first period. My cycle has never been regular. It runs in my mom's side of the family. Doctor: What is your family history of reproductive health conditions on your mom's side of the family? Patient: My mom and my aunt have both had total hysterectomies. Doctor: Is there any other personal medical history I should know about? Patient: I see Doctor X Y Z Allen for my abnormal heart valve condition. I am on S B E prophylaxis. I have to limit my activity because of my heart condition. Doctor: Do you avoid decongestants? Patient: Yes.","Section header: PASTMEDICALHX Section text: She denies sexual activities since two years ago. Her last menstrual period was 06/01/2004. Her periods have been irregular. She started menarche at 10 years of age and she is still irregular and it runs in Mom's side of the family. Mom and maternal aunt have had total hysterectomies. She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen. She avoids decongestants. She is limited on her activity secondary to her heart condition." "Doctor: How have you been feeling? How is your leg feeling? Patient: My right leg is in a lot of pain. The nurse just changed the bandage. I only have a rash where the bandage is. Doctor: It looks like we have you taking Vicodin for the pain. Is the medication not helping? Patient: The pain medication is horrible. I have been throwing up, off and on. I have been constipated since I have been here. Doctor: I'll note that. Vomiting since February nineteen of two thousand seven. I am sorry to hear that. I will make a change to the medication and get you something for the constipation issue. Patient: Thank you. Doctor: Have you had any shortness of breath, chest pain or coughing up blood? Patient: No. Doctor: Any joint pain, headaches or rashes? Patient: No. Just a rash where the bandages are like I said earlier. I also want to discuss this acne while I am here. I have had it for about two years. It's nothing big, just mild to moderate in severity.","Section header: ROS Section text: He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain." "Doctor: Does anyone in your family have a neurological disorder? Patient: No, not to my knowledge.",Section header: FAM/SOCHX Section text: unremarkable. "Doctor: Do you smoke, sir? Patient: Well, I used to a long time ago, but I don't anymore. Doctor: Good, what about alcohol, do you drink? Patient: Well, my wife and I have a drink or two a day.",Section header: FAM/SOCHX Section text: He has a very remote history of tobacco use. He has one to two alcoholic drinks per day. He is married. "Doctor: Did you had any medical issues in the past? Patient: No, nothing major. Doctor: You said nothing major, so, what was there? Patient: I had a little curve in the spine. It was not major. Doctor said that it can be corrected by exercises.",Section header: PASTMEDICALHX Section text: Also positive for some mild scoliosis. "Doctor: Do you have any medical conditions that I should know about? Patient: Yeah, I have chronic diarrhea, and C O P D. Doctor: Are you a smoker? Patient: Yes, I have been for a long time. Doctor: How would you characterize your smoking level? Patient: Um, I'd say it's pretty heavy.",Section header: PASTMEDICALHX Section text: Includes chronic diarrhea as I mentioned before and chronic obstructive pulmonary disease secondary to heavy smoking. "Doctor: You have atrial fibrillation from the past? Patient: Yes, rhythm problem is bad. Doctor: And no dizziness? Patient: Yes. I do. Doctor: Okay well...",Section header: ASSESSMENT Section text: 1. Atrial fibrillation. 2. Dizziness. "Doctor: Do you have any allergies? Patient: No allergies. Doctor: Nothing? Cat dander, pollen? Patient: Nope.",Section header: ALLERGY Section text: None. "Doctor: Do you live with your husband? Patient: Yes, we live on a ranch about twenty miles away. Doctor: Do you have children? Patient: We had six children all together, but two of them passed away suddenly. Doctor: I'm so sorry to hear that. How old were they? Patient: One was forty years old and the other was forty five. Doctor: Wow, they were quite young. I offer you my sincerest condolences. Patient: Thank you. It's been really hard on my family, but we're trying our best to get by. Doctor: That's all you can do. It's important to spend time with each other every chance you get. Patient: Exactly. Doctor: I have a few more questions to ask before we end today. Patient: Go ahead. Doctor: Do you have family history of any medical problems? Patient: No. Doctor: Do you smoke or drink? Patient: Never.","Section header: FAM/SOCHX Section text: She is married, lives with her husband, has 2 children that passed away and 4 surviving children. No history of tobacco use. No history of alcohol use. Family history is noncontributory." "Doctor: So let's see here. Any history of high blood pressure or diabetes? Patient: No, sir. Doctor: How about heart disease? Patient: No, no heart disease. Doctor: And no cancers? Patient: No and for that I'm thankful.","Section header: PASTMEDICALHX Section text: None. No history of hypertension, diabetes, heart disease, liver disease or cancer." "Doctor: What is your family medical history? Patient: My dad had Alzheimer's disease. He is in a facility that cares for him now. Doctor: I am sorry that must be hard. Patient: It is. My aunt, his sister helped me get everything set up for him. She had a stroke last month. Doctor: Oh no. How is she doing now? Patient: She is home now but her husband is having to help take care of her. The doctors said it looks good for her to have a full or almost full recovery. Doctor: That is a relief. Patient: Yes, it is! Doctor: Any other family health problems that you know of? Patient: No not that I know of.",Section header: FAM/SOCHX Section text: Alzheimer's disease and stroke on paternal side of family. "Doctor: So, how much longer are you in juvie, young man? Patient: I've got about three weeks left, sir. Twenty five days, if you want to be exact. Doctor: Good, time to make the best of getting out, right? Patient: Absolutely, I don't want to go back. Doctor: Good. Do you smoke, young man? Patient: No sir, absolutely not.",Section header: FAM/SOCHX Section text: He is in Juvenile Hall for about 25 more days. He is a nonsmoker. "Doctor: Hello, I am Doctor Rez. I will ask you a few questions about your personal and family history, okay? Patient: Yes, that's okay. Doctor: Did any one in your family get diagnosed with any medical conditions? Patient: My mom has lumps in her breast but it is benign, however my granny on my father side had cancer. Doctor: What kind of cancer, do you know? Patient: Well, it was breast cancer don't know if there are types for it. Doctor: No, that's fine. Did you ever have palpitations? Patient: What do you mean by that? Doctor: Um, Palpitations means the sensation when you feel that your heart is racing or pounding really fast even without doing any strenuous exercise or anything. Patient: Oh, got it. No, I never had that. Doctor: What about any uncontrolled urine leakage? Any accidents? Patient: No. Doctor: What about any recent sudden hair loss or any other concerns? Patient: No, nothing like that. Doctor: Any other treatments in the past? Patient: Yeah, I recently got treatment for my sinus.","Section header: FAM/SOCHX Section text: Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis." "Doctor: Any history of smoking? Patient: Uh yeah, but I quit in two thousand seven. Doctor: On average, how many packs per day did you smoke? Patient: Uh if I were to guess, I'd say one pack per day. Doctor: Any other drugs? Patient: I used to do coke, but I quit that in two thousand five. Doctor: And any history of drinking? Patient: Um I used to drink one pint per day, but I quit drinking more than ten years ago.","Section header: FAM/SOCHX Section text: The patient is a former smoker, reportedly quit in 2007. He used cocaine in the past, reportedly quit in 2005. He also has a history of alcohol abuse, but apparently quit more than 10 years ago." "Doctor: Can you tell me more about your family's medical history? Are there any conditions of note? Patient: Well, my dad died from prostate cancer, and my mom died as well, she was an alcoholic. Doctor: I'm so sorry to hear that, ma'am, how old were they? Patient: Well, my father was eighty, and my mother was sixty seven. Doctor: I'm so sorry, do you have any siblings? Patient: Yeah, I had a brother, he passed away too, from bone and throat cancer. Doctor: I'm sorry, how old was he? Patient: He was seventy, doctor. Doctor: Do you have any children? Patient: I have four, two of each. Doctor: That's wonderful, how are your sons doing? Patient: They're thirty seven and thirty eight, and they're both doing really well. Doctor: That's great, what about your daughters? Patient: Well, they're sixty and fifty eight, and they both have cancer. They're real fighters. Doctor: I'm sorry, that must be so hard to deal with. Are there any other conditions you're aware of? Patient: Oh yeah, we have it all, nervous condition, high blood pressure, kidney and lung disease, depression, it's all there.","Section header: FAM/SOCHX Section text: Her father died at the age of 80 from prostate cancer. Her mother died at the age of 67. She did abuse alcohol. She had a brother died at the age of 70 from bone and throat cancer. She has two sons, ages 37 and 38 years old who are healthy. She has two daughters, ages 60 and 58 years old, both with cancer. She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family." "Doctor: Are you married? Patient: Yes. Doctor: Where do you work? Patient: I work as a secretary in a law firm. Doctor: Do you smoke or drink? Have you ever tried any illegal drug? Patient: No, none of these.","Section header: FAM/SOCHX Section text: Married, Secretary, No h/o tobacco/ETOH/illicit drug use." "Doctor: It looks like E M S found you in bad shape? Patient: What? Guest_family: My mother is hard of hearing. She is eighty five. They found her on the toilet. Doctor: Did your mother tell you anything about her condition before E M S arrived? Guest_family: She said she threw up right before they came and she had diarrhea. Doctor: Ma'am. How are you feeling now? Patient: I have been sick to my stomach. My belly has been hurting. I threw up. Doctor: How many times did you vomit ma'am? Patient: I don't know. Doctor: Do you recall the color of the vomit? Did you see any blood or notice the color of the vomit? Patient: I don't know.","Section header: GENHX Section text: The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing." "Doctor: Do you have kids, ma'am? Patient: Yes, I do. I have two sons and we adopted a girl. Doctor: Where did you adopt? Patient: Just here. Doctor: and you are married right? Are you working? Patient: Yes, I have been married a long time. I retired from Avon. Doctor: Do you smoke cigarettes or drink? Patient: I do not smoke or drink alcohol.","Section header: FAM/SOCHX Section text: She has two sons and an adopted daughter. She is married long term, retired from Avon. She is a nonsmoker, nondrinker." "Doctor: How's the little dude? Guest_family: He has fever and bad congestion for the last two days. He has had a fever for one. I try to suck the discharge out through nose. Doctor: I am guessing he has some mild problems with breathing while feeding. Guest_family: Yes, that is correct. He is drinking milk every couple hours, only for ten minutes instead of twenty minutes. Guest_family: He has fever too, so she gave him Tylenol. Guest_family2: He is very fussy. Doctor: Is he sleeping well? Guest_family: Yes, he sleeps. But he is not able to breath well even with albuterol. Doctor: How about wet and dirty diapers? Guest_family: He is peeing less I think because he used to have eight to ten wet diapers but now it's down to four in a day. And five dirty diapers. Doctor: How about any diarrhea? Guest_family: No, he doesn't have any diarrhea, they are soft and yellow. Doctor: Any rashes or acne? Guest_family: No. Doctor: How about vomiting? Guest_family: No, he did not vomit. Doctor: How old is he? And, sorry this is odd, but what ethnicity do you identify as? I need it foe the paperwork. Guest_family: Twenty one days old Caucasian male. Doctor: Do you notice him getting blue at all? Or does this area sink in when he tried to breathe? Guest_family: No, neither. Doctor: Is he having any trouble breathing in general? Guest_family: No.","Section header: GENHX Section text: The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol. Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature. The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea." "Doctor: Are you taking Benicar? Patient: Yes, twenty daily. Doctor: And what else? Patient: I take some multivitamin, glucosamine, Vitamin B complex, Vitamin E and a low dose Aspirin. Doctor: Okay that's good information.",Section header: MEDICATIONS Section text: Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin. "Doctor: Do you smoke? Patient: Nope. Doctor: How about alcohol intake? Patient: Nope. Doctor: What about any kind of drug usage? Patient: Nope.",Section header: FAM/SOCHX Section text: Denies ETOH/illicit drug/Tobacco use. "Doctor: Hi, how are you? Patient: I am okay. Doctor: Do you have any bone pain or issues around that? Patient: No, I do not. Doctor: So, they gave you a dose of Tylenol here in the emergency department to treat your pain. Is your pain under control? Patient: Yes, with medication I feel it is better, but I want to be removed from the backboard. Doctor: Okay, let's get you off. Yeah, your C T scans of the abdomen appeared normal. And there was no sign of bleeding. I believe, you just have a contusion and abrasion to abdomen from the seatbelt and likely from the airbag as well. Patient: Oh okay. Doctor: It's good that you can stand and walk through the emergency department without difficulty. I do not see any abrasions or lacerations. Patient: Yeah, nothing like that and I can walk.","Section header: EDCOURSE Section text: The patient was removed from the backboard within the first half hour of her emergency department stay. The patient has no significant bony deformities or abnormalities. The patient is given a dose of Tylenol here in the emergency department for treatment of her pain. Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard. The patient's CT scans of the abdomen appeared normal. She has no signs of bleeding. I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well. The patient is able to stand and walk through the emergency department without difficulty. She has no abrasions or lacerations." "Doctor: Lets talk about your family history, does cancer run in your family ma'am? Patient: Oh yes! My family has a history of lung, liver and prostate cancer. Doctor: Oh wow! Patient: Yeah. Doctor: And you mentioned that your mother had Alzheimer's? Patient: Well, I am not sure about Alzheimer, but she had some dementing disease. It started when she was in her eighties. It was kind of mild case. Patient: And she actually passed away in her eighties due to old age. Doctor: Okay, how about your siblings, do they have any signs of Alzheimer? Patient: No, they are fine. Doctor: Okay.","Section header: FAM/SOCHX Section text: Significant for lung, liver, and prostate cancer. Her mother died in her 80s of ""old age,"" but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient. No one else appears to have Alzheimer disease including her brother and sister." "Guest_clinician: What's their medical history? Doctor: I have here hypertension, diabetes, diabetic retinopathy, and elevated lipids. They're in post C V A. Guest_clinician: Do you know their neurologist? Doctor: I can have the nurse or scribe go in and ask again. Guest_clinician: Great.","Section header: PASTMEDICALHX Section text: Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy." "Guest_clinician: Were you able to get a history from her? Doctor: I tried but was unsuccessful. She's very out of it. Guest_clinician: Does she have a history of alcohol abuse? Doctor: According to her records, she has a long history of alcohol abuse.",Section header: PASTMEDICALHX Section text: Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded. "Doctor: The patient has a history of C A D. Guest_clinician: Are they being followed by a cardiologist? Doctor: Not to my knowledge. I can check their electronic medical records. One sec.",Section header: FAM/SOCHX Section text: Positive for coronary artery disease. "Doctor: Hi sir, how old are you? Patient: I am thirty. Doctor: We are following up today for your moderate to severe apnea, right? Patient: Yes, that is correct, I still can't sleep. Doctor: Okay and you did the CPAP? Patient: Yes. Doctor: Okay, let's review it today. Patient: Sure.",Section header: GENHX Section text: Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP. "Doctor: Any smoking or alcohol? Patient: No, I don't smoke but I drink wine. Doctor: Are you married? Patient: Yes, I am. Patient: I have three stepchildren and one of my own and I work for A B C D.",Section header: FAM/SOCHX Section text: He is a non-cigarette smoker. He has occasional glass of wine. He is married. He has one biological child and three stepchildren. He works for ABCD. "Doctor: Congratulations on your new baby! How are you doing today? Patient: I'm doing well, no headaches, and I'm breastfeeding well. Doctor: Have you had any bleeding? Patient: Nope, none. Doctor: Are you using a mini pad? Patient: Yeah, I use it twice a day. Doctor: Do you have any cramping or clotting? Patient: No, thankfully I don't. Doctor: What color is your discharge, ma'am? Patient: Well, its turned from red to brown, and now its kind of yellowish. Doctor: Okay, have you had sex again yet? Patient: No, we're waiting a little longer. Doctor: Are you going to the bathroom regularly? Patient: Regularly? Yes, but I'm having some pain with it, and then every once in a while I have some bright red bleeding. Doctor: Are you constipated? Patient: No, I'm not. Guest_family: She hasn't been eating her vegetables like she should. Doctor: That'll also do it. Patient: Okay, well, my seasonal allergies are back too. Doctor: What symptoms do you have with your allergies? Patient: I get itchy watery eyes, a runny nose, I can't stop sneezing, and I have a lot of pressure in my ears.","Section header: GENHX Section text: She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish. She has not yet had sexual intercourse. She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding. She has not been particularly constipated but her husband says she is not eating her vegetables like she should. Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears." "Doctor: Do you have any major medical conditions that run in your family that I should know about? Patient: What do you mean by that? Doctor: Well, it could be anything from diabetes to high blood pressure to cancer. Patient: Oh, yeah. My brother had prostate cancer.",Section header: FAM/SOCHX Section text: His brother had prostate cancer. "Doctor: Hi, how are you? Patient: Hi! I am okay other then this back pain. Doctor: I am so sorry. Tell me about your back. Patient: Three nights ago, I fell on my steps bringing in the groceries from the car. Doctor: How did you land when you fell? Patient: I fell and landed on my right hip. I hit my low back on the railing. Doctor: I would like to get some imaging done today. Patient: Okay.",Section header: GENHX Section text: Back pain after a fall. "Doctor: Have you seen your lab results? Patient: No, do you have those in today? Doctor: Yes, I have them right here. They're essentially negative, except it appears that you had C difficile in the past. Do you remember that? Patient: Yes, I got it when I worked at a hospital after graduating. Doctor: Yeah, its unfortunately more common there.",Section header: PASTMEDICALHX Section text: Essentially negative other than he has had C. difficile in the recent past. "Doctor: Breath in breath out, let me tap it and see. Well, your lungs sound clear. Patient: Okay.",Section header: EXAM Section text: CHEST: Lungs bilaterally clear to auscultation and percussion. "Doctor: Are you still taking the Trizivir? Patient: Yes. Doctor: How much are you taking? Patient: I take one pill two times a day. Doctor: Are you taking any other medications? Patient: I take Ibuprofen for body aches from time to time but that's it.",Section header: MEDICATIONS Section text: 1. She is on Trizivir 1 tablet p.o. b.i.d. 2. Ibuprofen over-the-counter p.r.n. "Doctor: I just need to confirm some information before we begin sir, you're forty one, correct? Patient: Yes sir, that's correct. Doctor: Good, so what happened? Patient: Well, I work at A B C, and about two days ago I slipped on some oil that had spilled. Doctor: How did you fall? Patient: I fell with both my arms outstretched, but I fell mostly on my left shoulder. Doctor: Where is your left shoulder pain? Patient: Mostly, it's in the back of my shoulder. Doctor: Going backwards a little, how about the right shoulder? Patient: It hurt really bad yesterday, but that's gone away now. Doctor: Good, do you have any pain in the front of the shoulder? Patient: No sir, I don't have anything there. Doctor: Good, how about weakness? Is there any shoulder weakness? Patient: No, it's not really weak at all. Doctor: How have your symptoms progressed over the last two days? Have they gotten better, or worse? Patient: Um, overall, I'd say it's gotten better. I have a little better range of motion. Doctor: Have you been able to do any activities? Patient: I was able to get in the swimming pool with my kids, and I didn't really have any trouble. Doctor: Good, what medicines have you taken for this? Patient: I've just taken some Advil so far.","Section header: GENHX Section text: The patient is a 41-year-old male presenting for initial evaluation of his left shoulder. He works at ABC and two days ago was walking though an area, where there was some oil spilled on the floor. He fell and landed on bilateral outstretched arms and then further fell landing primarily on his left shoulder. He presents today reporting primarily posterior shoulder pain. The right shoulder was bothersome yesterday, but is now asymptomatic. He has no anterior shoulder pain. He denies any feelings of weakness. He reports some improvement over the last two days especially in his range of motion. He was able to get into the swimming pool last night with his children without difficulty. He has had no additional treatment other than over-the-counter Advil." "Doctor: Hi there! It is good to see you both. How has everything been going for the both of you? Patient: Hi Doctor. Guest_family: Things have been pretty good. She has been having some new emotional outbursts. I made an appointment with the down syndrome behavioral specialist that you recommended from the last time we were here. Doctor: That is great. Keep me updated on her progress. Her bloodwork came back showing an underactive thyroid. This explains the recent weight gain and fatigue. I would like to start her on a medication called levothyroxine. We will need to check her bloodwork again in one month to see how her thyroid respond to the medication. Guest_family: Okay. Doctor: Is there any other concerns you have today? Guest_family: Yes. She has this toenail that looks strange and discolored. Doctor: Let me look. Can you remove your socks for me? Patient: Yes. Doctor: Is it this nail? Guest_family: Yes. Doctor: This is very common. It is called Onychomycosis. It is nail fungus. Since only one nail is affected, I would recommend starting off with a topical treatment. I will send the drops to your pharmacy. You will put on drop on the affected nail, daily.",Section header: ASSESSMENT Section text: 1. Down's syndrome. 2. Onychomycosis. 3. Hypothyroidism. "Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: Have you ever had surgery, ma'am? Patient: Actually, yes I have. I had pinning surgery done on both of my ears. Doctor: Do you remember how old you were when you had surgery? Patient: Um, I was five or six years old. It was when I was a kid, I know that for sure.",Section header: PASTSURGICAL Section text: Bilateral pinning of her ears. "Doctor: Do you have any allergies? Patient: Not that I know of. Doctor: Okay.",Section header: ALLERGY Section text: None known. "Doctor: What is your family medical history? Patient: My dad has high blood pressure. My mom has had a ton of skin cancer removed. Doctor: Do you know what type of skin cancer she has removed? Patient: I have no idea.",Section header: FAM/SOCHX Section text: HTN and multiple malignancies of unknown type. "Doctor: Hello, miss. Today we're going to do a recheck for your hypertension. Sound good? Patient: Yes, of course. Doctor: I just want to check to see if you have any symptoms that can possibly raise alarm. Patient: I have been coming to you for the last fifteen of my seventy eight years on Earth. I know how a follow up works. Doctor: You are a seasoned veteran. Alright. So how is your chest? Any pains or tightness? Patient: No, luckily I do not have that. Doctor: Is your heart beating alright? Do you feel like it is beating too fast or hard? Patient: No. I can't really feel my heart beat normally, but I guess that is better than feeling it beat constantly. Doctor: You are correct. You shouldn't notice it. How is sleeping? Patient: Sleeping has been fine. I sleep through the night. Doctor: Great. Any shortness of breath that causes you to wake up? Patient: None. I don't have shortness of breath at any other time of the day. Doctor: Are your legs doing well? Any swelling? Patient: No. No swelling.","Section header: GENHX Section text: The patient is a 78-year-old female who returns for recheck. She has hypertension. She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema." "Doctor: Hello, it's nice to meet you. Patient: It's nice to meet you as well. Doctor: My name is Doctor X and I will be taking care of you today. Patient: Thank you. Doctor: I've been told that you'd like a refill on your Xanax prescription and something to help you break your smoking habit. Patient: Yes, I feel like I've tried everything in the book and I still can't break the habit. One of my buddies was telling me about this medicine called Clantix or something like that. Doctor: Yes, I've heard of Chantix. We can look into it and see what's best fit. Patient: Okay, great. Since moving back home, I've ran out of Xanax. Doctor: How long have you been taking it? Patient: Almost a year now. I usually take it on days where my anxiety is really bad. Doctor: I see here that you also have mesothelioma in the lining of your stomach, is that correct? Patient: Yes, I need to find a new cancer specialist that's closer to where I live. Doctor: Are you currently experiencing any pain? Patient: Not at the moment, but I do get pain when I eat sometimes. Other times it's when I'm not even doing anything. It's been chronic so nothing new. Doctor: Do you take anything for the pain? Patient: I haven't in a while. Doctor: When were you diagnosed with mesothelioma? Patient: About six or so months ago.","Section header: GENHX Section text: The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain. She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office. She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try." "Doctor: Are you allergic to anything? Doctor: Like any medications? Patient: No, I am not allergic to anything. Doctor: Perfect! Patient: Hm.",Section header: ALLERGY Section text: None. "Doctor: Welcome to the clinic. Patient: Thank you. It is nice to meet you. Doctor: It is nice to meet you to. I hear an accent. Where are you from? Patient: I am from Denmark. I speak Danish as my first language. Me and my husband have been in the States for many many years. When we first got here, we did not speak a word of English. Doctor: Wow! Your English is excellent now. Patient: Thank you. Doctor: How old are you? Patient: I just turned seventy four last month. Doctor: Happy birthday! Patient: Thank you. Doctor: So, your primary care physician sent you here for possible hydrocephalus. Patient: Is that the water on brain thing? Doctor: Yes. Patient: Then, yes. Doctor: Can you tell me about the symptoms that you have been having. Patient: I think I have been walking funny lately. I have also been losing my balance. Doctor: How do you know that you have been walking funny? Patient: My husband noticed that I have been walking funny. He noticed it about over six months ago or so. Doctor: What do you notice about the way your wife's walk that has changed? Guest_family: She walks wider then she used to, and I noticed that she stooped over. She walks much slower than she did before. She is often losing her balance. I have noticed her touching the walls and furniture to stabilize herself. Doctor: Okay. Have you noticed her stabilizing herself all of a sudden? Guest_family: No. It has been happening more and more over the last six months or so. Doctor: What else have you noticed about the way she walks? Guest_family: I noticed that she is having trouble stepping up onto things like a scale. She seems very unbalanced. She also seems to take her time as she walks. She can't be hurried. Doctor: That is good that you are taking your time. Do you use any devices to assist you to get around? Like a cane or a walker? Patient: No. Guest_family: I must help her get in and out of the car. Not every time but sometimes. I am very concerned because she has been falling more and more recently. Patient: I have had one emergency room visit. Doctor: What happened that you had to go to the emergency room? Patient: I fell. I was walking to the bedroom. I lost my balance so I put my hand out to brace myself against the wall and my hand slipped. I fell on my wrist. Guest_family: She broke her wrist. Doctor: When did this fall happen? Patient: March two thousand and seven. Guest_family: She has fallen a few times since she broke her wrist. It makes me so nervous. Doctor: I can see why that would make you nervous. Have you had any headaches? Patient: No. I never get headaches. Doctor: Aren't you lucky. Patient: Yes, I guess so. Doctor: Have you had any problems with your memory or cognitive abilities? Patient: I am still able to pay the bills on time. I don't feel as smart as I used to be. I do feel like my thinking has slowed down over the last few months. Doctor: What is your perspective on her memory and her cognitive abilities? Guest_family: I have noticed some changes. She will occasionally start a sentence and then not know what words to use to finish the sentence. Doctor: Has she ever had trouble finishing a sentence the in the past? Guest_family: No, she has always been very well spoken never has lost thoughts. Doctor: Have you had any fainting or vertigo episodes? Patient: I have not fainted. I have had some dizzy spells in the past but not recently. Doctor: Have you had and problems with your bowel movements? Patient: No. Doctor: Any bladder issues or frequent urination? Patient: No. Doctor: Okey. Let us do some an exam. Patient: Okey.","Section header: GENHX Section text: The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband. With respect to her walking and balance, she states ""I think I walk funny."" Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture. Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself. She has difficulty stepping up on to things like a scale because of this imbalance. She does not festinate. Her husband has noticed some slowing of her speed. She does not need to use an assistive device. She has occasional difficulty getting in and out of a car. Recently she has had more frequent falls. In March of 2007, she fell when she was walking to the bedroom and broke her wrist. Since that time, she has not had any emergency room trips, but she has had other falls. With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency. The patient does not have headaches. With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, ""I do not feel as smart as I used to be."" She feels that her thinking has slowed down. Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing. The patient has not had trouble with syncope. She has had past episodes of vertigo, but not recently." "Doctor: I mean, I am so happy to see your report today, your blood pressure looks much better. That's amazing given your past few visits your B P was out of control and even with changing your medications we were having tough time bringing it down. Patient: Yeah, I feel much better, I read about my condition and it is called something as um refraction or-- Doctor: Refractory hypertension. Patient: Oh yeah that! Doctor: But the good news is that it is getting better. Patient: Yes. Doctor: Last time we talked about seeing the internal medicine doctor there at your senior center, right? Patient: Yes, I made an appointment last week, um, no week before that, but I completely forgot about it. Doctor: Hm, okay we need to reschedule that. Patient: Yes, I will do it today. Doctor: Okay, your reports look fine. G F R is below sixty percent, that's a good sign. Overall, Miss K, you look better, but we need to reschedule your appointment with the Internist. That's kind of important. Patient: Okay, I will do that. Thank you! Doctor: You are welcome.","Section header: ASSESSMENT Section text: This is a return visit for this patient who has refractory hypertension. This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. We had discussed with her in the past beginning to see an internist at the senior center. She apparently had an appointment scheduled and it was missed. We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%." "Doctor: Did you ever visit any hospital for any kind of surgery? Patient: No.",Section header: PASTSURGICAL Section text: No previous surgeries. "Doctor: Hi there! How are doing today? Patient: I am doing well. Doctor: How have you been doing with keeping your hemoglobin levels between four and five point six prercent? Patient: I have been doing well. I have been able to keep it within that range.","Section header: CC Section text: Followup diabetes mellitus, type 1." "Doctor: So, are you married, ma'am? Patient: Well, no I'm not. My husband and I got a divorce. Doctor: I'm sorry to hear that, do you have any children? Patient: It's okay, it was for the best. Yes, I have two. Doctor: Do you live with either of them? Patient: Yeah, um, I live with my son right now. Doctor: Do you smoke or drink? Patient: No I do not.",Section header: FAM/SOCHX Section text: Denies any tobacco or alcohol use. She is divorced with 2 children. She lives with her son. "Doctor: Good afternoon, so, who is the patient today? Guest_family: Good afternoon, doctor. My granddaughter is your patient today. Doctor: What seems to be the problem today, young lady? Patient: Well, I'm having a lot of headaches, I feel it in my face. Doctor: Does it feel like pressure? Patient: That, and I have the sniffles. Doctor: What other symptoms have you had? Patient: Um, well, last night I had a sore throat, and I was coughing up phlegm. Doctor: Interesting, anything else? Patient: Um, I've had a rash on my face, back, and arms for the last three days or so. Doctor: Is it itchy? Patient: Yes, so we've been taking a lot of Benadryl. Doctor: I see, are you going to school? Patient: I have been, there's been a lot of fifth disease this year. Doctor: Okay, and have you been wheezing lately? Patient: No, I haven't been. Doctor: I see you have asthma, have you had any medication for this? Patient: No, I haven't had anything.","Section header: GENHX Section text: Grandfather brings the patient in today because of headaches, mostly in her face. She is feeling pressure there with a lot of sniffles. Last night, she complained of sore throat and a loose cough. Over the last three days, she has had a rash on her face, back and arms. A lot of fifth disease at school. She says it itches and they have been doing some Benadryl for this. She has not had any wheezing lately and is not taking any ongoing medications for her asthma." "Doctor: Did you have any surgeries in the past? Patient: Yes, I had a partial removal of my ovaries and then I also had my appendix removed. Doctor: Okay anything else? Patient: Yeah, I also got my tummy tucked. Doctor: Okay.","Section header: PASTSURGICAL Section text: Significant for partial oophorectomy, appendectomy, and abdominoplasty." "Doctor: Good afternoon, young man. Patient: Hello, doctor. Doctor: How old are you, young man? Patient: I'm thirteen, sir. Doctor: Thank you, so, what happened? Patient: I sliced my right ring finger with a piece of glass while I was playing around with my friends. Doctor: You need to be more careful, young man. What kind of symptoms do you feel in that finger? Patient: You're right. I have a lot of, um, numbness and tingling in it.",Section header: GENHX Section text: This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger. "Doctor: Hello. How are you feeling today? Patient: Not so well. I went to a party last night and my chest and body have been hurting a lot. Doctor: I see. Did you smoke at the party? Patient: Nope. I never smoked in my life. Doctor: Great. Where on your body does it hurt? Patient: Like my upper right side of my stomach area. Doctor: I see. Did you drink alcohol last night? Patient: I had to drive some people home, so I was sober. I also don't like the taste of alcohol, so I stay away from it.",Section header: FAM/SOCHX Section text: Denies tobacco or alcohol use. "Patient: And do I have to restrict my movement or activities? Doctor: Um, I have taken the plaster off and your foot looks good. I don't want you to restrict your activities, but you are the best judge of the situation. So, I will advise you to take it slow and do as much as you can tolerate. Patient: Got it. Thank you, Doctor. Do I need a follow-up? Doctor: As long as you are doing fine, having no pain, I think we are okay. Patient: Alright then bye. Doctor: Bye.",Section header: PLAN Section text: As tolerated. "Doctor: What is your family medical history? Patient: My dad had stomach cancer. Doctor: How old was he when he was diagnosed? Patient: I think he was seventy something. My sister has breast cancer. She is in her fifty's. Doctor: Any family history of uterine, ovarian or colon cancer? Patient: No. Not that I am aware of.","Section header: FAM/SOCHX Section text: 1. A sister with breast carcinoma who was diagnosed in her 50s. 2. A father with gastric carcinoma diagnosed in his 70s. 3. The patient denies any history of ovarian, uterine, or colon cancer in her family." "Doctor: Do you drink or smoke? Patient: No I don't. I have to care for my daughter. She is a widow. Doctor: So you live with her? Patient: Yes, she lives at home.","Section header: FAM/SOCHX Section text: She denies alcohol or tobacco use. She is the caretaker for her daughter, who is widowed and lives at home." "Patient: I think I need help. Doctor: I am here to help. Tell me what's going on. Patient: I am having mood swings, sometimes I feel super happy and sometimes I am just super sad and angry with myself. I find myself in tears thinking about things or situations which are not even real. Doctor: How old are you ma'am? Patient: I have just completed five decades of my life. Doctor: Did you ever try to hurt yourself? Patient: No, that thought never came to my mind. I just feel sad, like nobody cares if I exist. Sometimes I feel I can conquer the world and do anything I put my heart and mind into. It's just that I am not sure how will I feel after an hour. Doctor: How long have you had these symptoms? Patient: It has been going on for many months. At first, I ignored everything but now It feels like I am not myself any more with all these mood swings. Doctor: Do you work? Patient: Yes, I am a hygienist and work in a Bright Dentals. Doctor: How are you doing at work with your mood swings? Patient: Huh, my symptoms have sure started affecting my work. You know what the worst part is, my boss came to me last week and asked if I was on some kinds of drugs. I literally shouted at her saying no and left the clinic in tears. I think I need some drugs; I mean some medications to deal with my issues. Doctor: Have you ever been on any kind of medicine or treatment before? Patient: Yeah, I was on Wellbutrin before. It was prescribed by Doctor Jonah. I was eating a lot and even gained like twenty pounds in just a few months. My insurance didn't even cover it, I had to pay from my pocket. Doctor: Do you know what you were diagnosed with? Patient: It is all in these papers, I got my file with me, I just want to be normal me again. Doctor: Let me check and enter it in the medical record for future references. According to this, they prescribed Wellbutrin for obsessive compulsive type disorder and yes it was related to your overeating. Did it help you? Patient: Yes, I was doing better once I started taking that medicine regularly. I continued it even though I had to pay out of my pocket. Doctor: Have you ever been on antidepressants? Patient: No. Doctor: Any hot flashes or night sweat? Did you ever find yourself waking up to wet bed due to sweating? Patient: No. Doctor: Just putting together all that you have told me here. You have mood swings; you find yourself in tears without any specific reason, you are not suicidal, never been on any kind of antidepressants. Am I missing something here? Patient: Sometimes I really find it hard to concentrate. As a hygienist I really need to focus on the gums of the patients and cleaning but sometimes it gets hard to focus. Normally, at work I just stop when it gets hard to focus and take a walk around the clinic. It has started affecting my work. I need help! Doctor: Okay, I understand. Anything else that I should be aware of? Patient: Oh yeah, the insomnia, I am hardly sleeping. At times I feel like a zombie. Doctor: Any surgeries in the past? Patient: Yeah, I had some complications and they had to remove my complete uterus along with tubes and ovaries. Doctor: Oh! When was this? Patient: In the December of two thousand and three.","Section header: GENHX Section text: A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stated may be she needed to be, meaning taking some medications. The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication. She has not been on any other antidepressants in the past. She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia. She denies any hot flashes or night sweats. She underwent TAH with BSO in December of 2003." "Doctor: Any known past medical history? Patient: I have high blood pressure. Doctor: Anything else? Patient: Yeah, I remember I also had higher number of fat in my blood.",Section header: PASTMEDICALHX Section text: Include dyslipidemia and hypertension. "Doctor: Good morning, ma'am, welcome in. I believe this is our first time meeting. Patient: Good morning, doctor. Yes, this is my first time in. Doctor: Great, how old are you? Patient: I'm fifty five, doctor. Doctor: Thank you, what seems to be the problem today? Patient: Well, I'm having a laundry list of symptoms coinciding with my allergies. Doctor: Like what, ma'am? Patient: Well, my sense of taste is diminished, dry mouth, um, acid reflux, and G I issues, and then I have asthma, and reactions to things like aerosols. Doctor: I see, do you have any food allergies? Patient: Um, I think.","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 chart for history and physical and review of systems and detailed medical history." "Doctor: What's your family history? Patient: Both my parents are deceased. Doctor: I'm so sorry to hear that. I offer you my sincerest condolences. Patient: Thank you. My dad passed away at seventy five from leukemia and my mom fell victim to heart problems and alcoholism at thirty eight. Doctor: Does anyone else in your family suffer from leukemia, cardiac problems, or alcohol abuse? Patient: One of my uncles on my dad's side was recently diagnosed with leukemia. Doctor: Oh, wow. I see.","Section header: FAM/SOCHX Section text: Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia. One of her uncles was diagnosed with leukemia." "Doctor: Any fever or chills? Patient: No. Doctor: Any headache or body pains? Patient: No. Doctor: Any nausea vomiting? Patient: I had vomiting a few times. Doctor: Did you observe any blood? Patient: No. Doctor: Okay, any diarrhea? Patient: No, on the contrary I am having constipation every now and then, it's really bothering me now. I feel bloated all the time and don't feel fresh in the morning or throughout the day. Doctor: Oh, how long have you had this problem? Patient: Couple of months now. Doctor: Hm, I see, does it hurt you to pass stool? Did you notice any blood? Patient: No. I use suppositories. Doctor: Oh, that's great. You are doing the right thing. In addition to that I will prescribe you some strong laxative you can drink that in morning it should help. Patient: Okay! Doctor: Any complains of heart burn or acidity or stomach pain? Patient: No, not really. I do get this twisty pain in my stomach sometimes which I think is mainly due to my constipation. Doctor: Yeah, you can get that kind of pain with constipation. Any cough or cold like symptoms? Any cough with sputum? Patient: No, I feel fine. Doctor: Okay, basically I don't think you have any stomach ulcer or anything, but we need to treat your constipation because I know it can be really uncomfortable.","Section header: ROS Section text: General review of system is significant for difficulty with intermittent constipation, which has been problematic recently. He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough." "Doctor: Do you take Diovan, estradiol, Norvasc, Wellbutrin? Patient: Yes, and the Wellbutrin is an inhaler. Doctor: Okay so inhaler SR? Patient: Yes. Doctor: Do you take oxygen therapy at home? Patient: Yes. Doctor: Okay.","Section header: MEDICATIONS Section text: Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2." "Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: How long have you and your husband been married? Patient: Oh, at this point I don't even know how long its been. Doctor: I assume you live together? Patient: Yes, we do. Doctor: What do you do for a living? Patient: I'm a school nurse for the School Department. I love working with the children. Doctor: That's wonderful. Do you drink or smoke? Patient: No, I don't drink, and I quit smoking cigarettes about twenty five years ago. Doctor: Good for you.",Section header: FAM/SOCHX Section text: The patient is married. She lives with her husband and is employed as a school nurse for the School Department. She had quit smoking cigarettes some 25 years ago and is a nondrinker. "Guest_clinician: Any past surgeries? Doctor: It looks like she had an appendectomy along with a total abdominal hysterectomy and bilateral salpingo oophorectomy sometime ago. Guest_clinician: Okay, noted. Doctor: Oh and it looks like she had a right hip fracture back in O five after a fall.","Section header: PASTSURGICAL Section text: Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO." "Doctor: Before we begin today, sir, I just need a few pieces of background information. I see here on my chart that you're thirty years old, is that correct? Patient: Yes doctor, that's correct. Doctor: Okay, and which hand is your dominant hand? Patient: I use my right hand for everything. Doctor: Now, take me through the timeline of your symptoms, please. When did everything start? Patient: I was doing well until July of nineteen ninety three. Doctor: What were your initial symptoms? Patient: I began having weakness in my right arm, and there was some neck pain too. Doctor: Okay, when these symptoms began, how did you manage them? Patient: At first, I went to a chiropractor, but after a while my arm started atrophying, and my right hand felt tight. I couldn't extend all my fingers out. Doctor: Once you noticed the atrophy and contractures, that's the tightness you were experiencing, how were you treated? Patient: After that, I went to a neurosurgeon close to my house, and he ordered an, um, C T scan of my neck. Doctor: Okay, do you have the report of that C T Scan with you today? Patient: Yes, doctor, I have it right here. They were one on the twenty fifth of September in ninety two. Doctor: Thank you, okay, this shows an intramedullary lesion at C two three, and an extramedullary lesion at C six seven. Patient: That means tumor, right? Doctor: Yes sir. Did you have neck surgery? Patient: Yeah, I have the op notes right here. Doctor: Okay, just so you know, you had a C six T one laminectomy, and they decompressed the spinal cord. How did you respond to this surgery? Patient: Well, honestly, I improved for about three months following the operation, but after that I just got worse and worse. Doctor: Once your symptoms worsened, what happened? Patient: Um, I started having this burning sensation on my left side. Doctor: Did you have any weakness, sir? Patient: Yeah, I had weakness in both my arms. Doctor: Was one side worse than the other? Patient: Yes, my right side was worse than my left. Doctor: In addition to the burning and weakness, did you have any other symptoms? Patient: Um, I had really bad balance, I felt nauseous, like I was going to throw up at all times, which I did do some, and, um, my heart was beating really fast, and my blood pressure went up really high. Doctor: After all these symptoms began, how were you treated? Patient: On, um, August thirty first nineteen ninety three I had an M R I of my neck, and I have that report right here, too. Doctor: Thank you, this shows diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. Patient: Sorry to interrupt, what does all that mean? Doctor: Well, that's more tumors in the spine. Did you have another surgery for this? Patient: Yeah, I had brain surgery. I have those notes right here, too. Doctor: Okay, so you had a suboccipital craniotomy with tumor excision, decompression, and biopsy. The biopsy showed hemangioblastoma. Patient: That's cancer, right? This was all done on September first of nineteen ninety three. Doctor: Well no, not exactly, it's a benign tumor. After this surgery how were your symptoms? Patient: I felt good, the doctors said I stabilized out. I went through some radiation procedures from September of ninety three to January nineteenth of ninety four. Doctor: How have your symptoms progressed since? Patient: I went to the NeuroOncology clinic on October twenty sixth nineteen ninety five because I was having weakness in both arms and both legs, as well as trouble swallowing food. Doctor: How much weakness was there? Patient: It was so bad I couldn't even put on a shirt, or raise my arms, or even feed myself. Doctor: Can you go up and down stairs? Patient: No, not really, but I can climb them. Doctor: How about going to the bathroom, is everything normal there? Patient: Yeah, no problems there. Doctor: Good, and what did the doctor at that clinic recommend? Patient: They were considering doing chemo.","Section header: GENHX Section text: This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94. He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention." "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: Only my elbow. Doctor: How long ago did this happen? Patient: About a week ago. Doctor: I see. Have you taken anything for it, such as Advil or Tylenol? Patient: No. I try to deal with the pain as best as I can before resorting to medicine.",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 nicotine patches because smoking brings with it many health problems. Patient: Tell me something I don't know. Doctor: I understand. How about any other drug use? Patient: I know you're not going to like hearing this, but I'm big on weed. I know, I know, I'm going to regret all of this at some point in time. It's just become a habit that's incredibly hard to break. Doctor: Okay. I'd rather you smoke weed than cigs. How many packs a year do you think you smoke on average? Patient: I go through a pack around every two weeks. Let's go with around twenty seven.",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? Patient: Yes. I have a two year old son. Doctor: Have you ever had any pregnancies? Including miscarriages or abortions. Patient: Yes. I had a miscarriage before my son was born. Doctor: I am so sorry to hear that. Patient: Thank you.","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 just couldn't stay back home and do nothing, so I just joined a private company and am working there part time. Doctor: Sounds great. Do you smoke or drink? Patient: No. Doctor: I am guessing no drugs either? Patient: Correct.",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 take a lot of prescription medication. Patient: Okay. Yes, that. Doctor: Thank you for that information. How long ago? Patient: I don't remember maybe more than twenty years.","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 sleeping? Patient: No. Doctor: Any palpitation, swelling or varicose veins or pain in your legs? Patient: No. Doctor: Any sore throat or cough or cough with mucous or blood sputum? Patient: I have this prolonged cough, but other than that nothing. Doctor: No wheezing? Patient: No, no wheezing. Doctor: Any heart burn, nausea or vomiting? Patient: No. Doctor: Loss of appetite or blood in stool or abdominal pain? Patient: No. Doctor: Constipation? Patient: No. Doctor: How is the color of your urine? Is it dark or cloudy? Patient: No. Doctor: Any pain while urinating or burning sensation? Patient: No. Doctor: Any flank or groin pain? Patient: No. Doctor: So, any joint pain, muscle stiffness or pain? Any backache? Ligament, tendon pain or strain? Patient: Nothing. Doctor: Did you experience any blackouts or seizures lately? Patient: No. Doctor: Any hallucinations or memory loss? Patient: No. Doctor: Any weakness? Numbness or tingling? Patient: No. Doctor: Tremors or loss of sensation like paralysis or- Patient: No. Doctor: Any anxiety, irritability, apathy or depression like feeling? Patient: No. Doctor: How is your sleep? Patient: It is fine. Doctor: And how is your appetite? Patient: It's good. Doctor: How is your mental state? Any suicidal thoughts crossing your mind? Patient: No, nothing like that. Doctor: Sorry, I have to ask these questions. Patient: It's okay. Doctor: Just a few more and we will be done. Patient: Sure. Doctor: Any unusual hair loss or hair or nail breakage? Patient: No. Doctor: Did you notice any skin lesion or discoloration? Patient: Nope. Doctor: Alright then.","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. RESPIRATORY: He has a chronic cough. Denies shortness of breath, wheezing, sputum production or bloody sputum. GI: Denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation. GU: Denies painful/burning urination, cloudy/dark urine, flank pain or groin pain. MS: Denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness. NEURO: Denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis. PSYCH: Denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts. INTEGUMENTARY: Denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration." "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 living? Patient: I am retired. I used to be an insurance salesman.",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 help. Doctor: What makes you think this, sir? Patient: Well, I did a quiz online on the Cialis website and I didn't score in the normal range, so I figured I would come in. Doctor: Is there anything else of note, sir? Patient: Well, there may be some decreased desire, but honestly, I don't think that's the main problem here. I'd like to have my erections last longer, doctor. Doctor: What was this quiz like? Patient: Well, on the quiz, I said that less than half of the time I'm able to get an erection and keep an erection after penetration. Doctor: Are you having difficulty maintaining an erection until completion? Patient: Well, I'd say there's slight difficulty. Doctor: Okay, do you have any significant medical conditions in the past that you have been treated for? Patient: No, not that I know of. Doctor: What about testicular infections? Patient: No, that sounds painful, but no. Doctor: Have you had any traumatic injuries to the groin? Patient: No, not that I can remember. Doctor: What about hernias? You can get them from playing sports or lifting weights. Have you ever had one of these? Patient: No, that doesn't sound familiar either.","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 did not score in the normal range, so he thought he should come in. Patient states that perhaps his desire has been slightly decreased, but that has not been the primary problem. In discussing with me directly, patient primarily expresses that he would like to have his erections last longer. However, looking at the quiz as he filled it out, he reported that much less than half the time was he able to get erections during sexual activity and only about half of the time he was able to maintain his erection after penetration. However, he only reports that it is slightly difficult to maintain the erection until completion of intercourse. Patient has no significant past medical history. He has never had any previous testicular infections. He denies any history of injuries to the groin and he has never been told that he has a hernia." "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 you both with your pain and nausea.",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, I just want you to continue Nexium forty M G once a day. Patient: I will do that.","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 concerning. Are you experiencing any nausea, vomiting, diarrhea, or abdominal pain? Patient: No. Doctor: How about chest pain, shortness of breath, cough, or heart racing? Patient: No. Doctor: Any neurological symptoms, such as numbness or tingling? Patient: No. Doctor: We'll get to the bottom of this. I'm waiting for your lab report to come back and then we can figure out the next steps.","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 stated in HPI." "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 noises, which really bothers me when I'm going up stairs. There's also some stiffness when I try to move them. Doctor: Were you previously a pretty active guy? Patient: I absolutely used to be, and had no problems, but now this pain is affecting my daily life and activities.","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 was happily married. But then my husband died. Doctor: Do you live alone or with family? Patient: I live alone. I do have family who lives very close by in the neighborhood. I have a niece who lives with her family in my house on Temple Street.","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 about the lungs, any history there? Patient: I know someone had C O P D. Doctor: Do you know of anyone with dementia or Alzheimer's? Patient: Yes, my uncle has dementia right now, actually. Doctor: I'm sorry to hear that, that's a hard disease to see your family go through. What about diabetes, does anyone have that? Patient: Thank you doctor, it's hard. Yes, my dad has the sugar.","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_family: Six months ago. Doctor: Any history of heart disease, diabetes, or stroke? Guest_family: No, but she's not able to control her bladder well which leads to her having frequent accidents. Oh and she's had back pain for several years along with degenerative changes to her spine. Poor thing. I can't help but feel so bad for her situation. It definitely hasn't been easy.","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. Before we begin I just want to confirm some information with you. Where is your primary residency? Patient: My mom can give you the address. I still live with her. Doctor: Thank you. One last question. Do you smoke? Patient: Nope. My Mother has forbidden smoking in her home.","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, she should have left me some notes, um, yep, these look good, I agree with all of this. This looks good. Patient: Thank you, Doctor.",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 accident was five years ago. Doctor: Which condition led to the disability? Patient: I don't know really. I sent in all the notes for my doctor for evaluation and they approved the disability. Doctor: Okay. Do you live alone or with family? Patient: I live with my wife. Doctor: Are you a smoke or have you ever been? Patient: I used to smoke. I quit years ago. Doctor: How long ago did you quit? Patient: Oh, about twenty years ago. Doctor: How many years did you smoke? And how much did you smoke? Patient: Probably twenty years. I was up to two packs a day. I feel way better now. Doctor: That's great. Any use of alcohol or illicit drugs? Patient: Nope. Doctor: What do you do for fun? Do you have any hobbies? Patient: I don't really do much these days. Work was my hobby. Doctor: Okay.","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 drug use. He lives with his wife. He does not really have any hobbies." "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 you're in for a follow up for your neck and back pain. Patient: Yessir. Doctor: Have you been going to pain management? Patient: Yeah, I go once every week or so. Doctor: How's your pain now? Patient: Manageable, I guess. Doctor: Is the pain still keeping you up at night? Patient: Not like it used to. Doctor: Good, great to hear.",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 side of the family but my dad did pass away from renal cancer. Doctor: I am so sorry for your loss. Patient: Thank you. Doctor: What about your mother or siblings? Do they have any health conditions? Patient: No. They don't have any health problems. That I know of.",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 husband and I were blessed with three wonderful children. Doctor: Fantastic, do they live at home? Patient: Nope, we got them all out of there. They're all grown now. Doctor: Do you drink or smoke? Patient: No, I never had either. Doctor: What about harder substances? Patient: No, absolutely not.","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 fever yesterday. Doctor: I see. What was his temperature? Guest_family: The thermometer was reading one hundred and one degrees Fahrenheit. Does he need to go to the hospital? Doctor: Let me evaluate and see what we can do for him today. Guest_family: Thank you, doctor. Doctor: I suspect that he has an upper respiratory infection, possible pertussis. Is he still experiencing apnea?","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 area, no evidence of herniation there.","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 your foster mom returns from her trip. Patient: Can my mom and grandmother come and visit me here on Thursday? That is the day they usually come to visit me at my foster home. Doctor: Yes. I think we can make some arrangements to make that happen.","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 Grandma do visit on Thursdays for about an hour." "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 children are all healthy with no medical problems.","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 people to share intimate details about their health to others, even when it comes to disclosing medical info to their own children. For now, I'll put unknown but please let me know if anything changes. Patient: Will do. Thanks for understanding. Doctor: Of course. It's not totally uncommon for people to not know their family history.",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 entry in our record is updated or not. Doctor: How old are you now? Patient: Twenty nine. Doctor: Where are you from originally? Patient: I'm from Vietnam. Doctor: I am seeing you today as a referral from A B C for reevaluation. Patient: Yes, for my hand eczema. Doctor: So, let's see what you have been treated with. Your record here says with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion. Does this sound right to you? Patient: Yes, that's correct. Doctor: Are you washing your hands in Cetaphil cleansing lotion? Patient: Yes, I'm doing all that. Doctor: What brings you here today? Patient: I'm having this flaring. My hands are all dry. I have these like cracks in my hands. I have been washing with the soap and the lotions that you prescribed, but still, it is happening. Maybe because of cracks or what, I don't know, but the Cetaphil cleansing lotion, whenever I'm applying that it is causing me a lot of burning pain. I have been wearing gloves though. Doctor: Are you married? Patient: Still, a single. I'm not even looking for a husband yet. Doctor: Are you working somewhere? Patient: Not currently.","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 moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed." "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 no hypertension or any kidney diseases? Patient: Nope. Doctor: Every been diagnosed with tuberculosis, asthma, or lung disease? Patient: No I have not.","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. Sometimes I feel hot even in a fully air conditioned room. Other times I just feel like opening the refrigerator and standing in front of it. Doctor: Any other symptoms? Patient: I am also experiencing a lot of mood swings for the last few weeks. Doctor: Based on all the symptoms my assessment would be mood swings along with postsurgical menopause. That would be the cause for your hot flashes.",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? Patient: No. Doctor: Any liver issues or jaundice? Patient: Um, no. Doctor: Okay.","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. Even though pot is legal here, I never ever felt like trying. Doctor: That's a good thing. Patient: Yeah.",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. Doctor: Oh, I am talking about the vein in your neck, it shows no bulging. No abnormal masses present. Can you turn your head from left to right and right to left, any pain in your neck or difficulty turning? Patient: No. Doctor: Can you rotate your head clockwise and anti clockwise. Patient: Sure. Doctor: Any pain? Patient: No. Doctor: Okay, let me just make a note here full range of motion with no pain.","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 changes. Check the chart, I answered that last time. Doctor: Great. Looks like drinking and smoking is off the menu. In regard to the mammogram, do you make sure to do self breast examinations? I believe I showed you how to do this last time. Patient: No, I do not. I don't see a point if I come and do the mammogram. Doctor: I highly suggest you start doing so. Sometimes people do not get mammograms for a few years and it is important to make sure nothing is growing. Patient: Yeah, I know. I am just lazy. Recently it has been hard to do a lot of my selfcare routines. I do not even exercise anymore.","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 alcohol." "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: I need to see what the problem is first.","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 started. Doctor: Fourteen, okay. Are you taking anything for it? Guest_family: Yeah, she is on medication. Doctor: Anybody else in the family have a similar problem? Guest_family: No, but her sixteen year old brother suffers from N S V T and he sees a specialist. Doctor: Okay, any other siblings or family members with medical conditions? Guest_family: Other kids in the family are doing fine, but her maternal grandma suffers from high blood pressure and diabetes. Doctor: Okay. Sorry but I must ask this, any recent death in the family in past one year child or adult? Guest_family: Thankfully no!","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 in the family who see a specialist or no child death less than 1 year of age." "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 go so they put it in. Doctor: Yes, it looks like five hundred M L came out. So possible urinary obstruction. Also, they started you on steroids and colchicine. How are you feeling now? Patient: I am feeling a little better, my pain is improving, and the swelling is getting better. Doctor: Okay that is good. Any fever and chills? Patient: No, no fever. Doctor: Any problem with urination like pain or frequency or blood in urine? Patient: No but I am not able to empty my bladder well, the pee has decreased a lot, I could not urinate. Doctor: Okay I will evaluate that. How about any cough, blood in sputum? Patient: No nothing like that. Doctor: Any chest pain, or difficulty breathing? Patient: No pain, I can breathe well. Doctor: Okay that sounds good.","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, and the pain is improving and the swelling is getting better. Denies any fever and chills. Denies any dysuria, frequency or hematuria. States that the urine output was decreased considerably, and she could not urinate. Denies any cough, hemoptysis or sputum production. Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea." "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 quite good.","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 was seeing at the time. A year before my diagnosis, I had a few falls and episodes of lightheadedness. I also noticed that I was staggering a lot more when walking. Doctor: Did you lose consciousness during any of your falls? Patient: Not that I know of. I had noticed that I was losing my normal voice to a degree. On top of losing my normal voice, my handwriting became smaller and smaller. I don't ever remember writing so small. Something seemed really off to me. Doctor: I'm sure that was difficult to experience. Patient: It was very difficult. Two months prior to being diagnosed, I started to move much slower than before. Doctor: By slower, do you mean the movements of your arms and legs were slower and impaired? Patient: Yes. I was prescribed Sinemet back in September of nineteen ninety five. Doctor: Did you notice any improvement while taking it? Patient: None. I was pretty disappointed and discouraged as a result. I have problems with coordination and walking without staggering even today. Doctor: Noting that it's February thirteenth nineteen ninety six. Patient: I felt weak in the morning and worse as the day went on. Doctor: Are you experiencing any other symptoms, such as stroke like events, vision changes, seizures, or problems with moving and coordinating your arms? Patient: No. Doctor: Any headache, nausea, vomiting, chills, or fever? Patient: No.","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 handwriting was becoming smaller and smaller. Two months prior to diagnosis, she began experienced bradykinesia, but denied any tremor. She noted no improvement on Sinemet, which was started in 9/95. At the time of presentation, 2/13/96, she continued to have problems with coordination and staggering gait. She felt weak in the morning and worse as the day progressed. She denied any fever, chills, nausea, vomiting, HA, change in vision, seizures or stroke like events, or problems with upper extremity coordination." "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 coughs. He had a bad coughing fit this morning. I got nervous and decided to bring him in. Doctor: During his coughing episode this morning, did you notice any loss of breath or gasping for air? Guest_family: No. Doctor: Has he had a runny nose? Guest_family: No. Doctor: Any fever? Guest_family: No. He has not been eating much. Doctor: Is anyone else in the household sick? Guest_family: No. Doctor: Is anyone in the household a smoker? Guest_family: No.",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 cigarette smoke exposure. She brought him to the emergency room this morning after a bad coughing spell. He did not have any apnea during this episode. "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've talked about before? Patient: No, they haven't helped at all. Doctor: I see, you'd be a good candidate for a knee replacement. Patient: What's the risk of infection from the surgery? Doctor: Historically, it's less than one percent, we use prophylactic antibiotics to control for infection the entire time. Patient: Great, and will I be asleep for this? Doctor: Yes, you won't feel a thing.",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: Oh, it's a long list. Here it is. Doctor: Thank you. Let me take a look. Looks like you have some general allergies and food allergies, loss of taste, problems with your G I tract, asthma, G E R D, and dry mouth or xerostomia. Patient: Yeah, that sounds about right. I think I forgot to add it, but I also have bad allergies during the spring time. Doctor: Oh, I see. I would describe that as environmental inhalant allergies.","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 chart for history and physical and review of systems and detailed medical history." "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 on hand in case my asthma gets outta control. Doctor: Is it up to date? Patient: You mean is it expired? No, I don't think so. It hasn't been long since I visited the pharmacy. Doctor: Good. I always like to advise my patients to check expiration dates.",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 exertion. At that time, we evaluated you and we realized that there was some evidence of irregular sleep and daytime fatigue. At that time you also complained of nighttime choking episodes which got less intense over the past many months. Patient: That's right. I was then scheduled for the overnight sleep study to be evaluated for interruptions in my sleep and here we are today to discuss results. Doctor: Sure. But first tell me, how is your sleeping routine like? Patient: It is consistent. I go to bed anytime between nine to ten at night and wake up in the morning around five to six. Doctor: Are you able to sleep as soon as you go to bed? Patient: No, it's hard for me to start that sleeping process and then I'm awake in like every one or two hours throughout the night. I keep on tossing and turning throughout the night. I always find my sheets out of order when I wake up. Doctor: How would you compare your sleep here in the lab and at your home? Patient: I would say I slept better in the laboratory than I do at home. Doctor: How do you feel when you wake up in the morning? Patient: Honestly, I feel tired. Sometimes I also have this dull headache. Doctor: Do you snore? Patient: I don't know for myself, but yeah, my daughter was teasing me another day that I was snoring and was talking in my sleep. Doctor: Did you ever feel that you have difficulty breathing while you are asleep? Patient: No. But I used to cough a lot in the middle of the night. Doctor: You said you used to, so it is not anymore? Patient: Yeah, I haven't been coughing for the last few weeks. Doctor: How's your daily routine? Do you nap in the daytime? Patient: I spent a lot of time reading and watching T V. Sometimes I doze off while doing that. Not regular, but I do take nap sometimes in between two to three in afternoon and also in the evening hours. Doctor: Do you smoke? Patient: Oh yes, I take around one to two packs of cigarettes each day mainly after dinner. Doctor: Have you noticed any change in your weight? Patient: My weight always keeps fluctuating. I remember I was at my maximum weight of two hundred and sixty pounds around one year ago. Doctor: If that was your maximum how is your weight now? Patient: Now it is down by approximately thirty pounds. Doctor: So, for your health care, you are coming here in the outpatient psychiatry and also going to your maintenance clinic, right? Patient: Yes, that's right. Doctor: Your current medications include Methadone, Trazodone, and Seroquel. Patient: That sounds right.","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 several months. In the meantime, she had been scheduled for an overnight sleep study performed to evaluate her for sleep apnea, returns today to review her study results. The patient's sleep patterns consist of going to bed between 9.00 and 10.00 p.m. and awakening in the morning between 5.00 and 6.00 a.m. She reports difficulty in initiating sleep and then recurrent awakenings every 1 to 2 hours throughout the night. She reports tossing and turning throughout the night and awakening with the sheets in disarray. She reports that her sleep was much better quality in the sleep laboratory as compared to home. When she awakens, she might have a dull headache and feels tired in the morning. Her daughter reports that she has heard the patient talking during sleep and snoring. There are no apneic episodes. The patient reports that she used to cough a lot in the middle of the night, but has no longer been doing so in recent weeks. During the daytime, the patient reports spending a lot of sedentary time reading and watching TV. She routinely dozes off during these sedentary activities. She also might nap between 2.00 and 3.00 p.m., and nods off in the evening hours. The patient smokes perhaps one to two packs of cigarettes per day, particularly after dinner. She reports that her weight has fluctuated and peaked at 260 pounds approximately 1 year ago. Since that time, her weight is down by approximately 30 pounds. The patient is managed in Outpatient Psychiatry and at her Maintenance Clinic. She takes methadone, trazodone, and Seroquel." "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: Okay. Doctor: And currently are you on any medications? Patient: Just Coumadin, for my chronic A Fib. I have been on it three years. Doctor: Yeah, atrial fibrillation. Patient: Yes.","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, thyroid problems, autoimmune disease, possible multiple sclerosis, and depression issues. Doctor: That is a lot. What is your medical history involving your parents? Patient: My dad died due to complications of his diabetes. He passed when he was sixty. My dad was a chef. My mom is doing well. She is ninety three. Both my parents never finished high school. My dad had a third grade education and my mom made it through fourth grade. She was a janitor. She was a smart woman she just never finished her schooling. My parents encouraged me to finish school and to go to college. I got my Bachelor of Science in Nursing at the State University in nineteen seventy nine. Doctor: Did you have any problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems? Patient: No. I mostly got A's and B's. My strongest subject was math, but my worst subject was spelling. My grades were still quite good in spelling, but I had to work hard at it. Doctor: Are you married? Patient: I was married for two years. We had two children together. They are forty three and thirty now. My son is the youngest, lives nearby and calls me or stops by every day. My daughter calls me often but she lives in New York. We are close. Their dad, my exhusband passed away in nineteen eighty. He was an alcoholic. His pancreas had enough and shut down. Doctor: I am so sorry. Patient: He did it to himself. Doctor: Are you working in health care with your nursing degree? Patient: I worked for Hospital Center for four years. Prior to that, I worked for an outpatient mental health center. I was there for about two and a years. I was fired or laid off I guess? I was not sure why they let me go. I was given no explanation. And before that, I worked for Walter P. Carter Center for twenty one years. I also worked as an O B nurse. Other than the two instances, I had never been fired or let go from a job. Doctor: What do you do in your spare time now? Patient: I enjoy reading, doing puzzles, playing computer games. I joined a women's support group for women my age. I keep myself, busy.","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. She reported that she has no cognitive problems at this time. Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression. The patient completed a Bachelor of Science in Nursing through State University in 1979. She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems. She was married for two years. Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse. She has two children ages 43 and 30. Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York. In school, the patient reported obtaining primarily A's and B's. She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling. The patient worked for Hospital Center for four years. Prior to that, she worked for an outpatient mental health center for 2-1/2 years. She was reportedly either terminated or laid off and was unsure of the reason for that. Prior to that, she worked for Walter P. Carter Center reportedly for 21 years. She has also worked as an OB nurse in the past. She reported that other than the two instances reported above, she had never been terminated or fired from a job. In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games." "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 that from the report. Guest_family: So, we're here for a second opinion on that. Doctor: Yes, we should do surgery on this knee. There's gross instability of the fragment, and we don't want that get worse. Guest_family: Okay, that's about what we've heard so far. What are the risks of infection of the procedure? Doctor: It's less than one percent. We use antibiotics to control for infection. Other risks include bleeding, changes in sensation of the limb, changes in motion, failure to relieve pain or restore the articular cartilage, the possible need for another procedure, and possible early arthritis. I would not worry, though. These things are rare. Guest_family: Okay, will he be asleep the entire time? Doctor: Yes, he won't feel a thing. Guest_family: Okay, my husband agrees. We want to do the surgery.","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 instability of the fragment. Risks and benefits of surgery were discussed. The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis. All questions were answered and parents agreed to the above plan." "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 here, and your last P P D was negative, but we'll do another one today. Patient: Okay, that's fine, doctor. Doctor: Have you been compliant with all of the medicine you've been prescribed? Patient: Yes, I've taken everything exactly as you told me to. Doctor: Good, do you remember when your last dentist appointment was? Patient: Yeah, it was in November of two thousand seven. Doctor: What did they do for you at your last visit? Patient: They pulled two teeth for me. Doctor: Good, and when was your last pap smear? Patient: It was about a year ago. Doctor: I assume it was negative? Patient: Yes, thankfully. Doctor: Have you had a mammogram yet? Patient: No, not yet. I'm not old enough. Doctor: Do you have a family history of breast cancer? Patient: No, I don't, at least not that I know of.","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. Last dental exam was in 11/07, where she had 2 teeth extracted. Last Pap smear was 1 year ago was negative. The patient has not had mammogram yet, as she is not of the age where she would start screening mammogram. She has no family history of breast cancer." "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 how old are you? Patient: That's true. I'm just teasing you. I'm fifty one. Doctor: Are you right handed or left handed? Patient: I am right handed. Doctor: So, you said that your legs suddenly gave out. What happened exactly? Was it sudden? Or were you noticing some weakness before as well? Patient: Oh, I noticed weakness in my right leg before as well and sometimes, like, I have to give the support of my arm to actually move it. Sometimes during these episodes I just turn pale and it's like overall weakness. I feel so tired. My husband, he gives me some sugar, three teaspoons, and then it helps a little bit but not completely. Doctor: So, is your weakness like overall in your legs or it is at any single point? Patient: It's overall. I remember in one of these episodes I was, like, in an odd fisted posture. Doctor: Is there any change in your sensations? Like if I touch you, is it like same before or was there any change? Patient: No, nothing like that. Doctor: Is there change in vision? Are you seeing double? Patient: Nope. Doctor: Any difficulty in swallowing or eating? Any loss of consciousness? Patient: Nope. Doctor: Any difficulty in speech? Slurring, or anything like that? Patient: No. Doctor: You said that these episodes have been happening for some time, so did you see anyone for those before? Patient: Nope. It's just that I fall and then fell again last night. I was feeling so weak. Nothing was helping me. That's when, in the morning, my husband brought me to the U I H C hospital for the evaluation on the fifth.","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 husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an ""odd fisted posture."" She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93." "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 a brain hemorrhage. He was only forty nine. Doctor: Your family had been through a lot of loss. Patient: Yes, we have. Doctor: Do you have any siblings that are still living? Patient: I have another sister. Oh yeah. She is a diabetic. Doctor: Do you have kids? Patient: Yes, I have daughter. The only health problem she has is high cholesterol. Doctor: Do you know of anyone else in the family with neurological disorders? Patient: No. I don't think so.",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 hypercholesterolemia. He is unaware of any family members with neurological disorders. "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. Doctor: How have you managed this bunion so far? Patient: I got some wider shoes, and it's done absolutely nothing. Doctor: I see. Patient: Is there surgery or something we can do? I can't take the pain.",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 gear without long-term relief of symptoms and desires surgical treatment. "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 last time as well. I'm just here to understand if diet can help me with my gestational diabetes. Doctor: Sure. Patient: My Gynecologist was saying something about ketones, I don't know what they are. She asked me to talk about them with you. Doctor: Sure, I will explain everything to you. We also have a pamphlet to explain it. Here have a look. You can take it with you. Patient: Thank you. Doctor: Are you exercising? Patient: I walk everyday with my daughter. I go to drop her to school and then back home. Doctor: How long is the walk to school? Patient: It takes around twenty minutes on one side. So, everyday it is like forty minutes in the morning and same in the evening around four. Doctor: Do you drink milk? Patient: I try to, I know it is a good source of calcium and is very essential especially with my pregnancy, but I am not a big fan of drinking milk.","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 daughter to school and back home each day which takes 20 minutes each way. She is not a big milk drinker, but she does try to drink some." "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 and dog. My wife and I've been together for thirty some years now. Doctor: That's so wonderful to hear.",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. Patient: Yeah, I've been working really hard, but I haven't been able to get the weight down any further so far. Doctor: What has been your lowest weight? Patient: My lowest? That was one hundred thirty six. I'm just as frustrated as you are, doctor. Doctor: Well, if this plateau continues, we should discontinue the phentermine. Patient: Why is that? Doctor: It shouldn't be used to maintain your weight, but only to get the weight down. So, if it's not serving that purpose, we shouldn't use it. There's no real benefit there. Patient: Okay, yes, I agree.","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 farther down than she had when her lowest level was 136. She is frustrated with this as well. We agree that if she continues to plateau she really should not stay on phentermine. We would not want her to take it to maintain her weight but only to help her get her weight down, and she may have really lost any benefit from it, and she agrees. c" "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? Patient: No, my family moved to the eastern side of the Germany which was occupied by Russia at that time, but I decided to move to America in nineteen fifty seven. Patient: I had a high school degree from Germany, and I could speak German and English fluently. Patient: As soon as I landed here in America, I started working. I started as a secretary at a private firm and later did clerical work at I B M. Now I am retired for almost twenty years due to my cancer complications. Doctor: Your Mesothelioma? Patient: Yeah. Doctor: Okay, and who all are there in your family? Patient: Well currently I am alone without any companion. I am divorced. I have a son who lives in Santa Cruz he has grand children, but I have not seen them, I am trying to get in touch with them. I want to see my grandkids. Patient: Other than him I have a brother and a sister both are healthy and living their life we don't talk much. Doctor: Okay. Doctor: And do you drink or smoke? Patient: Hm, nothing significant. Doctor: Any funny drugs like heroine or coke? Patient: No. Doctor: Okay.","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 secretary and later worked as a clerical worker at IBM. She stopped working more than 20 years ago due to complications from her mesothelioma. She denies any significant tobacco, alcohol or illicit drugs. She is bilingual speaking, German and English. She has known English from before her teens. She has the equivalent of a high school education in Germany. She has one brother and one sister, both of whom are healthy and she does not spend much time communicating with them. She has one son who lives in Santa Cruz. He has grandchildren. She is trying to contact with her grandchildren." "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: Oh um it's at a five at the moment. Doctor: Have you been taking your diabetes medication? Patient: Micronase? Doctor: Yes. Patient: Yeah, I've been taking it every day. Doctor: Great. Okay, let's try to get to the bottom of this stomach pain.",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: Does diabetes or high blood pressure run- Patient: In the family? No, but heart disease does.","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 again? Patient: I am forty eight.",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 your temperature when you came in? Patient: Yes, she did. Doctor: Have you been experiencing cold like symptoms, such as cough, nasal congestion, headache, or nausea? Patient: Um no not really. Doctor: Have you tried taking any medicine to help with the fever? Patient: Yeah. I've taken Tylenol and that's helped a bit. Doctor: Have you had recent sick contacts? Patient: I don't think so. I live with three other roommates and they seem fine.",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 complications. Patient: Me too.",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 looks like your family is positive for atopy. Patient: Oh, yeah. We all usually get some type of rash. Doctor: I see. Do you know if you have psoriasis? Patient: Uh. What's that's? Doctor: It's a skin disease that usually has scaly patches. Patient: Uhm. I don't think so. Doctor: Great. Before I prescribe you medicine to treat your eczema, are you allergic to any drugs? Patient: Not that I know of.",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? Patient: I would say I am a good eater and follow a healthy diet plan. Doctor: Do you exercise? Patient: I walk every day around five miles. Also, I'm very regular in my sprint training.","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 did you experience any chest pain or shortness of breath? Patient: No. Doctor: Any feelings of abnormal heart rhythm? Patient: No. Doctor: Do you have any history of any cardiac problems? Patient: No. Doctor: How are you feeling now? Patient: I feel fine. Doctor: Do you know how old you are? Patient: I am sixty nine.","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 pain or shortness of breath. No palpitation. Presently, he is comfortable, lying in the bed. As per the patient, no prior cardiac history." "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. Doctor: Okay so mostly in the medial part. Tell me do you feel any weakness? Patient: No, but I do feel this tingling sensation kind of like numbness in my left hand, and it gets worse at night after doing repetitive work. Doctor: Are you left handed? Patient: No, I'm right handed Doctor: Hm, any neck pain? Patient: Not really, nothing substantial. Doctor: Can you please tell me your age again? Patient: I am fifty two. Doctor: Did you ever have these kind of signs and symptoms in the past? Patient: Nope! Doctor: Okay and are you taking anything for pain? Patient: Ah yes, I am taking Lyrica. Doctor: Lyrica okay and is it helping? Patient: Yes, somewhat. Doctor: Any problem in walking or change in how you walk? Patient: No. Doctor: And you are having regular bowel movements any changes? Patient: Yes, no changes. Doctor: How about urine, any burning or difficulty peeing? Patient: No, it's all fine. Doctor: Okay good. So, the neurological exam we did earlier, I have the results for it. Patient: And? Doctor: Well, you were tested positive for Phalen's test on your left hand. Patient: What does that means? Doctor: It means that you have something called Carpal tunnel syndrome, which explains your numbness and tingling sensation in your left hand. It also explains your pain in the middle part of your hand as it's caused due to pinching or compression of a nerve called median nerve. Patient: Oh, how did that happen? Doctor: Well, it's possible that your repetitive hand motion could have caused it or sometimes it's just the anatomy of your wrist. Patient: Oh, that explains my increased pain in the night after work. Doctor: Yeah. Patient: Anything else came in the neuro test? Doctor: No, rest of your neurological exam was normal. Patient: Okay. I am worried now. Doctor: Don't worry we are here. Patient: Thank you!","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 significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past. She is on Lyrica for the pain, which has been somewhat successful. Examination reveals positive Phalen's test on the left. Remainder of her neurological examination is normal." "Doctor: Have we gone over your survey results from your last visit? Patient: No, do you have those results with you right now? Doctor: Yes, I do, they show that you have anxiety disorder. Patient: That makes sense, thank you for sharing that with me.",Section header: PASTMEDICALHX Section text: Significant for anxiety disorder. "Doctor: I see here that you've been having some chest pain. Where along the chest? Patient: It's mostly on the left side. Doctor: When did it start? Patient: Um a few days ago. Doctor: How'd you describe the pain? Patient: Kinda dull. Doctor: Any other symptoms with the pain, such as shortness of breath? Patient: Not really, no. Doctor: How long does the pain usually last? Patient: For a few minutes. It comes and goes. Doctor: Have you taken anything for the pain? Patient: I've taken some Advil, but it doesn't seem to help. Doctor: Have you had similar pain in the past? Patient: No, I don't think so. Doctor: And you had surgery on your abdomen five days ago, correct? Patient: Yes. Do you think the pain is related? Doctor: I'd like to run some tests and get you in for a CAT scan to see what's going on.","Section header: CC Section text: For evaluation of left-sided chest pain, 5 days post abdominal surgery." "Doctor: It looks like he has a history of high blood pressure, high cholesterol, and Afib. Guest_clinician: Does he see a cardiologist for his Afib? Doctor: Not according to his chart. I'll see if I can call his emergency contact to confirm. Guest_clinician: Okay. Keep me posted.","Section header: PASTMEDICALHX Section text: Per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia." "Doctor: Do you smoke or drink alcohol? Patient: No, I do not smoke or drink alcohol. Doctor: How about drugs? Patient: Nope, I have never. Doctor: Who do you live with? Patient: Just my family.",Section header: FAM/SOCHX Section text: The patient is a nonsmoker. Denies any alcohol or illicit drug use. The patient does live with his family. "Doctor: How old are you now? Patient: I am sixty five. My kids just through me a surprise birthday party last week. Doctor: Oh wow! That is so nice. Happy belated birthday. Patient: It was nice. Doctor: It looks like you are here today for a recheck for the prostatitis. Patient: Yeah. Doctor: I see you have been followed by Doctor Mathis. Patient: Yes. Doctor: How often do you see him? Patient: He has me coming in about every three or four months. Doctor: Excellent. And the last time I saw you was in May two thousand and four. Patient: Has it been that long? Doctor: Yeah, it has. Okay. You are here to discuss some libido problems? Patient: Sadly, yes. Doctor: How long have you been having these difficulties? Patient: I noticed the change when I started taking the Proscar. Doctor: That is a common side effect that some men experience from Proscar. Have you tried any medication to help bring back your libido? Patient: I take Viagra sometimes. Doctor: Does it help at all? Patient: There is some improvement. Doctor: How many times a night do you get up to relive yourself now? Patient: I still get up about three to four times. Doctor: Okay, so still often. Patient: Yes, but I have not had any U T Is since I have been on the Proscar. Doctor: That is good news.",Section header: GENHX Section text: The patient is a 65-year-old man with chronic prostatitis who returns for recheck. He follow with Dr. XYZ about every three to four months. His last appointment was in May 2004. Has had decreased libido since he has been on Proscar. He had tried Viagra with some improvement. He has not had any urinary tract infection since he has been on Proscar. Has nocturia x 3 to 4. "Doctor: Are you married, sir? Patient: Yes, I am, Doctor: Doctor: Is this your only marriage? Patient: Well, no. I've been married three times now. Doctor: If you don't mind my asking, how long was your longest marriage? Patient: I don't mind at all, my longest was two years. Doctor: Do you have any children, sir? Patient: Yes, I have two. Doctor: How old are they, sir? Patient: They're both fifteen, they're twins, obviously. They're my wife's dependents, though. Doctor: Okay, thank you. Did you go to college, sir? Patient: Yeah, I have my bachelor's. I got the military to pay for it. Doctor: How long were you in the military? Patient: I did six years, sir. I was honorably discharged. Doctor: Where are you working currently. Patient: I've worked at Purdy Correctional Institute, you know, the one in Gig Harbor? I've worked there for nineteen years.",Section header: FAM/SOCHX Section text: Marital Status and Dependents: The patient has been married three times; longest marriage is of two years duration. He has two children. These dependents are ages 15 and twins and are his wife's dependents. Education: The patient has bachelor's degree. Military History: He served six years in the army and received an honorable discharge. Work History: He has worked at Purdy Correctional Institute in Gig Harbor for 19 years. "Doctor: So, looks like you have stones in your C B D. I am not hundred percent sure but most likely its stones. Patient: C B D? Doctor: Yeah, short for common bile duct. It's a small tube like structure which connects your liver duct and gallbladder. Patient: Oh! Doctor: Yeah, and because of that you have inflammation in your gallbladder. Patient: Oh, I see.","Section header: ASSESSMENT Section text: Choledocholithiasis, ? cholecystitis." "Guest_clinician: Has he had a blood transfusion in the past? Doctor: No, this is his first one. Guest_clinician: Okay, got it.",Section header: CC Section text: I needed a blood transfusion. "Doctor: Can you tell me more about your son, please? Guest_family: Sure, he's ten years old now. Doctor: How long has he used his walker? Guest_family: Well, he's been using that since he started walking. Doctor: How old was he when he started walking? Guest_family: He was about a year old. Doctor: Good, what seems to be the problem today? Guest_family: He keeps complaining about the back of his legs being tight. Doctor: Can you sit on the table, young man? Yes, I'm bending his legs, we call this the popliteal angle, and both sides flex to only about twenty. Guest_family: Where should that be normally? Doctor: He should be able to get to ninety. Guest_family: What can we do about this? Doctor: I think we should do surgery on this leg. How does he walk? Can I see? Guest_family: Well, just look at him. Doctor: Yes, he does not walk with a crouched pattern, but he is toe walking. Guest_family: Can we correct that instead of the hamstring tightness? Doctor: Well, I believe he should have surgery on the hamstring, as well. Guest_family: Okay, right now we want to do surgery to fix his walking. What are the risks of infection? Doctor: They're low, historically, they're less than one percent. The risks include anesthesia, infection, bleeding, changes in sensation and the motion of walking, and it may also not always cure the toe walking. There is also possible stiffness after wearing the cast and other cast issues. Guest_family: Okay, and will be under anesthesia during this? Is this worth it? Doctor: Absolutely, he won't feel a thing. It is worth it because the chances of the risks happening are low. Guest_family: Yes, we'd like to do the procedure. Let me text my husband really quick. Okay, yes, my husband agrees.","Section header: GENHX Section text: The patient is a 10-year-old boy who has been a toe walker since he started ambulating at about a year. The patient had some mild hamstring tightness with his popliteal angle of approximately 20 degrees bilaterally. He does not walk with a crouched gait but does toe walk. Given his tightness, surgery versus observation was recommended to the family. Family however wanted to correct his toe walking. Surgery was then discussed. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to resolve toe walking, possible stiffness, cast, and cast problems. All questions were answered and parents agreed to above surgical plan." "Doctor: Did you ever have any reaction to any medication given? Any known allergies? Patient: No. Doctor: Was there any swelling where your lymphnodes are? Patient: No. Doctor: Was there ever any complaint of abnormal lymph nodes? Patient: No.","Section header: ROS Section text: LYMPH: No history of systemic allergy, abnormal lymph nodes or swelling." "Doctor: Do you have anyone with psychiatric symptoms in the family? Patient: No, I don't have family! Doctor: What do you mean? Patient: My mom dad died and I was raised in the Philippines. Doctor: Adopted? Patient: No by myself. Doctor: Wow that must have been tough. Patient: Oh it's a story for another day.",Section header: FAM/SOCHX Section text: Listed as unknown in the chart as far as other psychiatric illnesses. The patient himself states that his parents are deceased and that he raised himself in the Philippines. "Doctor: Do you have any chronic conditions I should know about, sir? Patient: No, not that I can think of. Doctor: What about injuries, have you ever broken a bone? Patient: Yes, I have. I've broken my hand and tibia before.",Section header: PASTMEDICALHX Section text: The patient has no significant past medical history with the exception of previous hand fracture and tibia fracture. "Doctor: Welcome to the clinic. Patient: Thank you. Doctor: Do you have any family history of cancer? Either solid tumors or blood malignancies? Patient: No. None that I know of.",Section header: FAM/SOCHX Section text: There is no history of solid tumor or hematologic malignancies in his family. "Doctor: Can you tell me what surgeries have you had in the past? Patient: I have had appendix surgery when I was twenty one years old and eight years back I had C Section. Doctor: Okay. I want to know how many pregnancies you had and how many babies? Patient: Sure, I have only two. Doctor: Okay. Do you have any issues with your periods? Patient: Yes, I get heavy periods because of fibroids in my uterus. Doctor: Oh. When was your last menstrual period? Patient: Oh, you can say about three weeks back. Doctor: Okay. Good.",Section header: PASTSURGICAL Section text: Appendectomy at age 21. C-Section 8 years ago. Ob/Gyn: G2P2; last menstrual period 3 weeks ago. Heavy menses due to fibroids. "Doctor: Hello, sir. Before we begin your visit, could you verify your age and ethnicity for me, please? Patient: I'm forty nine years old, and I identify as white. Doctor: Thank you. What brought you in today? Patient: I was referred to you so that I could get whatever's wrong with me under control. Doctor: I see. What seems to be happening? Patient: I hurt the back of my leg pretty bad this past year when I was in A B C D. Doctor: What part of your leg? Patient: The back of my left thigh. Doctor: I see. So just the leg? Patient: I also hurt my kneecap from a boat when I was out in the water fishing. Doctor: Was that severe? Patient: It was a whole show. A helicopter came down and swooped me to X Y Z Hospital, where I got surgery. Doctor: I can see you still have an external fixation on your knee so that the fracture heals. Did the hospital give you a report on the surgery? Patient: Yeah, they did. Here you go. Doctor: Thank you. Let me take a look. So, it looks like you underwent grafting and full thickness skin grafting for closure for a large defect in your left posterior thigh. That seems to be healed in the gluteal fold on the left area. Patient: Yeah. Whatever that means. Doctor: Let me examine the area. Patient: Go for it. Doctor: I can see several areas that have hypergranulation tissues around the graft site and low in the leg. Patient: Is that bad? Doctor: I don't think so. Are you feeling any symptoms of a fever or anything? Patient: No, I'm not. Doctor: That's good. You don't have any infections then.","Section header: GENHX Section text: This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive surgery. He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. He has some drainage from these areas. There are no signs and symptoms of infection. He is referred to us to help him get those areas under control." "Doctor: And are you working? Patient: Ah yes, I am a painter. Doctor: Okay good. Doctor: Do you smoke? Patient: Yes, I do. Doctor: Hm and how much do you smoke? Patient: Well, about two packs a day. Doctor: And how about alcohol, do you drink? Patient: No sir, I don't drink. Doctor: Any drugs? Patient: You mean like cocaine and stuff? Doctor: Yeah. Patient: No, no drugs.",Section header: FAM/SOCHX Section text: He does smoke two packs of cigarettes per day. He has no alcohol or drug use. He is a painter. "Doctor: Welcome to the clinic, ma'am. I am Doctor Smith. Patient: Thank you. It is nice to meet you. Doctor: Doctor X referred you to us, is that correct? Patient: Yes. He is my primary care doctor. Doctor: It looks like you have a birthday coming up. Happy early birthday! Patient: Thank you. Yes, I am going to be seventy seven. Doctor: Doctor Kim's notes said that you have had pain in the left flank pain. Can you tell me more about the pain? Patient: Yes. The pain started four or five days ago. It has been in my stomach and through to my back, on the left side. Right here. Doctor: Okay. Have you had any nausea or vomiting? Patient: Yes. I had some nausea, and I threw up a few times. Doctor: Have you noticed any blood, pain and or burning during urination? Patient: No. Doctor: Any fever or chills? Patient: No. Doctor: I have the ultrasound results that Doctor X ordered the other day. The ultrasound found a stone in your left ureteral. The stone is about one point three C M in size. Patient: Is there some thing we can do to remove it? I really want this taken care of. Doctor: Yes. Let us go over the treatment options.","Section header: GENHX Section text: The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain. The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history. The patient has had pain in the abdomen and across the back for the last four to five days. The patient has some nausea and vomiting. The patient wants something done for the stone. The patient denies any hematuria, dysuria, burning or pain. The patient denies any fevers." "Doctor: Good afternoon, ma'am. You're forty one years old, correct? Patient: Good afternoon, doctor. Yes, that's correct. Doctor: Thank you, have you followed up with Doctor X since your surgery? Patient: Why would I do that? Doctor: Oh, just because she referred you to me. Patient: Oh, no, I haven't yet. Doctor: That's fine. Have you heard the details behind your surgery? Patient: I heard it once, but I can't remember anything. Can you remind me? Doctor: Well, you had a complicated case, but we did an anterior cervical discectomy, two level corpectomy, with a spinal decompression and fusion with fibular strut and machine allograft in your large cervical plate. Patient: Oh, that's a lot, doctor. Doctor: Yes, how are you doing today? Patient: Well, I've felt good for the last two days. Doctor: Have you been able to move your arms and legs for the last few days? Patient: Yeah, I can actually move all four. Doctor: Good, are you having any issues breathing? Patient: No, nothing of note there. Doctor: Okay, today, I think you'd be a good candidate for a halo vest placement. Patient: Yeah, doctor, I'm not going back to the O R. Doctor: Okay, we can do it here. Patient: Okay doctor, I'd like to do it here. Doctor: Let me get A B C to help me with this. Also, we're going to move you to S I C U room one. Patient: Can you tell me the details about what you're going to do? Doctor: Well, this is a P M T halo, I like this one better than the Bremer halo vest, and I'll use morphine and Versed. Patient: Are you going to use anesthesia? Doctor: Yes, I have local anesthetic, it's xylocaine and epinephrine, um, it's somewhere between fifteen and twenty C C.","Section header: GENHX Section text: The patient is a 41-year-old female who presented to me with severe cervical spondylosis and myelopathy. She was referred to me by Dr. X. The patient underwent a complicated anterior cervical discectomy, 2-level corpectomy, spinal cord decompression and fusion with fibular strut and machine allograft in the large cervical plate. Surgery had gone well, and the patient has done well in the last 2 days. She is neurologically improved and is moving all four extremities. No airway issues. It was felt that the patient was now a candidate for a halo vest placement given that chance of going to the OR were much smaller. She was consented for the procedure, and I sought the help of ABC and felt that a PMT halo would be preferable to a Bremer halo vest. The patient had this procedure done at the bedside, in the SICU room #1. I used a combination of some morphine 1 mg and Versed 2 mg for this procedure. I also used local anesthetic, with 1% Xylocaine and epinephrine a total of 15 to 20 cc." "Doctor: Is everything fine? Guest_family: My mom is not well. Doctor: When did this start? Guest_family: I don't know but she is not in her correct state of mind. Doctor: Okay let's see what we can do, how old is she? Guest_family: She is around seventy four years old. Doctor: Okay. Don't worry, we will see what we can do. Guest_family: Thanks! Doctor: Of Course.",Section header: CC Section text: A 74-year-old female patient admitted here with altered mental status. "Doctor: Welcome in, sir. Patient: Thank you. Doctor: Let us start off with a little background. Patient: Okay. Doctor: What is your current living status? Do you live with others or on your own? Patient: Well, right now I am living with my sister in Sacaton. I am currently looking for my own place, but I am staying with her for now. Doctor: Are you looking for a place in Sacaton? Patient: No. I will probably look for a place back in Coolidge. Doctor: Back in Coolidge? Have you lived there before? Patient: I recently separated from my wife. We lived in Coolidge together. Sacaton is too far away from everything, but it is fine for now. Doctor: I am so sorry to hear that. Patient: Thank you. My sister has been a saint. I am not working right now so my sister is letting me stay with her for free. She gave up her home office and made me a nice room to stay in. Doctor: Your sister is very generous. Are you and your sister close? Patient: Not when we were growing up but now that we are older, we have become very close. She has been a great support for me in these hard times. Doctor: That's wonderful. Are you a tobacco user? Patient: I smoke cigarettes. I only smoke a little bit. Doctor: How much do you smoke per day? Patient: I only smoke about one or two cigarettes a day. Doctor: Do you or have you ever used drugs or alcohol? Patient: I have never used drugs. I used to be a heavy drinker. I quit drinking a year ago. Doctor: That's great. Do you attend A A meetings? Patient: No, but I might start. Things have been very stressful lately with the separation and being on unemployment. Doctor: I think it could be beneficial to you. Patient: Okay. Doctor: I have a list for different support groups in the area that I can give you. Patient: Great. Thank you.","Section header: FAM/SOCHX Section text: He lives in Sacaton with his sister. He is separated from his wife who lives in Coolidge. He smokes one or two cigarettes a day. Denies drug abuse. He used to be a heavy drinker, quit alcohol one year ago and does not work currently." "Doctor: How are you feeling after that insulin drip, Miss A B C? Patient: I am feeling much better. My sugar levels are normal. Doctor: Yes, between one hundred fifteen and one thirty four. So, on the second day after your admission they did laparoscopic removal of your gallstones. You were very difficult to intubate. But everything went well with surgery. There was some swelling and adhesions around your gallbladder, but all is well that ends well. Patient: What was my blood sugar during surgery? Doctor: Great question. After surgery they were around two thirty three. Patient: I am getting a special insulin? Doctor: Yes, sliding scale insulin. Patient: Can I go home? Doctor: Yes, you are all set to go home, everything is stable.","Section header: EDCOURSE Section text: Ms. ABC was admitted to the hospital. She was seen by Dr. A. He put her on an insulin drip. Her sugars slowly did come down to normal down to between 115 and 134. On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy. She was noted to be a difficult intubation for the procedure. There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder. She underwent the procedure. She tolerated without difficulty. She was recovered in the Postoperative Care Unit and then returned to the floor. Her blood sugar postprocedure was noted to be 233. She was started back on a sliding scale insulin. She continued to do well and was felt to be stable for discharge following the procedure." "Doctor: Good morning, ma'am. Patient: Good morning, doctor. Doctor: Welcome to A B C D General Hospital. My nurse says that you are forty one years old, and you identify as a White female, is that correct? Patient: Yes, that's all correct. Doctor: Thank you, so, what seems to be the trouble today? Patient: Well, I'm having some pain in this foot, it's right over this bone. Doctor: Is your pain right here? Patient: Yes, it really hurts right there. Doctor: Okay, this is known as your navicular bone. What makes the pain worse? Patient: Usually wearing shoes makes it worse. Doctor: Do you have any past history of problems with this foot? Patient: Well, I have a history of multiple osteochondromas. Doctor: Do they know what caused these? Patient: No, no one ever figured it out, they just said it was hereditary. Doctor: Have they done surgery on these in the past? Patient: Yeah, I had a surgery for this a while ago. Doctor: Have you ever had this problem in your feet or spine? Patient: No, this is new. Can we do that surgery again? I can't take this pain.",Section header: GENHX Section text: This 41-year-old Caucasian female who presents to ABCD General Hospital. The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin. She states that she has been diagnosed with hereditary osteochondromas. She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back. The patient desires surgical treatment at this time. "Doctor: On April twenty two four we went over your list of medication and allergies. Patient: Okay. Doctor: Let me check something. Patient: Sure.",Section header: PASTSURGICAL Section text: As listed on 04/22/04 along with allergies 04/22/04. "Doctor: How's the low fat and low cholesterol diet going? Have you been finding it manageable? Patient: Yeah, I guess. I've tried to also reduce my salt intake to about two grams.","Section header: PLAN Section text: 2 g sodium, low fat, low cholesterol diet." "Doctor: Hello. Before we begin your visit, could I ask a few questions to fill in some missing information? Patient: Yeah, that's fine. Doctor: Does your family have any health related problems? Patient: Yeah, we do. We have a strong history of heart disease. I think it could be because we drink a lot. Doctor: So, would you say alcoholism runs in your family? Patient: Oh, yeah. We drink a lot every day. Beer, liquor, you name it.",Section header: FAM/SOCHX Section text: Strong for heart disease and alcoholism. "Doctor: Are you working these days? Patient: No, sir. I've been retired for a couple years now. Doctor: Congratulations. I hope you're enjoying your time off. Patient: You bet. Doctor: You mentioned having a smoking history. When did you quit and approximately how much did you smoke? Patient: Uh I quit about twenty seven years ago. If I had to guess, I smoked about two packs a day. Doctor: Did you smoke only cigarettes? Patient: Cigars, too. Doctor: How about alcohol? Patient: Hardly ever. Doctor: Great.","Section header: FAM/SOCHX Section text: The patient stopped smoking 27 years ago, he smoked approximately two packs a day with combined cigarettes and cigars. He has not smoked for the past 27 years. He hardly ever uses alcohol. He is currently retired." "Doctor: Good morning, sir, welcome to A B C D General Hospital. Patient: Thank you, doctor. I hope you can fix me up quickly. Doctor: We'll do our best. Um, before we begin, I just need some background information. So, how old are you? Patient: I'm forty seven years old. Doctor: Good, and what race do you identify with? Patient: I identify as white, sir. Doctor: Thank you, so, what seems to be the problem today? Patient: Well, I have this, um, mass of my left foot, it's been getting worse too. Doctor: I see it. How long has this tissue mass been there on that foot? Patient: It's been about two weeks now, but it's getting worse way faster now. Doctor: Do you have any history of cancer? Patient: No, but I've had an, um, shave biopsy in the past. Doctor: I see. Patient: Is there any surgery we can do for this to cut it off? I really want it gone.",Section header: GENHX Section text: This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot. The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size. The patient also has history of shave biopsy in the past. The patient does state that he desires surgical excision at this time. "Doctor: What do you do for a living? Patient: Actually, I'm retired now, but I was an engineer, and I did some real estate brokering as well on the side. Doctor: Wow, that's a lot. Congratulations on your retirement! Patient: Thank you, now I get to spend more time with my wife. Doctor: Wonderful, do you have any children? Patient: Yes, five in total, it's a full house. Doctor: Fantastic, do you drink or smoke? Patient: I don't smoke, but I drink a little. Doctor: How many drinks would you say you have a week? Patient: Um, I'd say up to three drinks a week. Doctor: Okay, and is there any history of drug or illicit substance abuse, sir? Patient: No, never anything like that.",Section header: FAM/SOCHX Section text: The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse. "Doctor: As per your chart I am going to put some of the following things in your diagnosis. Patient: Yes, I have diabetes, hypertension and gallstones. Doctor: Yes I can see that in your chart over here. Patient: What are the new things? Doctor: We now have added hyperglycemia and obstructive sleep apnea.","Section header: DIAGNOSIS Section text: Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis." "Doctor: Do you smoke? Patient: Nope. I quit like fifteen years ago.",Section header: FAM/SOCHX Section text: Quit smoking 15 years ago. "Doctor: Do you have any orthopedic conditions that run in your family that I should know about? Patient: What, like arthritis? Doctor: Yeah, does anything like that sound familiar? Patient: No, not that I know of.",Section header: FAM/SOCHX Section text: Noncontributory. "Guest_clinician: Hi there! Welcome to the clinic. Patient: Hi! Thank you. Guest_clinician: I'm going to get a little background information from you today. Patient: Okay. Guest_clinician: What are any of your medical history conditions? Past and present? Patient: I have Crohn's disease. Guest_clinician: How long have you had Crohn's? Patient: Oh, I don't know. A long time twenty five to thirty years. Guest_clinician: Have you had a colonoscopy recently? Patient: I had one, four years ago. Do I need to get another one this year? Guest_clinician: I am not sure. I will ask the doctor what his recommendation is for you would be. I will let him know that you had a colonoscopy four years ago. Patient: Sounds good. I am also a diabetic. That has been going on for four years now. Guest_clinician: Yes, I see you take insulin. I also see that you're on a blood pressure medication, do you have high blood pressure? Patient: Yes, I have high blood pressure and high cholesterol. I also have heart disease. I had a stent placed in there. Guest_clinician: Anything else? Patient: I have arthritis now. They said it's due to my Crohn's. Guest_clinician: That makes sense. Patient: I'm being treated for depression now as well. Guest_clinician: Okay. Any other surgeries other than the stent? Patient: Oh, I had a kidney stone removed several years ago. Twenty five years ago. That's it. That's all I got for you. Guest_clinician: Okay, great! Thank you. I will go let the doctor know that you are ready and she will be right in to see you. Patient: I'll be here.","Section header: PASTMEDICALHX Section text: He has had diabetes for five years. He also has had hypercholesterolemia. He has had Crohn's disease for 25 or 30 years. He has had a colostomy for four years. He has arthritis, which is reportedly related to the Crohn's disease. He has hypertension and coronary artery disease and is status post stent placement. He has depression. He had a kidney stone removed about 25 years ago." "Doctor: Any sugar or B P problem? Patient: No, it is normal. Doctor: Okay, how about thyroid or any other hormone related problem? Patient: No, everything is fine. Doctor: Cholesterol? Patient: No cholesterol problem.","Section header: ROS Section text: ENDOCRINE: Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones." "Guest_clinician: What's her diagnosis? Doctor: Refractory anemia. Guest_clinician: Gotcha.",Section header: DIAGNOSIS Section text: Refractory anemia that is transfusion dependent. "Doctor: Do you have patient's family history? Guest_clinician: At this point of time, we don't have it. Doctor: Hm, okay.",Section header: FAM/SOCHX Section text: Unknown. "Doctor: Hello, miss. How can I help you today? The nurse said the matter was urgent. Patient: Yes, I have been having dizzy spells. I have also noticed a new rash on my right calf. Doctor: Can you describe what type of dizzy spells you are having? What do they feel like? Patient: It is general dizziness and vertigo. I am also lightheaded during the spells. Doctor: Are you feeling okay right now or are you experiencing symptoms? Patient: I am having headaches off and on randomly, but nothing right now. The neck pain and muscle aches also are intermittent. Doctor: Let me take a look at the rash on your legs. Are the bruises new? Patient: They are new, I think. I have noticed them more than usual. Doctor: In the past couple days have you had a fever or chills? Patient: No, nothing like that. Doctor: What about chest pains? Patient: I have had some tightness in my chest, but not right now. Doctor: Does the dizziness make you nauseous? Patient: Yes, but I have not had to throw up or anything. Doctor: What about diarrhea? Patient: No, thank goodness. Doctor: Are there any parts of your body that are hurting? Patient: I do have some left shoulder pain. Not so much painful, but it is uncomfortable and tender. Doctor: Have you measured your blood sugar at all? I ask because the notes state there is a history of gestational diabetes and when blood sugars are out of the normal limits this can cause some of the symptoms you are having. Patient: I measured it today. After lunch it was one fifty five.","Section header: GENHX Section text: The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf. She describes her dizziness as both vertigo and lightheadedness. She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias. She has noticed a few more bruises on her legs. No fever or chills with slight cough. She has had more chest pains but not at present. She does have a little bit of nausea but no vomiting or diarrhea. She complains of some left shoulder tenderness and discomfort. She reports her blood sugar today after lunch was 155." "Doctor: Does anyone in your family have or have history of any colon cancer or unusual polyps? Patient: No. Doctor: Any other family history? Patient: Yes, my father died of a cancer called mesothelioma and my mother died of Hodgkin's Lymphoma.","Section header: FAM/SOCHX Section text: Negative for any colon cancer or polyps. Her father died of mesothelioma, mother died of Hodgkin lymphoma." "Doctor: Any known medical history in the family? Patient: Nope. Doctor: How about anyone with high blood pressure or heart disease or diabetes in the family? Patient: Nope.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: How are you feeling today? Patient: I am feeling very tired. Doctor: According to your chart, you have seen with us for three separate self harm attempts. Have you had any other self harm events that you have not come to see use for? Patient: No. I have been seeing Doctor Lin. Doctor: I also see that this is your third time in the last two months that you have attempted to harm yourself. Is there anything that is currently going on in your life that could be triggering these resent episode? Patient: Last month I lost my job. And then this month my boyfriend left me. Doctor: I am so sorry. That is a lot to deal with. Patient: Yeah, it has been hard. Doctor: Have you been diagnosed with any mental health conditions? Patient: Doctor Lin just said that I was depressed. Doctor: Have you ever been put on any medication for the for your depression? Patient: I have taken Lexapro before. Doctor: How long ago did you take the Lexapro? Patient: I can't remember. Doctor: Okay.","Section header: GENHX Section text: As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X. She has a remote history of being on Lexapro for depression." "Doctor: Do you have any drug allergies? Patient: No. None that I know of.",Section header: ALLERGY Section text: No known drug allergies. "Doctor: So, if you see here Doctor Patrick there are multiple areas with hypergranulation tissue on the left leg posteriorly and I get a sense that it's associated with the trauma to the back of his right leg. Guest_clinician: Yeah, I agree.",Section header: ASSESSMENT Section text: Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg. "Doctor: How're you today? Patient: Not too bad. I'm hanging in there. My asthma has been acting up. Doctor: Oh no. How long has this been going on? Patient: For the past three months. I've been using my inhaler every day. I used to use it every now and again. This is definitely new for me. Doctor: Are you experiencing any allergies alongside your asthma? Patient: Yes, actually. My husband has been hauling a lot more corn this season and it seems to be making my allergies much worse. Doctor: Do you take anything for your allergies? Patient: Not really. I'll sometimes take Allegra and that seems to help just a tiny bit. I was previously prescribed Flonase, but I can't remember the last time I took it. Oh and I was on Advair, too. Doctor: Did the Flonase or Advair help at all? Patient: I had to stop Advair because it started to bother my lady parts. Doctor: How so? Patient: I noticed that it became more itchy as a result. Doctor: I'm sorry to hear that. Patient: Speaking of this, I wanted to also share that I've been experiencing a lot of P M S symptoms lately. I'm super impatient and moody. Doctor: Do you notice these symptoms are still there after you finish your cycle? Patient: Um lemme think. The symptoms start about a week before my period and tend to get less intense once I get over the first day of bleeding. Doctor: Are your cycles generally regular? Patient: For the most part, yes. I feel like they don't last as long as they used to. I'm not sure why. I do, however, notice some spotting after my cycles end. Doctor: Do you get any night sweats or hot flashes while you're on your period? Patient: No. Doctor: Have you had any other medical troubles recently? Patient: I did have a U T I and some blood in my urine because of it. Doctor: Do you remember how many times you noticed blood in your urine? Patient: Hm about three times. I was prescribed antibiotics for it. Doctor: Have you had any other urinary symptoms since? How about bdominal pain, nausea, vomiting, or anything of the like? Patient: Nothing now. Doctor: Have you gotten your urine rechecked recently? Patient: No, not yet. I really should get it checked out again. Doctor: I can write an order for you if you'd like or you can make an appointment with your urologist. Do you have a specific urologist that you see? Patient: Yeah, I can call to make the appointment tomorrow. Do I also need to get blood work done? Doctor: Yes, in fact I'd like to order some blood work while you're here. Patient: I had blood work done a few days ago for my life insurance application. I am forty two so thought I should get that going. My Swedish mother always used to nag about how I procrastinate on important things. Anyways, do I still need to get more blood work done? Doctor: Do you know what they checked? Patient: I think the typical blood work with cholesterol added. Doctor: Do you happen to have a copy on hand or could you fax me the resulxts? Patient: I can fax them to you once I get them back. Doctor: That would be great. Thank you. Let me write down our fax number for you.","Section header: GENHX Section text: 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 aggravate things. She has not been taking Allegra daily but when she does take it, it seems to help somewhat. She has not been taking her Flonase which has helped her in the past. She also notes that in the past she was on Advair but she got some vaginal irritation with that. She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle. She has been more impatient around that time. Says otherwise her mood is normal during the rest of the month. It usually is worse the week before her cycle and improves the day her menstrual cycle starts. Menses have been regular but somewhat shorter than in the past. Occasionally she will get some spotting after her cycles. She denies any hot flashes or night sweats with this. In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously. Her urine has not been rechecked. She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available." "Doctor: Okay, so your psych evaluation came out unremarkable. Do you have any other problems? Patient: I have this acne. I hate it. I am not feeling comfortable in my own skin.",Section header: PASTMEDICALHX Section text: Acne. Psychiatric history is unremarkable. "Doctor: Hello there, how are you? Guest_family: I am little scared. Doctor: I understand, so how old is she? Guest_family: She is ten days old today. Doctor: And just wanted to confirm the ethnicity is Caucasian, right? Guest_family: Yes. Doctor: Okay, so tell me what's going on with her? Guest_family: I was feeding her and then I suddenly noticed this unusual jerky movement in both her arms and legs. Guest_family: It lasted about a minute. Doctor: When did you first notice it? Guest_family: The first day when I was feeding her, she was barely a day old. Doctor: Okay, and how many times till now? Guest_family: About six times. Doctor: Did you notice any interrupted breathing or bluish color around her mouth? Guest_family: No. Doctor: While the episode occurs do you notice any color changes in the baby? Guest_family: No. Doctor: Did you happened to notice any arching of the back or eyes rolling back? Guest_family: No, it usually happens while she is sleeping, so I didn't notice her eye movements. But I am able to wake her up and stop the hand and leg movements. Doctor: Okay. Otherwise, is she feeding well and is active? Guest_family: Yes, absolutely! Although she falls asleep a lot during breast feeding but other than that everything is fine. Doctor: And how often are you feeding her and for how long? Guest_family: I breast feed her every two to three hours for about fifteen to twenty minutes. Doctor: Okay, and how many dirty diapers? Guest_family: Well, her pee diapers have increased to up to eight and I would say about six to seven poopy diapers a day. Doctor: And did you notice the color of her poop? Guest_family: Yeah, it's like dirty yellowish color. Doctor: Okay.","Section header: GENHX Section text: The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These movements are without any back arching. They mainly occur during sleep, so mom is unaware of any eye rolling. Mom is able to wake the patient up during this periods and stop the patient's extremity movements. Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast. She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours. She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day." "Doctor: Has anyone in your family had heart diseases? Patient: Yes my father. They did his heart bypass surgery when he was sixty. Doctor: Is he alright now? Patient: Yes I know what you mean. Patient: Yes by God's grace, both my parents are alive. Doctor: What exactly was the heart disease named? Do you know? Patient: Yeah they said it was something called coronary artery disease and he had many strokes due to that. Doctor: How old is he now? Patient: My father is in his eighties. My mother is eighty years old too and she has dementia. My father has dementia too. Doctor: Okay. Do you smoke or drink alcohol? And how much? Patient: No I do not drink or smoke.","Section header: FAM/SOCHX Section text: Strongly positive for heart disease in his father. He had a bypass at age 60. Both parents are alive. Both have dementia. His father has history of coronary artery disease and multiple vascular strokes. He is in his 80s. His mother is 80, also with dementia. The patient does not smoke or drink." "Doctor: Are you on steroids? Patient: No. Doctor: Any history of cancer, chemotherapy or anything related? Patient: No.","Section header: ROS Section text: IMMUNOLOGIC: Negative; Negative for steroids, chemotherapy, or cancer." "Doctor: How have you both been doing? Guest_family: We are good. Doctor: I see she has been gaining weight since she has been home. Have you been following the meal plan that we discussed? Guest_family: Yes. It has been helping. Doctor: Great!",Section header: DISPOSITION Section text: Stable disposition to home with her mother. "Guest_clinician: I don't see any past medical history here in this report. Doctor: We don't have any record of P M H for this patient. Guest_clinician: Okay.",Section header: PASTMEDICALHX Section text: None. "Doctor: Oh, dear God! What happened? Guest_family: Hi Doctor, I am his mom. Doctor: Hello, so what happened? Guest_family: He was trying to climb a tree, slipped from there and got a deep cut on his thigh. Doctor: So, you fell from the tree? Patient: Yes.",Section header: CC Section text: Fall and laceration. "Doctor: What is up with your teeth man? It's been giving you problems huh? Patient: Yes, yes, many, many problems. Firstly, they pulled out so many teeth and now I have this bad tooth problem. Doctor: Oh, so this is new? Patient: Yes, it's a new pain. Right now it has been going on for three days on left side's upper and lower teeth. Doctor: Then why didn't you go and visit your regular dentist? Patient: I would have but I have missed so many appointments that they now do not allow me to schedule regular appointments. So they put me on a standby appointment now. Doctor: Oh I am sorry. Patient: It is okay. Doctor: Okay any other problems or any other complaints? Patient: No. Doctor: How about any recent illnesses or injuries? Patient: No, no illness whatsoever. Doctor: Do you have any medicine at home for pain? Patient: Yes I have OxyContin and Vicodin at home. I use it for my knee pain. But I want more pain medicines. I do not want to use up that medicine for my toothache. Doctor: Okay I understand. How old are you again? Patient: I am twenty nine.","Section header: GENHX Section text: This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled. Complains of new tooth pain. The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days. The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only. The patient denies any other problems or complaints. The patient denies any recent illness or injuries. The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me." "Doctor: How's your jaw doing? Patient: The pain seems to have gotten worse. Doctor: Do you mind if I take a look? Patient: Sure. Ow, ow, ow. That's the spot that hurts the most. What's causing it? Doctor: It's hard to say, but I'm thinking it could be T M J. I'd like to get you in to see a T M J specialist.",Section header: CC Section text: Jaw pain. "Doctor: Are you taking Citalopram for depression? Patient: Yes, I take it once a day. Patient: It is ten M G tablet. Doctor: Is that so? Patient: Yes. Doctor: What do you take for pain? Patient: Just Tramadol as needed.",Section header: MEDICATIONS Section text: Citalopram 10mg once daily for depression; low dose tramadol PRN pain. "Doctor: What is your family health history? Patient: My mom and dad are both diabetics. My mom has high blood pressure. My brother is having some issues with his liver.",Section header: FAM/SOCHX Section text: Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented). "Doctor: Can you tell me about your family? Patient: I have or had two sons both born normally without any complications. Doctor: Why did you say had? Patient: One of my sons was a heavy smoker, he uses to smoke a whole packet or more in a day. We tried everything possible, but he just couldn't quit. He died of clots. Doctor: Does anyone in your family like parents or siblings had any medical issues? Patient: Yes, my father had heart related issues, he died in his sixties, my mother died of colon cancer. I also have a sister but I don't think she has any issues.",Section header: FAM/SOCHX Section text: Her father died with heart disease in his 60s and her mother died of colon cancer. She has a sister who she believes is probably healthy. She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy. She has two normal vaginal deliveries. "Doctor: Do you smoke cigarettes? Patient: Yes. Doctor: How about alcohol? Patient: No, I don't consume alcohol. Doctor: Okay. And any history of using drugs like marijuana or stuff like that for fun? Patient: No.",Section header: FAM/SOCHX Section text: Active smoker. Does not consume alcohol. No history of recreational drug use. "Doctor: Are you married, sir? Patient: No divorced. I live a lone. Doctor: What work do you do? Patient: I am a retired postal worker. Doctor: Do you have kids? Patient: Yes, I have three of my own and seven grandkids. Doctor: Do you smoke cigarettes? Patient: Yes I do. Doctor: How much and what kind? Patient: I keep changing the brands but Newport, one pack a day. Doctor: Okay. How about alcohol or drugs like substance abuse? Patient: No drugs but I drink occasionally depending on the company. Doctor: How long have you smoked? Patient: Thirty years now.","Section header: FAM/SOCHX Section text: Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren. He smokes 1 pack a day of Newport for 30 years and is a social drinker. He denies any illicit drug use." "Doctor: Hello! How are you doing? Patient: Hello Doctor! I am good. Patient: I am here today for my follow-up, as suggested. Doctor: Has it been a month already? Patient: Yes, seeing you after a month.",Section header: CC Section text: One-month followup. "Doctor: Do you have any allergies? Patient: I am allergic to IV contrast. Doctor: Are you sure? Patient: Yes.",Section header: ALLERGY Section text: IV contrast. "Doctor: Just to debrief, we will rule out angina related heart problems while evaluating your jaw pain. Patient: Oh can that be related to each other? Doctor: Yes they might be. Patient: What else? Doctor: Pardon? Patient: I am asking anything else? Doctor: We have discussed this before, but keep track of your high cholesterol and hypothyroid.","Section header: ASSESSMENT Section text: 1. Jaw pain, sounds musculoskeletal. We will rule out angina equivalent. 2. Hypercholesterolemia. 3. Hypothyroidism." "Doctor: Hello, sir. How are you feeling today? Patient: Very itchy. I just keep scratching myself. Doctor: Oh, wow. I can see the rashes all over your arms. Are there rashes anywhere else? Patient: Yeah, it's all over my back and stomach. Doctor: I see it on your torso. When did this all start? Patient: I woke up this morning and started itching my back. After a few minutes, I noticed the rash was on my arms, chest, back, and stomach areas. Doctor: I'm going to take a look at the rashes and the rest of your body. Patient: Sounds good. Doctor: It looks like your face and lips are not swollen. Could you say ah for me? Patient: Ah. Doctor: It looks like your tongue isn't swollen either. Patient: That's good to hear. Doctor: Have you been feeling a shortness of breath, wheezing, or other related symptoms? Patient: Not that I know of. Doctor: Sounds good. I wonder why this happened. Did you do anything the night before? Patient: Uh. A few days ago, I was working and had to remove some insulation. Other than that, I don't know what else could have given me these rashes. Doctor: I see. Do you remember being itchy after that? Did you try any new foods? Patient: Nope I was not itchy. Also, my diet has been the same. Doctor: Are you taking any new medications? Patient: I haven't. Doctor: You don't recall being exposed to any other substances? Patient: Not that I know of.","Section header: GENHX Section text: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheezing, or other associated symptoms. He cannot think of anything that could have triggered this off. There have been no changes in his foods, medications, or other exposures as far as he knows. He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day." "Doctor: Do you have any family medical history of migraines? Patient: I know that my brother has them too. Mom, do you know if anyone else gets them? Guest_family: Your grandfather had migraines. Doctor: Okay.",Section header: FAM/SOCHX Section text: There is a history of migraine in the family. The condition affects the patient's brother and maternal grandfather. "Doctor: What do you do for work? Patient: I am retired now. I was a school teacher. Doctor: Are you a smoker? Patient: Yes. Doctor: How much do you smoke per day? Patient: I would say about a half to a full pack a day. Doctor: How long have you been a smoker. Patient: Probably sixty years.",Section header: FAM/SOCHX Section text: retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years. "Doctor: Are you allergic to anything? Patient: No, I am not. Doctor: Are you sure? Penicillin or sulfa? Patient: Nope nothing. Doctor: That's good.",Section header: ALLERGY Section text: Denies any drug allergies "Doctor: Hi there, sir! How are you doing today? Patient: I feel out of it. Doctor: Have you been using any substances? Patient: I did a little heroin and some coke earlier today. I still feel high. Doctor: Okay. Any shortness of breath, chest pain, abdominal pain or back pain? Patient: No. Doctor: Are you having any headaches, hallucinations or visual disturbances? Patient: No. Doctor: Do you have any open sores or wounds? Patient: No.","Section header: ROS Section text: The patient states that he did use heroin as well as cocaine earlier today and feels under the influence. Denies any headache or visual complaints. No hallucinations. No chest pain, shortness of breath, abdominal pain or back pain. Denies any abscesses." "Doctor: Have you had any surgical procedures done? Patient: Yes, in fact I had a hysterectomy back in March of ninety nine. I believe it was done on the twentieth of the month. Doctor: Got it.",Section header: PASTSURGICAL Section text: Hysterectomy (3/20/99). "Patient: You know Doctor, I am widowed for eighteen years now. Never remarried, I live by myself in my house. Doctor: Oh okay, are your still working? Patient: No, I use to run a restaurant, but now retired. Doctor: Hm. And you smoke cigarettes? Patient: No, I don't! Never liked the smell. Doctor: How about alcohol? Patient: No, I don't drink either.",Section header: FAM/SOCHX Section text: She is a nonsmoker and nondrinker. She has been widowed for 18 years. She lives alone at home. She is retired from running a restaurant. "Doctor: How old are you, sir? Patient: I'm sixty five years old. Doctor: Are you right handed or left handed? Patient: I'm right handed. Doctor: When was your last stroke? Patient: Well, it was on January seventeenth. I had these episodes where I was like always so confused and looks like I lost everything. All my memory and everything. And then they did a scan. It was verified that I was having a stroke on the same day. Doctor: Did they put you on some medications? Patient: They gave me an anticonvulsant and aspirin. Doctor: Are you taking them regularly? Patient: There have a few times like one or two days that I forgot to take my, uh, dyphenhydramine, but even when I'm taking it regularly, I'm still having all those symptoms or forgetfulness, confusion, and everything. Doctor: Do you feel anything else along with these episodes like a urine urgency, tendency to bite your tongue, headaches, any visual change, or your heart is beating very fast? Any kind of weakness or numbness or shortness of breath? Patient: No nothing else, just the confusion and forgetfulness. Doctor: How frequent are these episodes? Patient: Well, they occur like two or three times in a week. Each one of the episodes lasts for like one or two minutes.","Section header: GENHX Section text: This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The ""stroke"" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week." "Doctor: Any medical disorders in the family? Patient: Yeah, my father had a special kind of tumor, which doctors said is very rare. Doctor: Do you know the name of the tumor? Patient: I don't remember the exact name of the disease, but it was a big name and it started with something with V.",Section header: FAM/SOCHX Section text: Father with Von Hippel-Lindau Disease. "Doctor: Do you have any major medical conditions that I should know about? Patient: Actually, I have a whole list of conditions. I have them written down here. Doctor: Thank you, so I see congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, and a history of paroxysmal atrial fibrillation. Oh, and azotemia. Patient: Yes, I told you I have a lot going on. Doctor: Are you taking any medications? Patient: Well, they wanted me to take Coumadin but I had, um, a subdural hematoma so they would let me. Doctor: I see, what about any neurological or psychological conditions? Patient: Well, I have depression, and I've had panic attacks while taking Doxepin before. Doctor: I see here that you also have perioperative anemia, does that sound familiar? Patient: Yes, another doctor told me about that. Doctor: Do you have any other symptoms you'd like to report today? Patient: Um, I'm having some difficulty swallowing.","Section header: PASTMEDICALHX Section text: Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation. Remote history of subdural hematoma precluding the use of Coumadin. History of depression, panic attacks on Doxepin. Perioperative anemia. Swallowing difficulties." "Doctor: Doctor Shami, can you please take down the notes as I examine the patient? Guest_clinician: Sure. Doctor: Can you put the heading as cervical lymph nodes. Guest_clinician: Okay. Doctor: I am going to check for any swelling in your neck okay? Can you look down? Patient: Okay. Doctor: Alright, I do not feel anything here. Can you look up? Patient: Sure. Doctor: No palpable nodes here. None of the lymph nodes are enlarged or have any swellings. Guest_clinician: So, no lymph adenopathy? Doctor: Yeah.",Section header: EXAM Section text: LYMPH: Cervical lymph nodes. No lymphadenopathy. "Doctor: You have chronic pain? Patient: Yes I do. Doctor: You use tobacco also? Patient: Yes. Doctor: And you have a history of hepatitis C, right? Patient: That sounds right. Doctor: Okay. Patient: Yeah.",Section header: DIAGNOSIS Section text: 1. Chronic pain. 2. Tobacco use. 3. History of hepatitis C. "Doctor: Have you had any surgeries in the past? Patient: No, none.",Section header: PASTSURGICAL Section text: None. "Doctor: Do you live close to the office, or did you have to drive a long way here? Patient: I live right around here, I'm a local girl. Doctor: Good, are you working right now? Patient: Yes, doctor, I work full time. Doctor: That's good, sometimes it's nice to stay busy. Is there any history of drug or alcohol abuse I should know about? Patient: No, absolutely not, doctor.",Section header: FAM/SOCHX Section text: The patient lives here locally. She does not report any significant alcohol or illicit drug use. She works full time. "Doctor: How are you, Mary? Patient: I am okay, I have got this ulcer on my right hip again. Doctor: Oh, is it like the one you got last time? Patient: Pretty much. Doctor: Oh, I remember that one. It took almost three treatment cycles to get resolved. Patient: Yeah. They keep saying I have some hidden split in my spine still. Doctor: Yeah, it looks like you have residual spina bifida. Patient: I am just so frustrated sitting in my wheelchair. I am spending around sixteen hours a day in this wheelchair. Doctor: I think, that is the reason you developed this pressure ulcer. It appears to be on the right trochanter area. In simple terms you have developed a pressure sore on the outer part of your hip. Patient: Yeah, I recently celebrated my thirtieth birthday just sitting in my wheelchair the whole day. Doctor: Oh, I am sorry dear. So, how long since you have had this ulcer? Patient: It's been several weeks, so I thought I should get it checked. Doctor: Yeah, good thing you came. We need to treat it. Did you experience any chills or fever? Patient: No. Doctor: Any other symptoms? Patient: No.","Section header: GENHX Section text: This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida, thus spending most of her time in a wheelchair. She relates recently she has been spending up to 16 hours a day in a wheelchair. She has developed a pressure decubitus on her right trochanter ischial area of several weeks' duration. She is now presenting for evaluation and management of same. Denies any chills or fever, any other symptoms." "Doctor: Do you have any history of heart disease that you know of? Patient: Nope, nothing like that. Doctor: How about diabetes? Patient: No, there's no sugar here that I know of. Doctor: Good, and how about your lungs? Do they work well. Patient: Absolutely, they're in great shape. There's nothing like that here.","Section header: PASTMEDICALHX Section text: Denies diabetes, cardiovascular disease, or pulmonary disease." "Doctor: How about allergies to medications? Patient: Nope.",Section header: ALLERGY Section text: No known drug allergies. "Doctor: Your chest x ray showed diffuse pulmonary edema. This means that you have fluid in your lungs. That would explain your chest pain and the difficulies with your breathing. I would like to start you off with a course of antibiotics to prevent any possible infection. I will also send in a prescription for Furosemide. It will reduce the fluid accumulation in your lungs. Do you have any questions? Patient: When should I start to feel better? Doctor: You should start to feel better within three to five days.",Section header: IMAGING Section text: Chest x-ray revealed a diffuse pulmonary edema. "Doctor: Any headaches? Patient: No. Doctor: Any history of seizures or epilepsy? Patient: No. Doctor: Any sudden loss of consciousness or have you blacked out? Patient: Um, no. Doctor: Any weakness? Feeling any tremors in your body? Patient: No, nothing like that. Doctor: Any history of stroke or any brain related condition? Patient: No, no such history.","Section header: ROS Section text: NEUROLOGIC: Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor. No history of strokes, no history of other neurologic conditions." "Doctor: Are there any known disease running in your family? Patient: My dad has high blood pressure, and he takes medication for it. He is now eighty two years old. He had a stroke around two years ago. This was his second stroke. First one he had when he was forty five. Doctor: What about your mom? How old is she? Patient: My mom is eighty years old. She does have sugar issues.",Section header: FAM/SOCHX Section text: Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80. "Doctor: Are you currently living alone? Patient: Yep. Just me, myself, and I. Doctor: What do you do for a living? Patient: I've been working as a plumber for the last five years. Doctor: Nice. Where do you work? Patient: Mostly in the city. Doctor: Do you drink, smoke, or do injection drugs? Patient: I drink and smoke here and there, but I've never tried hard drugs. Doctor: Any recent travel? Patient: I was in Mexico earlier this year. Doctor: That sounds nice. How was your trip? Patient: Relaxing. Much needed. Doctor: Great to hear. I have a few more questions I need to ask so bear with me. How is your sexual history? Are you sexually active? Patient: I'm sexually active with women, but my sex life isn't as good as it was in Japan. Over there, I would mix and mingle with prostitutes. Doctor: Did you use protection? Patient: I don't really remember. Doctor: Have you been tested for S T D's? Patient: Yep. I'm negative for right now. Doctor: Have you ever been incarcerated? Patient: Nope. Doctor: One last question. Have you ever been in need of a blood transfusion? Patient: No, thank God.",Section header: FAM/SOCHX Section text: Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico . "Doctor: Good afternoon, champ, how you holding up? Patient: Good afternoon, Doctor, I have a lot of lower back pain. Doctor: Oh no, before we begin, how old are you, sir and which hand do you write with? Patient: I'm seventy five now. Right. Doctor: Great, so tell me, how long have you had this lower back pain? Patient: It's been about ten days now. Doctor: Have your symptoms improved at all since they began? Patient: No, they keep getting worse. Doctor: Does the pain radiate into your legs? Patient: Yes, it started radiating down my right leg three days after the lower back pain began, and then the left leg three days after the right. The next day I could barely walk, the pain was so severe. Doctor: Do you remember the initial date of the beginning of your low back pain? Patient: Um, it was on December third nineteen ninety five. Doctor: Have you seen another doctor for this pain? Patient: Yes, I saw my local physician, um, it was on December eleventh, but he wasn't able to pinpoint what was going on. Doctor: What kind of treatments did he recommend? Patient: He gave me some antiinflammatories and sent me on my way. Doctor: Did you drive yourself? Patient: Yes, I did. Doctor: How did the antiinflammatories work? Patient: Um, by the time I got home, I could hardly walk due to the back pain, and I had weakness in my legs. I was, however, able to feed my dogs, and I fixed myself some dinner. Doctor: Was there any leg numbness? Patient: Yes. Since December eleventh. Doctor: Have you seen an orthopedist for this pain? Patient: Yes, I saw one the day after my primary care physician, but my legs gave out and I fell while walking to my car because of the leg weakness and back pain. Doctor: What kind of imaging studies did that orthopedist do? Patient: He did a C T and x rays of my lower back, but he didn't see anything wrong. He recommended I follow up at U I H C. The imaging was on my L S Spine.","Section header: GENHX Section text: This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were ""negative."" He was then referred to UIHC." "Doctor: Alright. So this is going to be a complex case. Your wound is complicated by methicillin-resistant staphylococcus aureus cellulitis. Patient: Is there a treatment for my right leg? Doctor: There is. It will be more aggressive, but we can do it.",Section header: DIAGNOSIS Section text: Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis. "Doctor: What is going on with him? Guest_family: He is complaining of chest pain.",Section header: CC Section text: Chest pain. "Doctor: Good morning, young man. You're a patient of Doctor X Y Z, correct? Patient: Yes sir, that's right. I've seen him for years. Doctor: I just need to confirm some demographic information before we get started today. So, you're a twenty nine year old white male, correct? Patient: Yes, doctor. That's all right. Doctor: Great, thank you. So, what seems to be the problem today? Patient: Well, I got stung by a Yellow Jacket Wasp yesterday. Doctor: Do you have a lot of swelling? Patient: Yes, it's in my right hand and right arm. Doctor: Have you every been stung by wasps before? Patient: Yeah, this wouldn't be the first time. Doctor: Have you had similar reactions before? Patient: Yeah, I have. I have had one severe reaction. I came because I wanted to make sure it didn't get to that point again. I've never had, um, anaphylaxis, nothing super serious to date. Doctor: Okay, that's good. Do you have any shortness of breath or difficulty with your throat? Patient: No, it's never felt like it was going to close up or anything like that. Doctor: Do you have any rapid heartbeat or anxiety? Patient: No, I don't have anything like that either. Doctor: So, it's just the localized swelling where you got stung? Patient: Yes, that's really all, doctor.","Section header: GENHX Section text: He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm. He says that he has been stung by wasps before and had similar reactions. He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past. He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs." "Doctor: When was your last menstrual period? Patient: Um, it was around June third of two thousand nine. Doctor: Okay so it says you have had an abortion recently? Patient: Yes I have, but I am not sure if it is finished, because I am still bleeding. Doctor: Okay. Patient: Do you want me to do a pregnancy test? Doctor: No I would have you see our Gynecology and Obstetrician. Patient: Okay.","Section header: GYNHX Section text: Her last menstrual period was 6/3/2009. The patient is admitting to having a recent abortion done. She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN." "Guest_family: My nipples are cracked, and they are bleeding. Doctor: Oh, I am so sorry to hear that. Guest_family: He has some fluid coming out of his belly button as well as his penis. Doctor: Okay I will look at it. But other than that, everything else looks good? Any other problems related to circumcision? Guest_family: No, no other issues.","Section header: ROS Section text: Mom's nipples are currently cracked and bleeding. Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area. He is status post a circumcision. Otherwise, review of systems is negative." "Doctor: Welcome to the clinic, Miss A. Patient: Thank you. Doctor: Let's start with your medical history. What medical conditions do you have? Patient: Okay. I have high blood pressure, asthma and sleep apnea. I had blood clots in my left leg about six months ago. I also have cancer. Doctor: What kind of cancer do you have? Patient: I have stomach cancer. They also did a total abdominal hysterectomy. Doctor: Did they put you on an anticoagulant medication for the blood clotting? Patient: Yes. I took it for six months. I stopped taking it and then I had the stroke. Doctor: Have you had any other surgeries? Patient: Yes. I had a colonic resection to remove benign polyps. I had another benign lump removed from my breast. Doctor: How are you feeling today? Patient: I am still having weakness in my left leg. That is why I still have to us my walker, but I have been able to get around easier. Doctor: Have you been experiencing any daytime fatigue? Patient: No. I have been falling asleep at work. I think it is from looking at my computer screen all day. My supervisor caught me snoring one day and forgot where I was at. My supervisor offered to give me a coffee. This has happened more than once. Doctor: This could be due to your sleep apnea. Who is treating you for your sleep apnea? Patient: Doctor X did a consult and had me do one of those sleep test about two years ago. I only get sleepy when I look at my computer screen. Doctor: Did Doctor X recommend a C P A P machine to use at night? Patient: Yes, but I never used to use it. I had another follow up visit with her and she told me that I need to use it every night. I have been using it every other night. Doctor: How much uninterrupted sleep do you think that you get per night? Patient: Maybe two to five hours, on a good night. Doctor: That is not enough sleep. No wonder you are falling asleep at work. I recommend following up again with Doctor X regarding your sleep apnea. You are at a much higher risk for obesity and high cholesterol if you continue to not address the issues you have been having with the lack of sleep and sleep apnea. Patient: Okay. I will make a follow up visit with her.","Section header: GENHX Section text: Ms. A continues to have some residual left leg weakness and continues to use a rolling walker for ambulation, but she reported that her motor functioning had improved significantly. She was diagnosed with sleep apnea approximately two years ago and was recently counseled by Dr. X on the need to use her CPAP because she indicated she never used it at night. She reported that since her appointment with Dr. X, she has been using it ""every other night."" When asked about daytime fatigue, Ms. A initially denied that she was having any difficulties, but repeatedly indicated that she was falling asleep at work and thought that it was due to looking at a computer screen. She reported at times ""snoring"" and forgetting where she is at and said that a supervisor offered to give her coffee at one point. She receives approximately two to five hours of sleep per night. Other current untreated risk factors include obesity and hypercholesterolemia. Her medical history is also significant for hypertension, asthma, abdominal adenocarcinoma status post hysterectomy with bilateral salpingo-oophorectomy, colonic benign polyps status post resection, benign lesions of the breast status post lumpectomy, and deep vein thrombosis in the left lower extremity status post six months of anticoagulation (which she had discontinued just prior to her stroke)." "Doctor: They gave you Procrit for your anemia? Patient: Yes I think so. That is how they treated it in the past. Doctor: Okay. Are you married? Who do you live with? Patient: Oh I am by myself. Doctor: Okay, and do you smoke or drink alcohol? Patient: No I do not. Doctor: Great. Patient: Okay.",Section header: PASTMEDICALHX Section text: As above plus history of anemia treated with Procrit. No smoking or alcohol use and lives alone. "Doctor: Hello. How are you doing? Patient: Not doing that good. I'm here so that you can help me. Doctor: Tell me how can I do that? What's bothering you? Patient: I have gestational diabetes and I'm here for consultation related to my diet. No matter what I eat, I'm kind of scared that it will spike up my numbers. Doctor: Hold on, hold on. First, tell me how old are you? Patient: Sorry. I am thirty eight. Doctor: Okay, now tell me what are you afraid of? Patient: No matter what I eat, my number goes up and I just, I'm so afraid of eating anything now. Doctor: Do you work? Patient: I do, at Walmart. I try not to eat anything whenever I'm on the third shift. Doctor: Tell me about the eating habits. Do you prepare meals at home, or do you order from outside? Patient: Well, before all this, I mean this gestational diabetes and pregnancy, I used to eat out a lot. Almost like every day. I like to eat rice a lot. It is like the staple food for me. Doctor: You said you don't try to eat, so are you facing any symptoms because of not eating? Patient: Yeah, whenever I'm on my late shift, I work from ten in the night to seven in the morning. I try to avoid eating. And then I feel very fatigued and tired all the time. I also have young kids at home, so after finishing my duty here at in the morning I go home and then there are young children who keep me busy. Doctor: What is your sleeping pattern? How much are you sleeping throughout the day? Patient: Around two to four hours at a time. Doctor: When do you test for ketones? Patient: Normally, it is the first thing that I do when I reach back home from my shift in the morning.","Section header: GENHX Section text: This is a 38-year-old female who comes for dietary consultation for gestational diabetes. Patient reports that she is scared to eat because of its impact on her blood sugars. She is actually trying not to eat while she is working third shift at Wal-Mart. Historically however, she likes to eat out with a high frequency. She enjoys eating rice as part of her meals. She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home. She sleeps two to four hours at a time throughout the day. She has been testing for ketones first thing in the morning when she gets home from work." "Doctor: How old are you? What brings you here today? Patient: I am fifty six years old. I am here for this pain in my legs. It hurts mostly in the night. Doctor: Does changing positions helps you? Patient: Yeah, it helps. Whenever I stand it just goes away. Doctor: Is it only in your legs or it starts there and goes somewhere else as well? Patient: It normally starts in my hips and then it goes down my leg and sometimes into my ankles as well. Doctor: When did you first notice it? Patient: It all started after taking that medication. What is it called? Something with L? Yeah, Lipitor. Doctor: Have you ever noticed any night sweats? Patient: Sometimes I do sweat at night. Doctor: Any other issue? Anything else going on? Your body temperature is a little on the higher end. Patient: Yeah, I do feel feverish and have nausea as well. Doctor: How are your sugar numbers? Patient: They have been low for quite some time. You know, I have started going to Genesis in Wichita and I've been doing water aerobics. And you know what? Surprisingly, I have lost thirty pounds. Doctor: That's good. How much is your fasting sugar? Patient: Anywhere between a hundred to one hundred and twenty. I check them one and a half hours after meals as well. They are, they have been one hundred and eighty five regularly. Doctor: Okay. Patient: Yeah. I have a request to make. I will be coming for my diabetic checkup in one month. Can we do all the labs before that? Doctor: Yeah, sure, that's a great idea. I should tell my assistant and they will call you for labs before your appointment for diabetes checkup. Doctor: Anything else going on? How is everything else? Patient: I tried to control my cholesterol with diet, but it didn't help. I cannot keep on dieting. It is just not my thing. I have started eating more meat though. I feel full after that.","Section header: GENHX Section text: This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle. She has noticed it since she has been on Lipitor. She has had some night sweats occasionally. She has had a little bit of fever and nausea. She has noticed her blood sugars have been low. She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita. She has noticed her fasting blood sugars have been ranging from 100 to 120. Blood sugars one and a half hours after meals have been 185. She is coming in for a diabetic checkup in one month and wants lab prior to that time. She has been eating more meat recently and has not been on a diet for cholesterol." "Doctor: Are you married? Patient: Yes. Doctor: Do you have kids? Patient: Yes, I do have seven. I have a handful. Doctor: Do you work? Patient: Yeah, I'm a driver for FedEx. Doctor: Did you ever smoke? Patient: Nope. Doctor: What about alcohol or any other kind of drugs? Patient: Nope. None of that.","Section header: FAM/SOCHX Section text: Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use." "Doctor: Is patient allergic to any medication? Guest_clinician: Yes, actually he is allergic to quite a few medicines. I have noted them down, here is the list. Doctor: Okay, so he is allergic to Lamisil, Equagesic. Oh, he is allergic to Bactrim too. Guest_clinician: Yeah, and Dilatrate and cyclobenzaprine. Doctor: That's quite a lot, we need to be careful while making his treatment plan. Guest_clinician: Yeah.","Section header: ALLERGY Section text: Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine." "Doctor: Hi there! I am Doctor Smith. Patient: Hello! It is nice to meet you. Doctor: Let's start with your family medical history. Patient: My mother had breast cancer. My father had lung cancer that ended up taking his life. He was seventy nine when he passed. My mother also passed but not from an illness but from an infection she got after having an elective surgery. Doctor: I am so sorry for your loss. How old was your mother when she passed? Patient: Thank you. She was eighty one when she passed. I am an orphan now. My only living sibling died at forty. He had a hard life. He struggled with mental illness. Doctor: How did your brother pass away? Patient: He had pancreatitis. Oh, my dad had glaucoma. Doctor: You have had a lot of loss. Patient: Yes, I have. My good friend passed away a year and a half ago. It has been a lot. Doctor: I have a support group I can refer you to for people to have been through loss. Would you be interested a referral, sir? Patient: Yes. I would like that. Thank you.",Section header: FAM/SOCHX Section text: Father died from CA at the age of 79. Mother died from postoperative infection at the age of 81. Brother died from pancreatitis at the age of 40 and had a prior history of mental illness. Father also had a prior history of lung cancer. Mother had a history of breast cancer. Father also had glaucoma. He does not have any living siblings. Friend died a year and half ago. "Doctor: I will ask some simple questions, okay? Patient: Hm Doctor: How old are you and how would you define yourself in terms of ethnicity? Patient: Well, I am forty seven and would proudly call myself as Latin American. Doctor: Great. What brings you to the emergency room? Patient: I had a blood test before and then it came out to be high potassium. I also went to a regular clinic the other day as I was feeling very weak and extremely tired. Doctor: Okay. Patient: My potassium came out to be seven and it was highlighted in red. That really scared me, so I wanted to know everything what's going on inside me. I told the emergency doctors too that all these weakness and tiredness is going on for more than half a year. Doctor: Did you noticed any other symptoms other than weakness? Patient: Yes, there was the fever and chills. I was sweating a lot in the nights, and I also had weight loss of around twenty pounds. During that time, I sometimes have nausea and was throwing up a lot. I was not eating. I always felt dizzy every time I tried to stand. Doctor: Did you have wet cough? Patient: No, not wet cough but I did notice back pain gets intense on the upper side whenever I coughed, like in my ribs. I normally massage that area and it gets better. Doctor: Any shortness of breath? Patient: Nope. Doctor: How about while sleeping or doing something else? Patient: Not while sleeping, but I did notice that if I'm walking for two to three blocks then I get out of breath easily. Previously it was not like this. I used to jog for two to three miles without even a single breath loss. Patient: I noticed one more thing. I feel like my balls on one side are getting big. Doctor: Which side left or right? Patient: I think its left. Doctor: For how long? Patient: I guess over the past year. I did see someone when all of this started, and he put me on some antibiotics, but nothing changed. For last few months there is yellow fluid coming out of it too. Doctor: Did you ever get any type of injury in the area? Patient: No. Doctor: What about your bowel movements? Patient: Nope everything is as usual. Doctor: Any change in urinary habits? Patient: Nope. Doctor: Any changes in your skin? Any rash? Any kind of eyesight issue? Patient: Nope, no changes. Doctor: What about pain? Like headache or any joint pain? Patient: Nope, no pain anywhere.","Section header: GENHX Section text: A 47-year-old Latin American man presented to the emergency room after being told to come in for a high potassium value drawn the previous day. He had gone to an outside clinic the day prior to presentation complaining of weakness and fatigue. Labs drawn there revealed a potassium of 7.0 and he was told to come here for further evaluation. At time of his assessment in the emergency room, he noted general malaise and fatigue for eight months. Over this same time period he had subjective fevers and chills, night sweats, and a twenty-pound weight loss. He described anorexia with occasional nausea and vomiting of non-bilious material along with a feeling of light-headedness that occurred shortly after standing from a sitting or lying position. He denied a productive cough but did note chronic left sided upper back pain located in the ribs that was worse with cough and better with massage. He denied orthopnea or paroxysmal nocturnal dyspnea but did become dyspneic after walking 2-3 blocks where before he had been able to jog 2-3 miles. He also noted that over the past year his left testicle had been getting progressively more swollen and painful. He had been seen for this at the onset of symptoms and given a course of antibiotics without improvement. Over the last several months there had been chronic drainage of yellowish material from this testicle. He denied trauma to this area. He denied diarrhea or constipation, changes in his urinary habits, rashes or skin changes, arthritis, arthralgias, abdominal pain, headache or visual changes." "Doctor: Have you ever had surgery, ma'am? Patient: Yeah, I've had a few. First, I had, um, tubal ligation, and three milk ducts removed. Doctor: What year was that in? Patient: That was in, um, nineteen seventy nine. Doctor: Great, thank you. What else have you had done? Patient: I had a breast biopsy in nineteen eighty nine, and a colonoscopy in two thousand seven. Doctor: Thank you, do you have any children? Patient: Well, doctor, I've been pregnant four times, but I've had three children. Doctor: I'm so sorry to hear that. Did you have a C section with any of them? Patient: No, doctor. I had a natural birth for all of them.","Section header: PASTSURGICAL Section text: In 1979, tubal ligation and three milk ducts removed. In 1989 she had a breast biopsy and in 2007 a colonoscopy. She is G4, P3, with no cesarean section." "Doctor: Did you had any surgery in the past? Patient: No.",Section header: PASTSURGICAL Section text: Noncontributory. "Doctor: Any allergies? Patient: Yes just molds. Doctor: Okay so molds reaction.",Section header: ALLERGY Section text: Molds. "Doctor: Hi there, how are you dear? Patient: I am fine, thank you. Guest_family: Hi Doctor, I am her mother. Doctor: Nice to meet you. So I see you have been referred by Doctor X. Guest_family: Yes, she is our family doctor. Doctor: Okay, so you noticed some behavioral problems with your daughter and reported to her, is that right? Guest_family: Yes, I have been noticing them for a while. She loses her focus quickly. We also got a few complaints from school regarding her behavior. We also met a couple of other doctors but they diagnosed her with Attention Deficit Hyperactivity Disorder. Doctor: Well, looking at her reports I am afraid it looks like she does have A D H D, but the good news is we can treat her, so don't worry. Guest_family: Okay. Doctor: I am going to prescribe her some medicines which will help her deal with this. Guest_family: Thank you. Doctor: So, I will write her a prescription for Adderall and Clonidine. They have some really good results in treating A D H D. Which pharmacy do you go to? Guest_family: We go to Costco pharmacy by the X Y Z corner. Doctor: Okay, I will send it there. Patient: Thank you doctor, it was nice meeting you. Doctor: Nice meeting you too, take care.",Section header: MEDICATIONS Section text: Adderall and clonidine for attention deficit hyperactivity disorder. "Doctor: He had circumcision? Patient: Yes. Doctor: Do you remember the date? Patient: No I do not. But it should be in the chart.",Section header: PASTSURGICAL Section text: Circumcision. "Doctor: Good morning, sir. You're sixty one years old, correct? Patient: Good morning, doctor. Yes, that's correct. Doctor: Great, and you identify as Caucasian, right? Patient: Yes, that's correct as well. Doctor: Thank you, do you have any medical conditions that I should know about? Patient: Yes, I have diabetes. Doctor: How are you handling your diabetes? Patient: Well, I've had diabetes for a long time but had never been treated for it. Doctor: Okay, thank you for telling me. What seems to be the problem today? Patient: I've been working in my garage over the past few days, and I have this redness and swelling in my right foot. Doctor: Do you have any itchiness or pain? Patient: Yes, and it's getting worse. Doctor: Have you seen any other doctors about this? Patient: Um, yes. I went to the A B C D General Hospital E R and they gave me an evaluation there. Doctor: Do you have any images from this visit? Patient: Um, yes. I have them right here. Doctor: Okay, these show a foreign body in the foot. Patient: But what about all the stuff on the outside of my foot? Doctor: Well, that's consistent with cellulitis. Patient: What's that? Doctor: It's a skin infection we clean it up in surgery. Patient: What kind of procedure can we do? Doctor: We should do an irrigation debridement for the cellulitis, and remove the foreign body. I think that will really help. Patient: Yes, I agree, doctor.","Section header: GENHX Section text: The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus. The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot. He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room. He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics. It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity. After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body." "Doctor: Hello, sir. How are you doing today? Patient: I'm flustered. I brought my wife so she can speak for me. Doctor: Hello, ma'am. What seems to be the problem with your husband? Guest_family: He's been having some problems with his skin in his private region. He's too shy to talk about it himself.",Section header: FAM/SOCHX Section text: The patient is accompanied with his wife. "Doctor: Are you married, ma'am? Patient: Yes, to my wonderful husband. Doctor: Does he help you out around the house? Patient: Yes, he is just wonderful. Doctor: So, do you drink or smoke? Patient: No, I don't do any of that. Doctor: How about more illicit substances, do you use any of that? Patient: No, absolutely not.","Section header: FAM/SOCHX Section text: She is married and has support at home. Denies tobacco, alcohol, and illicit drug use." "Doctor: Anything else going on from head to toe? Patient: No doctor, everything else is fine. Doctor: Are you sure? Patient: Yes I am sure.",Section header: ROS Section text: Not contributory. "Guest_family: How's my husband doing? Sorry, I had to take a call outside. Doctor: He's doing much better. He'll be going home today with a prescription for Zithromax. Guest_family: I'm glad he's able go home and get some rest. Doctor: However, I'd like to still see him in the office next week for a reevaluation. Guest_family: Great. Can we make the appointment right now? Doctor: Yes, the front desk will be able to help you with that.",Section header: DISPOSITION Section text: The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week. "Doctor: How long have you been running a fever? Patient: It's been on and off for a few days now. I'm also having chills. Doctor: Have you taken anything for the fever? Patient: Tylenol and Advil. I've been taking them interchangeably. Doctor: When was the last time you took your temperature? Patient: An hour ago. The thermometer read one O one point four. Doctor: Are you experiencing any other symptoms, such as shortness of breath, nausea, vomiting, diarrhea, or others? Patient: I've been having a stronger urge to pee a lot more than usual. Not sure if that's related. Doctor: It could be. We're still waiting on your urine results. Do you have a history of cataracts or glaucoma? Patient: No. Doctor: Okay, great. Any signs of pneumonia or valley fever? Patient: Nothing of the sort. Doctor: What about blood in your vomit or feces? Patient: Nope. Doctor: Any neurological symptoms like T I A or C V A? That is slurred speech or stroke symptoms. Patient: Luckily, no. I don't have seizures or anything like that. Doctor: Great to here. With the pandemic I wanted to check on your mental health too. Any depression or anxiety? Patient: I have always been a homebody. This is normal for me. Nothing like that in my head. Doctor: Cool. Do you have any issues with blood disorders? Patient: Nothing like that.","Section header: ROS Section text: CONSTITUTIONAL: No history of fever, rigors, or chills except for recent fever and rigors. HEENT: No history of cataract or glaucoma. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: Nausea and vomiting. No hematemesis or melena. UROLOGICAL: Frequency, urgency. MUSCULOSKELETAL: No muscle weakness. SKIN: None significant. NEUROLOGICAL: No TIA or CVA. No seizure disorder. PSYCHOLOGICAL: No anxiety or depression. HEMATOLOGICAL: None significant." "Doctor: Hello, miss. It looks like some information is missing for your profile. Is it fine if I ask you a few questions? Patient: Of course. Go ahead. Doctor: Do you currently smoke? Patient: No, I finally stopped smoking cigarettes. Doctor: Did you smoke before? Patient: I did. I smoked a half a pack for about twenty years. Doctor: Well, it's good to hear that you've stopped. I encourage you to continue to not smoke. Patient: I agree. I need to change up my lifestyle. Doctor: Last question. Do you drink alcohol? Patient: No, I don't. I don't like anything that has alcohol. I can't stand the taste of it. If I do it is rare.","Section header: FAM/SOCHX Section text: The patient used to smoke cigarettes for about 20 years, one-half pack a day. She currently does not, which was encouraged to continue. She rarely drinks any alcohol-containing beverages." "Doctor: Hello, sir. So, remind me, how long ago was your procedure? Patient: Let me think. Now, it's been about four months. I just turned fifty nine. Doctor: Okay, and just to refresh your memory, we did a percutaneous screw fixation of a Schatzker I V tibial plateau fracture, and we've managed those toe fractures nonoperatively. Patient: Which toes did I break? Doctor: You broke your second and fifth toes. Patient: Do you have the x rays? Can I see where the breaks are? Doctor: Absolutely, if you look here, right here is where the breaks are. These are called the metatarsal heads. Patient: Wow, that's right where it hurts. Doctor: Yep, and where are you living now? Patient: Thankfully, I left the nursing home, and I'm back in my own house now. Doctor: That's really good. Are you in any pain today? Patient: No, not today. Doctor: Great, have you been going to P T? Patient: Yeah, I've been going about two or three times a week. Doctor: Are there any signs of infection, like drainage from the incision? Patient: Nope, the wound healed up nicely. I'll be able to wear shorts again. Doctor: Great, are you having any fever symptoms, like cough, runny nose, sore throat, fatigue, anything like that? Patient: No, but I have had some tingling in both my feet. I don't know if its related to surgery. If I'm remembering the names right, um, I have a history of spinal stenosis and neuropathy in my legs. Doctor: With your history of spinal stenosis, the broken toes, and the surgery, that's a pretty normal side effect.",Section header: GENHX Section text: The patient is a 59-year-old gentleman who is now approximately 4 months status post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures. He is currently at home and has left nursing home facility. He states that his pain is well controlled. He has been working with physical therapy two to three times a week. He has had no drainage or fever. He has noticed some increasing paresthesias in his bilateral feet but has a history of spinal stenosis with lower extremity neuropathy. "Doctor: Do you currently smoke? Or did you smoke in the past? Patient: Quit in nineteen seventy two. Doctor: Great to hear. Are you working right now? Patient: Yeah, I work at a nursing home. Doctor: Does your job allow you to take time for yourself? Patient: Yeah, my job is very supportive. I've actually been trying to lose weight. So far, I've lost a good amount since starting a new diet several months back.",Section header: FAM/SOCHX Section text: She works at nursing home. She is a nonsmoker. She is currently trying to lose weight. She is on the diet and has lost several pounds in the last several months. She quit smoking in 1972. "Doctor: Hello. Are you ready for your surgery today? Patient: Can we reschedule? I'm too scared to do it. Doctor: It'll be fine. Don't worry too much about it. Have you ever had a surgery before? Patient: Never. What if something goes wrong? Doctor: You have nothing to worry about. I've done this procedure multiple times, and everyone was fine after. Patient: Thank you, Doctor. Let's get started then.",Section header: PASTSURGICAL Section text: Denied. "Doctor: What is your family medical history? Patient: I don't really remember anyone having any major health problems. Doctor: Okay. Patient: Everyone is pretty healthy. Doctor: That is fortunate. Patient: Yeah, it is.",Section header: FAM/SOCHX Section text: Unremarkable. "Doctor: How's it going? I haven't seen you in a long time. Patient: Hey, Doctor. My headaches have been getting worse. Doctor: Remind me again. Does you family have a history of migraines. Patient: I don't think so. Doctor: Okay. Let's perform some tests.",Section header: FAM/SOCHX Section text: unknown. "Doctor: Hello, this is your follow up visit, right? Welcome back! Have you been taking your Plaquenil for lupus, ma'am? Patient: Yeah, I am. Doctor: Your prescription is two hundred M G twice a day, correct? Patient: Yeah, that's it. Doctor: Do you have your eye report with you today? Patient: Yes, doctor. Here you go. Doctor: Good, thank you, what seems to be the problem today? Patient: Well, I'm having some aches and pains in my hands and elbows. Doctor: When did this pain start? Patient: It's been a few weeks now. Doctor: Is there any associated trauma? Did you fall? Patient: No, no falls or anything. It just started one day, and it's really bothering me. Doctor: Are you having any fever or chills, or cold or flu like symptoms? Patient: No, I'm not. Doctor: How about swelling? Are any of your joints swollen? Patient: No, everything is normal there. Of note, I have been losing a lot of hair recently. Doctor: Okay, that's interesting.","Section header: GENHX Section text: The patient is here for a follow-up. The patient has a history of lupus, currently on Plaquenil 200-mg b.i.d. Eye report was noted and appreciated. The patient states that she is having some aches and pains of the hands and elbows that started recently a few weeks ago. She denied having any trauma. She states that the pain is bothering her. She denies having any fevers, chills, or any joint effusion or swelling at this point. She noted also that there is some increase in her hair loss in the recent times." "Doctor: So, I know you're technically not allowed to drink, but I'm required to ask this anyway. Do you drink at all? Patient: No, actually. I try to steer clear of drinking while training for my marathon. Doctor: When is that by the way? Patient: Next summer. Doctor: Wow, good luck. It'll be yet another big accomplishment. Patient: Thank you. Doctor: And how about smoking of any kind? Patient: Nope.",Section header: FAM/SOCHX Section text: The patient denies smoking and drinking. "Doctor: Welcome in. Patient: Thank you. Doctor: Let us start with your family medical history. Patient: I have a lot of diabetes in the family. Doctor: Who has diabetes? Patient: My father had diabetes. He passed away. Doctor: I am so sorry. How did he pass away? Patient: He had cancer. He actually had breast cancer. Doctor: That is incredibly rare. Is your mother still with us? Patient: Yes, she is. She just had her eighty ninth birthday. Next year we are going to plan a big birthday bash for her. Doctor: Do you have any siblings? Patient: Yes. I have a sister. She has diabetes too. Doctor: Do you know of any family members with neurological disorders such as M S, epilepsy, or Huntington's? Patient: No. I don't know of anything like that.",Section header: FAM/SOCHX Section text: His father died from breast cancer. He also had diabetes. He has a strong family history of diabetes. His mother is 89. He has a sister with diabetes. He is unaware of any family members with neurological disorders. "Doctor: How're your other children doing? Guest_family: Not so wonderful. They're all on antibiotics. Doctor: For the same? Guest_family: Yep. They all have ear infections and chest colds. Doctor: Your hands are full then. Guest_family: Tell me about it, doctor. I can't seem to catch much of a break. Doctor: It's definitely been a tough winter for you and your family.",Section header: FAM/SOCHX Section text: All siblings are on antibiotics for ear infections and URIs. "Doctor: Do you use tobacco or other drugs? Patient: No. Doctor: Do you drink? Patient: No.","Section header: FAM/SOCHX Section text: No smoking, alcohol, or drug abuse." "Doctor: Is this your mother with you today? Patient: Yes, this is my mommy. Doctor: Great, welcome, what did you do this this ankle, young lady? Patient: Well, I was running when I twisted my ankle. Doctor: Which ankle did you twist? Patient: It was my right ankle. Doctor: Where does it hurt the worst? Patient: Right here, on the outside of my ankle. Doctor: Do you have a primary care physician? Guest_family: Yeah, we go to Doctor Brown. Doctor: Do you have any other injuries to speak of? Patient: No, it's just my ankle really.",Section header: GENHX Section text: The patient was running and twisted her right ankle. There were no other injuries. She complains of right ankle pain on the lateral aspect. She is brought in by her mother. Her primary care physician is Dr. Brown. "Doctor: Good afternoon, young lady. Patient: Hello, doctor. Doctor: What grade are you in, young lady? Patient: I'm in middle school, um, I'm in the eighth grade. Doctor: Do you play any sports? Patient: Yes, I love to play basketball. Doctor: Good, are both of your parents at home? Patient: Yes, I live with my mom and dad. Doctor: Do you have any siblings? Patient: Yes, I have a little brother, um, he's nine now. Doctor: Great, have you started your periods? Patient: Um, yes, my first one was in September.",Section header: FAM/SOCHX Section text: She is currently an eighth grader at Middle School and is interested in basketball. She lives with both of her parents and has a 9-year-old brother. She had menarche beginning in September. "Doctor: How many children do you have, ma'am? Patient: I was blessed with four beautiful children. Doctor: That's wonderful. Did you have any complications with the pregnancies? Patient: Actually, I had two c sections for both of my sons.",Section header: PASTSURGICAL Section text: Cesarean section x 2. "Patient: I'm right handed. Doctor: Tell me what brings you here, sir? Patient: I'm having these cramps in my feet, in my hand and I just wanted to get checked. It has been happening for like six months. I develop muscle contractions in my toes and both feet. It only happens in night. Doctor: How frequent is it? Patient: Around three times a week. Doctor: What do you do when you have these cramps? Patient: I try to stand and it helps me relieve some of the discomfort. I noticed my toes are kind of extended. Whenever I step on the ground, it seems to pop into place. With all these cramps, I've started having pain in my calf. Sometimes because of that I could not sleep, or it wakes me up in the night. Similar to my toes, these cramps have also started coming up in my hands. They are not that strong or frequent. They're completely random and not in the nighttime. Sometimes my thumb gets so flexed that I have to move it to bring it to the right position and to relieve the cramp. Doctor: Did you ever have this symptom before? Patient: No, not like this. Doctor: Are you taking any medications? Patient: Yeah, I took an antibacterial called Bactrim around nine months ago. I was taking it briefly before, but now I'm taking it consistently. I cannot think of anything that is causing it. Doctor: Do you have any other medical condition? Patient: I have H I V for the last twenty one years and I was taking antiretroviral medications for it. I stopped those medications around six or seven years ago. Doctor: Why did you stop the medications? Patient: I could not tolerate them. They were making my stomach weak. Doctor: Do you know your C D four count? Patient: It was three hundred and twenty six. I never developed autoimmune deficiency syndrome. I think I should restart my medicines.","Section header: GENHX Section text: The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to ""pop into place."" He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep. He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp. He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms. He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment." "Doctor: So, this is your follow up? How are you doing so far with Lamictal? Patient: Yes, it's the follow up. Lamictal was okay. There was no side effect with that. But I had twitching in my muscles a lot of times. It was not generalized, but I was very afraid that this will happen. Doctor: What time of day was it? That you had these episodes. Patient: Mostly in the mornings. Doctor: I have your recent E E G report. It did show multiple spikes and some complexes on both the sides, but it is more prominent on left. Patient: I have been taking my medications very regularly and I was getting a good amount of sleep as well. Doctor: Are you able to drive? Patient: Yes. Doctor: Is there any change in your social history or any other symptoms that arise or, or is it same as before? Patient: Looks same to me.","Section header: GENHX Section text: The patient returns for followup. Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking. She has not had a generalized seizure. She is very concerned that this will occur. Most of the myoclonus is in the mornings. Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left. She states that she has been very compliant with the medications and is getting a good amount of sleep. She continues to drive. Social history and review of systems are discussed and documented on the chart." "Doctor: What types of surgeries have you had in the past? Patient: I had gall bladder and appendix surgery then they also took out my ovaries. Doctor: Okay.","Section header: PASTSURGICAL Section text: Cholecystectomy, appendectomy, oophorectomy." "Doctor: Have you had any surgeries in the past? Patient: Yeah, I have, I actually had it to repair an undescended testicle. Doctor: Oh, wow, do you remember it at all? Patient: No, nothing about it, I had that done when I was a baby.",Section header: PASTSURGICAL Section text: He had a history of surgery for an undescended testicle. "Doctor: Do you smoke cigarettes? Patient: I don't smoke cigarettes but I do have one on a rare occasion. Doctor: Do you drink alcohol or use any recreational drugs? Patient: I don't drink but I do occasionally smoke weed. Guest_family: He has a drink every now and again when we get together with friends. Doctor: Okay.",Section header: FAM/SOCHX Section text: Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife. "Doctor: Do you smoke or drink? Patient: No, neither. Doctor: Any history of drug abuse? Patient: No, I have never used any illegal drugs in my life. Doctor: Okay.","Section header: FAM/SOCHX Section text: She denies the use of alcohol, illicits, or tobacco." "Guest_clinician: Is the patient being admitted for disseminated C M V infection? Doctor: Yes. I suspect they have possible C M V pneumonitis as well. Guest_clinician: Are they on immunosuppressants? Doctor: Yes. They have polymyositis and they're taking Prednisone and Methotrexate. Guest_clinician: Got it.",Section header: DIAGNOSIS Section text: 1. Disseminated CMV infection with possible CMV pneumonitis. 2. Polymyositis on immunosuppressive therapy (methotrexate and prednisone). "Doctor: Alright we already spoke about your past medical history, anything else you might want to add? Guest_family: Oh, dad did you also talk about your depression? Doctor: Depression? I don't think we spoke about that. Patient: Yeah we didn't, it slipped out of my mind. Guest_family: My father has a history of depression and anxiety. Doctor: Okay, let me make a note of it.",Section header: PASTMEDICALHX Section text: He also has anxiety and depression. "Doctor: How are you? Patient: Not good. Doctor: What brings you here today? Patient: This ulcer in my ankle is just not healing. Doctor: Is it on both sides? Patient: No, just on the right side.",Section header: CC Section text: Nonhealing right ankle stasis ulcer. "Doctor: Do you remember the details of your surgery, sir? Patient: No, can you remind me? Doctor: We did a left inguinal hernia repair. Patient: Thank you for reminding me. Doctor: You have a history of prostate cancer as well, correct? Patient: Yes, they said it was Gleason, um, three plus four. Doctor: Yes, that sounds familiar. What medicines are you taking right now? Patient: I'm taking Lupron, currently.","Section header: PASTMEDICALHX Section text: 1. He is status post left inguinal hernia repair. 2. Prostate cancer diagnosed in December 2004, which was a Gleason 3+4. He is now receiving Lupron." "Doctor: How many people do you have in your family? Patient: Well, I have four children, all healthy with no medical conditions. Doctor: Wow, that's great! Patient: My father passed away at the age of sixty nine due to C V A. And my mom died exactly ten years later, her heart just suddenly stopped. She was seventy nine. Doctor: Okay. And do you have siblings? Patient: Well, believe it or not I had eleven siblings, including me twelve. Doctor: Wow! Patient: Yes, I lost six of them. Four of them to diabetes, one of my brothers passed away at the age of seventy two and we could never determine the reason my sister died. Doctor: Hm okay.","Section header: FAM/SOCHX Section text: The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her ""heart stopped"". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems." "Doctor: You are referred for some abdominal infection right? Patient: Yes, they told me I might have C Diff? Doctor: Yes that's what we will evaluate you for.",Section header: CC Section text: I was asked to see the patient for C. diff colitis. "Doctor: Hi, how are you doing? How old are you? Patient: I am good, how are you? I am seventy two years old. Doctor: Good. How can I help? Patient: Actually, there is a wooden splinter stuck beneath my left fifth fingernail. I am an American farmer by blood, so this has happened before. Doctor: Oh, when did this happen, sir? Patient: Yesterday evening around four P M. Doctor: Okay, then what did you do? Patient: Then I tried to remove it with tweezers at home, but it did not come out. So, I want you to remove this. Doctor: Okay let me see. Patient: Yeah, here. Doctor: Okay. Can you tell me when the last time you had a tetanus shot? Patient: Oh it's been so long. I would say it has been over ten years since I have had any tetanus shot. Doctor: Okay and are you allergic to anything? Patient: Oh yes. I am allergic to horse serum. I think it is added in vaccinations? Doctor: Oh, okay. Patient: But I don't want any tetanus vaccine now. Doctor: Oh! But you need it. Patient: I know, but I get a bad reaction to vaccines so I don't want it. Doctor: Okay. let me fine some alternative. Patient: Thanks.","Section header: GENHX Section text: Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday. He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him. The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with ""horse serum."" Consequently, he has declined to update his tetanus immunization." "Doctor: Have you had a recent vaccination? Patient: I had a flu shot last winter but I have not had and recent vaccines. Doctor: Do you have any planned in the near future? Patient: I was going to get another flu shot but I don't think I am due for that for another three months. Doctor: Great.",Section header: IMMUNIZATIONS Section text: Nothing significant. "Doctor: How old are you? Patient: Seventy one. Doctor: Are you right handed or left handed? Patient: Right handed. Doctor: What exactly happened? Patient: I, I had this bad headache on fifth of November and then I had a big sneeze, like it was too loud. I had-- it was going on for like three to four days. Then, on the seventh, I had this severe pain over my left eye and I kind of lost my vision there. Doctor: When did you see changes in your eyelid? Patient: Yeah, on the following day, it seemed like swelling and then my eyelid, it began like pulling down and getting down. Kind of drooping. We went to a local doctor, and he did some x rays. Doctor: Yeah, I have your brain C T report from there. There is no sign of any kind of bleeding, but I do see a torturous blood vessel there. Patient: Yeah, after looking at this report they transferred us here to the U I H C on the twelfth.","Section header: GENHX Section text: 71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92." "Doctor: I see here that you're in for a med refill. Is that correct? Patient: Yep. I ran out of Klonopin one or two days ago. Doctor: What are you taking it for? And how long have you been on it? Patient: Panic attacks. I have really bad episodes without it. Um I think I started it about four months ago. I could be wrong though. I've lost track of time. Doctor: Who usually prescribes it to you? Patient: My doctor back in Georgia. Doctor: Do you happen to have their name or contact info on hand? Patient: No, unfortunately. Doctor: How much Klonopin do you take for your panic attacks? Patient: I take a pretty low dose. I think I'm on zero point five milligrams a day. Is there any way you could verify the dosage? Doctor: I can try to look it up online. When were you last prescribed Klonopin? Patient: Over two months ago I think. Doctor: Let me pull up the page and see if we can figure out your dosage and when you're due for a refill based on your doctor's orders. Patient: Okay, thank you. Doctor: Are you experiencing any symptoms currently, such as headache, nausea, vomiting, shortness of breath or chest pain? Patient: Not right now, no. I did have some nausea yesterday. Oh and I guess I had a slight headache when I woke up this morning, but that's about it.",Section header: CC Section text: I need refills. "Doctor: How are you? I haven't seen you in a long time. Patient: I'm doing fine. I hurt my hand the other day. Doctor: How did that happen? Patient: My husband and I moved into our new home, and we were building a desk. I tried to nail something in, and I hammered my hand. Doctor: Oh, no. So, you and your husband live together now? Patient: Yeah. We do. We just got married.",Section header: FAM/SOCHX Section text: She is married. She lives with her spouse. "Patient: Man, what a night. Doctor: What kind of car were you driving that night? Patient: I was driving my small sports car through an intersection when another car hit me from the left side. The impact forced my car off the road and into a utility pole. Doctor: I'm so sorry to hear that. I'm glad that you are here in one piece. Were you wearing your seatbelt? Patient: Yeah, I had my belt on and everything. Doctor: Good. Patient: Unfortunately, the driver was drunk and ran a traffic signal. Doctor: That's such a shame. Do you remember how fast the car was going when it collided into you? Patient: If I had to guess maybe eighty miles per hour. It looks like the driver who hit me was already cited by police. Doctor: Did you lose consciousness at all? Patient: Yeah, I briefly lost consciousness when help arrived at the scene. I felt an immediate headache when I regained consciousness. I also had lower back and neck pain. Doctor: Did you get out of the car by yourself? Patient: Yeah, I got out by myself. Once I made it out, the Rescue Squad drove me to Saint Thomas Memorial Hospital. I was seen in the emergency room and later discharged. Doctor: This was on January fifteenth, correct? Patient: Yessir.","Section header: GENHX Section text: Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient's vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released." "Doctor: How're you doing? Patient: Good for the most part. I'm still pretty tired most days, but I'm trying to stay more active. I'm wondering if it has to do with my sugar levels? Doctor: Hm let's see. I'd like to check your glucose and lipid panels and get you back in here again. Patient: And oh I've noticed some blood in my stool. I'm not sure if it's related. Doctor: How long has that been going on? Patient: Maybe a week or so? Doctor: Are you having any other symptoms? Black or tarry stool? Nausea, vomiting, diarrhea? Lightheadedness? Patient: No, none of that. Doctor: I'd like to order a hemoccult then. It's going to check to see if you're still having blood in your stool. Patient: Can I do this at the blood work place? Doctor: Yes, they'll be able to help you and answer any additional questions you may have. Patient: Okay. I'll try to go in tomorrow. Doctor: Remember you need to fast for the lipid panel, so I'd recommend going in early tomorrow morning before eating breakfast. Patient: Okay, got it. Doctor: And before I send you on your way, have you been able to schedule your yearly mammogram? Patient: Oh shoot. I still need to do that. I'll call them tomorrow.","Section header: ROS Section text: Significant for occasional tiredness. This is intermittent and currently not severe. She is concerned about the possibly of glucose abnormalities such diabetes. We will check a glucose, lipid profile and a Hemoccult test also and a mammogram. Her review of systems is otherwise negative." "Doctor: Hello, ma'am. How are you doing? Patient: My knees hurt. They've been slowly getting worse each year. Life's getting hard at seventy two. Doctor: I'm sorry to hear that. Have you always had knee pain? Patient: I have. Both knees are messed up. Doctor: Are you able to do any activities still? Patient: Nope. I just sit all day. Doctor: I see. We can offer to do arthroplasty to fix your knees. Patient: What's that? Doctor: It's like a reconstruction of your joints. It'll help increase your ability to do daily activities. Patient: I'm up for it. I need to get my life going. Doctor: Sounds great. I just want to confirm some information. Would you say your quality of life and daily activities is decreasing? Patient: Oh, yeah. These knees are making my life terrible.",Section header: GENHX Section text: The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs. She wishes to proceed with arthroplasty at this time. "Doctor: How's he doing? Guest_family: Not so great. He's been out of it. He hasn't been acting like himself. Doctor: How long has it been since you noticed any behavioral changes? Guest_family: A few days now. Doctor: Is he complaining of any pain? Guest_family: Yeah he's been- Doctor: He's been? Guest_family: Sorry, my phone was on vibrate and I had to turn it off. Doctor: No problem. Guest_family: He's been pointing to his stomach and saying it hurts. Doctor: Is he having any other symptoms? Guest_family: He's told me he feels queasy. I took his temperature the other night and he was running a fever of one O two. Doctor: Any vomiting with the nausea? Guest_family: Yeah, he's thrown up a handful of times.","Section header: CC Section text: Abdominal pain, nausea, vomiting, fever, altered mental status." "Doctor: Good morning, sir. Remind me please, when was your surgery? Patient: Hello, doctor. It was about a week ago now. Doctor: Great, and just to remind you, you had a removal of Ex Fix from the right knee with an M U A following O R I F of a right tibial plateau fracture. Patient: Yes, that all sounds familiar. What's M U A? Doctor: It stands for manipulation under anesthesia. We bent the knee in order to forcibly break up some scar tissue. Patient: Oh, wow. Doctor: Yeah, it's great, eliminates some need for P T in fact. How are you doing today? Patient: Overall, my pain is under control. Doctor: Are you having any flu like, or infection symptoms? Patient: No, nothing like that at all. Doctor: So, no fever, or chills, or sweating at night. Patient: Yeah, nothing like that. Doctor: Great. I see you're having some drainage from the pin sites, but that doesn't bother me too much. Patient: Okay, good. I was getting worried. Doctor: No need to worry. Are you doing your range of motion exercises? Those are imperative. Patient: Yes, doctor. I am. Doctor: Good, and do you have any numbness or tingling? Patient: No, doctor. I don't have any of that.","Section header: GENHX Section text: The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture. The patient states that this pain is well controlled. He has had no fevers, chills or night sweats. He has had some mild drainage from his pin sites. He just started doing range of motion type exercises for his right knee. He has had no numbness or tingling." "Doctor: Hi, how are you doing? Patient: I'm good. Thank you. Doctor: How old are you, young lady? Patient: Eighty four. Doctor: What brings you here? Patient: I had a fall. And I was told to consult you for my heart conditions. Doctor: Okay. Um? Can you tell me a little detail about anything you experienced before or diagnosed before? Patient: Yeah, I have high blood pressure. And they also diagnosed me with other heart diseases. I cannot pronounce all the names I don't remember. Doctor: That's fine. Let me go through your medical record first. Doctor: Let's see what we have here. Looks like you have your plate full. Your record says you had hypertension I mean, high blood pressure. Also, you have a history of severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation. Patient: Wow! Those are a lot of fancy words that I can never remember. Doctor: Ha ha. So, it says here they they want me to check you for atrial fibrillation. Yet another fancy word to add to your list. Patient: What does it mean? Doctor: It means I must check if you have faster than normal heartbeat after your fall. In simple words, just to check if there are any irregularities in your heart beating, okay? Patient: Hm, okay. Doctor: So tell me what happened? How did you fall? Patient: I'm not sure about how it happened, but yeah, I fell yesterday on my driveway and kind of hit a rock. Doctor: Which side did you hit the rock? Patient: Um I think it was left side. Doctor: What happened in the emergency room? Patient: They gave me some medicine. And they put something on my finger. They said that my heart rate was very high. Doctor: Yeah, in the record it says that they found rapid atrial tachyarrhythmia. So, according to this, they have given you Cardizem and they stopped it when your heart rate came to fifties. Doctor: Let me review your electrocardiogram from emergency. It says that there was rapid heart rate. Your heart was really beating very fast and then there was one more electrocardiogram which showed that your pacemaker is acting weird. Patient: They also did the same test this morning. Doctor: One they did this morning shows normal rate with frequent early heartbeats. Looks like they also tested your blood. Your potassium level is three point one. Doctor: How was your heart feeling when you fell yesterday? Patient: I felt that I just ran in a race. I could feel all the pain after that fall. It was ugly. My heart was pounding so fast it was ready to come out, I never felt like that before in my life. Doctor: Did you feel the same way afterwards as well? Patient: No, it was just after fall. It did not stay like that for long, I was normal later. I never felt it again after that incident. Doctor: That is good. Do you have any pain or discomfort in your chest? Patient: I don't think so. Doctor: How about before the fall? Did you have any pain or discomfort in your chest before the fall? Patient: Nope. Doctor: how about shortness of breath? Patient: No, not even before the fall. I'm able to walk and I'm sure I can climb stairs. Maybe two floors without any problems.","Section header: GENHX Section text: The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped. Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker. An ECG this morning showing normal sinus rhythm with frequent APCs. Her potassium at that time was 3.1. She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. She denies any chest pain nor shortness of breath prior to or since the fall. She states clearly she can walk and she would be able to climb 2 flights of stairs without problems." "Doctor: So just a few quick questions before we wrap up. Do you smoke or drink? Patient: I drink sometimes. I've never smoked. Doctor: Any drug use? Patient: No. Doctor: Are you sexually active? Patient: Uh I was back in Haiti, but that was back in eighty two. I had several male partners, but no sex since moving here. Doctor: Did you use protection in your previous encounters? Patient: Most of the time, yes. Doctor: Any history of S T Ds? Patient: No. Doctor: Are you currently working? Patient: Yep. I work for a car dealership down the street.","Section header: FAM/SOCHX Section text: He occasionally drinks and is a nonsmoker. The patient participated in homosexual activity in Haiti during 1982 which he described as ""very active."" Denies intravenous drug use. The patient is currently employed." "Doctor: Are you taking any medications for your pain? Patient: Yeah, occasionally. Doctor: Which one? Patient: Just a regular pain medicine.",Section header: MEDICATIONS Section text: Occasional acetaminophen. "Doctor: Good morning, sir, I hear you're a patient of Doctor A. Patient: Yes, that's correct. Doctor: Did she refer you to me? Patient: Yeah, I'm fifty five, so I'm not too young anymore, but I have developed iron deficiency anemia with blood in my stool. At least, that's what she's told me so far. Doctor: Are you having diarrhea? Patient: Yeah, I am. Doctor: How would you describe the frequency? Patient: I'd say it's chronic at this point. Doctor: How long have you known you have anemia? Patient: Um, it's been a few months now. Doctor: What markers were evaluated in order to diagnose this? Patient: I had, um, an unusual pruritus, and I had a C B C. Doctor: Do you have the results of that? Patient: Yes, right here. Doctor: Thank you, so this shows a hemoglobin of nine, and M C V of sixty five. Patient: Are those high? Doctor: Well, actually, both of those are low. Patient: Oh, okay. Doctor: How long have you had blood in your stool? Patient: Um, it's been about five months now. Doctor: What has the color been like? Patient: Well, it's been both dark and bright blood, actually? Doctor: When was your last colonoscopy? Patient: It was about three years ago, I had it with Doctor X. I did it in Las Cruces. Doctor: Was there any abnormality found? Patient: Yeah, I had polyps removed. Doctor: Were those polyps evaluated? Patient: Yeah, the doctors said they were, um, hyperplastic. They diagnosed me with, um, lymphocytic colitis. Doctor: I see, when was the last time you were treated for diarrhea? Patient: At this point, it's been more than three years.","Section header: GENHX Section text: The patient is a 55-year-old gentleman, a patient of Mrs. A, who was referred to me because the patient developed iron deficiency anemia and he had blood in his stool. The patient also has chronic diarrhea. His anemia was diagnosed months ago when he presented with unusual pruritus and he got a CBC. At that time he was discovered to have hemoglobin of 9 and MCV 65. The patient also had multiple episodes of dark blood and bright blood in the stool for the last 5 months on and off. Last colonoscopy was performed by Dr. X in Las Cruces 3 years ago. At that time the patient had polyps removed from the colon, all of them were hyperplastic in nature. The patient also was diagnosed with lymphocytic colitis. He was not treated for diarrhea for more than 3 years." "Doctor: Good afternoon, before we begin, what are your pronouns? Patient: I identify as a female, and I use she her pronouns. Doctor: Thank you, so, have you ever had surgery? Patient: Yes, I actually have a list of them written down. Doctor: That's really helpful, may I see it? Patient: Absolutely, here you go. Doctor: Thank you. So I see you've had a multiple bowel surgeries, including, um, a hysterectomy, rectocele repair, and an appendectomy. Do all of those sound familiar. Patient: Yep, I got this list from all of the surgeons. Doctor: Are there any other major conditions I should be aware of? Patient: Yes, actually, I have another list, um, I have polymyalgia rheumatica. Doctor: That's all great information to know, thank you very much.","Section header: PASTSURGICAL Section text: She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy. She also has a diagnosis of polymyalgia rheumatica." "Doctor: Hello Mister Strange, can you please confirm your age and ethnicity for the records. Patient: Hi Doctor, I am fifty five now and would identify myself as a white male. Doctor: Let's first talk about your medical condition. There has been a diagnosis of polycythemia vera with secondary myelofibrosis. Also, you are J A K two positive. Do you remember when you were diagnosed? Patient: It was sometimes between two thousand and five and six. Doctor: They did phlebotomy and then subsequently you got yourself transferred here in our healthcare. Patient: Yes. Doctor: You have been on hydroxyurea and interferon, right? Patient: Oh, it was a terrible time, I could not deal with anyone of them. I had numbness and tingling with burning pain in my hands. Doctor: You do not have any siblings that we can try for transplant match? Patient: That's right! Doctor: You were also considered for the Matched Unrelated Donor Transplant, but you couldn't be on the list due to social support and also health was in reasonably better state than other candidates normally on that transplant list. Patient: We had some medications here as well when I first started my care here, I forgot the name. Doctor: Yes, here we started you on a trial of lenalidomide and prednisone for some time. You were doing great on that for a while, but then you developed intolerance to lenalidomide. Patient: Yes, I had severe diarrhea and I always felt tired like I have no energy left in me. Eventually it all stopped. Doctor: Yeah, here it says that you injured your leg? Tell me what happened. Patient: It all happened last week, I injured this left leg and got swelling. I had some prescribed steroids, so I took them for about three days only. The swelling is eventually gone now. Doctor: Any other related complaints? Patient: No. Doctor: Do you smoke or drink? Patient: I take marijuana. I feel really hungry after smoking it, so I eat a lot. In just the last few weeks I have gained a few pounds. Doctor: Okay, your overall performance status in the E C O G scale is one.","Section header: GENHX Section text: A 55-year-old white male who carries a diagnosis of polycythemia vera with secondary myelofibrosis. Diagnosis was made some time in 2005/2006. Initially, he underwent phlebotomy. He subsequently transferred his care here. In the past, he has been on hydroxyurea and interferon but did not tolerate both of them. He is JAK-2 positive. He does not have any siblings for a match-related transplant. He was seen for consideration of a MUD transplant, but was deemed not to be a candidate because of the social support as well as his reasonably good health. At our institution, the patient received a trial of lenalidomide and prednisone for a short period. He did well with the combination. Subsequently, he developed intolerance to lenalidomide. He complained of severe fatigue and diarrhea. This was subsequently stopped. The patient reports some injury to his left leg last week. His left leg apparently was swollen. He took steroids for about 3 days and stopped. Left leg swelling has disappeared. The patient denies any other complaints at this point in time. He admits to smoking marijuana. He says this gives him a great appetite and he has actually gained some weight. Performance status in the ECOG scale is 1." "Doctor: Do you have any family history of neurological disorders, such as multiple sclerosis, Parkinson's or dementia? Patient: Nope. Fortunately, no one in my family has neurological problems.",Section header: FAM/SOCHX Section text: Unremarkable. "Doctor: How long have you had this rash? Patient: Not long. Less than a day if I had to guess. Doctor: Is it causing you any pain? Patient: No, it's just really itchy. I tried applying Cortisone to it, but it didn't help much. Doctor: Is the rash localized to the left arm? Patient: Yeah. I've only noticed it on my left arm.",Section header: CC Section text: Itchy rash. "Doctor: Hello. How are you both doing today? Guest_family: We're doing great. The E D told us to come here. We're here to see if we could get the stuff in his leg taken out. Doctor: I see. Did he have a fracture before? Guest_family: Yeah, he did. Here's the report from the surgery from October two thousand and seven. Doctor: Great. Let me take a look. It looks like he had a distracted left lateral condyle fracture. He then underwent screw compression to fix the fracture, correct? Guest_family: That's correct. Doctor: Perfect. So, now we just have to remove the hardware that was used to fix the fracture, right? Guest_family: Yeah, that's correct. What are the risks of the surgery? Doctor: The risks include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion. Guest_family: Oh, wow. That's a lot. Could you go over the benefits? Doctor: Of course. Before I do, I just need to confirm your son's age. Guest_family: He can tell you. Patient: Hi. I'm five years old. My birthday is in four months. Doctor: Thank you. Happy almost birthday. Guest_family: He gets excited about birthdays. I just have a few more questions, but it looks like we're going to go through with the surgery.","Section header: GENHX Section text: The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture. He underwent screw compression for the fracture in October 2007. The fracture has subsequently healed and the patient presents for hardware removal. The risks and benefits of surgery were discussed. The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion. All questions were answered and the family agreed to the above plan." "Doctor: I am looking at her x ray report and she had a sternotomy in the past. Guest_clinician: Yes, and we placed an I C D implant and an aortic valve mechanical implant. Her pleural effusion was really worrisome causing left sided opacification of her diaphragm. Doctor: Oh I see!",Section header: IMAGING Section text: Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion. "Doctor: What happened to your right leg? Patient: I had a little accident with a dog, he bit me. I got really scared. Doctor: Don't worry we will take care of this.",Section header: CC Section text: Dog bite to his right lower leg. "Doctor: We've been following you for several conditions for a while now. What seems to be the problem today, sir? Patient: Um, I was peeing blood, it's back again. Doctor: Did you do anything that could have provoked it to come back? Patient: No, not that I know of. Doctor: Have you been taking the Flomax for your B P H? Patient: Yes, I have been. Doctor: What about the Coumadin? Patient: Yes, I've been taking that too. It has been held recently, but I ususally take it. Doctor: Remind me, I don't have my chart with me. What conditions have you been taking the Coumadin for? Patient: I have A F I B and stroke. Doctor: Thank you. Isn't this your second occurrence of gross hematuria this month? Patient: Yes, doctor. Doctor: Are you sure you haven't experienced any falls or anything recently? Patient: Yeah, actually I fell about a week ago. Doctor: Where is your pain from that fall? Patient: It's in my butt and leg. Doctor: Have you had your x rays taken yet? Patient: Yeah, the x ray tech just brought me back. Doctor: Okay, these x rays of the hips, knees, and ankles show severe degeneration in all areas. Patient: What does that mean, doctor? Doctor: I see some pretty significant arthritis in these areas. Patient: Can you tell me some good news, please? Doctor: Well, I don't see any fractures. Patient: I guess that's something. Doctor: When is your pain worst? Patient: It's so severe, and it's worst first thing in the morning. Doctor: Okay, I know you are, but be sure to keep taking the Coumadin, that helps with the stroke and A F I B. Patient: Yeah, I will. I'm having problems with my sinuses today too. Can I get some nasal spray too?","Section header: GENHX Section text: I am following the patient today for multiple issues. He once again developed gross hematuria, which was unprovoked. His Coumadin has been held. The patient has known BPH and is on Flomax. He is being treated with Coumadin because of atrial fibrillation and stroke. This is the second time he has had significant gross hematuria this month. He also fell about a week ago and is complaining of buttock pain and leg pain. We did get x-rays of hips, knees, and ankles. Clearly, he has significant degenerative disease in all these areas. No fractures noted however. He felt that the pain is pretty severe and particularly worse in the morning. His sinuses are bothering him. He wonders about getting some nasal saline spray. We talked about Coumadin, stroke risk, etc. in the setting of atrial fibrillation." "Doctor: Good morning. Patient: Good morning, Doctor. Doctor: Are you married? Patient: No sir, I'm happily single. Doctor: Good for you, what do you do for a living? Patient: I'm actually not working right now, I go to college full time. Doctor: Even better for you, so do you drink or smoke? Patient: No, I don't. Doctor: What about more illicit substances? Patient: Absolutely not, nothing like that. Doctor: Do you like to work out? Patient: I play tennis and swim every week, I love it. Doctor: That's very good, you're keeping very healthy.","Section header: FAM/SOCHX Section text: The patient is single. She is a full-time student at University. Uses no tobacco, alcohol, or illicit drugs. She exercises weekly, mainly tennis and swelling." "Doctor: Has anyone in your family suffered from dementia? Patient: Not that I'm aware of. Doctor: Is there any other medical history in your family? Any other medical issues? Patient: My mom died of a stroke. Doctor: How old was your mom when she died? Patient: She was sixty two.",Section header: FAM/SOCHX Section text: Negative for dementia. Her mother died of a stroke at the age of 62. "Doctor: When was the last time you had a cigarette? Patient: Seventeen years back. Doctor: Okay, and how much did you used to smoke? Patient: About one pack per day. I smoked for forty four years. Doctor: Okay, how about any I V drugs? Patient: No I have not done that.",Section header: FAM/SOCHX Section text: The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years. Denies any alcohol use. Denies any IV drug use. "Doctor: What brings this little guy in today? Guest_family: He's been complaining of a sore throat since last night. I noticed his eyes were really puffy before he went to bed and that's when I gave him some Benadryl. At that time, he also seemed nasally. Doctor: Sorry to hear that. Did he have a fever? Guest_family: When I took his temperature last night, it was one O one. Doctor: And did you give him anything for the fever? Guest_family: I was worried about giving him something on top of the Benadryl. Doctor: I see. And how has he felt otherwise? Guest_family: He appears more sluggish than usual. Fortunately, he's eating and drinking well. Doctor: Has he been coughing at all? Guest_family: No, but his voice has been a kind of raspy. Doctor: Any shortness of breath? Guest_family: Um no. Doctor: How about any episodes of vomiting, diarrhea, or stomach pain? Guest_family: No, I don't think so.","Section header: GENHX Section text: Mom brings patient in today because of sore throat starting last night. Eyes have been very puffy. He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday. He has had low-grade fever and just felt very run down, appearing very tired. He is still eating and drinking well, and his voice has been hoarse but no coughing. No shortness of breath, vomiting, diarrhea or abdominal pain." "Doctor: Do you have any major medical conditions that I should know about, sir? Patient: Maybe, I might. What exactly do you mean by that, doctor? Doctor: Well, it's broad, but it could be anything from depression to high blood pressure, to cancer. Patient: Okay, that's what I thought. I have high blood pressure. Doctor: What about your mental health, is there anything of note there? Patient: Um, yeah, I have anxiety, too.",Section header: PASTMEDICALHX Section text: Hypertension and anxiety. "Doctor: Are you a student? Patient: Yes, I am. I go to the University. Doctor: What are you majoring in? Or do you know yet? Patient: Yes! I am studying biology. Doctor: Excellent! Do you live in the dorms? Patient: Yes. Doctor: Are you from the area? Patient: I am from Breckenridge. That is where my parents live. Doctor: That is a beautiful place to be from. Do you use any tobacco, alcohol, or recreational drugs? Patient: I have smoked weed with friends, off and on but not much. I have a few beers at the occasional dorm party.",Section header: FAM/SOCHX Section text: The patient is a student at the University majoring in biology. He lives in a dorm there. His parents live in Breckenridge. He admits to having smoked marijuana off and on with friends and drinking beer off and on as well. "Doctor: Do you have any history of surgical procedures? Patient: No, none.",Section header: PASTSURGICAL Section text: None. "Doctor: Hello Hello! Patient: Hi there, how are you? I have a bad headache so can you please switch off the lights, it's too bright and uncomfortable. Doctor: Sure thing. Let's see what is going on here. How about that? Patient: Much better.",Section header: CC Section text: Headache. "Doctor: Okay, let's talk about your family history. Patient: Oh, I have very disturbing family history! Doctor: Why do you say so? Patient: Well, my mother passed away due to heart attack in her late sixties and my father had liver cancer and he passed away from that. Doctor: Oh- Patient: Oh, that is not all. My one son suffers from hypothyroidism and my daughter's two kids have cerebral palsy from being born prematurely. Doctor: Oh, that is so unfortunate. Patient: Yeah.","Section header: FAM/SOCHX Section text: Positive for mother passing away in her late 60s from heart attack, father had liver cancer, and passed away from that. One of his children suffers from hypothyroidism, 2 grandchildren has cerebral palsy secondary to being prematurely born." "Patient: Hey, man. Doctor: Hey, how's it going? It's been a while. Patient: Yeah, it's been a while that's for sure. Doctor: So anything new I should know of? Patient: Uh I had some stuff on my chest that I saw a dermatologist for. Doctor: What type of stuff? Patient: I think they were cysts. Doctor: Any cause for concern? Patient: Nah, the dermatologist said everything came back alright. Doctor: Glad to hear that. Patient: Me too. I'm actually here to see if you can write me up a P P D slip. Doctor: Is this for a job? Patient: Yeah, my last one was negative, but I need to get another one. Last one I did was in nineteen ninety four.","Section header: PASTMEDICALHX Section text: Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis. He had a recent PPD which was negative in August 1994." "Doctor: Have you notied her behaving strangly in any way? Guest_family: No. She is acting perfectly normal. Doctor: Has she been gagging, coughing, vomiting or any other symptoms? Guest_family: No. The only thing that I noticed is that she spilled the liquid all over her clothes, the ground and on her hands. Doctor: Did you see her ingest any of the fluid? Guest_family: No. We didn't see her put it in her mouth. I looked inside her mouth and didn't see anything.","Section header: ROS Section text: The child has not been having any coughing, gagging, vomiting, or other symptoms. Acting perfectly normal. Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes. They did not witness that she ingested any, but did not see anything her mouth." "Doctor: Any past medical problems I should know of? Patient: No, ma'am. I am forty three and this is the first time I have had a major issue. It's only been this past month where I've felt weaker than usual. I'm much more tired and short of breath whenever I move around. Doctor: Any recent weight loss? Patient: Yeah, I actually lost about fifteen pounds in less than two or three months. Doctor: How's your appetite? Any nausea, vomiting, diarrhea? Patient: Appetite is pretty fine. No nausea, vomiting, or diarrhea. Doctor: How about fever, chills, sweats, cough? Patient: No, ma'am. Doctor: And any chest pain with your shortness of breath? Patient: No, ma'am.","Section header: GENHX Section text: This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month. The patient also reports a 15-pound weight loss. He denies fever, chills and sweats. He denies cough and diarrhea. He has mild anorexia." "Doctor: Do you have any allergies? Patient: No I do not. Doctor: Are you sure? Patient: Yes I am.",Section header: ALLERGY Section text: No known drug allergies. "Doctor: What is your family medical history? Patient: Nothing that I know of.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Did you have a full term delivery? Guest_family: No, he is premature born. Doctor: Was he hospitalized? Guest_family: Yes. Doctor: Was he on any machine like the ones that help breathing? Guest_family: No. Doctor: Was he ever hospitalized afterwards? Guest_family: No. Doctor: Did he have any surgery? Guest_family: No.","Section header: PASTMEDICALHX Section text: Baby was born premature and he required hospitalization, but was not on mechanical ventilation. He doesn't have any hospitalizations after the new born. No surgeries." "Doctor: Do you have any allergies? Patient: No I do not. Doctor: Okay. Patient: Okay. Patient: Are you only asking for medical allergies? Doctor: No, I want to know about all allergies.",Section header: ALLERGY Section text: There are no known allergies. "Doctor: Anyone smokes in the house? Guest_family: Yes, we do. Doctor: Both of you? Guest_family: Yes, but outside, not inside. Doctor: Okay. Guest_family: We are careful.",Section header: FAM/SOCHX Section text: Parents do smoke around the house. "Doctor: Do you use any tobacco, inhalation or recreational drugs? Patient: No.","Section header: FAM/SOCHX Section text: No use of ethanol, tobacco, illicit, or recreational substances." "Doctor: How're you feeling today? Patient: Not great. Doctor: I'm sorry, why is that? Patient: I've had a headache all week along with neck and lower back pain. Doctor: How would you describe the headache? Patient: Throbbing pain. Doctor: Is it constant? Patient: It comes and goes for the most part. Doctor: How would you rate it on a scale of ten with ten being the worst? Patient: A seven or eight. Doctor: Do you have a headache currently? Patient: No, not right this second. Doctor: Have you taken- Patient: Anything for the pain? Doctor: Yes. Patient: I took some Ibuprofen, but it doesn't seem to be helping much. Doctor: Any other symptoms associated with the headache, such as fever, chills, nausea, vomiting, blurred vision, or sensitivity to light? Patient: No, not really. I don't feel like I have a cold or anything. Doctor: Any recent injuries to the head? Patient: No. Doctor: And your neck and lower back pain, is this new? Patient: Eh I can't say. It's been bothering me for some time now, but the pain feels a bit different. Doctor: How so? Patient: I don't really know. It's more pronounced.",Section header: CC Section text: Headache and pain in the neck and lower back. "Doctor: Do you have any other problems? Patient: I do actually, I have back disc degeneration. Doctor: Oh really? Patient: Yeah. Doctor: When were you diagnosed with it? Patient: Maybe twenty ten?",Section header: PASTMEDICALHX Section text: Significant for degenerative disc disease in the back. "Doctor: Any family history of disease? Guest_family: To be honest, I'm not sure. Possibly? I'd have to check and get back to you.",Section header: FAM/SOCHX Section text: unknown. "Doctor: Do you have any history of surgical procedures? Patient: I remember having surgery as a child, but I don't know what the surgery was for. It was so long ago.",Section header: PASTSURGICAL Section text: Years ago she had surgery that she does not recall. "Doctor: Who all are there in your family? Patient: Well, it's just me and my brother now. My mom passed away due to stroke at the age of seventy nine. Patient: My father had a good life with no medical conditions. He passed away due to old age, he was ninety one. Doctor: Wow! Any family history of heart disease or diabetes? Patient: My other brother had prostate cancer but that's just it. No diabetes or heart issues. Doctor: Okay.",Section header: FAM/SOCHX Section text: Mother died at age 79 of a stroke. Father died at age 91 of old age. Her brother had prostate cancer. She has one brother living. No family history of heart disease or diabetes. "Doctor: And are you allergic to any drugs? Patient: Oh yes, I am allergic to what you call Cipro- Doctor: Ciprofloxacin? Patient: Yes! And also, Asprin but that coated one, what is called? Doctor: Oh, you mean enteric coated Aspirin? Patient: Yes, yes, that one!",Section header: ALLERGY Section text: Ciprofloxacin and Enteric coated aspirin "Doctor: Hi, I am Doctor Chandler. Patient: Hello Doctor. Doctor: So, tell me what's going on? Patient: I am having a headache.",Section header: CC Section text: Headache. "Patient: In the past I have been treated for osteomyelitis of my right fifth toe with I V antibiotics therapy. Doctor: Oh, how long back was that? Patient: Ah, about five years back! I was treated for six weeks. Doctor: Oh, Okay. You also have a history of diabetes mellitus? Patient: That is correct.","Section header: PASTMEDICALHX Section text: Positive for: 1. Diabetes mellitus. 2. Osteomyelitis of the right fifth toe, which was treated with intravenous antibiotic therapy for 6 weeks about 5 years back." "Doctor: Do you have any major medical conditions that I should know about? Patient: Oh, yeah, I have a whole list of things going on, doctor. Doctor: Like what, ma'am? Patient: Well, I have high blood pressure, hypothyroidism, arthritis, and G E R D. Doctor: I see, what about any mental health, or neurological diseases? Patient: Um, I have an anxiety disorder, and I had migraines about thirty years ago. Doctor: Thank you, I also see on my chart that you've had Morton's neuromas before, is that true? Patient: Yeah, I have one on both feet.","Section header: PASTMEDICALHX Section text: Hypertension, hypothyroidism, degenerative joint disease, GERD, anxiety disorder, Morton neuroma of her feet bilaterally, and distant history of migraine headaches some 30 years ago." "Doctor: I will ask you a few questions about your past medical history. Were you ever diagnosed with anything medically related? Patient: No. Doctor: Were you ever diagnosed with diabetes or any heart conditions? Patient: No. Doctor: Did you ever take medications for any long-term disease? Patient: No. Doctor: Did you ever have any surgery? Patient: No.",Section header: PASTMEDICALHX Section text: Unremarkable. "Doctor: So, who is in your family? Patient: Well, my mom, dad, and I have four brothers aged eighteen, sixteen, fourteen and twelve and I also have a younger sister. She is only three. Doctor: Wow, and you all stay together? Patient: Yes, and we also have two dogs and two cats. Doctor: Okay. And everyone at home is doing fine? Guest_family: No, not really. Everyone at home is sick with a cough, cold and runny nose, except- Patient: Except for my mom! Guest_family: Yeah, except for me thankfully. Doctor: Hm, and did you travel anywhere recently, especially during the holiday season? Patient: No, right mom? Guest_family: Yeah, we didn't travel anywhere recently. Doctor: Okay. Anybody in your house smokes? Guest_family: No. Doctor: No exposure to smoke, right? Guest_family: No.","Section header: FAM/SOCHX Section text: At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister. All the residents at home are sick currently with cold, cough, runny nose, except for mom. At home also live 2 dogs and 2 outside cats. Mom denies any recent travel history, especially during the recent holidays and no smoke exposures." "Doctor: So, are you on any medication currently? Patient: Yes, I am taking Atenolol and Mevacor. Doctor: Hm, and no allergy to any medicine? Patient: Not that I know of.",Section header: MEDICATIONS Section text: She is on atenolol and Mevacor. ALLERGIES: NO KNOWN DRUG ALLERGIES. "Doctor: I think you are good to go home. I am going to prepare your discharge paper. Patient: That's great!",Section header: DISPOSITION Section text: The patient is discharged home. "Doctor: So how long have you two been married? Guest_family: We've been together for twenty seven years now. Doctor: Oh wow, that's so wonderful to hear. How did you guys meet? Guest_family: We actually met in high school. We dated for some time and then we took a break, but we ultimately got back together. Doctor: Aw, high school sweethearts. I have a few more questions to ask. Guest_family: Shoot. Doctor: Any tobacco, hard drugs, or alcohol? Guest_family: She doesn't do any of that. Doctor: Great. And do you know of any medical problems that run on her side of the family? Guest_family: Nothing major. Doctor: I see.",Section header: FAM/SOCHX Section text: Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her. Unremarkable FHx. "Doctor: I would like to get a detailed history of your inperforated anus and the curvature of the penis. It is a genetic condition. And do you know if you had surgery soon after birth? Patient: Yeah, my mother said that I had to have surgery after she gave birth to me. Doctor: Do you know all the surgeries that you have had for this? Patient: I don't know if I have all of them written down, but I do have most of them here. Doctor: Oh, good you have a list. Patient: Yeah. I was hospitalized in nineteen seventy for a U T I. That is when the problems started happening. It was a really bad infection. Doctor: Okay. Patient: In nineteen eighty eight I the tissue removed from the anus. There was a blockage. They also did an operation in the shaft of the penis too. Doctor: I bet things improved after that surgery. Patient: It did. I have here in January of nineteen ninety one I had a cystoscopy to remove a blockage. Doctor: Um hum. Patient: In two thousand and one I had a colonoscopy that was normal. Later that year I had a biopsy of my prostate. Doctor: What did the biopsy show? Patient: They said I had severe inflammation in the prostate. I was never told that cause of the inflammation. Doctor: Okay. Any other surgeries for your condition? Patient: Oh yeah. I had that same procedure done again when I was twenty seven and twenty eight. The same one that I had as a newborn. I had a third surgery when I was seventy with just a correction of the shaft area. Doctor: Um hum. Any other surgeries unrelated to your condition? Patient: Yeah. I have it written down here. In two thousand and one there was a left rotator cuff repair with acromioplasty and distal clavicle resection and in two thousand and three I had a left inguinal hernia repair with M E S H. That is what my notes say. Doctor: Have you ever had any complications during any of your surgeries? Patient: Yeah, I did. I have a blood clot that apparently went into my lungs. I was very scary. Doctor: That is very scary.","Section header: GENHX Section text: Soon after birth for treatment of an inperforated anus and curvature of the penis. At the age of 70 had another penile operation. At the age of 27 and 28 he had repeat operations to correct this. He did have complications of deep vein thrombosis and pulmonary embolism with one of those operations. He has had procedures in the past for hypospadias, underwent an operation in 1988 to remove some tissue block in the anus. In January of 1991 underwent cystoscopy. He was hospitalized in 1970 for treatment of urinary tract infection. In 2001, left rotator cuff repair with acromioplasty and distal clavicle resection. In 2001, colonoscopy that was normal. In 2001, prostate biopsy that showed chronic prostatitis. In 2003, left inguinal hernia repair with MESH." "Doctor: As per your chart, I see you have C O P D and hypertension. Patient: Yes that is right. Doctor: Okay.",Section header: PASTMEDICALHX Section text: COPD and hypertension. "Doctor: Do you use any tobacco products? Patient: No. Doctor: Do you drink alcohol or use any recreational drugs? Patient: No. Doctor: Any history of needle drugs or prescription drug abuse? Patient: No.",Section header: FAM/SOCHX Section text: Denied Tobacco/ETOH/illicit drug use. "Doctor: Hi! Patient: Hello, how are you? Doctor: I am good. Patient: I think I am all well now. Doctor: Yes, looking at your results I think your kidney failure is resolved too.","Section header: ASSESSMENT Section text: Acute renal failure, resolved." "Doctor: How old are you, young man? Patient: I am twenty one. Doctor: Are you right handed or left handed? Patient: I am right handed. Doctor: So, tell me what brings you here today? Patient: Everything started on the fifth of November. Then after I saw the gradual increase in my symptoms. So it was all like numbness. I could not feel my legs. They felt numb all the time and there was no coordination between them, and it also affected my walk. All these symptoms were at their limit in just like a half day or more. It is continuing the same way since then. I also feel like somebody is putting pins and needles on my legs approximately halfway up the calf on both sides. Doctor: You said that you felt decreased coordination or less coordination between your legs, right? Patient: Yeah, that's right. It totally feels like I'm walking in space and don't know where to put my next step. I have no up and down spatial awareness. Doctor: Do you have any issue with the bowel movements? Patient: Nope. Doctor: What about this weakness or the numbness anywhere else except your legs? Patient: No, it's only in the legs. Doctor: Did anything help you with those symptoms? Patient: Well, sometimes, you see, hot showers made me feel better, but it is like only sometimes. Doctor: Any recent flu like symptoms? Patient: Nope. Doctor: Did anyone in your family have anything like that or any other medical issues that was like going on in your family? Patient: Nope. Doctor: Did you have any surgery before? Patient: Nope. Doctor: What about any other major health issues in the past? Patient: No, no medical issues. Doctor: Are you taking any kind of medication for anything? Patient: No medications.","Section header: GENHX Section text: 21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications." "Doctor: What brings you in to the clinic today? Patient: Well, I have had a progressive loss of my vision in my right eye. My eye doctor told me that I should come and see a neurologist. So here I am. Doctor: Okay. How long has the vision loss been progressing for? Patient: About two months. It seems like it has been progressing really fast. I have always had bad vision in my left eye. That started about two years ago. Doctor: Can you still see out of you left eye? Patient: No. I am considered blind in this eye now. Doctor: Have you had any other symptoms associated with your vision loss? Patient: No. Doctor: Any headaches? Patient: Nope. Doctor: What is you dominate hand? Patient: What do you mean? Doctor: What hand do you write with or use dominantly? Patient: Oh! I am right handed. Doctor: And how old are you? Patient: I am sixty two. Doctor: Okay. I would like to run some test now. Patient: Okay.","Section header: GENHX Section text: This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA." "Doctor: Do you have any history of rheumatic fever as a child? Patient: No. Doctor: Any history of anything other then usual childhood illnesses? Patient: No.",Section header: GENHX Section text: Negative for rheumatic fever. The patient has usual childhood illnesses. "Doctor: So, tell me a little bit more about your family history, please. Patient: Sure, I know that my grandmother on my mom's side had pancreatic cancer, and my dad had prostate cancer. Doctor: Besides cancer, are there any other conditions that you know run in your family? Patient: Um, I know that my dad had heart disease, as well as diabetes. Doctor: Thank you, this is good information to know.",Section header: FAM/SOCHX Section text: His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father. "Doctor: What do you do? Patient: I am a registered nurse. Doctor: That's nice. Doctor: And do you smoke or drink? Patient: No sir. Doctor: Any history of drug abuse or anything? Patient: Absolutely not! Doctor: Okay, good.","Section header: FAM/SOCHX Section text: No history of any smoking, alcohol, or drug abuse. The patient is a registered nurse by profession." "Doctor: Hello, sir. How are you doing? Patient: I am doing well, thanks. Just trying to come to you more regularly to make sure my lungs and heart are okay. Doctor: That's great. The previous notes said that you quit smoking. Are you still off? Patient: Yes, I quit in nineteen ninety six. I come yearly to the doctor's office to make sure that the damage I did to my lungs is monitored. Doctor: You have a great attitude. I appreciate when patient's take their health into their own hands. We can only do so much, but it is up to the patient to bring themselves in. Patient: Yeah. I smoked for a long time and I know it was bad for me. It was just the norm back in the day. Doctor: Do you drink at all? Patient: I do. Only occasionally.",Section header: GENHX Section text: Quit smoking in 1996. He occasionally drinks alcoholic beverages. "Guest_family: Hello Doctor. I am from High Hope assisted living center. I am Mister Rath's assigned assistant. Doctor: Right. What brings you here? Guest_family: I got some of Mister Rath's food diary sheets here. He has already lost fifteen pounds in the last three months. We were just wondering if he needed to lose anymore. Doctor: Let me have a look.",Section header: GENHX Section text: The patient is brought in by an assistant with some of his food diary sheets. They wonder if the patient needs to lose anymore weight. "Doctor: Your condition and all your vital signs look stable to me right now. You must be very careful as your condition can get poor or it might improve as well. Patient: Okay, so what do you recommend? Doctor: Do you have any support system? Is there anyone at home to take care of you? Patient: Yes, my son and his family lives with me. They are very caring. Doctor: That is good. Do take care of yourself and let me know if your condition worsens.",Section header: DISPOSITION Section text: Guarded. "Doctor: Where do you work? Patient: I'm a truck driver. It's a big construction company. I work for them. Doctor: Do you smoke? Patient: Yeah. Doctor: Cigarette or something else? Patient: I do Cigar.",Section header: FAM/SOCHX Section text: Cigar smoker. Truck driver. "Doctor: Good morning, ma'am. I just need a few pieces of information before we get started today. Patient: Good morning, doctor. Absolutely, that's not a problem at all. Doctor: Do you smoke or drink, ma'am? Patient: I don't smoke, and I drink, um, I'd say on occasionally. Doctor: What about harder drugs, do you use any of those? Patient: No, I don't. Doctor: Are you married? Patient: Yes, to my wonderful husband. Doctor: That's great, what do you two do for a living? Patient: I'm a social worker, and my husband is a high school chemistry teacher. Doctor: What great work both of you are doing. What kinds of people do you work with as a social worker? Patient: I love it, I work with adult abuse and neglect issues. Doctor: Yes, that's great. Do you have any children? Patient: Yes, we have two sons. Doctor: Do they live at home? Patient: No, they're both grown and on their own now.",Section header: FAM/SOCHX Section text: She has no tobacco use. Only occasional alcohol use. She has no illicit drug use. She has two grown children. She is married. She works as a social worker dealing with adult abuse and neglect issues. Her husband is a high school chemistry teacher. "Doctor: Did both your parents have heart complications. Patient: Unfortunately, yes. My mom passed from a heart attack at seventy three and my father at eighty. Doctor: I'm so sorry to hear that. Patient: I lost my brother as well. He passed away from a brain tumor when he was nine years old. Doctor: I can't imagine how hard that must've been. Patient: It was a dark time in our lives, but we survived it as a family.","Section header: FAM/SOCHX Section text: Father died of MI, age 80. Mother died of MI, age73. Brother died of Brain tumor, age 9." Doctor: I am going write you a prescription for a stimulant. It is called Cylert.,Section header: MEDICATIONS Section text: Cylert. "Doctor: Are you married? Patient: Yes. I have been married for twenty two years. Doctor: Are you working? Patient: No. I am unemployed. I have not completed my collage degree yet. I have been in school for the last two years. Doctor: Keep at it.",Section header: FAM/SOCHX Section text: unemployed. 2 years of college education. Married 22 years. "Doctor: Nurse, do you have a report on my patient? Guest_clinician: I do. She has a two year history of small cell lung cancer, which spread to both femurs, lower lumbar spine, and pelvis. Doctor: Oh, no. Did she get chemotherapy? Guest_clinician: She's had chemotherapy and radiation treatments multiple times. She can't remember how many times she had those treatments because she lost track. She also said she finished a series of ten radiation treatments for pain relief. Doctor: How are her symptoms now? Guest_clinician: She's currently having severe pain. Doctor: I see. Does she have any imaging done? Guest_clinician: She does. A C T scan was done to check for metastasis. Doctor: Thank you, Nurse. I'll go see her now. Guest_clinican: No problem. Doctor: Hello, ma'am. What is the reason for your visit today? Patient: I wanted to see if I could get some treatment for my pain. Doctor: What kind of pain are you having? Patient: I feel like it's a burning feeling? I don't know. I can feel it one spot and then it spreads down. Doctor: I see. Where do you feel the pain? Patient: I feel it mostly on my lower right side of my back. Doctor: Do you feel it anywhere else? Patient: The back of my right leg and knee. Doctor: Would you said the pain radiates down from your back to your knee? Patient: That's it. Radiating. I forgot the word. Doctor: No problem. On a scale from zero to ten, with zero being no pain and ten being the worst pain of your life, how would you rate your back and leg? Patient: They're both a ten. Doctor: Oh, wow. Do you feel pain anywhere else? Patient: Yes. Could you check my feet? Doctor: Let me check them. I'll feel around your left foot. Let me know what you feel. Patient: I feel like the bottom is numb. Ouch. It also feels sharp at times too. Doctor: I see. The nurse stated here that you had some pain spreading to your mid back too. Let me feel it really quick. Let me know how that feels. Patient: Ouch! It hurts a lot. I feel a sharp and dull pain. Most of the time, it's just aching. Doctor: I see. When do you feel like the pain in your body gets the worst? Patient: I'd say when I'm sitting in a car for a long time. Doctor: So, just sitting for long periods of time? Patient: Yeah. When I stand and walk, too. Doctor: Have you ever taken anything for the pain? Patient: I am on a load of narcotics for the pain.","Section header: GENHX Section text: The patient is on my schedule today to explore treatment of the complaints. She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis. She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count. She says she has just finished a series of 10 radiation treatments for pain relief. She states she continues to have significant pain symptoms. Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee. She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times. She complains of some diffuse, mid back pain. She describes the pain as sharp, dull, and aching in nature. She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain. She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking. She is on significant doses of narcotics. She has had multiple CT scans looking for metastasis." "Doctor: Any fever, chills or rigors? Patient: No. Doctor: Any blurring of vision or history of glaucoma or cataract? Patient: No. Doctor: Did you experience any shortness of breath? Patient: No. Doctor: Any stomach discomfort? Patient: No. Doctor: Did you observe blood in your stool or in vomit? Patient: No, nothing like that. Doctor: Okay, good. Did you notice any increase in your urine frequency or urgency? Patient: No. Doctor: Do you feel any muscle weakness or tiredness? Patient: No, nothing of that sort. Doctor: Any known history of arthritis? Patient: Nope. Doctor: And no fever due to any fungal infection or anything, right? Like valley fever? Patient: No, nothing of that sort. Doctor: Any history of pneumonia? Patient: No. Doctor: And I am looking at your chart, so no history of stroke, C V A, or any seizure disorder. Patient: That's correct. Doctor: No thyroid or hormone related problem? Patient: No. Doctor: And you do not have any blood disorders, right? Patient: That is right.","Section header: ROS Section text: CONSTITUTIONAL: No history of fever, rigors, or chills. HEENT: No history of cataract, blurring vision, or glaucoma. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena. UROLOGICAL: No frequency or urgency. MUSCULOSKELETAL: No arthritis or muscle weakness. CNS: No TIA. No CVA. No seizure disorder. ENDOCRINE: Nonsignificant. HEMATOLOGICAL: Nonsignificant." "Doctor: Have you experienced any diarrhea? Patient: Yes. I have been having diarrhea. When I think about it, it started happening around the same time that the mouth sores started. I didn't have any diarrhea today though. Doctor: Have you experienced any episodes of nausea or vomiting? Patient: No. Doctor: Have you noticed any blood in your bowel movements? Patient: No. Doctor: Even though you have been taking the medications without any issue, for about ten years, the methotrexate may be the cause of the mouth sores and the inflammation in the small intestines. These are both common side effects from the use of methotrexate. I am not as familiar with NSAID's causing mouth sores. Aspirin use can cause gastrointestinal upset. I think the most likely cause of the sores is the methotrexate not the use of Aspirin.","Section header: ASSESSMENT Section text: Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems. Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed. She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting. I am not as familiar with the NSAID causing an erosive stomatitis. I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis." "Doctor: Are you on insulin? Patient: Yes. Doctor: Are you on metformin as well? Patient: Yes. Doctor: How about glucotrol? Patient: Yes I take that. Doctor: Are you on lipitor? Patient: Yes.","Section header: MEDICATIONS Section text: Insulin, metformin, Glucotrol, and Lipitor." "Guest_clinician: What was he given in the E R? Doctor: Epi one M G, zero point three M L subcutaneously along with fifty M G of Benadryl intramuscularly. In about fifteen to twenty minutes, he reported his itching had improved. The rash itself faded a little bit and he began to feel a lot more comfortable.","Section header: EDCOURSE Section text: The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly. After about 15-20 minutes he states that itching started to feel better. The rash has started to fade a little bit and feeling a lot more comfortable." "Doctor: Hello, how are you? Patient: I am good, Doctor. Doctor: So, what brings you here today? Patient: Well, I have many medical issues and I see Doctor X for them, but I wanted a second opinion, so he referred me here. Doctor: Yeah, he is a good man! Don't worry we will take care of you. Patient: Thank you. Doctor: So, let me start by getting your medical history. Patient: Sure, I had skin cancer which was treated by removal of that part. Doctor: Okay. Patient: Other than that, I have anemia and an acid reflux problem. I also have history of C O P D. Doctor: Alright. Patient: I also suffer from sciatica which was caused mainly due to my arthritis. Doctor: I see.","Section header: ROS Section text: The patient has multiple medical problems, for which she is under the care of Dr. X. She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease. There is a history of anemia and there is a history of sciatica, which has been caused by arthritis. The patient has had skin cancers, which have been treated with local excision." "Doctor: Welcome back to Sample Clinic, Mister Sample. Patient: Good afternoon, doctor. Doctor: What seems to be the problem today, sir? Patient: I'm having a lot of pain in my right heel. Doctor: How long have you had this pain? Patient: Um, it's been about two weeks now. Doctor: When is the pain the worst? Patient: Honestly, it starts with the first step first thing in the morning. Doctor: Does it get worse throughout the day? Patient: Yes, it gets worse all day with activities. Doctor: What treatments have you had for this? Patient: Well, nothing to date. Doctor: Where is your heel pain? Patient: It's on the right heel, then it's on the inside bottom part of the heel and into the inside of the heel. Doctor: Do you have any change in your medical history since your last visit? Patient: No, it's the same old same old. Doctor: Do you have any flu like symptoms? Patient: Like fever or chills? Doctor: That, or vomiting or headaches. Patient: Oh, no I don't have anything like that. Doctor: What about chest pain or shortness of breath? Patient: Thankfully, no nothing like that.","Section header: GENHX Section text: Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day. The patient states that he is currently doing no treatment for it. He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch. The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath." "Doctor: What is your family medical history? Patient: My family has a high blood pressure. I have a family member that had colon cancer. My daughter has a twitch. They don't know what caused it? Doctor: Okay.","Section header: FAM/SOCHX Section text: HTN, Colon CA, and a daughter with unknown type of ""dystonia.""" "Doctor: Hello Miss Long, I see that you have been referred today by A B C, D O, for a reevaluation. Are you having issues with your hand eczema again? Patient: Yes, it has been flaring. Doctor: Can you confirm your age for the records please? Patient: Sure, I'm twenty nine. Doctor: If I'm not wrong, you are from Vietnam, right? Patient: That's right. Doctor: Are you married? Single or with a partner? Patient: I'm single. Doctor: Are you working somewhere? Patient: No, currently I'm unemployed. Doctor: Okay, since you are an established patient here in our dermatology department, let me just update all your information into the records. Doctor: Okay according to my records we have last seen you here in our office on July thirteenth of two thousand and four. Patient: Yeah, I think so. Doctor: I have previously treated you with Aristocort cream and Cetaphil cream. I also ask you to increase your moisturizing cream and lotion and asked you to wash your hands in Cetaphil cleansing lotion. Patient: I've been doing all that, but now it looks like my eczema is flaring. I have these cracks in my hands and they feel very dry. Doctor: Have you been washing your hands with Cetaphil cleansing lotion? Patient: No, I was using soap. The Cetaphil cleansing lotion was not working. I had a lot of pain and burning sensation whenever I tried to use that. Doctor: It may be because of the fissures. I mean those cracks in your hands. Patient: I have been wearing gloves as much as I can. Doctor: Okay.","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 moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed." "Doctor: Have you been applying Triamcinolone zero point one percent three times a day to your rash? Patient: The one on my left wrist? Doctor: Yes. And Bactroban ointment is also three times a day as needed for your bug bites. Patient: Yep. Doctor: Are you still using Nystatin on your lips once a day as needed? Patient: Uh yeah. I've been using it much less now. Doctor: So let's see, your other medications are the same as of July thirtieth O four with the exception of Klonopin? Patient: Yeah, I mean I'm taking four M G in the morning and six M G at night instead of the six M G and eight M G that was recommended. I feel like I do better with the lower doses.",Section header: MEDICATIONS Section text: She is currently on her nystatin ointment to her lips q.i.d. p.r.n. She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs. Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg. "Doctor: So, I am looking at your reports, you don't have anemia or any other blood disorders. Patient: Well, that's a relief! Doctor: Yeah. Doctor: Let me check your lymph nodes. They are nonpalpable. I don't see any swollen glands or anything. Patient: Great!","Section header: ROS Section text: HEMATOLOGIC/LYMPHATIC:: Normal; Negative for anemia, swollen glands, or blood disorders." "Guest_family: Hi, how are you? Doctor: I am well, how's the baby? I see that he is eight pounds and thirteen ounces, and he was born via…? Guest_family: Yes, C section. Yeah, he is he has never been hospitalized. He was born a week early. Doctor: Okay, I would like to ask you some questions about the pregnancy and other history. Guest_family: Yes, sure go ahead. Doctor: Great, have you had any infections during pregnancy like G B S or S T D infections? Guest_family: No, I haven't, I only had thumb and toenail infections and we treated that with rubbing alcohol. We have a history of boils in the family, so I am not afraid of minor infections like this. Doctor: Did you smoke during pregnancy? Guest_family: Yes, I did, but stopped after five months. Doctor: Sir, have you had any S T D while she was pregnant? Guest_family_2: No, I was not diagnosed with anything unusual. Doctor: Great, so looks like you were discharged in forty eight hours and no more hospital stays for you. Guest_family: That is correct.","Section header: GENHX Section text: The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far." "Doctor: Welcome to the clinic, sir. I am Doctor Jones. Patient: Thank you. It is nice to meet you. Doctor: Do you use tobacco products? Patient: Yes. I smoke cigarettes. I am working on quitting. Doctor: I am glad you are attempting to quit. We have a lot of tools now to help with cravings. How much do you smoke per day now? Patient: I smoke about a pack a day. Doctor: Do you drink alcohol or use recreational drugs? Patient: I drink but I don't do any drugs. Doctor: How many alcoholic drinks do you consume per week? Patient: I drink about four drinks per night. I used to drink a lot more than that. I have cut back on my drinking. Doctor: Are you physically active? Do you exercise? Patient: I was very athletic when I was growing up. Now I don't exercise on a regular basis. Doctor: What do you do for employment? Patient: I am a network engineer. I work for Shepherd Pratt. Doctor: Are you married? Patient: Yes. I have been married to my wife for five years now. Doctor: Do you live at home with your wife and or is there anyone else living in your home? Patient: No. Just me and the wife.","Section header: FAM/SOCHX Section text: He lives with his wife. He works at Shepherd Pratt doing network engineering. He smokes a pack of cigarettes a day and is working on quitting. He drinks four alcoholic beverages per night. Prior to that, he drank significantly more. He denies illicit drug use. He was athletic growing up." "Doctor: Are you married? Patient: I'm divorced. Doctor: So, do you live alone? Or do you have kids? Patient: I live with my girlfriend, and we have a kid together. I also have three other kids from my former wife. Doctor: Do you smoke? Patient: I used to smoke. But I, I've quit like fifteen years ago. Doctor: What about alcohol? Patient: Yeah, I drink beer. Around one to two beers a day. Doctor: Are you working? Patient: I'm retired right now, but I used to work in an iron company.",Section header: FAM/SOCHX Section text: Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker. "Doctor: Do you want to go home? Patient: Yes, I do. Can I? Doctor: Yes, you sure can.",Section header: DISPOSITION Section text: To home. "Doctor: Are you studying? Patient: Yes. I'm doing my major in computer science. Doctor: Do you live alone? Patient: No, I live in my family. Mainly my parents and my sisters.",Section header: FAM/SOCHX Section text: lives with parents and sisters. "Doctor: Have you ever had surgery before? Patient: No, not that I know of. Doctor: So, no gallbladder removal, or joint replacements? Patient: Unless they did it while I was sleeping, but none that I can remember.",Section header: PASTSURGICAL Section text: No previous surgeries. "Doctor: I remember you had mentioned that one of your family members had bone cancer. Are there any other medical problems that run in your family? Patient: Sadly, yes. Stroke and dementia are the other two big ones. Doctor: I'm sorry to hear that.","Section header: FAM/SOCHX Section text: stroke, bone cancer, dementia." "Doctor: Are you allergic to any meds? Patient: Me? Doctor: Yes. Patient: No, I am not. Doctor: Are you sure? Patient: Yes, I am damn sure. Doctor: Okay great!",Section header: ALLERGY Section text: None known to medications. "Doctor: What's bringing her in today? Guest_family: Oh, doctor. She hasn't been doing well at all. Guest_family: I think she's actually gotten worse. Doctor: I understand. I'm sorry to hear that she hasn't been feeling well. Let me see what we can do for her today. Guest_family: I haven't taken her temperature since this morning. It was one hundred and three degrees when she woke up. Doctor: What time did she wake up today? Guest_family: Um, around eight I believe. She also suffers from apnea. Doctor: It looks like she has an upper respiratory infection. Guest_family: Is she going to get better? Doctor: Yes, she should feel better once we start treating the infection. But I'm worried it may be pertussis.","Section header: DIAGNOSIS Section text: Upper respiratory illness with apnea, possible pertussis." "Doctor: And you've had recurring abscesses for the past two years, correct? Patient: Unfortunately, yes. Doctor: Where have they been located? Patient: Um in the public area and my thighs. Doctor: Have you ever needed to get an abscess drained? Patient: Yeah. I've gotten about four I and D's.","Section header: CC Section text: Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years." "Doctor: How's your overall health? Patient: Fine, I guess. I'm being treated for I B S by my G I. Last time I was in, they told me that my white blood cell levels aren't where they were supposed to be.",Section header: PASTMEDICALHX Section text: Episodic leukopenia and mild irritable bowel syndrome. "Doctor: Do you have any family history of chronic illnesses that I should know about? Patient: What do you mean by that? Doctor: Well, it could be anything from depression, to arthritis, to cancer. Patient: Oh yeah, my mom has arthritis.",Section header: FAM/SOCHX Section text: Patient admits a family history of arthritis associated with mother. "Doctor: How are you moving around? Are you able to perform your day to day activities? Patient: Little bit, not so much. Doctor: So just listen to your body and go around as much as you can. Patient: Okay. Doctor: Do not overstress yourself. Patient: Okay I can do that.",Section header: PLAN Section text: As tolerated. "Doctor: Are you allergic to anything? Patient: No, I am not allergic. Doctor: Okay. Patient: Yeah.",Section header: ALLERGY Section text: No known drug allergies. "Doctor: Remind me, how did he hurt himself? Guest_family_1: He was riding quads on October tenth two thousand seven when he got thrown off. Doctor: Yes, and we did O R I F on his fracture dislocation of the left elbow. Guest_family_1: Yes, he also fractured the neck of his right glenoid, um, if I remember correctly. Doctor: Which hand does he write with? Guest_family_1: He writes with his right hand. Doctor: Okay. That fracture appears to have healed very well; kids generally heal pretty well. How does it feel today? Guest_family_1: Yes, he's only ten. He's been pretty stiff, so he's been going to P T, and using his Dynasplint. Doctor: That's good that he is already in P T. His left elbow fracture is healed, so we should do another surgery in order to remove that hardware. That may help decrease some of the irritation with elbow extension. He looks neurologically intact in terms of movement and reflexed in his wrist and hand. Guest_family_1: Yes, I agree. What is the risk of infection of this surgery? Doctor: Historically, the risk of infection is less than one percent. Guest_family_1: Oh, wow, that's low, how is that possible? Doctor: We'll use prophylactic antibiotics, this controls for infection, and helps keep everything clean. Other Risks include bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, and continued postoperative stiffness. Guest_family_1: Wow, that's great, will be he asleep the entire time? Doctor: Yes, we'll use anesthesia, he won't feel a thing. Guest_family_1: Will this fix his pain, for sure? Doctor: I can't guarantee it, he may still be in some pain. Guest_family_1: Okay, what about you, dear? What do you think? Guest_family_2: Yeah, I think we should do it, boys should be playing sports with their friends.","Section header: GENHX Section text: The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007. The patient underwent open reduction and internal fixation of his left elbow fracture dislocation. The patient also sustained a nondisplaced right glenoid neck fracture. The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint. The patient is neurologically intact distally. Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware. Risks and benefits of the surgery were discussed. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness. All questions were answered and the parents agreed to the above plan." "Doctor: Since you have a family history of coronary heart disease, let me check you for its risk factors. Patient: Yeah, my father had it. Doctor: Any history of high blood pressure or diabetes? Patient: No. Doctor: How about smoking, do you smoke? Patient: No, I don't smoke. Doctor: And in the past, did any other Doctor mention that you might have sign or symptom indicating that you may have coronary artery disease? Patient: No. Doctor: Okay.","Section header: GENHX Section text: CORONARY RISK FACTORS: No history of hypertension or diabetes mellitus. Active smoker. Cholesterol status, borderline elevated. No history of established coronary artery disease. Family history positive." "Doctor: Who all are there in your family? Guest_family: It's me, my husband, my two older kids and this little baby. Doctor: Everyone living together? Guest_family: Yes Doctor: Is she going to any daycare? Guest_family: No, she's at home all the time.","Section header: FAM/SOCHX Section text: Currently lives with her mom, dad, and two siblings. She is at home full time and does not attend day care." "Doctor: Do you drink? Patient: Oh, I do but occasionally. Who doesn't like a nice cocktail! Doctor: Okay. How about cigarettes, do you smoke? Patient: No, I don't smoke.",Section header: FAM/SOCHX Section text: The patient does not smoke. She does have an occasional alcoholic beverage. "Doctor: I am okay. Patient: I have bad nausea. Doctor: Oh, so sorry. Patient: And I feel very dizzy like I am going to faint. Doctor: Okay let me see what is going on. Patient: Okay.",Section header: CC Section text: Nausea and feeling faint. "Doctor: What brings you into the office today? Patient: I had a stroke about a month ago. The right side of my face is still not moving. Doctor: Is it only the right side of the face that is affected by paralysis? Patient: Yes. It has improved a little bit since I was in the hospital. Doctor: That is a good sign. It can take up to six months see how much movement you will regain.",Section header: CC Section text: Right-sided weakness. "Doctor: Do you use tobacco? Patient: What, like smoke cigarettes? Doctor: Yes ma'am, do you? Patient: Oh, no. I don't do anything like that.",Section header: FAM/SOCHX Section text: She is a nonsmoker. "Doctor: Have you ever had surgery, ma'am? Patient: Yes, I had it for melanoma some time ago. Doctor: I see here that you had a hysterectomy as well, is that correct? Patient: Oh, yes, that's true. I had that done too.",Section header: PASTSURGICAL Section text: Surgery for melanoma and hysterectomy. "Doctor: So, let's see here. You don't recall anyone in your family having a history of neuromuscular diseases, correct? Patient: No, no one I can think of. Doctor: Do you know of anyone who has had foot deformities or neuropathy in their arms or legs? Patient: No, not one person comes to mind. Doctor: Great. Does anyone in your immediate family have a high arch? Patient: No, at least no one that I know of. Doctor: And you said that your aunt or sister has type two diabetes? Patient: My aunt. She's had it for some time now.","Section header: FAM/SOCHX Section text: There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases. His aunt has a history of type II diabetes." "Doctor: So, what I feel is you might have short term memory loss due to high stress, but I also feel it's probably due to your current situation. The other impression I have is that you have anxiety issues and again it's stress related. Patient: Yeah, I do have anxiety issues.","Section header: ASSESSMENT Section text: 1. Short-term memory loss, probable situational. 2. Anxiety stress issues." "Doctor: Who's my patient today? Guest_family: Today, it's my brother. Doctor: What seems to be the problem today? Guest_family: Well, he's a vegetarian but he has high cholesterol and he's on a medication to control it. Doctor: Has he changed his diet? Guest_family: Yes, he did when he got a letter saying that his fat levels were high in the blood. Doctor: What kinds of foods did he eliminate? Patient: Oh, you know, all of the fun ones. Like cappuccino, quiche, crescents, candy, vending machines, all of that stuff. Doctor: Do you take your lunch to work? Patient: Yes, I do about three or four times a week instead of eating out so much. Doctor: Are you exercising right now? Patient: Yes, I do about six or seven days a week. Doctor: What kind do you like to do? Patient: Well, I do just about everything. I swim, I bike, run and then I lift weights. Doctor: How long do you workout per day? Patient: Usually, it's about one and a half to two and a half hours every day. Doctor: Good, are you training for anything specific? Patient: Actually, yes I'm going to do a triathlon. Doctor: Can I assume you're losing weight? Patient: Yes, I am.","Section header: GENHX Section text: His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts." "Doctor: The patient has possible free air in their diaphragm. Guest_clinician: How old is the patient? Doctor: Seventy six. Guest_clinician: Past medical history? Doctor: Unknown as of now.",Section header: CC Section text: Possible free air under the diaphragm. "Doctor: Out of ten, ten being the worst pain imaginable, how would you rate your pain today? Patient: Today it's about a six or seven, and it's usually pretty constant there. Doctor: Does the pain change with the weather? Patient: Yes, when it's cold out it turns to ten out of ten. It's better when it's warm out. Doctor: Does the pain change throughout the course of the day? Patient: Yes, it progressively gets worse and worse as the day goes on, but I also have a pretty hard time getting out of bed in the morning, too. Doctor: Out of ten, how would you rate your pain at night? Patient: Oh, it's ten out of ten. Doctor: Does the pain wake you up at night? Patient: If I sleep at all. I'm not sleeping well at all, and when I do it's for less than an hour at a time. Doctor: Are there any activities that really aggravate the pain? Patient: Yes, if I sit for more than about twenty minutes, or if I lay flat on my back. Doctor: Does anything alleviate the pain? Patient: Laying on my side helps a little.","Section header: GENHX Section text: The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather. The patient states that pain is dramatically less, when the weather is warmer. The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning. The patient states that she does not sleep at night well and sleeps less than one hour at a time. Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back. Easing factors include side lying position in she attempts to sleep." "Guest_family: For as long as I have been taking care of her, she has had this tracheal tube and she barely speaks. She mostly signals if she needs anything. Doctor: Okay. It's mentioned in her report that she has a history of smoking. Guest_family: She is nodding yes. Doctor: Well, it's alright. I think it's going to be difficult taking any past medical information from her.",Section header: FAM/SOCHX Section text: The patient had been previously a smoker. No other could be obtained because of tracheostomy presently. "Doctor: Have you been taking anything for high blood pressure? Patient: Yeah, I started taking Toprol and uh the one that starts with an A. I forget what it's called. Doctor: Hm are you talking about Avalide? Patient: Oh right, yeah that's the one.",Section header: MEDICATIONS Section text: Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned. "Doctor: Good afternoon, ma'am. Before we begin, may I ask how old you are? Patient: Good afternoon, doctor. I'm fifty six years old, now. Doctor: Great, thank you. What seems to be the problem today, ma'am? Patient: Well, I need some support for dietary recommendations for healthy eating for my husband and me. Doctor: Why would that be, ma'am? Patient: Um, I have a lot going on, high cholesterol, high blood pressure, acid reflux, and I just want to lose some weight. My husband has high cholesterol too. Doctor: Tell me more about your eating habits, please. Patient: Well, we live by ourselves now that our children are gone, but I'm used to cooking really large portions. Doctor: Are you struggling to make food for just two people? Patient: Yes, that's a good way to put it. I'd like to just make less food, that way we're not so tempted to eat so much. Doctor: I understand, are you busy, do you work? Patient: Well, I start a new job this week.","Section header: GENHX Section text: This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendations to assist both of them in healthier eating. The two of them live alone now, and she is used to cooking for large portions. She is having a hard time adjusting to preparing food for the two of them. She would like to do less food preparation, in fact. She is starting a new job this week." "Doctor: Hello! What brings you into the office today? Patient: Hi! I have not been able to go pee, and I have had this sharp pain in my left side. Doctor: Have you recently had any surgical procedures? Patient: No. Doctor: Do you have a history of an enlarged prostate or kidney stones? Patient: No. Doctor: I would like to get some imaging done. Patient: Okay.",Section header: CC Section text: Left flank pain and unable to urinate. "Doctor: Has he ever had any mental retardation problems in the past? Guest_family: No. Doctor: Did he go through mainstream education? Guest_family: Yes, he graduated high school last year. He had an I E P. He has a job now. Doctor: Oh really. That's great. Guest_family: We went through a program for the disabled to find him the job. He is doing well. Doctor: What is the job? Guest_family: He works at cardboard shop. Doctor: So, he is ambulatory. No issues with performing the work. Guest_family: No! His boss said he is doing very well.","Section header: FAM/SOCHX Section text: Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled." "Doctor: And you are- Guest_family: Hi, I am her nurse. Doctor: So, do you know about her past medical history? Guest_family: I have very limited information, as I very recently started working with her. She does have dementia and that's the main reason why I was hired. Her family wanted someone to look after her twenty four seven. Doctor: Oh, I see. Guest_family: But I do have her medical records. You can have a look. Doctor: Yeah, that will be nice. Let me check her reports quickly. She has a history schizophrenia, chronic anemia and hypothyroidism and she also suffers from asthma. Guest_family: Yes. Doctor: Oh, I also see here she tested positive for P P D, was she diagnosed with tuberculosis? Guest_family: I honestly don't know, but I wasn't told that. Doctor: Okay.","Section header: PASTMEDICALHX Section text: Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past." "Doctor: Your last visit was on April seventh two thousand five, correct. Patient: Ah no, it was on April eighth two thousand five, doctor. Doctor: That's right. So, has anything changed since then? Patient: No, everything is the same really.",Section header: PASTMEDICALHX Section text: Essentially unchanged from my visit of 04/08/2005. "Doctor: Any nausea, vomiting or diarrhea? Patient: Nope.","Section header: ROS Section text: No nausea, vomiting, or diarrhea." "Guest_family: What do you think doctor, what does she have? Doctor: Well, I think she has hay fever. Otherwise she looks like a healthy two year old. Guest_family: Hm, okay.",Section header: ASSESSMENT Section text: Allergic rhinitis. Otherwise healthy 2-year-old young lady. "Doctor: Hello, sir. I'll be your doctor today. How are you feeling? Patient: Um uh who? Where am I? Doctor: You're in the emergency room. Patient: I'm where? Doctor: The police found you outside of the local bar. Do you remember what happened prior to your arrival here? Patient: I'm no longer at the bar? Doctor: No, you're here because someone was worried you may need medical attention. Patient: I don't know what's going on. Can you call my girlfriend? She was there with me before we got into a fight.",Section header: ROS Section text: Not obtainable as the patient is drowsy and confused. "Doctor: How's your husband doing? Patient: He's good. He usually comes with me to my appointments, but he had to run some errands this morning. Doctor: Happy to hear that he's also doing well. Patient: Me too. Doctor: I just have one more question for you regarding your social history. Do you smoke? Patient: No, never. Doctor: Okay, so no changes.",Section header: FAM/SOCHX Section text: She is married. She is a nonsmoker. "Doctor: How are you feeling today? Patient: I am doing good, considering. Doctor: Are you sleeping well? Patient: Yes. I was able to get some good sleep last night. Doctor: Have you been able to eat without any trouble? Patient: Yes. I ate a little bit of breakfast this morning. Doctor: Have you been able to have a bowel movement yet? Patient: Yes, I did this morning. Doctor: Did you experience any difficulties with your movement? Patient: It was still a little difficult and hard. Doctor: Okay. Continue the high fiber diet that we discussed, and it should improve. Please let me or one of the nurses know if it has not improved or becomes worse.","Section header: ROS Section text: The patient has been eating fairly well, sleeping well, doing well with her sprints. A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI." "Doctor: Our records show that he is up to date with his vaccinations. Guest_family: Okay.",Section header: IMMUNIZATIONS Section text: Up-to-date. "Doctor: Are you allergic to any medications? Patient: No",Section header: ALLERGY Section text: None. "Doctor: So, do you remember when your last pap smear was? Patient: I have it written down right here in my notes. It was in October of two thousand one. Doctor: Great, do you have any children? Patient: Yes, I have a beautiful daughter. Doctor: That's wonderful. Have you only been pregnant once? Patient: Yes, I've just pregnant once and it was with my daughter.",Section header: GYNHX Section text: Last pap performed 10/2001. Gravida: 1. Para: 1. "Doctor: Have you undergone any surgeries? Patient: I had both my tubes tied in O one and I had a polyp removed when I was fourteen. Doctor: And that was a- Patient: Oh, sorry I didn't mean to interrupt. Doctor: It's alright. I just wanted to know if that polyp was found in your colon? Patient: Yes, it was.","Section header: PASTSURGICAL Section text: Bilateral tubal ligation in 2001, colon polyp removed at 14 years old." "Guest_family: Doctor can you check my baby boy? Doctor: Yes for sure. Guest_family: He has a fever.",Section header: CC Section text: Fever. "Doctor: Where's your rash? Patient: All over my torso and arms. Doctor: When did you first notice it? Patient: Well, it started on my back and then it made its way to my torso and arms. Doctor: Have you found yourself itching it? Patient: Yes. Doctor: Any potential triggers for the rash, such as dietary changes, new medications, or unfamiliar exposures? Patient: Nope. I mean I did remove some insulation in my basement a few days ago, but I didn't feel itchy that day. Doctor: Any shortness of breath, wheezing, facial swelling, tongue or lip swelling, or other associated symptoms? Patient: No.","Section header: GENHX Section text: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheezing, or other associated symptoms. He cannot think of anything that could have triggered this off. There have been no changes in his foods, medications, or other exposures as far as he knows. He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day." "Doctor: Are you allergic to anything? Patient: As in drugs? Doctor: Yes, sorry. I was referring to drug allergies. Patient: Oh yeah. I'm allergic to Sulfa drugs. Doctor: What happens when you take Sulfa drugs? Patient: Break out in a terrible rash. I remember I had to go to the E R the first and last time I took it. Doctor: Wow, I'm sorry. Rashes can be very uncomfortable and sometimes require immediate attention. Patient: Yeah, so no more Sulfa drugs for me. That's for sure.",Section header: ALLERGY Section text: Sulfa. "Doctor: Do you smoke? Patient: Yes. Doctor: How much do you smoke? Patient: Honestly, I smoke every day.",Section header: FAM/SOCHX Section text: The patient current smokes. "Doctor: Does any of your family member have any major medical problems? Patient: Yeah, my mother died of heart attack. She was seventy years old. My father died of cancer; it was prostate cancer. He was around eighty. Doctor: Anything anyone else? Patient: Hm, my brother had both heart disorder and prostate cancer and he died around seventy four.","Section header: FAM/SOCHX Section text: Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74." "Doctor: Where's your pain? Patient: Right above my belly button. It's been bothering me for three weeks now. Doctor: Does the pain come and go? Patient: Um it's pretty constant, but it does seem to get worse at night. Doctor: Do you find that sitting or laying down in certain positions helps the pain? Patient: Eh not really. I can't seem to really get comfortable since it started. Doctor: Have you taken any medicine for the pain? Patient: I uh- Doctor: Yes? Patient: Um I took Pepto Bismol a few times, but that didn't do much. Doctor: Did they already take you back for your C T scan? Patient: Yeah. Doctor: We should be getting the results of your scan fairly soon then. In the meantime, I'm going to put in some additional orders.",Section header: CC Section text: Abdominal pain and discomfort for 3 weeks. "Patient: Good morning, doctor. Doctor: So, I've reviewed your past notes, are there any other diagnoses I should know about? Patient: Well, I've had depression for a while now. Doctor: Thank you for sharing that with me.",Section header: PASTMEDICALHX Section text: Depression "Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: So, what do you do for a living? Patient: Right now, actually, I'm not working. Doctor: That's okay, I'm not here to judge. Are you married? Patient: No, I'm happily single right now. Doctor: Good for you, do you have any kids? Patient: No, I don't have any, its just me. Doctor: Do you drink or smoke? Patient: No, I don't do any of that. Doctor: Good, and do you use anything harder? Like illicit drugs? Patient: No, I absolutely do not. Doctor: Good, and with ten being the most stressful day every, how would you rate your stress level out of ten? Patient: Today, I'd say its about an eight out of ten.","Section header: FAM/SOCHX Section text: The patient is not working. Rates her stress level as an 8/10. She is single with no children. Does not smoke, drink, or utilize illicit substances." "Doctor: Hello. How are you doing today? Patient: My head has been hurting a lot. Doctor: I see. Did the nurse come in and ask you questions about past medical history? Guest_clinician: Sorry, Doctor. I was looking for you. I reviewed his history with him, and nothing has changed. Doctor: Perfect. Let's do some tests to see why your head has been hurting. Patient: I'm ready for less pain. Let's go.",Section header: PASTMEDICALHX Section text: otherwise unchanged. "Doctor: We're going to check around your knee now. Patient: Okay, sounds good. Doctor: Looks like your deep tendon reflexes are the same on both legs. Sensation seems great and intact.",Section header: EXAM Section text: NEUROLOGIC: Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch. "Doctor: Can you tell me something about your family? Any illnesses in family? Patient: My dad's mom has diabetes and hypertension and my dad's dad had emphysema and he was a smoker. Doctor: Okay. Patient: Yeah. Doctor: Is there any history of death of child who was less than a year maybe? Patient: No, there isn't. Doctor: Okay. That's great. No illnesses for small children? Patient: No.","Section header: FAM/SOCHX Section text: Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age." "Doctor: Alright, I am looking at your urine report and it confirms what I was suspecting. You have a urinary tract infection. Patient: I kind of knew it was a U T I. I have had it before, but nothing this painful and severe. I feel like I am going to die! Doctor: Oh yes, it is because you got something called as acute cystitis and its usually very painful and can cause some serious complications. Patient: Well, is it because of my diabetes? Doctor: I am afraid I don't have better news for you, but your diabetes is out of control. It's way too high and you must be really careful. Are you taking your medicines? Patient: Yes! Doctor: How bout diet? Patient: Yeah, sometimes I don't care about my diet. Doctor: Well, you must watch your diet, you can't just be careless. I am going to change your diabetes medication. And let's start you on the antibiotic that should give you relief. Also stay hydrated drink plenty of fluids it will help you flush the infection out. Patient: Alright, thank you! Doctor: Take care.",Section header: ASSESSMENT Section text: Diabetes type II uncontrolled. Acute cystitis. "Doctor: Good morning, ma'am. Patient: Good morning, doctor. Doctor: Before we begin, I just have a few questions. Do you remember what illnesses you had as a child? Patient: Yes, I got a few. I had strep throat, mumps, and, um, chickenpox growing up.",Section header: PASTMEDICALHX Section text: Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox "Doctor: Hi there! I am Doctor Sherman. Patient: Hello! It is nice to meet you. Doctor: It looks like your P C P sent you to us for a possible prostate problem. Patient: Yes. I am nervous. Doctor: Do not be nervous. We will start with discussing the symptoms you have been experiencing, a physical exam and then we will get a urine sample if you are able. Patient: Okay.",Section header: CC Section text: Urology. "Doctor: What are you taking for allergies? Patient: Claritin. Doctor: Okay. Patient: For my allergic rhinitis.",Section header: MEDICATIONS Section text: Claritin for allergic rhinitis. "Doctor: Do you have any known allergies to medication? Patient: Nope. None that I know of.",Section header: ALLERGY Section text: None. "Doctor: What is your family medical history? Patient: My dad had a heart attack and passed away at sixty one. Doctor: I am so sorry to hear that. Patient: Thank you. Doctor: Do you know of any other major health conditions in your family? Patient: No. None that I know of. Everyone is relatively healthy. Doctor: That's good.","Section header: FAM/SOCHX Section text: Father died, MI age 61." "Doctor: Hello, sir how are you feeling today? Patient: I feel terrible. Very sick and I can barely move. I feel so weak.",Section header: GENHX Section text: The patient states that he feels sick and weak. "Doctor: So, we looked at your previous blood work results, now let me see what these reports say from today's C B C exam. Patient: Sure. Doctor: Okay so your hemoglobin levels look within range, white counts are thirteen point three, then seven point six lymphocytes and twenty six thousand platelets. Doctor: Okay? Patient: Okay.","Section header: IMAGING Section text: The patient's CBC results from before were reviewed. Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000." "Doctor: Welcome back. Patient: Thank you. Doctor: You are back for a follow up on your right arm pain, right? Patient: Yes. It has been almost a year since the pain first started. Doctor: How has your arm been feeling? Patient: I still have this dull pain in my upper outer area of my arm. Doctor: How long does the pain last? Patient: It was coming and going, but now the pain is more persistent since I last saw you. It is still happening every day. Doctor: Remind me again. You are right handed. Right? Patient: Yeah. It makes is hard to do things with the persistent pain. Doctor: I bet it does. Are you experiencing any numbness or tingling sensation in your arm or hand? Patient: No, but I have had this achy sensation in my hand radiating down to my fingers. Doctor: Do you have a history of any other neck or shoulder injuries? Patient: It is not from a specific injury but I have had this neck pain for thirty years. Doctor: Did you see anyone for the neck pain? Patient: Yes. I saw someone for it in two thousand and six, and then I developed this ear pain. They could not figure out what was going on so eventually I was sent to have an M R I of my neck and upper spine, which showed some degenerative changes. Then I was referred to Doctor X who was treating me for neck pain. He gave me steroid injections. Doctor: Are you still seeing Doctor X for the epidural injections? Patient: Yes. I have been seeing him since two thousand and seven. Doctor: How old are you? Patient: I am fifty eight. Doctor: Are you experiencing any symptoms from receiving the injections? Patient: Those are for neck pain. My arm pain recent. I have been having the injections for a while now, without any trouble. Doctor: What medications have you been taking for the pain? Patient: There are a few of them that I take. I gave the list to the nurse. Doctor: Okay. Patient: I also have taken several Medrol packs. They make my blood sugars to increase so I try not to take it. Doctor: Okay. Does the pain prevent you from doing your daily activities or decrease your quality of life? Patient: No. I can do everything like normal, but constant nagging pain does get to me at times.","Section header: GENHX Section text: The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain. He states that a little less than a year ago he developed pain in his right arm. It is intermittent, but has persisted since that time. He describes that he experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm. He has had a 30-year history of neck pain. He sought medical attention for this problem in 2006, when he developed ear pain. This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes. He was then referred to Dr. X for treatment of neck pain. He has been receiving epidural injections under the care of Dr. X since 2007. When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain. He also has taken several Medrol dose packs, which has caused his blood sugars to increase. He is taking multiple other pain medications. The pain does not interfere significantly with his quality of life, although he has a constant nagging pain." "Doctor: What type of surgery have you had in past? Anything big or small? Patient: I had a C section for my kiddo and one D and C. Doctor: Okay.",Section header: PASTSURGICAL Section text: C-section and D&C. "Doctor: Are you currently taking any medications? Patient: No.",Section header: MEDICATIONS Section text: None. "Doctor: So are you allergic- Patient: To any medications? No allergies here.",Section header: ALLERGY Section text: No known medical allergies. "Doctor: Hello again! Patient: Hi! Doctor: The results from you M R I showed nothing concerning. The growth factors were normal with normal cell function and no signs of decreased blood supply to the brain. Patient: That's great news. Doctor: Yes it is.","Section header: FAM/SOCHX Section text: GF with CAD, otherwise unremarkable." "Doctor: So, I understand that you had a fall. Patient: Yes. I did fall. Doctor: What happened? Patient: I don't really know. I have balancing problems. I have been to my P C P for this issue a few days ago. I saw her about a week and a half ago because I had another fall. Maybe around late December since today is January seventh. I have been having trouble with my right hand. It is like I am clumsy on my right side. I ended up falling because my right hand missed the railing when I grabbed it to head up the stairs. Doctor: Are you left or right handed? Patient: Right. Doctor: Can you tell me a little bit more about the trouble that you are having with the right hand? Is it localized to the right hand? Patient: Yes, it is only on my right side. It is like the right side of my body is weak and it has been getting worse. Doctor: How long has this issue been progressing for? Patient: About two years. Doctor: Have you experienced any blurred vision or visual disturbances? Patient: Yes. Every once and a while. Doctor: How old are you? Patient: I just turned fifty eight last week. Doctor: Happy belated birthday! Patient: Thank you! Doctor: Did your P C P have any bloodwork or imaging done? Patient: Yes, she did. She did both. She said she would send my records over. Doctor: Oh. I see it here! Did Doctor Madison discuss the results of your H C T and the M R I yet? Patient: No. Doctor: Okay. The results showed clinoid masses. This explains that problems that you have been having with your right side, your balancing problems, and the visual disturbances. With only the M R I I cannot tell if the masses are malignant or not. Patient: So, are the masses cancer? Doctor: I don't know yet. I will have to run some more tests and potently have to do a biopsy. Patient: Okay.","Section header: GENHX Section text: This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses." "Doctor: Do you smoke? Patient: Yes, I do. Doctor: How much? I mean can you tell me approximate amount? Patient: Yes sure, I smoke half a pack a day. Doctor: How about alcohol and drugs? Patient: No, I do not drink or use. I have a five month old baby.",Section header: FAM/SOCHX Section text: She had a baby five months ago. She smokes a half pack a day. She denies alcohol and drug use. "Doctor: With ten being the worst pain imaginable, how would you rate your pain today out of ten, ma'am? Patient: Well, out of ten, I'd say it's about a seven. Doctor: How would you describe your pain? Patient: Um, I'd say it's deep, and it really aches. Doctor: Where is your pain located? Patient: It's in my right lower back, and then into my butt. Doctor: What activities make your surgery worse? Patient: I can't go up and down stairs without a lot of pain, and it hurts when I sit for a long time, like when I drive. Doctor: Before this pain, how would you describe your activity level? Patient: I was very active before all this started. Doctor: Are you able to do any of your prior activities? Patient: Not really, I'm having a lot of problems with stuff around the house, like all the chores and projects I used to be able to do.","Section header: GENHX Section text: The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse. The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region. Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects. The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete." "Doctor: Welcome in! Patient: Thank you. Doctor: Let us get a little background. What is your medical history? Patient: I have some memory loss problems. Doctor: What kind of memory problems? Patient: Well, I have seizures. Doctor: Do you know what kind of seizures that you have? Patient: I have temporal lobe seizures. Doctor: Do you have any other health conditions? Patient: I also have high blood pressure. Doctor: Okay.",Section header: PASTMEDICALHX Section text: Significant only for hypertension and left temporal lobe epilepsy. "Doctor: Did you have any medical issues? Patient: Nope. Doctor: What about surgery. Patient: No, I never had a surgery.",Section header: PASTSURGICAL Section text: She has undergone no surgical procedures. "Doctor: How old are you? Patient: I am seventy three. Doctor: Are you right handed or left handed? Patient: Right. Doctor: So, I see the chief complaint is memory loss and cognitive decline. Tell me what exactly happened, and how did you notice the symptoms? Let me document that today is January twelfth of nineteen ninety five. Guest_family: We noticed it the week prior to Thanksgiving last year in nineteen ninety four. We have a family tradition where we play a game and this time, we were taking her to Vail, Colorado to play ""Murder She Wrote"" at one of our family gatherings. She was chosen to be the assassin. Doctor: Okay. Guest_family: Kids played a trick with her and they hid a plastic gun, a toy gun in her luggage. As she walked through the security, the alarm went off and like within seconds she was all surrounded, and everyone was like panicked. There was so much panic, they searched her and interrogated her and what not. Eventually she and her family made it to the flight, and she seemed unusually frustrated and disoriented by all that. Previously, if any such incident would have happened in the past, she would just have like chuckled and brushed it off. And we all would have sat together and laughed about it. This time it was different. Doctor: I can see why she was frustrated. Anyone can be in such situations. Guest_family: When we were in Colorado, she seemed slow. She had difficulty reading her lines to her part when we were playing that game. She needed assistance to complete the whole game. Doctor: Was she slurring? Guest_family: Nope. Doctor: Was there any difficulty with vision? Or any weakness? Guest_family: Nope. Nothing that we noticed. Doctor: How was it after returning from there? Guest_family: She returned to work. She used to work in a local florist shop. She returned on the Monday following Thanksgiving. And she had difficulty. Patient: I was not able to take on with my usual task of flower arrangements or dealing with the cash at the cash register. Guest_family: She quit the next day, and she never went back. Doctor: How was it after that? Guest_family: She seemed to be doing fine and stable throughout November and December, and we were visiting a local neurologist as well, who was evaluating her. He did a few blood tests and did uh, M R I of the brain. He gave us all clear. He said there's nothing there. Doctor: Yeah, I see the working diagnosis of dementia of the Alzheimer's Type. When did these symptoms increase? Like when did you started noticing them more? Guest_family: One or two weeks ago, so end of December nineteen ninety four, she got lost in her own home. She was getting more sensitive and started saying that she is becoming a liability for everyone, which is not at all like her. Her walking was affected. She started walking like a bended form and also started veering to the right. She also did not recognize the location of where people were talking to her.","Section header: GENHX Section text: This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94. Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play ""Murder She Wrote"" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the ""assassin."" Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a ""chuckle."" While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing ""Murder She Wrote."" She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time. She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back. Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was ""Dementia of the Alzheimer's Type."" One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her." "Doctor: You are not allergic to anything? Patient: No, I am not. Doctor: Any food or other pollen? Patient: No, I am not allergic to anything. Doctor: Great!",Section header: ALLERGY Section text: None. "Doctor: April twenty two three we checked your list of medications. Doctor: We saw that it lifts up in the morning and evening. Doctor: Yeah. Patient: Yeah.",Section header: MEDICATIONS Section text: Her list of medicines is as noted on 04/22/03. There is a morning and evening lift. "Doctor: How old is the baby? Guest_family: He is twenty one months old. Doctor: What brings you here today? Guest_family: I have concerns about his motor development. Many times he seems to have lazy eyes and sometimes I can notice his jaw quivering. Doctor: How was your pregnancy? Guest_family: I had no complications in my pregnancy with him. My labor was very spontaneous, and it was a normal delivery. Doctor: Is this the only child? Guest_family: No, I have two more kids. Doctor: How much did he weigh at birth? Guest_family: He was around eight pounds and ten ounces. Doctor: Did you remember his milestones? Guest_family: Yes, I have all of it written down for all of my three kids and I brought this with me. He sat on his own by seven months. He was able to stand by eleven months and crawled around sixteen months but he was not walking until eighteen months. Doctor: What issues are he facing right now? Guest_family: He falls a lot. He cannot walk properly. He is kind of in toeing on his left. He's able to feed himself properly. He also throws, um, he picks up the things and throws them. His upper body looks strong. Doctor: How about his speech? How many words do you think he knows? Guest_family: He knows more than twenty words for sure. Doctor: Is he able to speak two word phrases? Guest_family: Yes. He says things like ,”give me,” and, “come here.” Doctor: Any other unusual behavior that you noticed? Any seizures or just the quivering movement of the jaw? Guest_family: No, it was only this and we have noticed this since birth. I don't know if it is related but I did notice that his left eye deviates outside.","Section header: GENHX Section text: This 21 month old male presented for delayed motor development, ""jaw quivering"" and ""lazy eye."" He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months. He currently cannot walk and easily falls. His gait is reportedly marked by left ""intoeing."" His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases. No seizures or unusual behavior were reported except for ""quivering"" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia." "Doctor: What brings you back into the clinic today? Patient: I have been having some severe bruising. I have been taking Coumadin for three months now. Am I taking to much Coumadin? Doctor: You are taking a normal start dose. Some people do not metabolize the medication as well as others. I would like to get you tested for hypersensitivity. After we get the test results back, we will be able to adjust your dosage accordingly. Patient: Okay.",Section header: CC Section text: Probable Coumadin hypersensitivity. "Doctor: Let me examine you. Tell me, did you have any fever or chills, any sweating or that sort of thing? Patient: Um no. Doctor: How about abnormal weight loss or weight gain? Patient: No. Doctor: Are you experiencing any chest pain on exertion or shortness of breath normally or when you try to sleep? Patient: No, no chest pain and shortness of breath. Doctor: Let me see your legs. They look good I don't see any pedal edema. Usually that happens due to excess water retention. Any palpitations? Patient: No. Doctor: Any feeling of numbness or tingling? Did you faint or lose consciousness anytime? Patient: No and no. Doctor: Okay, good! Doctor: Any double and or blurred vision? Patient: No. Doctor: Any difficulty hearing or any wired continuous sound you may hear? Patient: No. Doctor: Okay, um tell me if you had any um, allergies, or sneezing, or runny nose? Patient: No, no really. Doctor: Okay, got it. Doctor: Any indigestion, or heart burn? Did you notice any blood in stool or black stool? Patient: No. Doctor: Any diarrhea or vomiting? Patient: Nope. Doctor: Are you feeling thirsty frequently? Patient: No, just normal. Doctor: Okay. Doctor: And I see you got a urine test, so no pus cells or blood present. Patient: Yes. Doctor: Any pain while passing urine though? Any blood? Patient: No. Doctor: And how is the urine frequency? Do you have to wake up at night to urinate? Patient: Well, my frequency is normal. I don't have to wake up at night for urinating. Doctor: How bout the stream while passing urine? You think it's normal or somewhat slow? Patient: No, it's absolutely normal. Doctor: Okay, so any cough or cold like symptoms any sputum? Patient: Nope. Doctor: No wheezing, right? Patient: Yes, no wheezing. Doctor: I don't see any lesions, that's good. Any mood swings, feeling depressed or have anxiety? Patient: No. Doctor: Any joint pain in the legs, back or anywhere? Patient: Um no. Doctor: Okay, so no erythema in the joints. Any heat or cold intolerance? Patient: No. Doctor: Okay, any difficulty swallowing? Let me check here, lymph nodes look fine. And do you bleed easily and does the bleeding stop normally? Patient: Oh yes! Doctor: Do you bruise easy? Patient: No, not really. Doctor: Okay. Any abnormal skin lesions? Patient: No.","Section header: ROS Section text: General: No fevers, chills, or sweats. No weight loss or weight gain. Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations. Neurologic: No paresis, paresthesias, or syncope. Eyes: No double vision or blurred vision. Ears: No tinnitus or decreased auditory acuity. ENT: No allergy symptoms, such as rhinorrhea or sneezing. GI: No indigestion, heartburn, or diarrhea. No blood in the stools or black stools. No change in bowel habits. GU: No dysuria, hematuria, or pyuria. No polyuria or nocturia. Denies slow urinary stream. Psych: No symptoms of depression or anxiety. Pulmonary: No wheezing, cough, or sputum production. Skin: No skin lesions or nonhealing lesions. Musculoskeletal: No joint pain, bone pain, or back pain. No erythema at the joints. Endocrine: No heat or cold intolerance. No polydipsia. Hematologic: No easy bruising or easy bleeding. No swollen lymph nodes." "Doctor: Are you allright? Patient: Yes I am fine. Doctor: That's great. Patient: Thanks. Doctor: I think you can go home now.",Section header: DISPOSITION Section text: Stable. "Doctor: I'm reviewing my notes from your last visit. Your last visit was on May tenth two thousand four, correct? Patient: Yes, that's right. Doctor: Has there been any change since your last visit? Patient: Well, I'm having some increased paranoia. Doctor: Have you been treated, and are you taking medicine for this? Patient: Yes, and it's actually gotten a lot better with the medicine another doctor gave me.","Section header: PASTMEDICALHX Section text: Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications." "Doctor: I just met with one of my patients whom I believe has pertussis. Guest_clinician: Second case of the day. What's their name and date of birth? Doctor: Hm give me a second to pull up their information.",Section header: CC Section text: Public Health Department was notified of a case of suspected pertussis. "Doctor: Have you ever had psychiatric or psychological treatment? Patient: Uh no, no treatments whatsoever. I mean I do find myself in low moods every now and again when I'm dealing with certain stressors, but the decreased moods rarely ever long lasting.","Section header: GENHX Section text: The patient denied any history of psychological or psychiatric treatment. He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient." "Doctor: Do you remember when your last flu vaccine was? Patient: I don't remember what month, but it was in nineteen ninety nine. Doctor: Good, and do you remember your last pneumonia vaccine? Patient: Let me look at my notes here, um, it was in nineteen ninety six. Doctor: Thank you, now, tell me more about your parents. Do you know their medical histories? Patient: Let me think, my dad is still around, he had a stroke. Oh yeah, and he has high blood pressure. Doctor: How old is your father? Patient: He's seventy nine now. Doctor: Good, what about your mother? Patient: She died when she was seventy four, she had heart failure and emphysema. Doctor: I'm sorry to hear that. Do you have any brothers or sisters? Patient: Thank you doctor, no, its just me and my Dad now.","Section header: IMMUNIZATIONS Section text: Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996. Family Medical History: Father age 79, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 74. No brothers and sisters." "Doctor: How are you doing today, ma'am? Patient: I'm doing just fine. Doctor: Any kind of alcohol consumption? Patient: Nope. Doctor: Have you ever taken any kind of illegal drugs? Patient: Nope. Doctor: What about smoking? Patient: No. Doctor: Are you still working? Patient: No, sir. I had issues with my knees, and they had to put in the new ones. I was kind of disabled and that's why I retired.","Section header: FAM/SOCHX Section text: The patient is retired on disability due to her knee replacements. She does not smoke, drink or use any illicit drugs." "Doctor: Do you have any chest pain? Patient: No, I don't. Doctor: Any breathlessness? Patient: Yes, I do get breathless only when I have to do some form of exertion like walking a long time or running. Doctor: Okay. How about any bowel issues? Patient: No, I don't have any stomach problems except I have to go frequently to use a bathroom. Doctor: Okay frequency. How about any prolonged bleeding issues or anything like that sort? Patient: No nothing like that.",Section header: ROS Section text: He denies any chest pain. He admits to exertional shortness of breath. He denies any GI problems as noted. Has frequent urination as noted. He denies any bleeding disorders or bleeding history. "Doctor: Does she lives with anyone? Guest_family: Yes, we all stay together, so just the immediate family. My parents, me and my sister. Doctor: Okay.",Section header: GENHX Section text: She lives with her parents. "Doctor: Hi, the weather outside is beautiful, did you get some sunshine? Patient: Yes in fact I came in walking. Doctor: Great way to get some exercise in. Doctor: ok so what's going on? Patient: I am having a bellyache. Doctor: Since when? Patient: Oh, it's been a while now. Doctor: Can you tell me more about your pain like how did it start and what exactly are you feeling? Patient: Ok so the pain started as dullache but it is constant right here in the middle upper part of my stomach. And sometimes it is moving to the back. Doctor: Can you tell me if it is stabbing pain and if it is related to any specific time of the day? Patient: Sure, so i do get episodes of stabbing pain but they are not related to meals. Once the wave comes it lasts for only a minute or so. Doctor: Can you tell me when exactly you noted it? Patient: Approximately six months back. I took over the counter antacids and got some relief so i did not go to doctor. But two months back it got worse, I do get occasional nausea and vomiting. Doctor: I can see that they found H pylori positive infection and treated you with triple drug therapy for two weeks and then gave you antacid omeprazole. But it did not improve your pain. Patient: Yeah that's right. Patient: Do you know I lost twenty pound of weight since all these symptoms began but i have been also admitted for poor appetite. Doctor: Ok tell me how are your bowel movements and if you see any blood in stools? Patient: I get two to three loose bowel movements a day but no blood in stool or anywhere. Doctor: Are you taking any pain medication over the counter? Do you drink alcohol and maybe you are vomiting blood? Patient: No no, nothing like that. Doctor: Can you tell me if any change in position changes the quality of pain? do you have any fever? Patient: No position changing have no effect, no fever or anything. Doctor: Have you been exercising before all this? Patient: Yes I have had very active and healthy lifestyle.","Section header: GENHX Section text: 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unrelated to meals lasting only minutes. Patient noted that the pain started approximately six months prior to this presentation. He self medicated ""with over the counter"" antacids and obtained some relief so he did not seek medical attention at that time. Two months prior to current presentation, he had worsening of his pain as well as occasional nausea and vomiting. At this time the patient was found to be H. pylori positive by serology and was treated with triple therapy for two weeks and continued on omeprazole without relief of his pain. The patient felt he had experienced a twenty-pound weight loss since his symptoms began but he also admitted to poor appetite. He stated that he had two to three loose bowel movements a day but denied melena or bright red blood per rectum. Patient denied NSAID use, ethanol abuse or hematemesis. Position did not affect the quality of the pain. Patient denied fever or flushing. He stated he was a very active and healthy individual prior to these recent problems." "Doctor: Any specific family medical history that I should be aware of? Patient: No. Doctor: Anyone in your family, even grandparents, if you know them, did they have diabetes or high blood pressure? Patient: No. Doctor: Anyone else sick at home? Patient: No.",Section header: FAM/SOCHX Section text: Noncontributory. No one else at home is sick. "Doctor: What is your family medical history? Patient: My mother has high blood pressure, and she had a stroke last year. Doctor: Is your mother still with us after the stroke? Patient: Yeah. She is doing well. Doctor: Good. What about your father's medical history? Patient: My father died in a car accident, when he was forty. Doctor: I am so sorry to hear that. Patient: Thank you.",Section header: FAM/SOCHX Section text: Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 years. "Doctor: Anyone in your family have a history of drug or alcohol abuse? Patient: No. Doctor: Any other medical conditions that might run in your family? Patient: Nope.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Do you drink? Patient: Like, every day? Doctor: No, just in general. Patient: No, I don't drink at all. Doctor: Do you smoke? Patient: No, I don't do that at all, either.",Section header: FAM/SOCHX Section text: The patient does not smoke nor drink alcohol. "Doctor: Any drug allergies? Patient: Ah yes, I am allergic to... what's the name of the drug? It's called Napro- Doctor: Naprosyn? Patient: Yes, Naprosyn.",Section header: ALLERGY Section text: Naprosyn. "Doctor: Hi, how old are you madam? Patient: I am ninety three. I am a super duper old Swedish woman. Doctor: Ha! Not so old okay! Patient: I had vomiting episodes and I am feeling very nauseous. Doctor: Oh I am so sorry to hear that. Patient: I have pain in urination too, I think I might have the U T I? Doctor: Let's see here. So you already have a right hip issue, bone disease, hypertension, depression, and heart rhythm disorder for a long time. Patient: Yes that is correct. Doctor: Let me see what we can do here. Patient: Thank you doctor.","Section header: PLAN Section text: The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection." "Doctor: Do you drink? Patient: No, never! Doctor: Did you ever smoke? Patient: No. Doctor: How about drugs? Marijuana or anything? Patient: Well, I always stayed away from drugs. Doctor: Good. And what is your living arrangement? Do you stay with your kids? Patient: I live at my place. My kids visit me but mostly I live alone. Doctor: Okay.","Section header: FAM/SOCHX Section text: No history of smoking, alcohol, or drug use. She lives at home." "Doctor: Good afternoon, how old are you? Patient: Hello Doctor, I'm fifty four years old. Doctor: What gender do you identify with? Patient: I identify as a female. Doctor: Thank you. What symptoms are you experiencing in your right hand? Patient: I have numbness and tingling in my right hand. Doctor: Are there any specific fingers that you feel it in? Patient: I really feel it in my fifth, fourth, and third fingers. Doctor: What kind of treatments have you done for this pain? Patient: I've taken antiinflammatories, stayed away from sports and stuff like that, and rested. Doctor: Has this helped at all? Patient: No, not at all, its still numb and tingling. Doctor: This sounds like carpal tunnel, there's a quick, minimally invasive surgery I can do on this hand, since it hasn't responded to nonoperative treatments. I think that'll really help. Patient: I'd like to do that, what's the name of the procedure? Doctor: Its called a carpal tunnel release.",Section header: GENHX Section text: This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management. "Guest_family: Congestion and cough. Doctor: Oh, how long? Guest_family: It's been three weeks now. Doctor: Okay. Guest_family: He has been like this for so long, but nothing else. Doctor: How about fever nausea vomiting diarrhea? Guest_family: No fever, no vomiting, nothing else. Doctor: Okay great.",Section header: ROS Section text: He has been congested for about three weeks ago. Coughing now but no fevers. No vomiting. Review of systems is otherwise negative. "Doctor: What do you do? Are you working or in school? Patient: I am in school. Doctor: Good. Patient: Thanks.",Section header: FAM/SOCHX Section text: The patient is currently in school. "Doctor: Do you have any children, ma'am? Patient: Yes, I have a wonderful baby girl at home. Doctor: Wonderful, were there any complications with your pregnancy or delivery? Patient: Nope, everything went very smooth. I'm thankful. Doctor: Good, have you ever been hospitalized for any issue? Patient: No, thankfully. Doctor: Good, so I can assume you've never had surgery? Patient: Correct, I never have.",Section header: GENHX Section text: Pregnancy and delivery with no complications. He has no history of hospitalizations or surgeries. "Doctor: Any past surgeries that I should know of? Patient: I had a hip replacement years ago. Doctor: Both hips? Patient: My left. Doctor: Total? Patient: Yeah. Doctor: Got it. Patient: I also had my uterus and appendix removed. I was young when I had my appendix taken out. Doctor: Do you happen to remember who did your most recent surgeries? Patient: Wish I did. I'd have to look back at my records and get back to you. I have everything at home. Doctor: That's no problem. I should be able to look it up from my end, too.","Section header: PASTSURGICAL Section text: Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age." "Doctor: Where do you live? Patient: I live with my mother around the corner where the Whole Foods is. I have been there for a few years now. Doctor: Are you the mother of the patient? Guest_family: Yes, I'm the mother. Doctor: How are you dealing with everything? Guest_family: We just want what is best for him. We want to support him in every possible way. He has only one elder sister. She lives in Texas and she also wants the same for him. Before he started living with us, he has been living in the A B C D places and some were in very bad condition. He was not striving there. That's why we asked him to move in with us.",Section header: ROS Section text: PSYCHIATRIC: The patient lives with his mother and has been staying with her for a few years now. We have talked to her. She is very supportive. His only sister is also very supportive of him. He has lived in the ABCD houses in the past. He has done poorly in some of them. "Doctor: Are you taking any medications? Patient: Yes, I am taking Accutane for my acne issues. Doctor: Okay, any other medicines? Patient: No, just that. Doctor: Okay.",Section header: MEDICATIONS Section text: Accutane and takes no other medications. "Doctor: Do you have any history of surgeries, sir? Patient: The most recent was seven years ago. I had a craniotomy. I had a brain hemorrhage and there was bleed inside and outside the brain that they had to fix. Doctor: How was the recovery for that? Patient: I took a while but the doctors said I had a normal recovery time. Doctor: That is good. Have you had any other surgeries? Patient: I had surgery on my leg for a fracture. They put some pins in my leg. Doctor: Okay. Patient: I had some kind of surgery done on my stomach when I was a kid. I am not sure what the surgery was. All I know is that it was a very common procedure with no complications. Doctor: Okay. Is that all? Patient: Yep. That's it.",Section header: PASTSURGICAL Section text: 1. He has a surgery on his stomach as a child. He does not know the type. 2. Surgery for a leg fracture. 3. Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma. "Doctor: Do you have any past medical problems that I should know about? Patient: Well, what exactly do you mean by that, doctor? Doctor: Well, it could be anything from A D H D to depression to epilepsy. Patient: Oh, no. I don't have anything like that.",Section header: PASTMEDICALHX Section text: No significant past medical problems. "Doctor: So, lets talk about your family, anybody in your family have any neurological problems? Patient: No, I don't think so, my parents did experience some memory loss but that was when they were in their nineties. And I am assuming it was mostly from the old age rather than any neuro problem. Doctor: Yeah, that is true. And how about your brothers and sisters, do you have any? Patient: Oh yeah, I have five siblings and they are pretty healthy! I mean all of them are doing good, no one has any memory issues as far as I know or any neuro related illness. Doctor: Okay.","Section header: FAM/SOCHX Section text: Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family." "Doctor: Do you have any family history of heart disease? Patient: My mother has coronary artery disease.",Section header: FAM/SOCHX Section text: Mother with history of coronary artery disease. "Doctor: Hello, miss X Y Z. Dr. X and I will go over your report with you to make sure everything is correct. Then, I will ask you a few questions. Patient: Sounds good to me. Doctor_2: Hi, ma'am. Could you confirm your age for me, please? Patient: I'm seventy six years old. I'm also a resident of A S D F if that matters. Doctor_2: Thank you, ma'am. Doctor: Doctor A B C requested for you to see us, correct? Patient: That's correct. Doctor: Perfect. Doctor X, could you go over her previous diagnoses? Doctor_2: She is diagnosed with hyperlipidemia, hypertension, and atherosclerotic cerebrovascular disease. Is this all correct, ma'am? Patient: Sounds about right. Doctor: I see she underwent a procedure. What was it, Doctor X? Doctor_2: She underwent a decompression for L three and L four. Did Doctor Stanley Gertzbein perform this procedure for your back? Patient: He did. He also did surgery on my lower legs. Doctor_2: Thank you for confirming. Doctor: I see after the surgery, you had some pain in your right L four distribution, correct? Patient: That's correct. Doctor: Doctor X, did the M R I report of the outside lumbar come in? Doctor_2: It did. We also have a report of a lumbar C T myelogram, but no films came. Doctor: What does the C T myelogram say? Doctor_2: It says she has spondylolisthesis and L four and L 5 stenosis with right posterior surgical fusion changes at both levels. Doctor: I see. There are some notes from Doctor Reitman. What does it say? Doctor_2: It looks like she is being sent for an L four selective nerve root block to rule out if she would be a candidate for a T L I F at L four and L 5. Doctor: I see. Could you review the M R I film as well? Doctor_2: The M R I reveal a grade two L four anterior spondylolisthesis without major canal stenosis. She does, however, have facet joint disease at this level and dorsal postoperative changes. She also has a foraminal disc protrusion on the right and a severely degenerated disc at L three and L four. Doctor: Thank you for that. So, miss. Where are you feeling pain today? Patient: I feel it in the font of my lower leg and right hip. Doctor: What kind of pain are you feeling? Patient: I told Doctor X about it. He could let you know. Doctor_2: She claimed she had a burning, shooting, aching, and constant pain in nature. Doctor: I see. Is it worse when you do certain activities? Patient: Yes. When I walk and stand. Doctor: Are you able to walk at all? Patient: I can walk around a block before it gets to the point where I get weak. Doctor: When does it feel better? Patient: I feel more comfortable when I'm resting, sitting, sleeping, or getting a massage. Doctor: From a scale of zero to ten, with ten being the worst pain, how would you rate the pain on average? Patient: I'd say like a nine. Doctor: That's the intensity on a daily level, correct? Patient: Yeah, that's correct. Doctor: What's the lowest pain you've ever felt? Patient: I think it was a five. Doctor: I see. Doctor X, did you ask her the series of questions about bowel function? Doctor_2: I did. She denied any bowel or bladder dysfunction, saddle area hypoesthesia, numbness, tingling, weakness or Valsalva related exacerbation. Doctor: Great. Have you taken any medication recently? Patient: Uh. I think it starts with a T. Doctor_2: It states here you took Tylenol, correct? Patient: That's correct.","Section header: GENHX Section text: Ms. XYZ is a 76-year-old resident of ASDF. She is seen at the request of Dr. ABC. She carries a diagnosis of hyperlipidemia, hypertension, and atherosclerotic cerebrovascular disease. She underwent an L3-4 decompression in Month DD, YYYY by Dr. Stanley Gertzbein for back and bilateral lower extremity pain. Shortly after surgery, she began having pain in the right L4 distribution and is seen today with an outside lumbar MRI only. I have a report of a lumbar CT myelogram as well, but no films. She has apparently spondylolisthesis and L4-5 stenosis with right posterior surgical fusion changes evident at both levels. According to Dr. Reitman's notes, she is being sent for an L4 selective nerve root block to rule out whether or not she would be a candidate for a TLIF at L4-5. Her MRI films are reviewed. These reveal grade 2 L4 anterior spondylolisthesis without significant canal stenosis, though she has facet joint arthropathy at this level and dorsal postoperative changes. She has a foraminal disc protrusion on the right, as well as a severely degenerated disc at L3-4. The patient complains essentially of pain along the anterior tibia and along the right hip, which his burning, shooting, aching and constant in nature. It is worse with standing and walking. She can walk about a block before her symptoms become debilitating. She is more comfortable in recumbency. She denies bowel or bladder dysfunction, saddle area hypoesthesia, numbness, tingling, weakness or Valsalva related exacerbation. She rates her pain as 9/10 in average and her daily level of intensity and 5/10 for her least level of pain. Alleviating factors include sitting, recumbency, sleeping, and massage. She treats her pain with Tylenol currently." "Patient: Um, do I have to follow some special or soft diet? Doctor: No, nothing like that. You can have a normal diet. Whatever you like to eat. Patient: At this age, my diet is very limited. I am going to be eighty-two next month. Doctor: Well, I don't think you need to restrict your diet. You can follow your regular diet. Patient: Alright, thank you.",Section header: PLAN Section text: Regular for age. "Doctor: Do migraine headaches run in the family? Patient: My mother gets migraines and she told me that it runs on her side of the family. Doctor: Any family history of blood clots? Patient: No.","Section header: FAM/SOCHX Section text: Migraine headaches on maternal side, including her mother. No family history of thrombosis." "Doctor: Are you married? Patient: I was, but my husband died thirty years ago. Doctor: Are you working? Patient: Nope. Doctor: What is your highest degree? Patient: I did high school. I was living alone for fifteen years until December of ninety four. Doctor: How is your living situation now? Who is taking care of you? Patient: My daughters have started taking care of me on a shareable basis. Doctor: Do you smoke? Or drink or have ever used any drugs. Patient: Nope.","Section header: FAM/SOCHX Section text: She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use." "Doctor: Do you smoke, or have you smoked in the past? Patient: Yeah, I quit two years ago. But before that I used to smoke two packs per day. I first started smoking as a teenager. Doctor: Do you drink at all? Patient: I used to drink six packs of beer plus two additional drinks a day for many years. Good news is that I've been dry for two years now. Doctor: Any illicit drug use, such as cocaine, marijuana or heroin? Patient: No none of that.",Section header: FAM/SOCHX Section text: 2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use. "Doctor: Hello, miss. How are you doing today? It looks like we are evaluating C O P D and emphysema. Patient: Yes, the last time I was seen in Pulmonary Medicine Clinic was March two thousand and four. Doctor: It has been quite some time. How are you feeling? Patient: I have actually been hospitalized for psychiatric problems and now live in a nursing facility. Things have not been too great. I don't like living there. Doctor: I understand the frustration. When you live in a nursing facility you lose a lot of your freedom. Patient: I want to live back in my apartment, but I know I am too ill to care for myself. Doctor: In spite of all of that how are your respiratory issues? Patient: I feel pretty stable. I still have shortness of breath when I do activities, but with my condition I feel like that is something I will have to live with. Doctor: Unfortunately, that is the nature of the disease. I am happy to see that the pulmonary disease has not changed significantly since your last visit. Patient: The only thing that seems to have changed is that I have a small cough and produce some mucus. Doctor: Okay. Do you have any fever or chills? Patient: No, none of that. Doctor: Do you experience any chest pains? I want to check especially since you have been coughing up some mucus. Patient: No, I luckily do not have any chest pains.","Section header: GENHX Section text: The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself. At the present time, respiratory status is relatively stable. She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit. She does have occasional cough and a small amount of sputum production. No fever or chills. No chest pains." "Doctor: You can continue working, I just want you to be careful. Patient: Thanks Doctor. I will be. Doctor: Great.",Section header: FAM/SOCHX Section text: He was released to regular work. "Doctor: Can you confirm your age for me, ma'am? Patient: Sure, I'm fifty six years old. Doctor: Great, so what brings you in to see me today? Patient: Um, I'm peeing a lot, and I'm having a little bit blood in that urine as well. Doctor: Have you ever had a cystoscopy? Patient: Yes, it was unremarkable, that's what they told me. Doctor: When are your episodes for the most part? Patient: Um, usually during the day. I don't usually have them at night. Doctor: Are you having any pain with urination? Patient: No, no pain. Doctor: Aside from the little bit of blood, can you tell if there's any pus in your urine? Patient: No, I don't have any of that, it's just the little bit of blood. Doctor: Have you taken any medications for this? Patient: Um, I had Ditropan, and it didn't do very well. Doctor: Well, this ultrasound of the kidney is also unremarkable, so at this time I think we should try a different medication.","Section header: GENHX Section text: The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night. No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms. The patient had been previously on Ditropan and did not do nearly as well. At this point, what we will try is a different medication. Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease." "Doctor: Any health issues on your mom or dad's side? Patient: No, we're a pretty healthy family.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Hello sir, how are you? Patient: I don't know, I don't know whether I am good, or my problem is getting worse and that is the reason I got myself to your clinic for a neurological consult. Doctor: Hm, don't worry! We will take care of you, let me start by taking some details. Patient: Sure! Doctor: So were you referred by someone or- Patient: Oh, no I referred myself to your clinic. Doctor: Okay. And what is your age? Patient: I am sixty four years young! Doctor: Ah, that's clever, you certainly look very young. And which is your dominant hand? Are you left handed, or right? Patient: I am right handed. Doctor: So, tell me what is going on with you? Patient: Well, lately I am having difficulty remembering names and phone numbers or even events. Doctor: Well, it's not uncommon. Patient: I know, but I am usually very good at remembering things. I would have not worried that much, but it was brought to my attention by my clerical staff. Doctor: Oh, okay. What do you do? Patient: Well, I was the catholic priest at my parish, like we have our own small administrative district and church. Doctor: Okay, and when did you notice first that you are forgetting things? Patient: Around twelve months back. Doctor: And did it cause any problem at work or any mishaps? Patient: No, not at all! No social or professional faux pas whatsoever. Doctor: Okay, I have my notes let me put the date, oh what is the date- Patient: It's twenty eighth of February. Doctor: Thank you!","Section header: GENHX Section text: This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral." "Doctor: All right, you can go home now. Patient: Thank you doctor. Doctor: You can stay at your friend's place and make sure to take good care of yourself. Patient: Yes. Doctor: Make sure you follow up with Doctor X on Monday or Tuesday. I know that Doctor Y already discussed his plans. Continue taking your medicines except Prozac. Okay?",Section header: DISPOSITION Section text: She is being discharged to home. She will stay with a friend for a couple of days. She will be following up with Dr. X on Monday or Tuesday. Apparently Dr. Y has already discussed the situation and the plan with her. She will continue on her usual medications except for discontinuing the Prozac. "Doctor: Do you smoke or drink? Patient: Nope, I've never touched a cigarette nor do I plan on ever doing so. Same goes for alcohol.",Section header: FAM/SOCHX Section text: She does not drink or smoke. "Doctor: Hi there! Welcome to the Neurology clinic, sir. Patient: Hi! Thank you. Doctor: What brings you in to the clinic today? Patient: I was diagnosed with binocular diplopia twenty five years ago but I haven't had much of an issue with it until about a year ago. Doctor: What did you notice as far as symptoms? Patient: Suddenly, I started having double vision. Doctor: Did the double vision happen more than one time? Patient: It has been happening almost every day off and on through out the day. Doctor: How long do the episodes last? Patient: They last for only a few minutes at a time. When I was first diagnosed years ago it happened for a year and then it stopped happening. It was not happening as often as it is now. Doctor: Did you ever receive any treatment for your binocular diplopia? Patient: No. It spontaneously resolved and so I didn't need to seek any treatment. Back when all this was happening it had two episodes of a drooping eyelid. I thought I had myasthenia gravis but I was told that that was probably not the case. Doctor: What eyelid was drooping? Patient: I don't remember? Doctor: What is your dominate hand? Patient: I am right handed. Doctor: And how old are you? Patient: I am sixty seven. Doctor: Involving the double vision, does it become worse when looking at distant objects? Patient: Yes. Doctor: When you look at objects off to either side of midline does it become worse? Patient: Yes. That makes it worse too. When I put my hand over one eye is goes away. Doctor: Do you have any other symptoms related to the vision issues? Patient: No.",Section header: GENHX Section text: This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia. "Doctor: How old is your son? Guest_family: He is almost five and a half years old now. Doctor: What seems to be the problem? Guest_family: He has a lot of pain about both feet, and if you look at it, it looks like his feet rotate inwards. Doctor: Okay, let me see, okay, um, he has rocker bottom feet. Guest_family: Okay. Doctor: I believe he would benefit from a subtalar arthrodesis, possible autograft, and lengthening of the Achilles. I'll go over the details of that procedure right now. Guest_family: Can we do the surgery soon? Doctor: Yes we can. But we'll probably need to do another procedure until his foot matures some more. This is a stabilizing measure. Guest_family: What are the risks of infection if we do the surgery? Doctor: Historically, the risk of infection is very low, usually less than one percent. Guest_family: How do you get the risk so low? Doctor: We use prophylactic antibiotics to minimize the infection risk. Guest_family: Will he be able to walk again right after the surgery? Doctor: No, he'll need to stay off it for a while, we call this nonweightbearing. It will only be for some time after the procedure, it's not permanent. Guest_family: What are the rest of the risks? Doctor: The total risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. I would not worry about these risks, though. The risk is low. Guest_family: Okay. Let's do the surgery.","Section header: GENHX Section text: The patient is a 5-year-4-month-old male who presents for evaluation of feet. He has been having significant feet pain with significant planovalgus deformity. The patient was noted to have flexible vertical talus. It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening. This was explained to the mother in detail. This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. All questions were answered and the mother agreed to the above plan." "Doctor: Welcome back to the clinic. Patient: Thank you. Doctor: I understand that we are doing an impairment rating exam today. Patient: Yes, that's correct. Doctor: And we are evaluating your right shoulder injury. Correct? Patient: Yes. Doctor: Was this a workrelated injury? Patient: Yes. I was working as a C N A at the Veteran's House. Doctor: How did the work injury happen? Patient: I was transferring a patient from a wheal chair to a bed, and I hurt my shoulder. Doctor: What is the date of the incident? Patient: January first, two thousand and two. Doctor: Are you currently working? Patient: No. I have not been able to go back to work yet. Doctor: I am required to ask some specific questions for the L and I paperwork. What is your ago, ethnicity and gender? Patient: I am a thirty one year old, white, female. Doctor: Have you ever had a prior injury to your right shoulder? Patient: No. Doctor: Are right or left hand dominant? Patient: Right. Doctor: Other then your shoulder injury, do you have any other chronic health problems? Patient: No. Doctor: Are you experiencing any fever, chills or illnesses? Patient: No. Doctor: Let discuss some of the previous treatments and test that you have been done for your shoulder. Patient: Okey. I have done a lot of different treatments. Doctor: What treatments have you done? Patient: I tried physical therapy. They did a subacromion decompression treatment in November, two thousand and two. Doctor: Did either of those treatments help? Patient: Not much. I went and saw Doctor Lin and he said that I might have a nerve fiber injury. I forget what he called it. Doctor: Brachial plexopathy? Patient: Yes. That sounds right. Doctor: Oh, I see his notes in your chart. It says that he felt like you had a right superficial radial neuritis and blocked this with resolution of your symptoms. Then it looks like he sent you to get E M G testing at Valley Medical. Let me look for those results. Patient: Okey. They should be in my chart. I had Doctor Lin send over all my records. Doctor: Here it is. It says that the right suprascapular neuropathy although a C5 radiculopathy could not be ruled out. MRI testing on the cervical spine was then done which was negative for disk herniation and underwent suprascapular nerve decompression of the scapular notch on December eighteenth, two thousand and three. Patient: Whatever that means? I ended up getting a nerve block because I was still in pain. Doctor Lin did one in the frount of my shoulder and then another in the back. Doctor: This has been a long drawn out course of treatments for you. Patient: Yes, it has been.","Section header: GENHX Section text: The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02. She formerly worked for Veteran's Home as a CNA. She has had a long drawn out course of treatment for this shoulder. She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002. She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy. He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms. He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out. MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03. She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X. She comes to me for impairment rating. She has no chronic health problems otherwise, fevers, chills, or general malaise. She is not working. She is right-hand dominant. She denies any prior history of injury to her shoulder." "Doctor: Are you up to date on your vaccines? Patient: I've actually never been vaccinated before. My parents don't believe in vaccines.",Section header: IMMUNIZATIONS Section text: None. "Doctor: Hi there! Welcome in, sir. Patient: Hi! Thank you. Doctor: What is your past medical history? Patient: No. I don't have any health problems. Doctor: Do you have a primary care doctor? Patient: No. I don't have health insurance right now.",Section header: PASTMEDICALHX Section text: The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured. "Doctor: Are you married, ma'am? Patient: Yes. Doctor: Do you smoke, use alcohol or use recreational drugs? Patient: No.","Section header: FAM/SOCHX Section text: She is married. She does not smoke, use alcohol or use illicit drugs." "Patient: In the past I was very very fat! Actually, I was morbidly obese. I also had high blood pressure, but after my surgery it got resolved. Doctor: So, everything is okay now? Patient: Yeah.","Section header: PASTMEDICALHX Section text: Significant for hypertension and morbid obesity, now resolved." "Doctor: So, you were referred by Doctor X. Patient: Yeah. Doctor: According to him, I see no changes or correction to your present illness, right? Patient: Yeah, I think so.",Section header: GENHX Section text: As per Dr. X without any changes or corrections. "Doctor: Do you have any related family history? Patient: You mean like heart issues in the family? Doctor: Yeah, something like that. Patient: My brother died of heart attack. It was sudden everyone was shocked. Doctor: How old was he? Patient: He was not that old; he was just in his fifties.",Section header: FAM/SOCHX Section text: She states her brother died of an MI suddenly in his 50s. "Doctor: So, tell me what's going on? What brings you to the emergency? Patient: I felt like my heart will explode. I have never felt palpitations like this. I am feeling so weak. Doctor: When did it start? Patient: This afternoon. Doctor: Hm, so your blood pressure is one ninety five by eighty three and your heart rate is one twenty one which is quite high. Doctor: We have started you on I V Metoprolol. This will help to bring your heartrate down. Doctor: And you said you are sixty six? Patient: Yes. Guest_family: My mom has stopped taking her medications. Doctor: I can tell from her reports. Her blood pressure is quite high. Guest_family: It's been several months since she last took her medicines. Doctor: Well, that's not good! Doctor: And does she drink and smoke? Guest_family: Yes, both. Doctor: How much do you drink Ma'am? Is it occasional? Guest_family: She drinks a lot! Patient: Well, I drink about four to five glasses of wine every day. I drank last night. Doctor: Well, I think you need to cut down on it. Patient: I am trying doctor and honestly these are all withdrawal symptoms. I have never felt like this before. Doctor: Hm, I understand. For now I have put you on five M G of Metoprolol and looks like your blood pressure is under control and your heart rate has come down to seventy.","Section header: GENHX Section text: This 66-year-old patient has history of hypertension and has not taken medication for several months. She is a smoker and she drinks alcohol regularly. She drinks about 5 glasses of wine every day. Last drink was yesterday evening. This afternoon, the patient felt palpitations and generalized weakness and came to the emergency room. On arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83. The patient received 5 mg of metoprolol IV, after which heart rate was reduced to the 70 and blood pressure was well controlled. On direct questioning, the patient said she had been drinking a lot. She had not had any withdrawal before. Today is the first time she has been close to withdrawal." "Doctor: Hello, how are you today? Patient: I am here for a breast cancer screening. Doctor: Have you gotten a mammogram before? Patient: Yes, I have. I also try to keep up with my self examinations every few weeks. Doctor: That is great. I am happy to see you on top of your preventative healthcare. Patient: I try to be as careful as I can since my sister had breast cancer.",Section header: FAM/SOCHX Section text: Her sister had breast cancer. "Doctor: Good morning, sir. Patient: Good morning, doctor. Doctor: So, what seems to be the problem today, sir? Patient: Well, I've had toe problems in the past. Doctor: I see, what about the rest of the lower body, any problems there? Patient: Actually, yes, I've had left knee issues in the past, too.",Section header: PASTMEDICALHX Section text: He has had toe problems and left knee pain in the past. "Doctor: Do you have a history of any health conditions that I should be aware of, ma'am? Patient: Um, yeah, I had a mastectomy, and chest tube placement. Doctor: Oh, wow. Do you have any chronic conditions? Patient: Yeah, I have chronic A F I B.","Section header: PASTMEDICALHX Section text: History of mastectomy, chest tube placement, and atrial fibrillation; chronic." "Doctor: How have you been handing erectile dysfunction since your last visit, sir? Patient: Well, I've been taking the Cialis, it's the, um, ten M G version. Doctor: Have you seen any improvement? Patient: Yes, I've had some, which is good. Doctor: Have you had any side effects? Patient: No, none yet. Doctor: Good, can you describe your erections for me, sir? Patient: Well, they're firm now, and I can penetrate again for about ten minutes. Doctor: Good, are you having any chest pain? Patient: No sir, I stopped using my nitroglycerin too. Doctor: Good, are you having any fever or chills? Patient: No, nothing like that. Doctor: Are you having any pain with urination, or blood in the urine? Patient: No, nothing like that, sir, everything is normal. Doctor: How often do you urinate during the day? Patient: I go about every three hours or so, I have a good stream and everything. Doctor: Do you wake up at night to go to the bathroom? Patient: No, I sleep through the night very well. Doctor: Good, do you have any other conditions that I should know about? Patient: Well, I have a history of elevated P S A, and I had a biopsy in June when I had a, um, high grade P I N. Doctor: Do you know what that P S A value was? Patient: It was eleven point six. Doctor: Thank you, I see here on Doctor X's notes that there were two specimens that were too small to evaluate.","Section header: GENHX Section text: The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg. He indicates that he has noticed some mild improvement of his symptoms, with no side effect. On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes. No chest pain, no nitroglycerin usage, no fever, no chills. No dysuria, gross hematuria, fever, chills. Daytime frequency every three hours, nocturia times 0, good stream. He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate. PSA 11.6. Dr. X's notes are reviewed." "Doctor: I am afraid, I don't have better news for you, your reports confirm cancer. Patient: We were suspecting it all along, but now since it is confirmed it's just hard to accept. Doctor: I am sorry, I totally understand. Do you want some time? Patient: No, I am okay. Doctor: Hm, you also have hypertension and diabetes. Patient: Yeah, that I know. Doctor: Did you have any chest pain or shortness of breath or uneasiness? Patient: No, I don't have any heart condition. Doctor: Okay and no dizziness or loss of consciousness or stroke like symptoms? Patient: No. Doctor: Okay. Well, your B M I looks fine, that means you are not overweight. Patient: Hm.","Section header: FAM/SOCHX Section text: Positive for hypertension, diabetes, and cancer. Negative for heart disease, obesity or stroke." "Doctor: Are you married? Patient: Yes. I am happily living together with my husband and my four kids. Doctor: Oh, do you smoke? Patient: Nope. Doctor: What about alcohol or any other kind of drug use? Patient: Nope.","Section header: FAM/SOCHX Section text: Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use." "Doctor: Anyone in the family had any medical issues? Patient: Oh yes. Doctor: Can you please elaborate? Patient: So, my mother's side family had heart issues. My dad's sister had sugar problem.",Section header: FAM/SOCHX Section text: There was a history of coronary artery disease and diabetes mellitus in the family. "Doctor: And you are not allergic to anything right? Patient: That's right. Doctor: Any drugs or pollens or anything? Patient: Nope nothing. Doctor: Good.",Section header: ALLERGY Section text: No known allergies. "Doctor: Has the redness worsened over the last few days? Guest_clinician: I think so. Her right big toe looks worse to me. Doctor: Is she otherwise healthy? Guest_clinician: Um besides her toe and some nasal congestion, she's doing fine.","Section header: ROS Section text: She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness. Review of systems is otherwise negative." "Doctor: You had a surgery on your breasts? Patient: Yes, they removed lump from my left breast. Doctor: Okay, and what other surgeries have you had? Patient: I do not have a gall bladder, then I had a breast augmentation, I have had heart surgeries three times and they have removed half of my pancreas. Doctor: Okay. Patient: And knee surgery too, on the left side. Doctor: Okay. What type of heart surgery did you have? Patient: Cardiac ablation.","Section header: PASTSURGICAL Section text: Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas." "Doctor: What happened? Guest_clinician: She was brought to emergency by her son. Apparently, she is doing fine, no distress. She is alert, and I was able to communicate with her and take her history, she was cooperative and calmy responded to all my questions. Doctor: Okay, that's good.","Section header: EXAM Section text: GENERAL: Alert and in no apparent distress, calm, cooperative, and communicative." "Doctor: What is your family medical history? Patient: My family has high blood pressure and diabetes. Doctor: Do you have any family history of nervous system disorder or disease such as multiple sclerosis, Alzheimer's disease, Parkinson's disease, epilepsy, or stroke? Patient: No. Doctor: Do you have any children, miss? Patient: Yes. I have a son, he was born on October thirty first, two thousand and eight.","Section header: FAM/SOCHX Section text: There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008." "Doctor: Have you ever had any heart problems in the past? Patient: I remember I did have something heart related but I don't know what that was. I do not understand any medical terms. Doctor: Okay that's fine, I completely understand. We will try to look for your past medical history. Patient: I do have hypertension and diabetes, you know that right? Doctor: Yes, type two diabetes. Do you know of any other things that you had in the past? Patient: Yes, four years back I had lung embolism. I also get frequent urine infections. Doctor: Okay. And I can see on the file that you have high cholesterol and a gastric ulcer too. Patient: Yes, that's about right. Doctor: Okay. What surgeries have you had in the past? Patient: I have had my appendix taken out, then C Section, cataract surgery and hernia repair done in the past.","Section header: PASTMEDICALHX Section text: She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history. She states that she has underlying history of heart disease but is not able to elaborate to any significant extent. She also has a history of hypertension and type II diabetes but is not currently taking any medication. She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections. Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair." "Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: So, are you married? Patient: Yes, happily to my husband. Doctor: That's wonderful, um, what do you do for a living? Patient: I work as an office manager right now. Doctor: Do you smoke? Patient: Yes, I do. I've smoked a pack a day for the last twenty years. Doctor: Do you drink? Patient: Actually, yes, I drink daily. Doctor: How much do you drink every day? Patient: Well, it varies, but usually about anywhere from three to five drinks a day. Doctor: Okay, do you do any illicit drugs? Patient: No, absolutely not. Doctor: What do you do for exercise? Patient: Well, I go for walks, and like low impact cardio. But, I do like playing softball with my friends too. Doctor: Very nice, how often do you exercise? Patient: I work out a few times a month.","Section header: FAM/SOCHX Section text: The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball." "Doctor: I'm going to run down a list of symptoms and I'd like you to tell me if you've experienced any. Patient: Okay. Doctor: Headache? Patient: No headaches. Doctor: Are you coughing at all? And if yes, then are you bringing up any blood with your cough? Patient: No cough. Doctor: Any chest pain or shortness of breath that wakes you in the middle of the night? Patient: Nope. Doctor: Do you feel short of breath when you move around? Patient: Nope. Doctor: Any visual, hearing, or swallowing problems? Patient: None. Doctor: And finally any changes to your bowel movements or urinary habits? Patient: Nope. All normal.","Section header: ROS Section text: No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND, orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI." "Doctor: Looking at your medical history now. Any changes since your last visit? Patient: No changes.",Section header: PASTMEDICALHX Section text: Otherwise reviewed and noted. "Doctor: Hello, sir. Looks like we are here for a general wellness check? Patient: Yes, sir. In my seventy eight years on this Earth, I have learned to take my health more seriously. I need to start catching things before they come, not after. Doctor: I could not agree more. From your last checkup notes, it looks like you had right knee surgery and back surgery about eighteen months ago. How is that going? Any pain? Patient: Yes, I had a right knee replacement. I am doing great so far. Nothing to complain about. I can do almost anything I desire now. It is such a good lifestyle change from before surgery. Doctor: What do you do with your new body? Patient: I travel every chance I get. I just got back from a cruise. Doctor: I hope to be as agile as you when I get to retirement. Now let's check the other systems. Do you feel any type of chest pain? Any heaviness, tightness or pressure? Patient: No, nothing like that. Doctor: How about shortness of breath? Patient: I only get short of breath when I walk up the stairs. Doctor: That is decently normal. I get out of breath when walking from floor to floor in this hospital too. Patient: I thought so. I remember being young and still struggling with stairs. Doctor: Unfortunately, some things are just with us for life. Do you have any coughing fits or irregular heart beating? Patient: No. Doctor: Great! You are getting a clean bill of health from me today. On the notes it says you have Crohn's disease. Are you getting regularly checked for that? Patient: Yes. Doctor Ferguson takes care of me for that. Doctor: Excellent. Are you scheduled for a prostate check? Patient: Yes, I go to Doctor Roszhart. Doctor: You are wonderfully on top of it. What a breath of fresh air. From all of your travelling, how are your ankles? Have you noticed any swelling? Patient: Surprisingly, from all the walking I do, I do not have any swelling. After quitting smoking ten years ago I had to get addicted to something else and that was walking and travelling.","Section header: GENHX Section text: This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has, and he just got back from a cruise. He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations. He sees Dr. Ferguson. He is known to have Crohn's and he takes care of that for him. He sees Dr. Roszhart for his prostate check. He is a nonsmoker and denies swelling in his ankles." "Doctor: And when did you had your last tetanus shot? Patient: Um, I don't remember correctly, but it should be in my reports. I did have one sometime back, just don't remember when exactly. Doctor: Ah, no problem. I see it here in your reports and it's up to date. So that's good. Patient: Cool.",Section header: IMMUNIZATIONS Section text: Up-to-date. "Doctor: So where do you stay? Patient: I stay nearby in my apartment. Doctor: Alone? Patient: No, I stay with my boyfriend. Doctor: Okay, and do you smoke and drink? Patient: Both. Doctor: And how much would say you smoke per day? Patient: Well, I smoke a lot. Seven to eight packs per day. Doctor: Oh! And for how many years? Patient: I don't remember exactly but for many, many years, I have a long history of chain smoking. Doctor: Hm. And alcohol? Patient: Same, I drink heavily. I have been drinking for many years. Doctor: Hm.",Section header: FAM/SOCHX Section text: She lives with her boyfriend. The patient has a history of heavy tobacco and alcohol abuse for many years. "Doctor: How are you, sir? Patient: One less than sixty. Doctor: So, what happened? Patient: I was visiting my son in Cheyenne, Wyoming, then I on October tenth when I was taking a shower, I felt a pop in my head. I don't know what happened after that. Guest_family: We thought he was having a long shower that day. Then about one and a half hours later my son suspected something is not right and we went up to check. There we found him unconscious on the shower floor. Our son, he then drove us back to Iowa and since then he is complaining of these headaches and that he's not feeling well. He gets unconscious or falls asleep I don't know but it is happening a lot of the time. We got him to local hospital today in the morning. It is three days after that shower incident. Doctor: Yeah, his report says he got a hemorrhage, I mean, blood clot in his brain. Guest_family: Yeah, after that report they transferred us to this hospital.","Section header: GENHX Section text: 59y/o male experienced a ""pop"" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC." "Doctor: Is this your first surgery or have you had other surgeries in the past? Patient: This will be my second. I had a hernia repair back in O ten.",Section header: PASTSURGICAL Section text: Hernia repair. "Doctor: Where do you work? Patient: I work at the Hilton as a head chef. Doctor: Do you smoke or consume any form of tobacco? Patient: Nope. Doctor: Do you drink or have ever used any illegal drug? Patient: No, none of that.",Section header: FAM/SOCHX Section text: Employed cook. Denied ETOH/Tobacco/illicit drug use. "Doctor: Where do you feel the most pain? Patient: I'd have to say at the heels of my feet. I spend a lot of time on my feet at work. Doctor: I see. What kind of shoes do you normally wear to work? Patient: Regular tennis shoes. Doctor: Are they cushioned? Patient: Eh not really, but they're pretty durable. Doctor: I'd advise getting an orthotic for your shoes to help with the heel pain and resting your feet when you're home. In the meantime, I'd like for you to see a specialist to make sure nothing else is going on. Patient: Alright, I'm good with that plan. Doctor: Are you having any other problems? Joint pain, difficulty walking, nausea, vomiting, or other symptoms? Patient: No, just heel pain for now.",Section header: ROS Section text: Positive findings of the foot that have been recorded. All other systems reviewed were negative. "Doctor: I'm here to take your social history. So, tell me about yourself. Patient: I was taking drugs. I tried all the methods, mainly I was using inhalation and I V drugs. Doctor: Right now, you are on methadone, right? Patient: Yes. I'm also going to the psychiatry department for my depression and these drug issues. Doctor: What is your living status? Patient: I live with my roommate.",Section header: FAM/SOCHX Section text: The patient has a history of inhalation on intravenous drug abuse. She is currently on methadone maintenance. She is being followed in Psychiatry for depression and substance abuse issues. She lives with a room-mate. "Doctor: I will ask you a few questions about your family history, sir. Patient: That's okay. Doctor: Does anyone in your family ever have any medical problems? Patient: Both of my parents had diabetes.",Section header: FAM/SOCHX Section text: His father and mother had diabetes. "Doctor: Are you aware of any medical issues in your family? Patient: I don't know. Doctor: What about your paternal family? Patient: I don't know my father. No idea about his family. Doctor: What about your mom? Maternal family? Patient: I have no idea. I'm not in contact with her.",Section header: FAM/SOCHX Section text: She did not know her father and was not in contact with her mother. "Doctor: Good morning, sir. Before we begin, how old are you? Patient: Good morning, doctor. I'm forty one. Doctor: Thank you, and how long have you had this left knee pain? Patient: It's been about two years now. Doctor: Is there an injury? Patient: Yeah, I sprained my MCL while playing hockey back then. Doctor: What kind of symptoms have you had in this knee since then? Patient: Well, the knee locks up on me, I can't extend it all the way, and it just hurts really bad if I try to. Doctor: Do you feel any instability? Patient: No, not at all.","Section header: GENHX Section text: The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain. He has had a positive symptomology of locking and pain since then. He had no frank instability to it, however." "Doctor: I see here that you've been feeling more short of breath. Patient: Yes, for three days now. Doctor: Is it worse when you exert yourself? Patient: Um no, not really. I've had a terrible cough along with frequent headaches and chest congestion. I have also had a low fever. Doctor: Did these symptoms start around the same time? Patient: I think so. Doctor: Where does your chest feel most congested? And how would you rate the pain right now? Ten being the worst. Patient: Both sides. I'd say it's at a three currently. Doctor: Does it send pain or numbness or tingling down your arms? How about any jaw pain as a result? Patient: No, but it does get worse whenever I cough. Doctor: Is this your first time experiencing this type of congestion? Patient: Oh no. I had something like it about ten months ago. Doctor: Did that improve on its own? Patient: It would come and go, but over the past few days it's gotten worse. I am a strong German man so I held out coming to the doctor as long as I could. Doctor: You are very strong! You are sixty nine though, so I don't think anyone would see it as weak if you came to the doctor more often.",Section header: GENHX Section text: 69-year-old Caucasian male complaining of difficulty breathing for 3 days. He also states that he has been coughing accompanying with low-grade type fever. He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing. Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since. "Doctor: Are you aware of any medical problems in your family? Patient: No. Doctor: Anyone with any heart disease or diabetes? Patient: No.",Section header: FAM/SOCHX Section text: Unremarkable. "Doctor: Besides pain in your left eye, are you having any other problems? Patient: No. Doctor: Do you happen to have a history of eye problems? Patient: None.","Section header: ROS Section text: Focal left eye pain without any changes in visual acuity or photophobia. He has no prior ophthalmologic problems. Review of systems for cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine, immunologic systems is negative." "Doctor: Hello, sir how can I help you? Looks like we are talking about snoring today. Patient: Yeah, I need to get this loud and obnoxious snoring under control. I keep waking up my partner. I have a C P A P right now because I was told I have almost severe sleep apnea. Doctor: Yes, I see on your chart that you were given ten centimeters of H two O nasal pressure and that you predominately suffer from hypopnea. Hypopnea is shallow breathing. How has the device been working? Patient: It definitely has reduced my snoring, but my partner keeps waking me up in the middle of the night because the mask pops off. I wear it around five to seven nights a week, but for some reason it falls off or I take it off randomly in the night. My wife usually must remind me to put it back on. Doctor: So what is your sleep pattern now? When do you usually go to bed and wake up? Patient: Usually I sleep around eleven or eleven thirty and wake up at six or seven on the weekends. I'll sleep in until eight or nine on the weekdays. On Saturday's I might go to sleep around midnight because I usually watch a show with my family. I feel good when I wake up though. Much less tossing and turning. The sheets are always on the bed still. Doctor: That's some good news. I see you have lost a bit of weight too. Around fifteen to eighteen pounds is something to be proud of. Patient: Thanks. It has been a lot of exercising and dieting. I am motivated because I want to stop snoring. Doctor: How has work been? Do you think it has been stressful at all? Patient: I still work at Smith Barney in downtown Baltimore. I work from around eight or eight thirty to five or five thirty. I deal with training on how to sell managed funds and accounts. I do not think I have been stressed because I am able to stay awake through my shift and even when I come home at night. I may get a little tired during hay fever season, but that is rare. Doctor: Yes, I see that you have hay fever. Fatigue is a common symptom from the allergy.","Section header: GENHX Section text: The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure. He has been on CPAP now for several months, and returns for followup to review his response to treatment. The patient reports that the CPAP has limited his snoring at night. Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask. The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night. The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays. On weekends, he might sleep until 8 to 9 a.m. On Saturday night, he might go to bed approximately mid night. As noted, the patient is not snoring on CPAP. He denies much tossing and turning and does not awaken with the sheets in disarray. He awakens feeling relatively refreshed. In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures. He continues to work at Smith Barney in downtown Baltimore. He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m. He is involved in training purpose to how to sell managed funds and accounts. The patient reports no change in daytime stamina. He has no difficulty staying awake during the daytime or evening hours. The past medical history is notable for allergic rhinitis." "Doctor: How are you feeling today? Patient: I have a lot of anxiety. Doctor: Anything else? Patient: I have a lot of pain in my chest as well. Doctor: Do you drink? Patient: Yes, I cannot stop myself. I have tried many times but it's hard to control.","Section header: CC Section text: Anxiety, alcohol abuse, and chest pain." "Doctor: So, do you smoke? Patient: No. Doctor: How about alcohol? Patient: I drink, but just normal. I don't have any alcohol problem. Doctor: Okay. So, no history of any drug or alcohol abuse, right? Patient: No, not at all. Doctor: Okay.","Section header: FAM/SOCHX Section text: He is a nonsmoker. He has been drinking alcohol today, but has no history of alcohol or drug abuse." "Doctor: Hi, how can I help you? Patient: I am here for a follow up on my heart rhythm problem. I think it is atrial fibrillation. Doctor: Oh yes. You are not on Cardizem and your heart rate is up just a little bit today. Patient: That's right. I misplaced it. Doctor: Okay. Let me see. What symptoms are you experiencing right now? Patient: I am feeling very dizzy. I do have some vertigo and lightheadedness. Doctor: You are on blood thinners, right? That is Coumadin therapy? Or am I wrong here? Patient: No, you are right but please stop the Coumadin. I am tired of these regular blood draws. Doctor: See, I understand it is hard to control it. It is difficult to regulate that. Patient: Yes exactly. That is why I don't want it. Give me something simple. Doctor: Okay I will investigate it. Are you experiencing any chest pain or shortness of breath? Patient: Oh no, I am not feeling that. Doctor: Okay great! Patient: Actually, I am moving around a little bit better now and my arm does not hurt. Doctor: How about your back pain? Patient: Um, it is improving as well. Doctor: Okay, cool. Patient: Yeah.","Section header: GENHX Section text: ABC is in today for a followup of her atrial fibrillation. They have misplaced the Cardizem. She is not on this and her heart rate is up just a little bit today. She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy. She is very adamant that she wants to stop the Coumadin. She is tired of blood draws. We have had a difficult time getting her regulated. No chest pains. No shortness of breath. She is moving around a little bit better. Her arm does not hurt her. Her back pain is improving as well." "Doctor: Good morning, young man. Patient: Good morning, doctor. Doctor: Who is this young lady, is this your grandmother, or sister? Guest_family: Oh doctor, yes, I am his grandmother. Doctor: Good, my chart says that you're fourteen years old. Is that correct? Patient: Yes sir. Doctor: Good, so what seems to be the problem today? Patient: I've been having pain in this knee for about a month now. Doctor: Can you remember a specific injury to this knee? Patient: Um, yeah, I was playing basketball when I jumped, and then when I landed I felt this knee pop. Doctor: Do you remember the date of your injury, young man? Guest_family: Um, it was on December twenty second two thousand seven. Doctor: Good, so how have you been treated for this so far? Patient: We went to another clinic first, and they put me in a splint. Guest_family: Yeah, and then they referred us over to Children's. Doctor: Have they taken x rays yet? Patient: Yes, I got back a few minutes ago. Doctor: Let's have a look. Well, you broke your leg. Patient: What, where? Can you show me? Doctor: Right here, this is a tibial tubercule avulsion fracture with patella alta. Guest_family: What does that mean, doctor? Doctor: Well, he's broken his leg, and pulled some bone off by doing so. We'll need to do surgery on this. Guest_family: Oh no, what's the name of the procedure? Doctor: It's called an O R I F. We'll go in there with some hardware to put everything back together, and he can get on the road to healing. Guest_family: Let me call his father while we discuss this. What's the risk of infection from this surgery? Doctor: Historically, it's less than one percent. We use antibiotics to control for infection. Guest_family: Okay, will he be asleep for this? Doctor: Yes, he won't feel a thing. Guest_family: That's good too. Will he need this hardware out in the future? Doctor: We can remove everything once he has healed up nicely. Other risks include bleeding, changes in the sensation of the leg, hardware failure, need for post op rehab, need for hardware removal, and failure to restore extensor mechanism tension. But I would not worry about these things. I have been doing these surgeries for years and things like this rarely happen. Guest_family: Yes, his father agrees. We're going to do the surgery.","Section header: GENHX Section text: The patient is a 14-year-old male who reported having knee pain for 1 month. Apparently while he was playing basketball on 12/22/2007 when he had gone up for a jump, he felt a pop in his knee. The patient was seen at an outside facility where he was splinted and subsequently referred to Children's for definitive care. Radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta. Surgery is recommended to the grandmother and subsequently to the father by phone. Surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal. Risks of surgery include the risks of anesthesia, infection, bleeding, changes on sensation in most of the extremity, hardware failure, need for later hardware removal, failure to restore extensor mechanism tension, and need for postoperative rehab. All questions were answered, and father and grandmother agreed to the above plan." "Doctor: Good afternoon, ma'am. Can you confirm your age for me, please? Patient: Sure, good afternoon, doctor. I'm sixty one years old. Doctor: Great, what brings you in for a visit today? Patient: I have some notes here with me, but I have a history of polyarteritis nodosa mononeuritis multiplex. Doctor: Is this in your legs, or arms? Patient: Um, it's in my legs. Doctor: I see here that you have sleep apnea too. Patient: Yeah, I was involved in an overnight sleep study on C P A P and oxygen. Doctor: Why did they do this? Patient: It was in order to determine why I had difficulty falling asleep and staying asleep. Doctor: Have You had any other treatments? Patient: Yeah, I had a review done while I was in the hospital about two weeks ago, I have the results right here. Doctor: Thank you, so, how is your leg pain been managed? Patient: Um, I take pretty substantial doses of opioids in order to control it. Doctor: Do you have any swelling? Patient: Yes, I take Lasix for my leg swelling. Doctor: How do you sleep with the C P A P? Patient: I can fall asleep with it, but I usually rip my mask off because I toss and turn. Doctor: How would you rate your quality of sleep? Patient: I'd, um, say it's pretty terrible.","Section header: GENHX Section text: This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep. She returns today to review results of an inpatient study performed approximately two weeks ago. In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex. She also takes Lasix for lower extremity edema. The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has ""terrible quality sleep.""" "Doctor: Hi there, what's going on? Guest_family: I am her daughter. I brought her to the emergency. She lives in a skilled nursing home. Today, when I went to meet her, I found her with the right side of her face drooping. I immediately rushed her here. Doctor: Oh, you did the right thing. Ma'am, how are you feeling? Guest_family: She has dementia, most of the time she doesn't even remember me. Doctor: Oh, okay.How old is she? Guest_family: She is eighty three. She also has a history of stroke after which she developed this condition where she knows what she wants to speak but is unable to make the word or sentence. Doctor: Oh, I see. She has expressive aphasia, correct? Guest_family: Yes, that. Doctor: Okay, let me check her. She does have a droop to her right side of the face. Ma'am, do you feel any weakness on the right side of your body? Guest_family: She says yes. Doctor: She had her C T scan earlier today and I have the report. It does not show any acute attack or anything. Guest_family: Okay! Doctor: But it does show that she has a new onset of a stroke. Guest_family: Is there anything to worry? Doctor: I think we need to admit her for observation. We need to monitor her. We will also get her a proper treatment for her urinary infection which is not getting better due to resistance to the oral medicines. Guest_family: Yeah, sounds good! Doctor: Yeah, let me talk to the nurse. Guest_family: Thank you.","Section header: GENHX Section text: The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation. While in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop. The CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications." "Doctor: Hello, are you translating for the patient today? I am sorry, but I do not speak Spanish. Guest_family: Yes doctor. Doctor: My chart says this man is fifty two years old, is all of that correct? Guest_family: Yes doctor, that's correct. Doctor: Good, so, what seems to be the problem today? Guest_family: He hurt himself a while back when he slipped on a grape while he was at the grocery store. Doctor: Oh no, when was this? Guest_family: It was on October second two thousand eight. Doctor: Which knee did he injure? Guest_family: Doctor, it was his left knee. Doctor: How has he been treated for this so far? Guest_family: He went straight to the E D immediately, and then he saw his P C P. Doctor: What did the P C P recommend? Guest_family: He only referred him to P T, and gave him a knee brace.","Section header: GENHX Section text: The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the emergency room and then followed up with his primary care physician. The patient was then ultimately referred to Physical Therapy. After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only." "Doctor: Do you smoke cigarettes? Patient: I smoke about three packs in a month. Doctor: Do you drink alcohol or use recreational drugs? Patient: No. Doctor: What do you do for work? Patient: I am an editorial assistant at the local newspaper.","Section header: FAM/SOCHX Section text: editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs." "Doctor: Have you had any adverse reactions to medications you've taken in the past? Patient: No, thankfully.",Section header: ALLERGY Section text: He has no allergies. "Doctor: Are you okay? Patient: Yeah, yeah, I am fine. Doctor: I am asking this as you look a little pale. Patient: No I am okay. I have always been healthy my whole life. Just a little fatigued now. Doctor: Okay that won't be something we can't fix. Patient: Yeah, but I am okay. Doctor: Yes, I do not see any issues with your past history. Patient: As I said, I am healthy.","Section header: PASTMEDICALHX Section text: Otherwise, reviewed. Fairly healthy." "Doctor: Hello today I have my assistant with me, and she will be representing your case. Tell me who do we have today? Guest_clinician: Patient has been cared by Doctor X since two thousand and two. She had a Codman Hakim shunt set at ninety M M H two O. She last came to our clinic in January two thousand and eight. At that time, she was recommended to follow up with Doctor Y for the medical management of her chronic headaches. She was also recommended to see a psychiatrist for her depression. Doctor: Did you go and see a psychiatrist? Patient: I did. It was okay. Doctor: What brings you here today? Patient: My headaches are back. They are very severe this time. It all happened that, after that scan. Doctor: When did she have her scan? Guest_clinician: She had her stunt adjusted which was after the M R I on April eighteenth. Patient: Yes, and after that I'm having these very bad headaches. Doctor: Are you able to sleep in the night properly? Patient: No, these headaches wake me up in the night. I haven't had a proper sleep in like ages. Doctor: Is there anything that elevates this pain? Or decreases it? Patient: Everything seems like increasing it. It just gets worse with coughing, straining, sneezing, even when I'm trying to stand. I tried all the medications, but nothing is helpful. There was Imitrex and I also tried Motrin eight hundred M G twice a day, but nothing seems to be like effective. Actually, it helps a bit when I lie down. Doctor: Is it like specific to any particular area of your head? Patient: It is like all over but, uh, very much intense in the forehead. Doctor: Is there any nausea associated with the headaches? Patient: No. Doctor: Anything else that happens along with these headaches? Patient: Yeah, I get that ringing sound in my ears, and I just don't feel well. Doctor: Any changes in your vision? Patient: Yeah, it gets blurry, and I feel like lights are dimming. I will be meeting Doctor Y tomorrow. Doctor: Any other thing you want to add? Patient: No, that's it.","Section header: GENHX Section text: Dr. X has cared for her since 2002. She has a Codman-Hakim shunt set at 90 mmH2O. She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches. We also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself. Today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04/18/08. She states that since that time her headaches have been bad. They woke her up at night. She has not been able to sleep. She has not had a good sleep cycle since that time. She states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up. She states that they feel a little bit better when lying down. Medication shave not helped her. She has tried taking Imitrex as well as Motrin 800 mg twice a day, but she states it has not provided much relief. The pain is generalized, but also noted to be quite intense in the frontal region of her head. She also reports ringing in the ears and states that she just does not feel well. She reports no nausea at this time. She also states that she has been experiencing intermittent blurry vision and dimming lights as well. She tells me that she has an appointment with Dr. Y tomorrow. She reports no other complaints at this time." "Doctor: Tell me about the medical issues you had in the past or still do. Patient: Well, I have asthma, sinus. I also have hives and there is a history of psoriasis. Doctor: Wow, okay. Any known allergies? Patient: Nothing that I have known.","Section header: ALLERGY Section text: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies." "Doctor: Any known allergies? Patient: No.",Section header: ALLERGY Section text: None. "Doctor: Hello there, how are you doing? Patient: Sorry, I'm just not feeling well. Something is wrong. Doctor: Don't worry, I will check you up. We will figure it out. Do you remember when you had your last physical? Patient: It was sometime in early May in two thousand and eight. Doctor: Okay, I'm going through your chart. It looks like you have not been feeling well for about two weeks now. Patient: That's right. Doctor: Tell me what is happening exactly. Patient: In the beginning I was thinking that it was just the stress and anxiety, but then I become worried that it might be something really different or something bad. Doctor: What are you experiencing exactly? What are your symptoms? Patient: It started with a lot of palpitations at first. My heart was beating so fast it looks like it was ready to go out. I was having this fluttering feeling in my chest. Doctor: Were you feeling tired or fatigued? Patient: Yes, very much for the last two weeks. I am worried it's my job. It is really getting to me. Doctor: What else are you feeling? Patient: Feeling very nervous an anxious actually. Doctor: Have you noticed anything that you are doing or anything else that kind of increasing these symptoms? Patient: Oh yeah, whenever I'm stressed. I feel like I have more palpitations and to the level that it causes a lot of chest pain. Doctor: Is it the same when you are doing a lot of physical stuff like physical activities or something like that? Patient: Nope. Haven't noticed it with the exertion part. Doctor: Do you have any history of any heart issues in the past? Patient: I had the same kind of symptoms like nine or ten years ago. Doctor: Okay. What did you do that time? How did you recover? Patient: Well, at that time a full work up was done but everything came out to be negative, so they just gave me something for my nerves. It kind of helped. Doctor: Do you remember what they gave you? Like name or anything of the medicine. Patient: No. It was many years ago, I don't remember. Doctor: Anything else going on? Patient: Yeah, for the last three days and I am having these tummy issues. I'm having on and off nausea and also, my stools are coming loose. Doctor: Have you seen any color change in your bowel movements? Patient: Yeah, it's been some really funny green color. I don't know what's going on inside. Doctor: Have you ever noticed blood in the stools? Patient: Nope. Doctor: Is there any pain in your tummy? Patient: Nope, it's just some nausea. Doctor: How's your appetite? Patient: Not as good as before. Doctor: Do you smoke? Patient: I never did.","Section header: GENHX Section text: This patient presents to the office today because he has not been feeling well. He was in for a complete physical on 05/02/2008. According to the chart, the patient gives a history of feeling bad for about two weeks. At first he thought it was stress and anxiety and then he became worried it was something else. He says he is having a lot of palpitations. He gets a fluttering feeling in his chest. He has been very tired over two weeks as well. His job has been really getting to him. He has been feeling nervous and anxious. It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain. These symptoms are not triggered by exertion. He had similar symptoms about 9 or 10 years ago. At that time he went through a full workup. Everything ended up being negative and they gave him something that he took for his nerves and he says that helped. Unfortunately, he does not remember what it was. Also over the last three days he has had some intestinal problems. He has had some intermittent nausea and his stools have been loose. He has been having some really funny green color to his bowel movements. There has been no blood in the stool. He is not having any abdominal pain, just some nausea. He does not have much of an appetite. He is a nonsmoker." "Doctor: So just to double check, you're not on any medications? Patient: You got it. Nothing since last year.",Section header: MEDICATIONS Section text: None. "Doctor: What brings you in today? Patient: I have this nasty cough and my nose has been super stuffy. Doctor: Are you bringing anything up when you cough? Patient: Not really, no. Doctor: Are you having any other symptoms, such as chest pain, headaches, nausea, or vomiting? Patient: No. I did have a slight headache last night but I took Advil and it's since gotten better. Doctor: Are you taking anything for the cough or stuffy nose? Patient: Just drinking tea and taking cough drops here and there. Doctor: Okay. Let's take a look at you. Hm it appears that you have a U R I.",Section header: ASSESSMENT Section text: Upper respiratory infection. "Doctor: How are you feeling today, sir? Patient: I feel pretty weak right now, but I am doing okay at the moment. Doctor: I reviewed the chart notes that was sent to me by the nursing home. They also sent me your medical history. You have been going through a lot recently. Patient: Yes, I have. They moved me into the nursing home after I was released from the hospital. I hope that it is just temporary. Doctor: I understand that you had a seizer and that is why you were taken to the hospital. Patient: I had multiple seizures. After I was stabilized from the last seizure this side of my body in not working right. Doctor: Okay so you are having some partial weakness on this side? Patient: Yes. That is why they moved me to the nursing home. I can't stand up. I am too weak. I can't take care of myself. The nurses have to help me do everything. Doctor: I am going to try to help you get back to doing things on your own. Patient: After being in the hospital I got an infection in my intestines. They put me on some antibiotic that I have never heard of and a probiotic. Doctor: Okay. I see here in the chart that you had two surgeries on July sixth. Patient: Yes, and then I had a radiation treatment too. Doctor: Oh yes. On August seventh. Patient: That sounds right. Doctor: Your surgeries may have been the reason for the C diff. Patient: What is C diff? Doctor: It is an infection in the large intestine. It is often caused by overuse of antibiotics, and you have been on them for a while due to the surgeries that you have had. Or it could be from the surgery itself. Patient: That make since.","Section header: GENHX Section text: He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07. He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. He is unable to stand at the moment. He is unable to care for himself. I reviewed the information that was sent down with him from the nursing home which includes his medical history." "Doctor: How is your sleep? Are you sleeping well? Patient: Yes, without any disturbance. I sleep like a log! Doctor: Good. Any mood swings or did you feel your emotions are out of control? Patient: Nah, just the normal mood swings around my periods otherwise no problem at all. Doctor: Any depression like feeling, sudden mood changes or feeling sad or hopeless? Patient: Nope! Doctor: Okay.","Section header: ROS Section text: PSYCHIATRIC: No history of emotional lability, depression or sleep disturbances." "Doctor: How's he doing today? Guest_family: I think he might have fifth disease with sinusitis. It's been running rampant at his school. Doctor: Oh, wow. Let's see what we can do.",Section header: ASSESSMENT Section text: Fifth disease with sinusitis. "Patient: Help! I need help! I need to see the doctor! Doctor: Yes, what's wrong? Where's your pain? Patient: My stomach! It hurts so much! I've never had this type of pain before! Doctor: When did it start? Patient: At ten! I don't know. It started hurting out of nowhere. One second I'm driving home and the next thing I know I had to call- Doctor: Yes? Patient: The pain is so bad! It's hard for me to even think straight.",Section header: CC Section text: Abdominal pain. "Doctor: Just want to ask you few routine questions, let me know if any of this is positive. Patient: Sure, go ahead. Doctor: Do you have any problems like headache, fever, rash, oral ulcer? Patient: None. Doctor: Any problem with vision? Like unable to see or double vision? Patient: Um no, I can see everything. Doctor: Okay. Do you get palpitations, like are you aware of your own heart? Patient: No, nothing like that. Doctor: How about breathlessness while lying down or do you have to get up in the middle of the night to catch a breath? Patient: No I don't feel anything like that. Doctor: That's great. Any diarrhea, constipation, or red blood come out in stool? Or pale stool? Like any change in the color of stool? Patient: No, it is fine. Doctor: Okay. Any jaundice recently? Patient: No. No jaundice. Doctor: Do you have problems with appetite? Patient: Yeah, I mean you can say my appetite is decreased. Doctor: Because of that have you noticed any weight loss? Patient: Oh no. Doctor: Okay sounds good. Patient: Sure.","Section header: ROS Section text: No rashes, headache, photophobia, diplopia, or oral ulcers. No palpitations, orthopnea or PND. No diarrhea, constipation, melena, bright red blood per rectum, or pale stool. No jaundice. Decreased appetite, but no weight loss." "Doctor: Good morning, ma'am. What seems to be the problem with your knee? Patient: I've had pain in this knee since I tripped on some ice on March tenth two thousand three. Doctor: How old are you now? Patient: I'm forty seven. Doctor: What kind of symptoms have you had since the fall? Patient: It's hard for me to stand up without significant pain, and it feels like my knee is going to give way. Doctor: Has this knee given out before? Patient: It has. Doctor: Is there any swelling in this knee? Patient: Yes, I also feel a popping, like when I go up the stairs. Doctor: What kind of treatments have you had for this knee? Patient: I've had antiinflammatories and P T, but I didn't respond well at all. Doctor: Have you had surgery on this knee in the past? Patient: Yes, but I can't remember the name of the operation.","Section header: GENHX Section text: The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice. The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure." "Doctor: How're you doing today, sir? Patient: Uh I'm hanging in there. Doctor: I see that you've recently celebrated your seventy second birthday. Patient: Yep. My kids and grandkids threw me a surprise party. It was really nice. Doctor: Aw surprises are always fun. However, I'm sorry to hear that you're not doing that well today. Patient: Yeah, me too. The other day, I had a lot of difficulty getting up from my chair because of weakness all over and a lightheadedness I can't seem to explain. Doctor: Is this new for you? Patient: Um I mean I've had falling spells several times a month for the past year, but I've always been able to get myself up one way or another. Doctor: Do you remember losing consciousness during any of those episodes? Patient: Not that I recall. I've noticed I'm a lot weaker than before so maybe that's why I keep falling more frequently. Doctor: I see. Do you experience room spinning dizziness at all? Patient: No. I also forgot to mention that four hours after not being able to get up from my chair, my left hand became numb for about two hours. Doctor: Are you right or left handed? Patient: Right handed. Doctor: And besides what you've mentioned to me so far, no other symptoms of concern? Patient: No.","Section header: GENHX Section text: On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo. He had been experiencing falling spells without associated LOC up to several times a month for the past year." "Doctor: And where do you live? Patient: Well, I live in this small town called Fayetteville in Tennessee. Doctor: Ah, I see. And do you have lot of friends there? Patient: I have few. Doctor: Okay, and do you drink? Patient: No. Doctor: How about smoking? Patient: Never did!","Section header: FAM/SOCHX Section text: She does not drink or smoke. Lives in Fayetteville, Tennessee." "Doctor: How are you feeling? Patient: I am feeling better now. Doctor: What happened last night? Guest_family: She went out to a party last night. She came home drunk and high. Doctor: What did you take? Patient: I took Ecstasy. I only had two drinks. Doctor: How much Ecstasy did you take? Patient: I didn't take them all at once. I think I took six tabs. Doctor: What time did you start taking the tablets? Patient: We started taking it kind of late. I think it was midnight. Guest_family: When she came home, she was agitated and physically shaking. She was pacing all over the house. Then she threw up. That is when I got nervous and called nine one one. Doctor: Mom, did you notice any blood, or any yellow or green color in the vomit? Guest_family: No. Doctor: Are you still feeling nauseous? Patient: No. I feel fine. Well, I feel weird but not nauseous. Doctor: Are you experiencing any pain at all? Patient: No. Doctor: Did you or do you feel depressed? Patient: No. Doctor: Do you or have you ever had suicidal thoughts? Patient: No. Doctor: Are you seeing or hearing things that are not real? Patient: No. Doctor: Do you or have you ever had thoughts of harming yourself? Patient: No. I was not trying to harm myself or anyone else. I just wanted to have a little fun. Guest_family: She seems to be back to her usual self now. Doctor: Just one more question. Prior to last night have you had any recent illnesses or injuries? Patient: No.","Section header: GENHX Section text: This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecsasy tablets. The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis. Mother called the EMS service when the patient vomited. On arrival here, the patient states that she no longer has any nausea and that she feels just fine. The patient states she feels wired but has no other problems or complaints. The patient denies any pain. The patient does not have any auditory of visual hallucinations. The patient denies any depression or suicidal ideation. The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself. The patient denies any homicidal ideation. The patient denies any recent illness or recent injuries. The mother states that the daughter appears to be back to her usual self now." "Doctor: Do you have any support system? Patient: No, I am single. Doctor: Okay so live alone at home? Patient: Yes. Doctor: Do you smoke or drink? Patient: Nope I do not.",Section header: PASTSURGICAL Section text: The patient is single. Living at home. No smoking or alcohol. "Doctor: So, are you married? Patient: No, my wife and I got divorced a while ago. We have three children together, though. Doctor: Okay, and do you have someone who is managing your case? Patient: Yes, I have an lawyer handling everything. Doctor: Do you smoke or drink? Patient: No, I never really smoke or drink.",Section header: FAM/SOCHX Section text: He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney. "Doctor: Have you ever had surgery? Patient: No, not that I can remember. Doctor: No gallbladder or appendix removal, c sections, or joint replacements? Patient: Nope, never had anything done.","Section header: PASTSURGICAL Section text: Otherwise, negative." "Doctor: I just need to confirm a few pieces of information from my nurse before we begin today, sir. Patient: Sure, no problem, doctor. Doctor: Great, so it says here that you are forty five years old, and you identify as Caucasian. Is that correct? Patient: Yes, that's correct. Doctor: Thank you, so, what seems to be the problem today? Patient: Well, I have this pain in my right knee, sir. Doctor: Where is your pain? Patient: It's right here, on the inside of my right knee. Doctor: Is there an injury associated with this pain? Patient: Actually, yeah. I twisted it while I was at work.","Section header: GENHX Section text: The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain. He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee." "Doctor: Good morning, sir. Can you confirm your age for me, please? Patient: Good morning, doctor. I'm fifty nine years old. Doctor: Great, and which hand is your dominant hand? Patient: Um, I use my right hand for everything. Doctor: Great, thank you. So, what seems to be the problem today? Patient: I have had this weird feeling in both of my legs for about three weeks now. Doctor: Have you been treated for this so far? Patient: Um, I went to the E R about a week ago. Doctor: What did they tell you there? Patient: They said I had progressive sensory and motor deficits in both legs. Doctor: Can you describe your symptoms for me, please? Patient: Um, I have numbness, like here starting at my trunk, and then over the last month or so, it moved into my legs. Doctor: I'm going to apply some pressure right here at the nipple line, can you feel that? Patient: No, I'm numb from there down. Doctor: Have you had any weakness in your legs? Patient: Yeah, I have for the last week or so. Doctor: Is it getting worse? Patient: Yes, it is. Doctor: When did you start using the cane? Patient: Um, about five days ago, now. Doctor: Why did you begin using it? Patient: I'm having trouble walking and going up and down stairs. Doctor: Are you able to stand without it? Patient: No, I'm not. Doctor: Have you had any loss of bowel or bladder control? Patient: No, thankfully not, but at the same time I haven't had a bowel movement in about three days. Doctor: When was the last time you urinated? Patient: It was about twenty four hours ago. Doctor: In addition to the numbness, how else would you describe your leg symptoms? Patient: Um, I'd say it feels cold, at least I've felt that for the last day or so. Doctor: Do you have any back or neck pain? Patient: No, nothing there. Doctor: Do you have any shortness of breath? Patient: Well, I've had it chronically for a while now, but I think it's getting worse. Doctor: Have you had any lightheadedness or feelings of faint? Patient: Um, yeah, when I try to stand up. Doctor: How long have you had that feeling? Patient: I've had it for about two days now.","Section header: GENHX Section text: This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation." "Doctor: Do you have any known allergies to medications? Patient: No.",Section header: ALLERGY Section text: None. "Doctor: Good evening, and welcome to A B C D General Hospital E D. Patient: Thank you, Doctor, I've really messed up this ankle. Doctor: Before we begin, how old are you? And which gender do you identify? Patient: Thank you for asking, Doctor, I'm a fifty year old man. Doctor: Thank you, what happened? Patient: I fell off my liner, and I landed right onto my left foot. Doctor: How far did you fall? Patient: Um, it was really about ten feet. Doctor: Oh, yes, I see. I have some good news for you, there's no gross deformity in this ankle. Patient: What does that mean, exactly? Doctor: I don't see any ankle dislocation, which is good. Patient: Oh, that's good news. Doctor: Have you had your x rays taken yet? Patient: Yeah, the tech just brought me back. Doctor: Great, let me pull them up here. Okay, um, if you look here, you'll see a fracture of your talus. Patient: Which bone is that? Doctor: That's your heel, to be specific, it's a grade I V Hawkins fracture of the left talus. You are still neurovascularly intact in the distal region. Patient: What are we going to do about this? Doctor: Do you have any other pain from the fall, aside from the ankle? Patient: No, the ankle really took all of the weight of the fall. Doctor: Okay, I think we should do surgery in order to repair this ankle. Patient: Why is that? Doctor: There is very weak blood flow to the body of this bone, there's a risk for avascular necrosis, which is bone death. Patient: Okay, you're right. What are the risks of this infection with this surgery? Doctor: Overall, the risks of infection are less than one percent. We'll use antibiotics to keep everything clean. Patient: Will I be asleep for this? Doctor: Yes, you'll be under anesthesia. Patient: Okay, yes, um, I'd like to go forward with the surgery.","Section header: GENHX Section text: This is a 50-year-old male who presented to ABCD General Hospital Emergency Department with complaints of left ankle pain and disfigurement. There was no open injury. The patient fell approximately 10 feet off his liner, landing on his left foot. There was evidence of gross deformity of the ankle. An x-ray was performed in the Emergency Room, which revealed a grade IV Hawkins classification talus fracture. He was distal neurovascularly intact. The patient denied any other complaints besides pain in the ankle. It was for this reason, we elected to undergo the procedure in order to reduce and restore the blood supply to the talus body. Because of its tenuous blood supply, the patient is at risk for avascular necrosis. The patient has agreed to undergo the above-named procedure and consent was obtained. All risks as well as complications were discussed." "Doctor: What medications are you currently taking? Patient: Augmentin, Detroal LA and lisinopril.",Section header: MEDICATIONS Section text: Augmentin; Detrol LA; lisinopril. "Doctor: Did you ever have any surgery? Patient: No.",Section header: PASTSURGICAL Section text: Negative. "Doctor: Hello, miss. How are you doing today? Patient: I have this massive headache. Doctor: I see. Do migraines usually run in your family? Patient: They do. Everyone has it. We've been having it for many years. Doctor: Oh, wow. I'm looking at your blood reports, and it shows you have high blood sugar. Does diabetes run in your family too? Patient: Yup. We all eat too much rice for dinner.",Section header: FAM/SOCHX Section text: There is family history of migraine and diabetes in her siblings. "Doctor: What's bringing you in today? Patient: I've had a terrible toothache. I can't stand the pain anymore. I have never experienced this pain in fifty eight years. Doctor: Where are you experiencing the most pain? And when did this pain start? Patient: It started about three weeks ago. It's mostly on the left side of my mouth. Kind of on the lower end. It goes from my jaw all the way up to my left ear. Doctor: That doesn't sound the least bit comfortable. Let's get you feeling better. Do you think it's related to your tooth? Patient: No, I don't think so. I'm pretty good at making my dentist appointments, although I haven't been in since this new pain started. Doctor: I see. When was the last time you visited the dentist? Patient: About two months ago for a routine clean. Doctor: Have you noticed any facial swelling since all of this started? Patient: No, no swelling. Doctor: Any headaches, throat swelling, sore throat, difficulty swallowing or chewing? Patient: No. Doctor: How about any neck pain, swollen lymph nodes, chills, fever, or other symptoms? Patient: No, thank goodness.","Section header: GENHX Section text: This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear. Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began. The patient denies any facial swelling. No headache. No swelling to the throat. No sore throat. No difficulty swallowing liquids or solids. No neck pain. No lymph node swelling. The patient denies any fever or chills. Denies any other problems or complaints." "Doctor: How long has your finger been in pain, sir? Patient: Well, at this point, it's been more than a few months. Doctor: Have you seen another doctor for this pain? Patient: Yeah, I saw another guy a little while ago. Doctor: Do you have the records from the visit? Patient: Yeah, actually, they're right here. Doctor: Okay, so I see you have a trigger finger, and a mucous cyst, and this other doctor gave you injections. Is that correct? Patient: Yes sir. Doctor: Did the injections help at all? Patient: No sir, honestly, they did nothing. Doctor: So, your finger is still locking today? Patient: Yes sir, the other doctor referred me over here to see if there was anything more we could do. I'd like to try surgery.","Section header: GENHX Section text: The patient has been followed elsewhere, and we reviewed his records. Essentially, he has had a trigger finger and a mucocyst, and he has had injections. This has been going on for several months. He is now here for active treatment because the injections were not helpful, nonoperative treatment has not worked, and he would like to move forward in order to prevent this from keeping on locking and causing his pain. He is referred over here for evaluation regarding that." "Doctor: Hello, I am Doctor James. Guest_family: Hi Doctor, this is my daughter Miya, and I am Jena. Doctor: Nice to meet you ladies. So, Miya how old are you? Patient: I am fifteen. Doctor: Okay, so tell me what is going on with you? Patient: Well, I am having a severe headache. Guest_family: She has been complaining about it for almost six hours now. Doctor: Oh wow. Can you tell me where exactly the pain is? Patient: Um, it started from my neck and then moved up to the back of my head. Doctor: I see. Did you get hurt or bump your head? Patient: No. Doctor: Does she have any history of headaches? Guest_family: No. Doctor: Okay, any nausea or vomiting? Patient: I am having nausea, but it's coming and going but no vomiting. Also, I am not able to tolerate light at all. Doctor: Hm, are you able to see properly though, any change in your vision? Patient: No. Doctor: Any fever? Patient: No. Guest_family: No, no fever. Doctor: Okay.",Section header: GENHX Section text: This is a 15-year-old girl presenting with occipital headache for the last six hours. She denies trauma. She has been intermittently nauseated but has not vomited and has some photophobia. Denies fever or change in vision. She has no past history of headaches. "Doctor: And you said you're right handed, correct? Patient: Yep. Right handed. Doctor: Okay, great. I've made note of it in your chart. I have one more question to ask regarding tobacco and alcohol. Do you smoke or drink? Patient: I don't do either. I can't even think of the last time I took a sip of alcohol.",Section header: FAM/SOCHX Section text: The patient is right-handed. She does not smoke and does not drink alcohol. "Guest_clinician: What brings him in today? Doctor: He's here for sepsis and I suspect he may have spontaneous bacterial peritonitis. Guest_clinician: Let me pull up his chart.","Section header: CC Section text: Sepsis, possible SBP." "Doctor: Let's check your throat. Okay, I don't see any swelling or any mass. Is there any pain when I touch you? Patient: No pain. Doctor: I don't feel any kind of lump in your throat. That is a good sign. It looks very flexible and symmetric.","Section header: EXAM Section text: NECK: Supple and symmetric. There was no thyroid enlargement, and no tenderness, or masses were felt." "Patient: Good afternoon, doctor. Doctor: Remind me, please, how old are you? Patient: I'm sixty nine years old, doctor. Doctor: Thank you, what seems to be the problem today? Patient: Oh, I've had pain in these knees for years, but it's been getting a lot worse over the last few months. Doctor: Is the pain messing with your ability to do activities? Patient: Absolutely, sir, yes it is. Doctor: What kind of treatments have you had so far? Patient: Another doctor called it conservative treatment, um, I've taken antiinflammatories and had some injections. Doctor: Do you remember what kind of injections you've had? Patient: It was, um, cortisone, and Synvisc. Doctor: Did these relieve the pain at all? Patient: Well, it was only a temporary relief. Is there anything else we can do? Doctor: Well, there is surgery for this. Patient: What are the risks of infection from the surgery? Doctor: Historically, it's less than one percent. Patient: How is this possible? Doctor: We use prophylactic antibiotics in order to eliminate the risk. Patient: That's great, I've heard of D V T from the commercials, is there a risk for that? Doctor: There's a risk, but it's low. Other risks are pulmonary embolism, need for further surgery, and further pain. Patient: Okay, yes, I'd like to do the surgery.","Section header: GENHX Section text: This is a 69-year-old male with complaints of bilateral knee pain for several years and increased intensity in the past several months where it has affected his activities of daily living. He attempted conservative treatment, which includes anti-inflammatory medications as well as cortisone and Synvisc. This has only provided him with temporary relief. It is for that reason, he is elected to undergo the above-named procedure. All risks as well as complications were discussed with the patient, which include, but are not limited to infection, deep vein thrombosis, pulmonary embolism, need for further surgery, and further pain. He has agreed to undergo this procedure and a consent was obtained preoperatively." "Doctor: How's this little guy doing today? Guest_family: I think he might have another ear infection. Doctor: Oh, I'm sorry to hear that. Let's have a look see. Guest_family: He's been telling me over and over again that his left ear is hurting him. He was here on April fourteenth and prescribed Amoxicillin. Doctor: Did that seem to help? Guest_family: It did at first, but the pain is back again. Doctor: Has he been running any fevers? Guest_family: No, no fevers. Doctor: He sounds a bit congested. Guest_family: He is. When he blows his nose, he brings up really thick mucous. This never really went away even with antibiotics. He's also been coughing a fair amount. Doctor: Is his cough productive? Guest_family: Yeah. Doctor: Does it seem to be keeping him up at night? How does the mucous look? Guest_family: No, I don't think so. It is pretty thick and viscous. The cough isn't constant or anything. Doctor: And no shortness of breath or wheezing that you've noticed? Guest_family: No.","Section header: GENHX Section text: Mom brings the patient in today for possible ear infection. He is complaining of left ear pain today. He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today. He has not had any fever but the congestion has continued to be very thick and purulent. It has never really resolved. He has a loose, productive-sounding cough but not consistently and not keeping him up at night. No wheezing or shortness of breath." "Doctor: How are you feeling today, sir? Patient: I'm doing much better today, doctor. Doctor: How is your strength and muscular pain? Patient: They're both improving. Doctor: Do you have any other complaints today? Patient: No, I'm doing quite well, honestly.","Section header: GENHX Section text: The patient was seen and examined. He feels much better today, improved weakness and decreased muscular pain. No other complaints." "Doctor: You have cholesterol issues, right? Patient: Yes. Doctor: Okay. I see. Gemfibrozil? That sounds familiar? Do you take that? Patient: Yes, I think that one. But I am not sure. Doctor: Okay. Do you remember taking them at all as an outpatient? Patient: I mean I don't remember. Doctor: Okay don't worry I can look at your previous records. We do have them.",Section header: PASTMEDICALHX Section text: The only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil. The patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient. "Doctor: Are you taking any medicine? Patient: No.",Section header: MEDICATIONS Section text: None. "Doctor: So it looks like you're here today for a noticeable foreign body sensation in your eye. Patient: Yeah, my left eye. Never had this happen to me in my forty one years. Doctor: First time for everything I guess! When did you first notice the sensation? Patient: Um when I was at work this morning. It felt like something was in my eye. I went to the bathroom mirror to check it out, but didn't see anything. I flushed my eyes with water in hopes of it helping with the weird feeling. Doctor: Okay. Hm, are you experiencing any eye pain, blurred vision, or sensitivity to light? Patient: The pain has definitely gotten worse since this morning. My vision is fine and bright lights don't seem to be a problem.","Section header: GENHX Section text: This is the initial clinic visit for a 41-year-old worker who is seen for a foreign body to his left eye. He states that he was doing his normal job when he felt a foreign body sensation. He attempted to flush this at work, but has had persistent pain which has progressively worsened throughout the course of the day. He has no significant blurriness of vision or photophobia." "Doctor: What brings you in today? Patient: I've had a lot of discomfort in my private area. Doctor: When did it start? Patient: It's been going on for about two weeks now. Doctor: Have you noticed any abnormal discharge? Patient: Not really, no. But it's been super itchy down there. Doctor: Any abdominal pain, nausea, vomiting? Patient: Uh no, but I'm having some pain here. Doctor: Near your pelvis? Patient: Yeah. Doctor: Have you started any new lotions or products? Patient: No. Doctor: Have you tried anything for the pain or itching? Patient: No, not yet. I thought it'd go away on it's own. Doctor: If it's okay with you, I'd like to do a pelvic exam. Patient: Fine with me. Doctor: Have you been sexually active prior to or after noticing these concerns? Patient: Uh once this past week, but it was pretty painful. Doctor: I see. You may have an infection, which is why I'd also like to send out samples to the lab. Did you use protection? Patient: Yeah, I take birth control. But I've been struggling a bit with my mood and I'm wondering if it's because of the new birth control pills. Doctor: We can look into that as well. Hang tight while I grab the nurse for the pelvic exam.",Section header: CC Section text: 1. Infection. 2. Pelvic pain. 3. Mood swings. 4. Painful sex. "Doctor: Do you have any allergies? Patient: No, I do not have any allergies. Doctor: Okay so no medically relevant allergies then. Nothing? Patient: Nope.",Section header: ALLERGY Section text: She has no known medical allergies. "Doctor: I don't think we need to do any major procedure right now. Patient: Okay.",Section header: PROCEDURES Section text: None. "Doctor: Did you have any medical issues? Patient: Nope.",Section header: PASTMEDICALHX Section text: Otherwise negative. "Doctor: Any known allergies? Patient: Oh yes, I cannot take Sulfa drugs. Doctor: Let me add that to your record.",Section header: ALLERGY Section text: She is allergic to Sulfa. "Doctor: So how are you feeling? Patient: I am feeling well. Doctor: Any illness or fever? Patient: No, nothing like that. Doctor: Any headache or nausea? Patient: No. Doctor: Any vomiting or stomach upset? Patient: No. Doctor: Okay, any numbness tingling or loss of sensation in the hand? Patient: No, not at all. Doctor: Otherwise feeling well? Patient: Yeah.",Section header: ROS Section text: Otherwise well. No febrile illness. No motor or sensory complaints of any sort or paresthesias in the hand. "Doctor: Welcome to the clinic. I am Doctor Frank. Patient: Thank you. It is nice to meet you. Doctor: What brings you into see me today? Patient: I think I may have had a stroke. Doctor: What happened to make you think that you had a stroke? Patient: This morning, I felt like something in my throat. It was a strange feeling. Then I felt really dizzy. My left hand and jaw felt numb. Doctor: Did you lose consciousness? Patient: I don't know. It is a bit confusing. I woke up this morning and I was so disoriented that I thought it was the middle of the night. My hand was numb. I also felt the numbness on the left side of my neck and my face. Doctor: Did the dizzy episode happen after you woke up this morning? Patient: Yes. I got dizzy when I tried to get out of bed. Doctor: Has anything like this happen to you in the past? Patient: About three weeks ago, I had a dizzy episodes and I ended up falling down. Doctor: Did you have any other symptoms like you did this morning? Patient: No. Doctor: Did you see a doctor after the fall you had three weeks ago? Patient: I saw Doctor X Y Z. Doctor X Y Z put me on Antivert. Doctor: Have you had any cold or any other resent illnesses? Patient: I have not had a cold, but I did have an earache about a day or so ago. Doctor: Okay. How old are you? Patient: I am seventy five years young. Doctor: Fantastic.","Section header: GENHX Section text: The patient is a 75-year-old female who comes in today with concerns of having a stroke. She states she feels like she has something in her throat. She started with some dizziness this morning and some left hand and left jaw numbness. She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert. She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck. She said she had an earache a day or so ago. She has not had any cold symptoms." "Doctor: What is your family medical history? Patient: My mom was healthy all her life. She died of old age. She was eighty nine years old. My dad died of a stroke. He was eighty nine as well. Doctor: Do you have siblings? Patient: Yes I had a brother and a sister. My sister died way too young. She was only thirty when she passed away from cancer. My brother lasted until he was seventy four. He had coronary artery disease.","Section header: FAM/SOCHX Section text: Mother died age 89 of ""old age."" Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of cancer." "Doctor: Do you have any known drug allergies? Patient: No.",Section header: ALLERGY Section text: None. "Doctor: Any history of heart attack? Patient: No. Doctor: Any chest pain, palpitations or shortness of breath on exertion? Patient: No. Doctor: How about your blood pressure? Patient: It's normal. Doctor: Any swelling? Patient: No. Doctor: Any history of irregular heartbeats? Patient: No.","Section header: ROS Section text: CARDIOVASCULAR: Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema. No history of heart attack, no history of arrhythmias, no history of hypertension." "Doctor: Hi, do you smoke? Patient: No, sir, I don't. Doctor: Do you take any drugs? Patient: No. Doctor: What about drinks? Do you take alcohol in any form? Patient: No, none of those.",Section header: FAM/SOCHX Section text: Denies Tobacco/ETOH/illicit drug use. "Doctor: Hi there, so you are here for your follow up? Patient: Yes, I had a surgical removal of multiple abscesses on my right thigh. Doctor: Okay, let me quickly check your discharge sheet. Patient: Sure. Doctor: It says you had multiple extensive subcutaneous abscesses on your right thigh and there was a massive open wound as well. Patient: Yes, that sounds about right! Doctor: Okay, and then they did multiple abscesses excisions on your thigh. Patient: Yes, on my right thigh. Doctor: Okay.","Section header: DIAGNOSIS Section text: 1. Multiple extensive subcutaneous abscesses, right thigh. 2. Massive open wound, right thigh, status post right excision of multiple subcutaneous abscesses, right thigh." "Doctor: Hi Gina, how are you? Patient: I wish, I was in better state but yeah, I am okay. Doctor: I understand. So, you are here for your follow up post your surgeries, right? Patient: Yes, I am. Doctor: Alright, I see you recently had your left breast removed due to cancer. Patient: Correct. Doctor: And then you also had your right knee replaced due to arthritis in your kneecap, right? Patient: Yeah, I had arthritis in my knee bone so I got it replaced. Doctor: Hm.",Section header: PASTSURGICAL Section text: Status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis. "Doctor: Hello. How are you all doing today? Guest_family: We're doing fine. I'm the mother of my four year old boy. Doctor: Hello, ma'am. What seems to be the problem? Gest_family: We just wanted to follow up after my son's E R visit. Doctor: Oh, no. What happened? Guest_family: He was playing at the park and thought it was a good idea to jump off the swing. Crazy kid, right? Doctor: It happens. Live and you learn, as they say. Do you have any information from the E R visit. Guest_family: I gave it to the nurse. Did you not get it? Guest_clinician: Sorry. I got really busy, but here is the report. Doctor: Could you read it to me, please? Guest_clinician: Of course. So, their son severely injured his left distal humerus. No problems were claimed before the injury. The E R saw him for his deformed elbow. Doctor: Are there any exams on the report? Guest_clinician: There is an x ray and physical exam. They both confirmed a closed type three supracondylar fracture of his left distal humerus with severe puckering of the skin anteriorly with major ecchymosis in the same region. He did have a radial pulse palpable Doctor: Thank you, nurse. Mom, were you there before his surgery? Guest_family: My husband and I were. My husband rushed from this cultural event he had planned. Doctor: I see. What do you all identify as? Guest_family: We identify as white. Doctor: I see. I'm going to perform a neurological exam on your son now. Hi buddy. Is it fine if I do a quick exam? Patient: Sure. Doctor: Thanks. It'll be quick. Patient: Okay. Doctor: After doing the exam I see his ulnar, median, and radial nerves are intact. I couldn't do the entire exam because the pain might be too much for him. Guest_family: Thank you so much for your help.","Section header: GENHX Section text: This is a 4-year-old white male, apparently dominantly right-handed who suffered a severe injury to his left distal humerus after jumping off of a swing. He apparently had not had previous problems with his left arm. He was seen in the Emergency with a grossly deformed left elbow. His parents' were both present preoperatively. His x-ray exam as well as physical exam was consistent with a closed type-III supracondylar fracture of the left distal humerus with rather severe puckering of the skin anteriorly with significant ecchymosis in the same region. Gross neurologic exam revealed his ulnar, median, and radial nerves to be mostly intact, although a complete exam was impossible. He did have a radial pulse palpable." "Doctor: You had a heart procedure done couple months back right? Patient: Yes, they had to do a cardioversion on me because of my heart rhythm disorder. Doctor: Okay. Patient: And I am taking a blood thinner right now. Doctor: Yes, I saw, you are on Coumadin. Do you know other medications you are on? Patient: Yes, I have a list with me. Here, look. Doctor: Wow! That is great. Thank you for being so thorough. Patient: Sure. Doctor: So you are on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and some other. Patient: Yes. Doctor: Do you have diabetes? Patient: No, I do not. Doctor: Okay, have you smoked in the past? Patient: Yes, I have, but I quit some years back. Doctor: Okay. Have you ever had lung problems? Patient: No, I have not. Doctor: Okay. How about your family? Anyone sick? Patient: No, no one is sick in family.","Section header: GENHX Section text: He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation. He also lists some other medications. I do have his medications list. He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other medicines. Those are the predominant medicines. He is not a diabetic. The past history otherwise, he has had smoking history, but he quit several years ago and denies any COPD or emphysema. No one else in the family is sick." "Doctor: What is your family medical history? Patient: My uncle on my dad's side of the family had kidney failure. I lot of my family members have diabetes and asthma.",Section header: FAM/SOCHX Section text: Family history is positive for asthma and diabetes. There is also positive family history of renal disease on the father's side of the family. "Doctor: What is your family medical history? Patient: My dad passed away from a heart attack. He was fifty nine. My mom died from complications with her diabetes. Doctor: Do you have any siblings? Patient: Yes. My brother had a bypass with a graft in August of ninety five.",Section header: FAM/SOCHX Section text: Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95. "Doctor: Hello, how are you? Patient: What? Doctor: How are you related to the patient? Guest_family: Hello doctor, I am his son. Doctor: Hello. How old is he? Guest_family: He is eighty years old. He is suffering from dementia. Doctor: I see. Do you think he will be able to provide me with his medical history? Guest_family: I don't think so. Sometimes he even forgets his name. Patient: He's kidding. I know my name. I also know his kids' names. I do agree that sometimes I forget my things or feel lost. Doctor: I don't blame you. I forget my things at my age. Guest_family: Yeah, it is something like episodic that he forgets everything and sometimes he's absolutely normal. On good days, he's very nice to talk to. Doctor: What is his living status? Guest_family: He lives at a board and care. It is a cozier homelike place. Doctor: That's good. So what brings you here in the emergency today? Guest_family: He started complaining of stomach aches. Luckily, I was there. It was very sudden at one moment he was talking to me nicely and then all of a sudden he started complaining of severe pain in his stomach area. That's when I decided to bring him here in the emergency room. Doctor: Do you have any previous reports? Patient: I have these reports. Doctor: Do you remember when was this scan done? Patient: I have no idea. I just had these reports with me. Doctor: Do you remember of any medical issues before? Patient: Huh uh. Doctor: Okay, let me see what your scan says. I am reading the C T Scan report provided by the patient. It states that patient has dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter. Patient: Hm. Doctor: I see that you have already been given some I V fluid along with antibiotics by the emergency room doctor. Guest_family: Yeah. Doctor: Did he ever complain of pain during urination or nausea and vomiting? Guest_family: Yes, he had fever a few days back. When we asked him about other symptoms, he said, it's hard to urinate and it is painful. Nausea and vomiting are something that I am not sure about. He was normally rushing to the restroom and every time used to say he didn't want to pee as it hurt him. He also had a few accidents in the last few days where he wet himself. Doctor: Thank you for providing me with all his history. It will be very helpful for me to treat him now.","Section header: GENHX Section text: The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain. In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter. The patient is unable to provide further history. The patient's son is at the bedside and confirmed his history. The patient was given IV antibiotics in the emergency room. He was also given some hydration." "Doctor: What is your family medical history? Patient: My mother had cancer. She had multiple myeloma. She passed away at age eighty three. My dad died when he was eighty one.",Section header: FAM/SOCHX Section text: Father passed away at 81; mother of multiple myeloma at 83. "Doctor: How are your parents doing? Patient: Unfortunately, they both passed away. Doctor: Oh no, I'm so sorry to hear that. Patient: Thank you, its okay, I manage.",Section header: FAM/SOCHX Section text: The patient's parents are deceased. "Doctor: What's going on? Patient: I am having a bellyache. Doctor: Since when? Patient: Oh, it's been a while now. Doctor: Okay. Patient: Yeah.",Section header: CC Section text: Chronic abdominal pain. "Doctor: So, you are following up for your high blood pressure and high cholesterol? Patient: Yes.",Section header: CC Section text: Followup on hypertension and hypercholesterolemia. "Doctor: Hey, what's going on with you today? Patient: Oh, I have a chest pain. Doctor: You have fever too? Patient: Yes, I did.",Section header: CC Section text: Chest pain and fever. "Doctor: Hi, how are you? Patient: I am feeling not so good. Doctor: What happened and how long since it started? Patient: Oh, I don't remember it. Just my head is hurting so much. Guest_family: Hi doctor, she is my mother. Her dementia has progressed and most of the time she does not remember anything. Doctor: Oh, I see. Let me try and see if she can answer few questions Guest_family: Sure. Doctor: Did you have any nausea or vomiting? Patient: I don't know.",Section header: ROS Section text: She has moderate-to-severe dementia and is unable to give any information about history or review of systems. "Doctor: Any past medical history I should be aware of? Patient: Nope.",Section header: PASTMEDICALHX Section text: None. "Doctor: Do you have allergies to any medications? Patient: Um I'm allergic to Clonidine and Medifast. Doctor: What happens when you take Clonidine? Patient: I get a really bad rash. Doctor: And how about with Medifast? Patient: I get very tired after taking it. The last time I took it, I had trouble getting out of bed.","Section header: ALLERGY Section text: He has known history of allergy to clonidine, Medifast does fatigue." "Doctor: Good morning, ma'am. My nurses tell me that you're thirty nine years old, is that correct? Patient: Good morning, Doctor. Yes, that's correct. Doctor: So, what seems to be the problem today, ma'am? Patient: I hurt my knee while on the trampoline back in late August. Doctor: Do you remember the mechanism of injury to this knee? Patient: What do you mean? Doctor: Well, was it a twisting, pulling, snapping kind of injury? Patient: Oh, I twisted my knee. Doctor: Okay, have you seen another doctor for this? Patient: Yeah, and I got an M R I. Doctor: Can I see the report? Patient: Yes, here you go. Doctor: This M R I shows an A C L tear. Do you have any instability in this knee? Patient: Yeah, I feel like my knee joint has been unstable for years. Doctor: Have there been any dislocations? Patient: Yeah, there have been. What can be done about this? Doctor: Well, there's surgery to fix this. I can repair that A C L. Patient: What are the risks of infection with the procedure? Doctor: Historically, it's less than one percent. We use antibiotics to control for infection. Patient: Will I go under for this? Doctor: Yes, you won't feel a thing. Patient: Okay, yes, I'd like the surgery done.",Section header: GENHX Section text: This is a 39-year-old female who has sustained a twisting injury to her knee while on trampoline in late August. She was diagnosed per MRI. An MRI confirmed the clinical diagnosis of anterior cruciate ligament tear. She states she has had multiple episodes of instability to the patellofemoral joint throughout the years with multiple dislocations. She elected to proceed with surgery to repair the anterior cruciate ligament as well as possibly plicate the medial retinaculum to help prevent further dislocations of the patellofemoral joint. All risks and benefits of surgery were discussed with her at length. She was in agreement with the treatment plan. "Doctor: Can you tell me more about your family history, ma'am? How is your father doing? Patient: Well, doctor, my father passed away from leukemia a while back. Doctor: I'm so sorry to hear that. What about your mother? How is she doing? Patient: She died too. She had kidney and heart failure. Doctor: I'm sorry, ma'am. Patient: Oh, it's okay doctor, thank you. Doctor: Do you have any siblings? Patient: Yes, I have two brothers and five sisters. Doctor: That's a big family, do they have any conditions that you know about? Patient: One of my sisters has breast cancer. Doctor: Okay, thank you. Do you have any children? Patient: Yeah, I have two sons and a daughter. Doctor: That's great. Do you have any other conditions I should know about? Patient: Well, in addition to all of that, there's some high cholesterol, um, depression, and a nervous condition.","Section header: FAM/SOCHX Section text: Her father died from leukemia. Her mother died from kidney and heart failure. She has two brothers; five sisters, one with breast cancer; two sons; and a daughter. She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family." "Doctor: Anyone sick at home? Patient: No, fortunately. Everyone else is feeling fine.",Section header: FAM/SOCHX Section text: Everyone else is healthy at home. "Doctor: Hi there! What brings you in today? Patient: I have not been feeling well. I am tired and feel weak. Doctor: Have you had any other symptoms? Patient: I noticed after I went to the bathroom this morning, that my urine was dark. Doctor: Have you been staying hydrated? Patient: Yes. Doctor: Lets get a urine sample. I will have the nurse come in with a sample cup. Patient: Okay.",Section header: CC Section text: Dark urine and generalized weakness. "Doctor: Good afternoon, sir. Patient: Good afternoon, doctor. Doctor: You're forty four, correct? Patient: Yes sir. Doctor: Great, what seems to be the problem today, sir? Patient: Well, doctor, I've had lower back pain for a while now. Doctor: Does the pain go into your legs? Patient: Yeah, I have pain in my right thigh too. Doctor: Is there an injury associated with this pain? Patient: Yes, I had an incident back in nineteen ninety four. Doctor: Do you have any paperwork or medical records from the initial injury? Patient: No sir, I don't have those today. Doctor: What do you do for a living, sir? Patient: Right now, I work at Taco Bell. I have a workers comp claim open. Doctor: Your pain came back while working there, correct? Patient: Yes, that's correct. Doctor: Do you remember when your last appointment here was? Patient: Um, yes, it was on April twelfth two thousand five. Doctor: With ten being the worst pain imaginable, what was your pain out of ten at your last visit? Patient: Um, I'd say it was an eight out of ten. Doctor: Have you taken any medicine for this? Patient: Um, I had a Medrol Dosepak prescribed at my last visit. Doctor: How did your pain respond to the Dosepak? Patient: It took it down to about a four or five out of ten. Doctor: Can you point to me where the pain is, sir? Patient: Yes, it's right here. Doctor: This band right here? Patient: Yeah, that's the spot. Doctor: Okay, this is between your L four and sacrum. How would you describe your right leg pain? Patient: I'd say it's intermittent and minimal now, it's not always there. Doctor: Have you ever had back surgery? Patient: Um, yes, I've had two laminectomies, one in nineteen ninety and the other was in ninety four. Wait, I also had a discectomy some time in between. Doctor: Do you know where the focus was? Patient: It was at L four L 5. Doctor: Have you had any imaging done on the lower back? Patient: Yes, I had an M R I on October eighteenth two thousand four. I have the report right here. Doctor: Okay, this shows multi level degenerative changes, with facet involvement at L two L three, L three L four, and L five S1, with no neural impingement, which is good. Patient: What does that mean, doctor? Doctor: In summary, you have a significant amount of arthritis in the back. Patient: Oh yeah, I had an M R myelogram as well, here's the report. Doctor: Okay, this shows severe spinal stenosis at L three L four, but it may have been artifact. Patient: What does that mean? Doctor: This finding may be a misinterpretation.","Section header: GENHX Section text: The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain. He attributes this to an incident in which he was injured in 1994. I do not have any paperwork authenticating his claim that there is an open claim. Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05. He rated pain of approximately 8/10 in severity. He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10. He still localizes it to a band between L4 and the sacrum. He initially had some right leg pain but states that this is minimal and intermittent at the present time. His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994. The area of concern was L4-L5. The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1. There was no neural impingement. He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding." "Doctor: Did you have an allergic reactions to any medication? Patient: Nope. Doctor: Okay.",Section header: ALLERGY Section text: No known drug allergies. "Doctor: Hello, how are you? Patient: I am doing well. Just here for a follow up visit. Doctor: Are there any changes from the last visit in your social history or medical history? Patient: No. Whatever you wrote last time should be correct. I was here just three months ago. I was here December third of two thousand and three.",Section header: OTHER_HISTORY Section text: Reviewed and unchanged from the dictation on 12/03/2003. "Doctor: Do you take any meds? Patient: No. Doctor: Are you sure? Patient: Yes.",Section header: MEDICATIONS Section text: He is on no medications. "Doctor: Did you have any surgeries in the past? Patient: No.",Section header: PASTSURGICAL Section text: Negative. "Doctor: Welcome to the clinic. Patient: Thank you. Doctor: I would like to start with your medical history. Do you have any medical problems or conditions? Patient: I don't have any medical conditions other then the one I was sent to you for. Doctor: Yes. Doctor Hanine sent over your recent blood test results and chart notes. Did he discuss those results with you? Patient: Yes, he did. He said I have multiple myeloma. And that the blood work levels are how he found it. Doctor: Yes. The I G G levels show that the subtype is multiple myeloma. Patient: Okay.",Section header: PASTMEDICALHX Section text: History of IgG subtype multiple myeloma. "Doctor: So, how are feeling? Doctor: You came here last time with C V A right? Patient: Yeah, I am recovering well. You asked me to follow-up for high sugar. Doctor: Oh yeah, you have diabetes mellitus. Did you happen to get a blood test done before this visit? Patient: Yes, I did here is the report.","Section header: CC Section text: Followup on diabetes mellitus, status post cerebrovascular accident." "Doctor: What is your family medical history? Patient: I don't know of any family health problems.",Section header: FAM/SOCHX Section text: noncontributory. "Doctor: What brings you here today? Patient: I have a queasy tummy and the feeling that I am about to throw up all the time. Doctor: Anything else? Patient: I'm actually throwing up a lot.",Section header: CC Section text: Vomiting and nausea. "Doctor: Do you smoke? Patient: Yeah, here and there. Doctor: On average, how many cigarettes would you say you smoke? Patient: Probably three or four if I had to guess. Doctor: Any medical problems that run in the family? Patient: Yeah, my brother had a heart attack when he was pretty young. Doctor: How old was he? Patient: Fifty two. Doctor: Oh wow, how's he doing? Patient: Good, he has to see a heart doctor at least once a year. Doctor: Does anyone else in your family have heart problems? Patient: Um my dad has some heart issues. He's also a type one diabetic.",Section header: FAM/SOCHX Section text: Her father has type I diabetes and heart disease. She has a brother who had heart attack at the age of 52. He is a smoker. "Doctor: Hello, miss. How are you doing? Patient: I am fine. I just have a few questions about diet and exercise. I want to get my health in order. Doctor: Okay, great. That's something we can handle today. Can you tell me about your familial history? This will help me see any possible ailments that we should watch out for. Patient: Yes. So let's start with my mom. She died of congestive heart failure. Doctor: How about your father? Your paperwork says both parents are deceased. Patient: Yes, unfortunately. My dad died from myocardial infarction at fifty six years old. Not sure how old my mom was. Doctor: Your family seems to have a history of ischemic cardiac disease. How are your siblings? The paperwork says you have brothers. Patient: Yes. Two are alive and one has passed. He died from lymphoma. One brother has had two angioplasties and the other brother just has asthma.",Section header: FAM/SOCHX Section text: Reviewed. Mother died from congestive heart failure. Father died from myocardial infarction at the age of 56. Family history is positive for ischemic cardiac disease. Brother died from lymphoma. She has one brother living who has had angioplasties x 2. She has one brother with asthma. "Doctor: Smoke or drink? Patient: No and no.",Section header: FAM/SOCHX Section text: The patient is a nonsmoker. He denies use of alcohol. "Doctor: Are you allergic to anything? Patient: No, I am not. Doctor: How about food allergies. Patient: No, I am fine. Doctor: Okay.",Section header: ALLERGY Section text: None. "Doctor: Do you have any food allergies? Patient: Nope. Doctor: Any drug allergies? Patient: No.",Section header: ALLERGY Section text: None. "Doctor: Do you smoke? Patient: Yeah, I smoke weed every now and again. It helps with my anxiety. Doctor: How about cigarettes? Patient: No, not the least bit interested in cigs. Doctor: Good to keep it that way.",Section header: FAM/SOCHX Section text: The patient smokes marijuana. The patient does not smoke cigarettes. "Doctor: Hello! Who do we have here today? Guest_family: Hello, this is our son, A B C. Doctor: How old is he? What is the issue? Guest_family: He is two. He is continuously complaining of pain in his belly and back. He is active otherwise. Doctor: Did you notice any change in his toilet habits or routine? Guest_family: No. Doctor: Any fever or chills or any other issue? Guest_family: No, we did not notice any such issues, he has been active and was acting very normal otherwise. Doctor: Any change in his eating habits? Guest_family: No, he has been eating and drinking as usual. He was acting normally but we did notice a foul odor coming from his nose. He was on antibiotics after removal of that piece of cotton from his right side of nose in our previous visit here. Doctor: How is his nose now? Guest_family: He got better but now we can notice that odor from his nose again. Guest_family: His mother started him on the antibiotics again, whatever was remaining, we think something is still there. Doctor: Okay, Is there anything else like runny nose or any pain in his ear or bad throat? How about cough or congestion? Or any other issues you have noticed? Guest_family: No, nothing of those instead he has been active and eating and drinking normally, no other issue. Doctor: Is he complaining of any pain or discomfort on bowel movements? Is there any increase in the frequency of urination? Guest_family: Well, we can't say it for sure as he still wears diapers but we have not noticed anything abnormal.","Section header: GENHX Section text: Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain. This does not seem to be slowing him down. They have not noticed any change in his urine or bowels. They have not noted him to have any fevers or chills or any other illness. They state he is otherwise acting normally. He is eating and drinking well. He has not had any other acute complaints, although they have noted a foul odor coming from his nose. Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics. His nose got better and then started to become malodorous again. Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there. Otherwise, he has not had any runny nose, earache, no sore throat. He has not had any cough, congestion. He has been acting normally. Eating and drinking okay. No other significant complaints. He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper." "Doctor: Can you tell me about the medications that you are currently using? Patient: I am taking Alesse twenty eight. Doctor: Do you know its strength? Um, like how many milligrams? Patient: Oh yes, it is twenty M C G and I take point ten milligrams of it. Doctor: When did you start it? Patient: On seventh August in two thousand and one. Doctor: Who prescribed it? Patient: My O B G Y N, Doctor A.","Section header: MEDICATIONS Section text: Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A." "Doctor: What type of surgeries have you had in the past? Patient: I don't know what surgery they did today. I mean I don't know the name of it. Doctor: It's okay, I know. It is Lap Band. Patient: And I have had right side foot surgery done in the past. Doctor: Okay great. Patient: Sure.",Section header: PASTSURGICAL Section text: 1. Lap-Band done today. 2. Right foot surgery. "Doctor: Please, tell me a little more about your son. Guest_family: Well, he's twelve years old now, but he was born at about a month and a half early. Doctor: Were there any other complications with the pregnancy? Guest_family: He was exposed to drugs in the womb while I was pregnant, and he has been diagnosed with autism. Doctor: Okay. I see he has previously had an operation on the right knee, can you tell me more about that? Guest_family: He previously had a lot of trouble straightening out both of his legs, and since the right was worse than the left he had an operation on the inside part of the back of that leg. Doctor: When was this operation? Guest_family: It was in February of two thousand seven. Doctor: How did he respond to the operation? Guest_family: He responded really well, he was walking much better, and even got back to playing sports with the other kids in the neighborhood. Doctor: What seems to be the problem today? Guest_family: Now, his left knee is getting really bad, it's like how the right knee was. He can't straighten this leg. I think we should do the same operation again on the left knee. Doctor: Yes, I think we'll have to do surgery. Guest_family: What is the risk of infection with the surgery? Doctor: Historically, it's been less than one percent, we use prophylactic antibiotics in order to minimize infection risk. Guest_family: Will he be under anesthesia for the procedure? Doctor: Yes, he will be. He won't feel anything. Guest_family: Will this completely solve his problem? Doctor: I can't guarantee that he won't need additional procedures in the future. The other risks include, bleeding, changes in sensation and motion to the leg, failure to restore normal anatomy, and risk it won't work in general. Guest_family: What's the name of this procedure? Doctor: It's called a distal medial hamstring release. Guest_family: This is the same procedure he had in two thousand seven, right? Doctor: Yes ma'am, the exact same one. Guest_family: Okay, that sounds good, we want to go through with the procedure. Doctor: Okay, here is my surgical scheduler's business card, give them a call, and they can walk you through everything.","Section header: GENHX Section text: The patient is a 12-year-old boy born at a 32-week gestation and with drug exposure in utero. The patient has diagnosis of autism as well. The patient presented with bilateral knee flexion contractures, initially worse on right than left. He had right distal medial hamstring release performed in February 2007 and has done quite well and has noted significant improvement in his gait and his ability to play. The patient presents now with worsening left knee flexion contracture, and desires the same procedure to be performed. Risks and benefits of the surgery were discussed. The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to restore normal anatomy, continued contracture, possible need for other procedures. All questions were answered and mother and son agreed to above plan." "Patient: Oh doc, I've had a lot of trouble breathing lately. Doctor: I'm sorry to hear that. We'll get to the bottom of it. Patient: Yeah, I lose my breath so quickly with just one to two flights of stairs. Doctor: When did you first start noticing this? Patient: I believe two weeks ago. Doctor: Any chest pain or tightness with the shortness of breath? Patient: No, thankfully. Doctor: Any fever, chills, or sweats? Patient: No. Doctor: Any cough or coughing up blood? Patient: No. Doctor: How about wheezing or swelling in your legs? Patient: No.","Section header: ROS Section text: Dyspnea on exertion. No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling." "Doctor: Can you tell me more about your family medical history, sir? How's your dad doing? Patient: Well, doctor, he passed away. He had mesothelioma. Doctor: I'm so sorry to hear that, sir. How is your mother? Patient: It's okay, thank you. I lost her too. She had A L S. Doctor: I'm sorry, that must be so hard. Patient: Yes, it is, but I manage.",Section header: FAM/SOCHX Section text: His father died of mesothelioma and his mother died of Lou Gehrig's disease. "Doctor: Good afternoon, who's the victim today, sir? Is it you, or your daughter? Guest_family: Good afternoon, doctor. It's my daughter today. Doctor: Remind me, how old is she? Patient: I'm thirteen, sir. Doctor: So, what happened? My nurses tell me she fell today. Patient: Yeah, I fell off the swing at school earlier this afternoon at about one thirty. Doctor: Where does it hurt, young lady? Patient: It's really bad here on my left elbow. Doctor: Which hand do you write with? Patient: I use my right hand for everything, thank goodness for that. Doctor: Before seeing me, have you seen anyone else? Guest_family: Yeah, we went to an Urgent Care and she had an x ray there. Doctor: What else did they do? Guest_family: They said her arm was broken, and they tried to do a reduction. Doctor: Do you have those x rays with you right now? Guest_family: Yeah, I have them right here, take a look, please. Doctor: Well, these x rays show an incarcerated medial epicondyle fracture, as well as a mildly angulated radial shaft break. Patient: What does that mean? Doctor: Well, in short, you broke the inside part of your elbow. In addition to the pain, do you have any burning or tingling feelings in that arm? Patient: Yes, I do. Doctor: Did you have this before they tried to do a reduction? Patient: No, I didn't, this is new. Doctor: Is this feeling getting worse? Patient: Yes, it is. Doctor: Okay, guys, there is a lot of pressure on that ulnar nerve because of the break and the attempted reduction. Guest_family: What should we do? Doctor: We need to do an O R I F procedure A S A P. I'll reduce that radial shaft fracture at the same time. Guest_family: O R I F? What's that Doctor: I'll put some pins in the elbow, in order to stabilize the break, and we can start the healing process. Guest_family: Will this not heal on its own? Doctor: No, we need to do the surgery. Guest_family: Okay, what are the risks of infection with the surgery? Doctor: Historically, its less than one percent. Guest_family: How is this possible? Doctor: We use prophylactic antibiotics, this helps us control for infection the entire time. Guest_family: Will she be asleep for this? Doctor: Yes, she won't feel a thing. Guest_family: Will she need this hardware taken out in the future? Doctor: Yes, in about a year or two, after everything is healed up nicely. The other risks include bleeding, changes in sensation and motion of the extremity, and hardware failure. I see good results from my surgeries so I would not worry about these things, but I must disclose. Guest_family: Okay, yes, we'd like to do the surgery.","Section header: GENHX Section text: The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today. The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow. After the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure. Given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve. At that same time, the patient's mildly angulated radial shaft fracture will be reduced. This was explained to the father. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms. All questions were answered. The father agreed to the above plan." "Doctor: So, tell me did anyone in your family have Idiopathic pulmonary fibrosis? Patient: Actually, my father passed away due to this disease. Doctor: Oh, sorry to hear that. Patient: Yeah. Doctor: Anything else that he or any other family member might have. Patient: Oh, he also had this spastic colon problem and irritable bowel syndrome. Doctor: Hm, I see. Doctor: Anything else? Patient: No.",Section header: FAM/SOCHX Section text: Significant for his father who died of IPF and irritable bowel syndrome. "Doctor: How are you today? Patient: I am doing okay. Doctor: Do you have any medical conditions? Patient: I have diabetes. Doctor: When were you diagnosed with diabetes? Patient: It was two thousand and three, I think. I also have high blood pressure, asthma and high cholesterol. Doctor: Okay.","Section header: PASTMEDICALHX Section text: He has had diabetes since 2003. He also has asthma, hypertension, and hypercholesterolemia." "Doctor: I do not feel any swellings in your neck or groin area. Patient: Oh yeah, I don't notice anything either. Doctor: Okay yeah, I was just trying to look for any lymph nodes. Patient: Okay. Doctor: Let me check. Patient: Sure.",Section header: EXAM Section text: LYMPH: There was no appreciated node that I could feel in the groin or neck area. "Doctor: Your bloodwork came back from the Coumadin sensitivity test. The results showed a high level of sensitivity. I am going to adjust your dosage of Coumadin to a much lower dose. This will help reduce the bruising and the bleeding episodes. Do you have any questions? Patient: No.",Section header: ASSESSMENT Section text: Hypersensitivity to Coumadin. "Doctor: Hello. You must be his mom. Guest_family: Yeah, he started having a sore throat last night. And that's why we are here. His eyes have been really puffy. Uh, we gave him some Benadryl. Doctor: Hm. Patient: I had a stuffy nose and it was hard to breathe. Doctor: When did it all start? Guest_family: It started yesterday. All of a sudden, he started complaining saying, “Mama my nose is not working,” and yeah, I noticed he was breathing from his mouth. Doctor: Any fever or any other symptoms? Guest_family: Yeah, he had some low grade fever. He looked very tired and when I asked him he said that, “I feel like I cannot stand. I have no energy. I want to just lie down.” Doctor: I can notice that his voice is a little bit hoarse. How's he eating and drinking? Guest_family: He's eating and drinking normally. Doctor: Any shortness of breath or pain in your stomach? Patient: No. Doctor: Any diarrhea or vomiting? Patient: No.","Section header: GENHX Section text: Mom brings patient in today because of sore throat starting last night. Eyes have been very puffy. He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday. He has had low-grade fever and just felt very run down, appearing very tired. He is still eating and drinking well, and his voice has been hoarse but no coughing. No shortness of breath, vomiting, diarrhea or abdominal pain." "Doctor: Do you use tobacco, alcohol, or recreational drugs? Patient: No.",Section header: FAM/SOCHX Section text: Denied Tobacco/ETOH/illicit drug use. "Doctor: What's a young thirty one year old like you doing in my office today, ma'am? Patient: Well, I got referred to P T after I had a fall. Doctor: When was your fall? Patient: Um, it was on October third two thousand eight. Doctor: What happened when you fell? Patient: I tripped over my dog's toy. Doctor: Did you twist your foot or ankle? Patient: Yeah, my left foot inverted. Doctor: Have you had any imaging done on this foot? Patient: Yeah, um, I've had x rays and an M R I already. Doctor: What were the impressions of those images? Patient: They told me that it was unremarkable. Doctor: How was the pain progressed since the onset? Patient: Well, after a month or so, the pain is still so bad I can't do any of my activities. Doctor: How long have you been wearing this walking boot? Patient: Um, it's been about a month now.","Section header: GENHX Section text: The patient is a 31-year-old female who was referred to Physical Therapy secondary to a fall on 10/03/08. The patient states that she tripped over her dog toy and fell with her left foot inverted. The patient states that she received a series of x-rays and MRIs that were unremarkable. After approximately 1 month, the patient continued to have significant debilitating pain in her left ankle. She then received a walking boot and has been in the boot for the past month." "Doctor: Do you smoke cigarettes? Patient: No, that never really appealed to me, doctor. Doctor: Good, what about more illicit substances? Patient: Oh, most certainly not. Doctor: What about alcohol, do you drink? Patient: Well, I'd say I'm an occasional drinker.",Section header: FAM/SOCHX Section text: The patient is a nonsmoker and does not use illegal drugs. Occasionally drinks. "Doctor: Do you mind elaborating more on your family history? Did either of your parents suffer from any medical problems? Patient: Sure. My dad had heart disease. He passed at seventy five. He had a sister with diabetes and I think my mom may have had diabetes as well. Doctor: Got it. Patient: As for my mom, she had a long history of mini strokes. She didn't have any memory problems or dementia when she passed at eighty five. They believe she passed due to old age. Doctor: Thank you for further elaborating. I'm so sorry for your losses. Losing a parent let alone two is profoundly difficult.","Section header: FAM/SOCHX Section text: Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85. In addition, his father had a history of heart disease and passed away at the age of 75. He has one sister with diabetes and thought his mom might have had diabetes as well." "Doctor: Any muscular pain? Patient: No, not really. Doctor: Any problem in walking? Patient: No, it's normal. Doctor: Let me check your toes and fingers. Can you move them for me? Patient: Yeah. Doctor: Everything looks fine. Nails looks fine too. No bluish discoloration no sign of any infection. Can you push your legs against my hand. Patient: Both legs? Doctor: Yes, both. Well, your muscular strength is equal and stable in both legs, so that's fine. Motion looks adequate. Doctor: Any tenderness? Patient: No. Doctor: And I don't see any swelling or fluid accumulation. Patient: Okay.","Section header: EXAM Section text: MSK: Normal gait and station. No pathology to digits or nails. Extremities move times four. No tenderness or effusion. Range of motion adequate. Strength and tone equal bilaterally, stable." "Doctor: Do you have a known- Patient: Drug allergy? Doctor: Oh no, I meant family history of disease.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Have you experienced any headaches or blackouts recently? Patient: No. Doctor: Dizziness or seizure? Patient: Nope. Doctor: Any history of stroke? Patient: No. Doctor: Okay, good.","Section header: ROS Section text: NEUROLOGIC: Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness." "Doctor: Hi there! I am Doctor Kim. Nice to meet you, miss. Patient: Hi! Nice to meet you. Doctor: How are you feeling today? Patient: I am feeling much better today. Doctor: How old are you? Patient: I am forty six. Doctor: How is your pain in the left side? Patient: It is much better. It is more like a dull pain now. Doctor: Are you still having trouble with urination? Patient: It has gotten better but is still a little difficult. Doctor: Okay. It looks like Doctor X did an exam yesterday. Doctor X consulted me on your status but I have a question for you. I see in your medical history that you had a bruised left kidney. Can you tell me more about the bruised kidney? Patient: Yes. I was in a car accident, years ago. The doctor told me that I had a bruised left kidney. They thought it was due to the accident, but they could not be certain.",Section header: GENHX Section text: The patient is a 46-year-old female who presented to the emergency room with left flank pain and difficulty urinating. Details are in the history and physical. She does have a vague history of a bruised left kidney in a motor vehicle accident. She feels much better today. I was consulted by Dr. X. "Patient: Well, I have a long family history of heart problems. My mom died quite young at the age of fifty due to heart attack and my father was detected with heart failure, he has a pacemaker. Doctor: Oh, I am sorry to hear about your mom. Patient: Yeah. Also, high blood pressure runs in my family. Doctor: Okay.",Section header: FAM/SOCHX Section text: She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed. "Doctor: Where are you experiencing the most pain? Patient: All over my belly. Doctor: How long has this been going on? Patient: Two to three weeks. Doctor: Does the pain come and go? Patient: It does. Doctor: And how would you describe- Patient: The pain? Doctor: Yes. Patient: Hm I'd describe it as a gnawing sensation. Doctor: Is this sensation new? Patient: I believe so. I don't ever remember feeling this way before. Doctor: Any past abdominal surgeries? Patient: None.",Section header: CC Section text: Abdominal pain. "Doctor: Hi, there. Patient: Hi. Guest_family: Hi! It is nice to meet you. Doctor: It is nice to meet you as well. You are the husband, correct? Guest_family: Yes. I am the husband. Doctor: How long have you two been married? Guest_family: We have been married for forty eight years. Doctor: Do you live in the same household? Patient: Yes. Doctor: Do you have a primary care physician? Patient: No, I am currently looking for someone. I have also been looking for someone to see for my mental health issues. Doctor: I have a few recommendations I can give to you if you would like. Patient: I would like your recommendations for both. Doctor: Are you working currently? Patient: No, I am not. I used to work as a registered nurse. It has become too much for me right now. Doctor: Do you drink alcohol or use any recreational drugs? Patient: I don't do any drugs. I drink very rarely. I only drink is social situations. Doctor: Have you ever taken any prescription drugs, muscle relaxants or sedative medications? Guest_family: I don't think that she has ever taken muscle relaxants or sedative medications without prescriptions. I give her, her medications every day so she doesn't forget. Doctor: Oh, okay. Guest_family: She does have a pattern of self-prescribing for minor illness. She loves WebMD. Doctor: Okay. How have you been feeling lately? Have you been participating in social activities? Patient: Since this last March I have been feeling more social and have been doing things on my own more. Guest_family: She used to never leave the house unless I go with her. She has defiantly been more independent lately. She even went and met a friend for coffee the other day. Doctor: That is great to hear.","Section header: FAM/SOCHX Section text: The patient lives with her husband of 48 years. She used to be employed as a registered nurse. Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions. She rarely drinks socially. She denies any illicit substance usage. Her husband reportedly gives her medication daily. Has been proactive in terms of seeking mental health care and medical care. The patient and husband report that from March 2009, she has been relatively independent, more socially active." "Doctor: Do you have a history of surgeries? Patient: I had a bone fragment removed from my right arm. I had a D and C done a long time ago. It was a treatment for H P V. More recently I had an ovarian cancer staging biopsy done. I have not heard back with the results yet. I only had it done less then a week ago. Doctor: How are you feeling after the biopsy? Patient: I had a significant amount of pain for two to three days after. I feel better now.",Section header: PASTSURGICAL Section text: 1. A D and C. 2. Bone fragment removed from her right arm. 3. Ovarian cancer staging. "Doctor: Anybody else in your family suffers from this condition? Patient: No. Doctor: Okay.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Hello Miss Jane, how are you? Patient: I am good, thank you for asking. Doctor: So, tell me what brings you here? Patient: I have so many issues and problems, where do I start? Doctor: Start by telling the one troubling you the most. Patient: I have this pain in my toes on the right side and I also feel this numbness there. Doctor: Okay and do you feel any tingling sensation? Or feeling like your leg is giving away? Patient: Yes, I feel the tingling and sometimes. I feel like my leg has fallen asleep. Doctor: Hm, tell me about your pain. Is it mild, moderate, or severe? Patient: Well, I will say it's moderate. Doctor: Would you define it as sharp shooting pain or dull kind of radiating pain? Patient: Maybe sharp pain but I am not sure how to describe it. But it radiates up the leg. Doctor: Okay. How long have you had this problem? Patient: It's been there for almost one year but now it started to get worst. Doctor: I see, does it get worse when you walk? Patient: No, mostly when I am in bed. And sometimes I feel it on my left toe as well. Doctor: It looks like you have paresthesia in the toes of your right foot and I feel your left toe also has the same problem. Patient: Yeah, I thought so. I read over the internet. But anyways, I am also having this shoulder pain on both sides, plus I am not able to sleep at night. Patient: I have high blood pressure and hypothyroidism. Doctor: Well- Patient: Well, that's not it. I have thrombo- Doctor: Thrombocythemia. Patient: Yeah, that. Doctor: How are your allergies by the way? Patient: I have no sinus allergies, thankfully.","Section header: GENHX Section text: The patient is in with several medical problems. She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain. She initially describes it as a sharp quality pain, but is unable to characterize it more fully. She has had it for about a year, but seems to be worsening. She has little bit of paraesthesias in the left toe as well and seem to involve all the toes of the right foot. They are not worse with walking. It seems to be worse when she is in bed. There is some radiation of the pain up her leg. She also continues to have bilateral shoulder pains without sinus allergies. She has hypothyroidism. She has thrombocythemia, insomnia, and hypertension." "Doctor: Do you have any known allergies to medications? Patient: No.",Section header: ALLERGY Section text: No known drug allergies. "Guest_family: He is coughing for one week now. Doctor: How about any congestion? Is it one week or more? Guest_family: No did I say that? I meant two to three weeks. I am so worried. He is just one year. Doctor: Don't worry let me see, can you tell me everything from the beginning? Guest_family: Sure. It started off as a congestion, but then he started coughing about a week ago and it is getting worse. Doctor: Okay, what else? Guest_family: Actually, he had Pop Can just three days ago and I never found the top of that and was wondering if he had swallowed that. Doctor: It is possible, have you seen any change in his breathing? Guest_family: His breathing has not gotten worse since that happened. Doctor: Any fever? Guest_family: No. No fever. Doctor: Okay.","Section header: GENHX Section text: This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks. Started off as a congestion but then he started coughing about a week ago. Cough has gotten worsen. Mother was also worried. He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened. He is not running any fevers." "Doctor: Hi, how are you? Patient: I am good, Doctor. Doctor: So, I see you recently moved to U S A from Brazil, right? Patient: Yes, about one year back. I was an engineer manager back there, but my job was so stressful that when I got admitted in the M B A program here in the states, I took it. Doctor: Wow, that's quite a move! Patient: Yeah. Doctor: How about your family; wife or girlfriend? Patient: I am a one women man. I married my childhood sweetheart. Doctor: Nice. Did you travel outside the country recently or have risk of any kind of exposure? Patient: No, I haven't traveled anywhere not even within the country. Doctor: Okay. Tell me something, do you smoke or drink? Patient: No, I don't. Doctor: And have you in the past used any recreational or illegal drugs? Patient: No, never. Doctor: Okay, good.","Section header: FAM/SOCHX Section text: The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was ""very stressful"". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind." "Doctor: Do you drink, sir? Patient: No, I don't drink at all. Doctor: How about tobacco? Do you smoke? Patient: Well, yes. Doctor: How much do you smoke, sir? Patient: I smoke about a half a pack of cigarettes a day.",Section header: FAM/SOCHX Section text: He does admit to one half pack of cigarette consumption per day. He denies any alcohol consumption. "Doctor: How are you feeling? You have been sick? Patient: Yes, I am not feeling well for the last three days. I have bad body aches, cough and a sore throat. Doctor: Do you get wet cough or it's dry? What color sputum comes out? Patient: It is wet and green colored stuff comes out. Doctor: Okay we will need to send it out to culture, maybe an infection. Doctor: How about fever, chills, nausea, vomiting, diarrhea anything like that? Are you sleeping well? Patient: Everything is fine except some chills? I am sleeping okay. Doctor: Do you need anything for cough? Patient: I don't need anything for the cough. I did call yesterday and got a refill of my Keflex. Then I took two Keflex this morning and I am feeling little bit better now. Doctor: Okay then why are you crying, ma'am? Patient: I am just tired of feeling like ran down. Doctor: I am so sorry. Patient: Hm.","Section header: GENHX Section text: XYZ is in today not feeling well for the last three days. She is a bit sick with bodyaches. She is coughing. She has a sore throat, especially when she coughs. Her cough is productive of green colored sputum. She has had some chills. No vomiting. No diarrhea. She is sleeping okay. She does not feel like she needs anything for the cough. She did call in yesterday, and got a refill of her Keflex. She took two Keflex this morning and she is feeling a little bit better now. She is tearful, just tired of feeling ran down." "Doctor: Hi there, what's going on with you? Patient: Well, I am having this weird jerky movement in my arm and leg. Doctor: Oh okay, let me take a look.",Section header: CC Section text: Arm and leg jerking. "Doctor: Good afternoon, sir. Is this your mother? Patient: Good afternoon, doctor. Yes, this is my mom. Doctor: Great, please, give me some background information on your history. Patient: Well, I used to live here in the city when I went to college, but I wanted to get away from a bad crowd, so I came back to live with my mom. Doctor: What do you mean, bad crowd? Patient: Well, I got addicted to drugs out there, and I used to inject heroin. Doctor: Did you see a doctor for this addiction? Patient: Yeah, I saw another doctor in the city. Doctor: How did they treat you at that time? Patient: They prescribed me methadone for a while. Doctor: Did that help at all? Patient: Honestly, no, it didn't help at all. Doctor: Do you remember the dosage that you were given? Patient: Um, it was ten M G. Doctor: How long did you take methadone for? Patient: Um, it was for three or four months. Doctor: Did you ever try to decrease your dosage? Patient: Yeah, um, I tried to wean off it for a while, but I was never really successful. Doctor: Have you been using heroin since? Patient: Um, yeah, I've been using it occasionally. Doctor: Were you roommates at school using drugs? Patient: Yeah, so it's hard to get away from the stuff, it was all over the house. Guest_family: Well, he can now, especially because he lives with me. Doctor: Good, when was the last time you used heroin? Patient: Um, it's been about eight days now. Doctor: Good, congratulations. When was the last time you had methadone? Patient: Um, it's been about a week for that now, too. Am I able to get more today? Doctor: We can discuss that. Have you had any feelings of depression recently? Patient: Yeah, I feel down and sad a lot. Doctor: What about your energy? Patient: I really don't have much. Doctor: What about your enthusiasm for the foods or activities you enjoy? Guest_family: He hasn't had much enthusiasm for anything, either. Doctor: Are you having any suicidal or homicidal thoughts or actions at this time? Guest_family: No, nothing like that, doctor. Doctor: Good, what about delusions, hallucinations, or disorganized thoughts or behaviors? Patient: No, nothing like that either, doctor. Doctor: Do you have any medical conditions in the past that I should know about? Patient: No, not that I know of. Guest_family: No, he hasn't been treated for anything before, doctor. Doctor: You completed your family and social history earlier with the nurses, is there anything you want to add to that? Patient: No, everything there is complete. Doctor: Do you have any allergies? Patient: No, I don't have any. Doctor: Good, and do you take any medications right now? Patient: No, doctor. I don't take anything. Doctor: Have you had any surgeries in the past? Patient: I voluntarily donated my left kidney.","Section header: GENHX Section text: This patient presents to the office today with his mom for checkup. He used to live in the city. He used to go to college down in the city. He got addicted to drugs. He decided it would be a good idea to get away from the ""bad crowd"" and come up and live with his mom. He has a history of doing heroin. He was injecting into his vein. He was seeing a physician in the city. They were prescribing methadone for some time. He says that did help. He was on 10 mg of methadone. He was on it for three to four months. He tried to wean down on the methadone a couple of different times, but failed. He has been intermittently using heroin. He says one of the big problems is that he lives in a household full of drug users and he could not get away from it. All that changed now that he is living with his mom. The last time he did heroin was about seven to eight days ago. He has not had any methadone in about a week either. He is coming in today specifically requesting methadone. He also admits to being depressed. He is sad a lot and down. He does not have much energy. He does not have the enthusiasm. He denies any suicidal or homicidal ideations at the present time. I questioned him on the symptoms of bipolar disorder and he does not seem to have those symptoms. His past medical history is significant for no medical problems. Surgical history, he voluntarily donated his left kidney. Family and social history were reviewed per the nursing notes. His allergies are no known drug allergies. Medications, he takes no medications regularly." "Doctor: Hi there, how is it going? Guest_family: Hi doctor, I am his son Ethan. Doctor: Nice to meet you. Doctor: So, I see your father has a history of drug abuse, right? Guest_family: Yes. Patient: Not abuse, I just used to do drugs. The last time I really made a big mistake I injected the heroine directly into both of my thighs and unfortunately, I got these ulcers which are not going away. Doctor: Yeah, this is really unfortunate. I can see these open wounds, it's because of the chronic abscesses. Guest_family: The right thigh looks worse than the left one. Doctor: Yeah, I see that. How old is your father? Guest_family: He is sixty two. Doctor: Does he have any other medical issues like sugar or blood pressure? Guest_family: No. Doctor: Okay, I think we need to surgically remove this whole area and then do a reconstruction. Guest_family: And is that the only way? Doctor: According to me, yes! I mean the wounds are not healing and it is only getting worst. Guest_family: Okay then we will follow whatever you suggest. Doctor: Okay.","Section header: CC Section text: The patient is a 62-year-old male with a history of drug use. He had a history of injection of heroin into his bilateral thighs. Unfortunately, he developed chronic abscesses, open wounds on his bilateral thighs, much worse on his right than his left. Decision was made to do a radical excision and then it is followed by reconstruction." "Doctor: Do you smoke cigarettes or use any tobacco products, miss? Patient: No. Doctor: Do you drink alcohol and if so, how many drinks do you consume in a typical week? Patient: I don't drink. Doctor: Do you use any recreational drug or other substances? Patient: No. Doctor: Do you have children? Patient: Yes. I have three kids. Doctor: Do your children have any health conditions? Patient: No. Doctor: Are you married? Patient: Yes.","Section header: FAM/SOCHX Section text: Married, 3 children who are healthy. She denied any Tobacco/ETOH/Illicit drug use." "Doctor: How is your family doing? Patient: They all are good. Doctor: Are you aware of any medical issues in your family? Patient: No, not to my knowledge.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Have you ever had spine problems before? Patient: What, like an injury? Doctor: Well, it's broad. It could be an injury, or just any kind of pain. Patient: Oh, no. I've never had any problems.",Section header: PASTMEDICALHX Section text: Unremarkable. "Doctor: Any past medical history? Patient: No.",Section header: PASTMEDICALHX Section text: Nonsignificant. "Doctor: With ten being the worse pain ever, how would you rate your pain out of ten today, ma'am? Patient: Um, out of ten, I'd say it's about a two. Doctor: That's good. What helps the pain feel better? Patient: Um, it gets better with elevation, and when I just rest.","Section header: GENHX Section text: The patient rates the pain at 2/10 on the pain analog scale. The patient states that with elevation and rest, her pain subsides." "Doctor: Nurse, did you get the documents from the patient? Guest_clinician: I did. Here is her full history and notes from her physical examination. She also completed the patient questionnaire before arriving. You can review that. Doctor: Thank you, Nurse. What is she here for today? Guest_clinician: She came in for a consultation because she's been experiencing difficult headaches, tunnel vision, and dizziness. Doctor: Sounds good. Was there anything else? Guest_clinician: Oh, yeah. These are the results from her tests. She brought them so you could refer to them. Doctor: Thank you, Nurse. I'll go see her now. Patient: Hello Doctor. I've been waiting a long time. I'm getting impatient as I get older. Doctor: What? You don't look old at all, ma'am. Patient: Oh, wow. That's a nice compliment for a sixty year old lady. Doctor: How can I help you today? Patient: I have these super bad headaches. Help me, please. Doctor: When did they start? Patient: I had them since I was twenty five years old. Doctor: Oh, wow. That long? Did you get them every day since then? Patient: Not every day. That's crazy. I did get them more when my husband died in nineteen ninety six. I was heartbroken. Doctor: I'm sorry to hear that. How did the headaches feel? Patient: It felt like a drum in my head. Doctor: I haven't heard that description before. Would you say it was pulsating? Patient: Something like that. Yes. Doctor: Did you take any medication? Patient: Lots of it. My son wrote it on a paper so that I could give you the names. Here you go. Doctor: I see you were given papaverine. Did that help? Patient: They did. My headaches would vanish. Doctor: How long did you take it for? Patient: I think six months. My headaches stopped for a while, but they came back in two thousand and four. Doctor: How often would you say you get headaches now? Patient: I think more than before. Like one to two per week. I also get some dizziness too. It says for two hours. Doctor: Do you take the papaverine when you feel it? Patient: I do. My headaches vanish after thirty minutes of taking it. Doctor: I see. Did you ever experience any problems with your vision too? Patient: Yes. A lot. There were zig zag lines coming out of nowhere. I thought I was going to die. Doctor: Oh, wow. I will do a test right now to check your vision. Patient: Will you use a bright pen? Doctor: I will. Does it give you any discomfort? Patient: The bright light hurts my eyes. Doctor: I see. I'll only do it to the side then. Just look forward for me, please. Patient: Thank you. Doctor: Are you able to see the light? Patient: What light? Doctor: It looks like you have trouble seeing things in your peripheral vision. The discomfort you experience with bright lights is also called photophobia. Patient: That sounds scary. Will I be fine? Doctor: Yeah. You don't have to worry. Are you experiencing any dizziness or lightheadedness right now? Patient: Now that you mentioned it, I am. Doctor: Have you ever fainted before? Patient: I think one time. My son was there to help. Doctor: That's good to hear. I'll write down that you experienced a syncope. Did you take any medication for this? Patient: I took some Russian medicine. Doctor: Oh, wow. Are you from Russia? Patient: No. I'm from Ukraine. Doctor: That's wonderful. How did the medicine help? Patient: It helped me a lot.","Section header: GENHX Section text: The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. I obtained and documented a full history and physical examination. I reviewed the new patient questionnaire, which she completed prior to her arrival today. I also reviewed the results of tests, which she had brought with her. Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25. She recalls that in 1996 when her husband died her headaches became more frequent. They were pulsating. She was given papaverine, which was successful in reducing the severity of her symptoms. After six months of taking papaverine, she no longer had any headaches. In 2004, her headaches returned. She also noted that she had ""zig-zag lines"" in her vision. Sometimes she would not see things in her peripheral visions. She had photophobia and dizziness, which was mostly lightheadedness. On one occasion she almost had a syncope. Again she has started taking Russian medications, which did help her. The dizziness and headaches have become more frequent and now occur on average once to twice per week. They last two hours since she takes papaverine, which stops the symptoms within 30 minutes." "Doctor: Do you drink? Patient: I used to drink before, but now I have stopped it completely. Doctor: How would you rate your pain? Patient: It is tolerable, like five out of ten but I do need some pain medications. Doctor: Then why do you need more pain medications? Patient: Sometimes it gets hard, I really need some more pain medications. Doctor: Do you have morphine? Do you need more? Patient: I don't like morphine. Can you change it to Dilaudid? I like that medicine. That one works for me great.",Section header: FAM/SOCHX Section text: History of alcohol use in the past. He is basically requesting for more and more pain medications. He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid. His pain is tolerable. "Guest_clinician: She has a vast history of surgeries. Doctor: Yeah, I am looking at her reports. She had surgery for spina bifida when she was a baby and they had to put a shunt. Guest_clinician: Yeah, later she had her uterus removed and also had to undergo a breast reduction surgery. Doctor: Hm.","Section header: PASTMEDICALHX Section text: Back closure for spina bifida, hysterectomy, breast reduction, and a shunt." "Doctor: Are you married or divorced? Patient: I am married. Doctor: Okay. Patient: Hm. Doctor: Do you smoke cigarettes or drink alcohol? Patient: No, I have never.",Section header: FAM/SOCHX Section text: She is married and does not smoke or drink nor did she ever. "Doctor: What is your family medical history? Patient: I am not sure. Everyone is healthy as far as I know.",Section header: FAM/SOCHX Section text: unremarkable. "Doctor: Good morning, ma'am. My chart says that you're forty nine years old, and White, is that correct? Patient: Yes, that's all correct. Doctor: What do you do for a living? Patient: I'm a secretary. Doctor: Great, welcome back to the Dermatology office, do you remember when your last appointment was? Patient: Um, I think it was on August tenth two thousand four. Doctor: Good, that's what I have here as well, so has your acne improved since your last visit? Patient: Well, not really, and I think I have a rash too. Doctor: How long have you been dealing with this? Patient: Um, at this point it's been about two months. Doctor: Where do you see this rash? Patient: Um, it's right here, on my chest, stomach, neck, and back, it's all over my upper body. Doctor: I see, it appears that your acne is flaring, and there are small lesions on the follicles as well. Have you been taking your Amoxicillin and using your Tazorac? Patient: Yeah, I taken five hundred M G of amoxicillin twice a day, and I use the cream as well. Doctor: Good, the acne on your face appears to be clearing. Patient: Thank you, I've been out of medicine for about three days now though. Doctor: Okay, we might refill that. Have you had any other treatments aside from what I've done? I Patient: Um, my husband drove me to Healing Waters and they did, um, photofacials. Is there anything that can be done in the office today, like, um, cosmetic procedures, or do you have any skin care products? I want to keep up my appearances since I work the front office as a secretary.","Section header: GENHX Section text: The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004. She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back. On examination, this is a flaring of her acne with small folliculitis lesions. The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also. She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc. The patient is married. She is a secretary." "Doctor: It looks like your Xrays show bronchitis. Patient: Is there anything I can take for it? Doctor: Yes, I'm going to prescribe you something that will help clear your lungs.",Section header: ASSESSMENT Section text: Bronchitis/URI. "Doctor: How's it going X Y Z? I see you're in a walking boot. What happened? Patient: I hurt my foot pretty bad yesterday. Doctor: How'd it happen? Patient: Basketball. I play for the University of Houston. I went up for a three and came down and landed on this guy's foot. I was so pissed. Doctor: Dang, that sucks. Were you guys playing a home game? Patient: We were traveling to Duke. We could've won the game if I didn't get hurt. Doctor: You'll get them next time. Did you keep playing? Patient: Yeah, I did. I got taped up by the trainer, and I went back into the game. Doctor: I see. Who was the trainer that helped you? Patient: His name is John Houston. Do you know him? Doctor: Oh, John! He's a good friend of mine. Patient: Yeah, he told me to come see you. He checked my foot. Here's the notes he wrote. Doctor: It looks like you have some tenderness around your navicular, which is a bone in your ankle. Patient: Dang, that's whack. Doctor: Which way did you twist your ankle? Patient: My foot twisted inwards. Kind of like this. Doctor: I see. Your foot inverted. Did it swell up right away? Patient: Aw, man. My foot was huge right after it happened. It hurt so much too. Doctor: Continue to keep that tape on. Are you limping or anything? Patient: Yeah, I am. I can't really put weight on my foot because it'll hurt a lot. Doctor: I see. Well, I examined your foot, and it looks like the pain is around the top, back and middle of your foot.","Section header: GENHX Section text: XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot." "Guest_family: So apart from constipation what is his problem? What is up with his lungs? Doctor: Yeah so, we call it foreign body impaction. It is mostly affecting his right nostril and as you said there is constipation.","Section header: ASSESSMENT Section text: 1. Infected foreign body, right naris. 2. Mild constipation." "Patient: I was working when it happened so we are going through workers comp. Doctor: Okay. Don't worry. Let's see. Oh wow! Patient: Yeah, this arm, it was a hot oil. Doctor: Yeah, too bad, looks like from elbow to wrist. The whole medial side is burnt. Patient: I am using cool packs since it happened. My friend is helping me so much, he drove me to Emergency Department. Doctor: Okay, how old are you? Patient: I am forty one. Doctor: What is your job? I mean what do you do? Patient: I am a cook at coffee shop.","Section header: GENHX Section text: This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care." "Doctor: Do you have any medical conditions that I should know about? Patient: Um, I have high blood pressure, and asthma. Doctor: I also see here that you have cervical cancer, can you tell me more about that? Patient: Yeah, I got diagnosed at fifteen years old. Doctor: How would you describe the progression of your cancer? Patient: Now, um, I'd say it's dormant.","Section header: PASTMEDICALHX Section text: Significant for hypertension, asthma, and cervical cancer. The cervical cancer was diagnosed as 15 years old. The patient states that her cancer is ""dormant.""" Doctor: You can take Ibuprofen as needed for pain.,Section header: MEDICATIONS Section text: Ibuprofen PRN. "Doctor: Do you take anything for acid reflux? Patient: Yeah, I take Aciphex. Doctor: Is that twenty M G once a day? Patient: It is. I also take one baby Aspirin in the mornings.",Section header: MEDICATIONS Section text: Aciphex 20 mg q.d. and aspirin 81 mg q.d. "Doctor: Do you smoke? Patient: Yes. Doctor: How much do you smoke? Patient: I smoke about two packs of cigarettes a day. Doctor: Okay.",Section header: FAM/SOCHX Section text: Smokes 2ppd cigarettes. "Doctor: Any numbness or tingling? Patient: No. Doctor: Are your experiencing any muscle weakness? Patient: No. Doctor: Any problem walking, or did you lose balance or fall? Patient: Nope. Doctor: So, your gait is fine. Any stroke in the past? Patient: No, nothing like that.","Section header: ROS Section text: NERVOUS SYSTEM: No gait problems, strokes, numbness or muscle weakness." "Doctor: Past surgeries I should know of? Patient: I had my gallbladder, appendix, and uterus removed. Doctor: Oh wow, I see. When did you get these surgeries? Patient: I had my gallbladder removed in O eight, appendix removed in twenty twelve, and uterus removed this past year. Doctor: Any other medical history? Patient: My bladder was sagging the last time I saw the urologist. Doctor: Does the diagnosis bladder prolapse sound familiar? Patient: Yeah, I believe so. They said it was grad four last time. Doctor: Have you followed up with your urologist recently? Patient: Chip Winkel? No, not as of late.","Section header: PASTSURGICAL Section text: Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted." "Doctor: Do you have allergies? How old are you, young man? Patient: Yes ragweed. I am twelve. Doctor: So basically, you are just congested? Patient: Yes that's right. The last ten days. Doctor: Any headache? What comes out of your nose? Patient: Yes I had a little yesterday. Clear boogers. Doctor: You feel hot? Patient: No. Doctor: Anyone sick at home? Guest_family: No.",Section header: GENHX Section text: This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion. He does have significant allergies including ragweed. The drainage has been clear. He had a little bit of a headache yesterday. He has had no fever. No one else is ill at home currently. "Doctor: Are you married? Patient: I'm divorced. Doctor: Do you have any kids? Patient: Yes, I have two boys and they live with me. Doctor: Any abnormal pregnancy. Any abortions? Patient: No, none of them. Doctor: Do you smoke or consume alcohol or have ever used any illicit drug? Patient: No.",Section header: FAM/SOCHX Section text: Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use. "Doctor: I want to go over your medical history. I see here you saw the dermatologist a month ago. Patient: Yeah. She said that I um have an overactive sweat gland. Doctor: Does hidradenitis suppurativa sound familiar? Patient: It does. Doctor: I ask because it's also included in your last visit with your dermatologist. Patient: Those are the red bumps, right? Doctor: Yes. There's a note here that you could've potentially had Staph with it as well. Patient: Oh yeah. I've also had a lot of abscesses in the past. Doctor: It looks like you've had them in your upper mid thigh, vulva area, and the area between your vulva and anus. Patient: For about two years now. Doctor: Right. And a history of asthma? Patient: Correct.","Section header: PASTMEDICALHX Section text: 1. History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years. Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa. Probably, she has had Staphylococcus infection associated with it as well. 2. Reported history of asthma." "Patient: Hello, how are you? Doctor: I am good, tell me what brings you here? Patient: I am having this chest pain. I was hospitalized last year in October and at that time they put this catheter in my heart. I also underwent a heart scan. It's here in this report. Doctor: Yeah, I see that you got nuclear and myocardial perfusion scan, which was normal. They were looking for some heart artery lesion but then it was thought to be due to spasm. Patient: Right. Doctor: It is also mentioned here that you have hyperlipidemia. Patient: Yes. Doctor: And are you still smoking? Patient: Yes, in fact I have been smoking actively from pass three to four days because I am really stressed. Doctor: Hm. And would you say, you might have had some exertion recently or did some steep hiking or some cardio exercises which might have caused some additional stress on your heart causing chest pain? Patient: No, I did not do any exertion. Just actively smoking that's all.","Section header: PASTMEDICALHX Section text: Hyperlipidemia, smoking history, and chest pain. He has been, in October of last year, hospitalized. Subsequently underwent cardiac catheterization. The left system was normal. There was a question of a right coronary artery lesion, which was thought to be spasm. Subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal. The patient continues to smoke actively since in last 3 to 4 days especially when he is stressed. No relation to exertional activity." "Doctor: I am sorry about that. Patient: Yes, for assault, that's why I was in detention. Doctor: Okay. Doctor: When was this? Patient: Around December of two thousand nine. Patient: Not sure if I am under legal contraints right now. Doctor: Okay so we don't know.","Section header: FAM/SOCHX Section text: He had an assault in December 2009, which led to his previous detention. It is unknown whether he is under legal constraints at this time." "Doctor: Do you smoke cigarettes? Patient: Yes, I do. Doctor: How many packs a day. Patient: Maybe one a day. Doctor: Okay, you should think about quitting.",Section header: FAM/SOCHX Section text: The patient is still a smoker. "Doctor: What happens when you take Sulfa drugs? Patient: Oh man, I get a really ugly looking rash. Doctor: I'll make note of that so we have it in your chart.",Section header: ALLERGY Section text: Sulfa (rash). "Doctor: Any known drug allergies? Patient: Nope, none whatsoever.",Section header: ALLERGY Section text: No known drug allergies. "Doctor: Do you smoke cigarettes or drink alcohol? Patient: No. Doctor: Any use of recreational substances or IV drug abuse? Patient: No.","Section header: FAM/SOCHX Section text: The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs." "Doctor: Tell me what brings you here today? Patient: I'm having some issues with my right hand. Doctor: What kind of issues? Patient: I'm having these pins and needles kind of feeling in my hand and it has been going on for several weeks. Sometimes I feel it gets numb. I think it might be carpal tunnel, but I'm not sure. I'm just worried. Doctor: Did you do anything for it? Patient: At work I recently moved my keyboard down. I just hope it will help. You know, I do a lot of the same kind of activities all the time. All of it I typing based. Doctor: What is more difficult, day or night? Patient: It gets worse at night. If I sleep on it, like in a certain way, it will just wake me up and it starts hurting. These tingling sensations are the worst. It helps if I shake it then the sensation goes away. It irritates me all the time. Doctor: Is it complete hand or is there any part of hand that is worse than others? Patient: It is mostly my middle finger, but maybe my first or second finger of the hand also, but mostly my middle finger. Doctor: Is there pain anywhere else? Patient: In my thumb as well. I'm just afraid it can be arthritis. I don't want that, too, on my plate.","Section header: GENHX Section text: This patient presents to the office today because of some problems with her right hand. It has been going tingling and getting numb periodically over several weeks. She just recently moved her keyboard down at work. She is hoping that will help. She is worried about carpal tunnel. She does a lot of repetitive type activities. It is worse at night. If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her. It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand. She has some pain in her thumb as well. She thinks that could be arthritis." "Doctor: Have you been in any accident? Patient: I have been a truck driver for some time but luckily have not been in any major auto accident. I had hit a moose once, where I bumped my head but do not remember getting hurt anywhere else. I had broken my ankle in the past. Doctor: Hm, I see here you mentioned to the nurse, that a car fell on your chest six years back? Patient: Oh yes, I was repairing my car and it fell off the car jack stand and fell on my chest but fortunately I was not hurt.","Section header: GENHX Section text: He had a broken ankle in the past. They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago. He told me that he hit a moose once, but he does not remember hitting his chest." "Doctor: Did you ever had pneumonia? Patient: No, never. Doctor: Do you have any history of lung disease? Patient: No. Doctor: Any history of tuberculosis? Patient: No. Doctor: Are you feeling any shortness of breath or difficulty breathing? Patient: No. Doctor: Okay. Do you have any wheezing? Patient: No.","Section header: ROS Section text: RESPIRATORY: No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias." "Doctor: Tell me about your past medical history. Is there anything that I should be aware of? Patient: No, I don't think so. Doctor: Any known allergies? Patient: No. Doctor: Have you ever been diagnosed with diabetes or high blood pressure? Patient: Oh, last year I did have some incidents of high blood pressure, but I didn't take any medications for it. Doctor: Have you seen any variation in your weight? Patient: How do you know? It's been up. About fourteen pounds since last year.","Section header: PASTMEDICALHX Section text: Unremarkable. There is no history of allergies. He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year." "Doctor: How did your treatment for the thrombosis go? I believe we did it on February nineteen of two thousand and seven. We finished the note the next day in order to send to your other following doctor. Patient: The treatment went well. Thanks!",Section header: PASTSURGICAL Section text: The treatment of the thrombosis was documented on 02/19/2007 and 02/20/2007. "Doctor: Where are you having numbness? Patient: In my left hand. Doctor: And no other symptoms? Any coughing or chest pain? Patient: No. Just that weird feeling in my left hand. Doctor: Any visual changes or motor changes. Patient: Nothing. Doctor: Great. What about any phlegm or shortness of breath? Patient: Nope.","Section header: ROS Section text: No coughing, sputum production, dyspnea or chest pain. No vomiting or abdominal pain. No visual changes. No neurologic deficits other than some numbness in his left hand." "Doctor: How are you feeling? Patient: I've been having a lot more joint pain lately. Doctor: You're seventy seven, correct? Patient: Don't remind me. Doctor: When did you first start experiencing joint pain? Patient: Couple years ago. Doctor: In what ways has it worsened? Patient: It's caused me to become less active in general. My hands and wrists aren't as mobile. Doctor: Have you noticed any increased swelling? Patient: No, but it's all gotten to be a little too uncomfortable. Doctor: I see here that you take the generic of Daypro. Is that helping? Patient: No. Doctor: And no redness to the area, right? Patient: No. Doctor: Fever or chills? Patient: I had diarrhea for a few days, but it's gotten much better. I was also having trouble holding my bladder. Doctor: Are you going to the bathroom more often, experiencing excessive thirst, or other problems? Patient: No. My incontinence is a bit better and so is my ankle and foot swelling. Doctor: How has your blood sugar been? Patient: A little better. Doctor: Have you checked your blood pressure recently? Patient: Not recently. Doctor: Any new medications? Patient: I'm back on Zoloft again because I think I might be depressed. Ever since losing most of my mobility, I haven't been feeling like my usual myself. I'm also sleeping all the time.","Section header: GENHX Section text: A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Daypro generic does not seem to be helping at all. No fever or chills. No erythema. She actually is doing better. Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema. Blood sugars seem to be little better as well. The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things. She has had no polyuria, polydipsia, or other problems. No recent blood pressure checks." "Doctor: Anyone in your family been sick lately? Patient: Yes, my sister has sinus problems. She was seen today. Doctor: Okay that means she will be treated. Patient: Yes. Doctor: How about other family members? Patient: No, my mom and dad are healthy. Doctor: Good. Good. Patient: Hm!",Section header: FAM/SOCHX Section text: The sister is in today with clinical sinusitis. Mother and father have been healthy. "Doctor: So, tell me what's going on with you? Patient: Well, yesterday evening between seven or eight I developed nausea and suddenly it started hurting on the right side of my chest? Doctor: Where exactly did it hurt? Patient: Ah, my upper chest part and it went all around my right side till my back. Doctor: Okay, how do you feel now? Patient: I feel very weak and tired, don't feel like doing anything but resting. Doctor: Any fever? Patient: Yeah, nurse just took my temperature it was one hundred point three. Doctor: Okay. Did you have these symptoms before? Patient: No, first time. I never felt like this before. Doctor: Okay. Any chills or shivering? Patient: No. Doctor: When was your last bowel movement? Patient: It was yesterday. Doctor: Did you notice any blood in your stool or any rectum bleeding? Patient: No. Doctor: How old are you? Patient: I am twenty eight. Doctor: Okay, and you had a gastric bypass surgery, one year ago. Patient: Yes, almost one year ago. I lost about two hundred pounds after that. Doctor: And you felt well after the surgery? Patient: Absolutely! Until yesterday when my nausea and pain started. Doctor: Okay.","Section header: GENHX Section text: The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on it but has not done so. He has overall malaise and a low-grade temperature of 100.3. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum." "Doctor: Okay, so it looks like your blood work shows that your sodium levels are very low. This could explain some of the symptoms you've been having lately. Patient: What does that mean? Why are my sodium levels so low? Doctor: It could be due to a number of- Patient: Should I start eating more salt? Doctor: Not necessarily. But I believe it's partly due to the diuretic that you've been taking these past few weeks. Your blood work also shows anemia. I'd like to start you on some iron supplements for now and get you back in for another eval. The front desk has access to your orders and they can print you out a lab slip. Patient: Do you think the iron will help with my tiredness? I've been so exhausted and caffeine hasn't been helping one bit.",Section header: ASSESSMENT Section text: 1. Acute tiredness. 2. Anemia of unknown etiology. 3. Acute hyponatremia. "Doctor: So, you are a cigarette smoker? Patient: Yeah. Doctor: How much do you some? Patient: Not as much as some people. Doctor: How much is that exactly? Patient: Well, I probably buy a new pack once a week. Doctor: Okay. So that is about four packs a month and fifty packs a year. Patient: Yeah, I guess so.",Section header: FAM/SOCHX Section text: 50+pack-yr cigarette use. "Doctor: Are you married, sir? Patient: Yes, to my wonderful wife. Doctor: Great, can I assume you support each other at home? Patient: Yes, doctor, that's correct. Doctor: Do you smoke or drink, sir? Patient: Well, I don't smoke, and I don't do anything harder, either. But I drink just about every day. Doctor: How much do you drink a day? Patient: I drink maybe two or three drinks a day, so maybe four or nine a week.",Section header: FAM/SOCHX Section text: He is married and has support at home. He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week. "Doctor: Do you know if anyone in your family has history of heart disease, stroke anything of that sort? Patient: Let me think. You mean only blood relatives? Doctor: Yes. Patient: Yes. We have some of those diseases in our family.","Section header: FAM/SOCHX Section text: Remarkable for coronary artery disease, stroke, and congestive heart failure." "Doctor: What kinds of surgeries have you had in the past? Patient: I have had a heart bypass surgery. Doctor: Is that C A B G? Patient: Maybe. And I have had my tonsils and appendix taken out. Doctor: Sure. Okay.","Section header: PASTSURGICAL Section text: CABG, appendectomy, tonsillectomy" "Doctor: Good morning, ma'am. Can you tell me more about this low back pain? Patient: Well, I'm not as young as I used to be, I'm fifty nine. Doctor: What set this pain off? Is there any injury? Patient: Yes, I had a fall in the beginning of two thousand six. I slipped on a freshly waxed floor. Doctor: What part of your lower back did you fall onto? Patient: I fell onto my tailbone and just general lower back. Doctor: Is this the only fall you've had? Patient: No, I had another one in March of two thousand six. Doctor: What happened when you fell that time? Patient: I was trying to qualify on the gun range with a handgun, when I lost my footing. Doctor: What made you lose your footing? Patient: I think it was more weakness than a loss of balance. Doctor: What treatments have you had for this? Patient: Well, I've been to P T, and I had, um, cauterization of some of the nerves in my lower back. Doctor: How many times have you had this cauterization done? Patient: I've had it twice, once in October and the other in November. Doctor: This was in two thousand eight, right? Patient: Correct. The P T said I have low back pain and degenerative disc disease.","Section header: GENHX Section text: The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient states that this occurred in October 2008 as well as November 2008. The patient has a history of low back pain, secondary to a fall that originally occurred in 2006. The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region. The patient then had her second fall in March 2006. The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance." "Doctor: Have you ever had surgery, ma'am? Patient: Yeah, doctor, I've had a whole lifetime worth of back surgeries. Doctor: How many surgeries have you had? Patient: I've had four. Doctor: Do you know the surgeries you've had? Patient: Actually, I have the op notes here. Doctor: I see, you've had an anterior cervical discectomy, and fusion of C three through C seven. Patient: Yes, I had all of those with Doctor L. Doctor: Do you have any children? Patient: Yes doctor, I have seven, but I had three miscarriages. Doctor: Were any of your children born through C sections? Patient: No, none of them were.","Section header: PASTSURGICAL Section text: She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L. She is G10, P7, no cesarean sections." "Doctor: Have you ever had any major surgeries? Patient: I had a skin tag removed but no. No major surgeries. Doctor: Okay.",Section header: PASTSURGICAL Section text: No significant past surgical history. "Doctor: With ten being the worst pain imaginable, out of ten, how would you describe your pain today? Patient: I'd say its about a six out of ten today. Doctor: What makes the pain worse? Patient: It's worse when I try to walk around on it. Doctor: Do you have any pain at night? Patient: No, thankfully I don't. Doctor: How long have you been wearing that exterior knee brace? Patient: Oh, for a little while now.","Section header: GENHX Section text: The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard." "Doctor: I need to ask you a few questions. Patient: Sure. Doctor: Do you feel any weakness or tiredness? Patient: No. Doctor: Any uneasiness or illness? Patient: No, nothing of that sort. Doctor: Any chills or high temperature? Patient: Nope. Doctor: Any excessive sweating or night sweating? Patient: Um, no. Doctor: How about allergies, are you allergic to anything? Patient: No, no allergies. Doctor: Alright.","Section header: ROS Section text: GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies." "Doctor: Do you smoke or drink? Patient: No. Doctor: Any drug use? Patient: No.","Section header: FAM/SOCHX Section text: No alcohol, drugs, or tobacco." "Doctor: Do you smoke? Patient: Yes! Doctor: How about alcohol, do you drink? Patient: Yes, I do. Doctor: And how much do you drink and is it occasional or on daily basis? Patient: Well, I love my wine, I drink about four to five glasses per day. Doctor: Wow! That's a lot.",Section header: FAM/SOCHX Section text: The patient is a smoker and drinks alcohol daily in considerable amounts. "Doctor: Do you smoke cigarettes? Patient: Yes.",Section header: FAM/SOCHX Section text: The patient is a smoker. "Doctor: Any important family history, any medical issues in the family? Patient: Well, my father died of a heart attack. I don't remember how old he was, but I do remember that he had some long run heart issues. Doctor: What about your mom? Patient: My mom's death was a mystery for all of us. She died of some complications because of the dental procedures. So never got to know what killed her. Doctor: Do you have kids? Are they all doing good health wise? Patient: I have a daughter, she's healthy.","Section header: FAM/SOCHX Section text: Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy." "Doctor: Hi there! How are you today? Patient: Hi. I am not doing so well. I have had this cough and a pain in my stomach. Right here by my belly button. Doctor: How long has this been going on? Patient: Two days. It has been very painful. Doctor: I would like to examine your abdomen. Is that okay? Patient: Yes.",Section header: CC Section text: Cough and abdominal pain for two days. "Doctor: Can you please confirm the medications that you have already taken? Patient: Yeah, I just finished the course for Minocin. I also took Duraphen II D M.",Section header: MEDICATIONS Section text: Recently finished Minocin and Duraphen II DM. "Doctor: Has anyone in your family had a history of heart disease or issues? Patient: Well, yeah. Actually, my dad passed away due heart disease. Doctor: Oh, I am sorry to hear that. Do you know what kind of heart problem he had? Patient: Yeah, it is called co- Doctor: Oh, coronary heart disease? Patient: Yes, exactly! Doctor: I see.",Section header: FAM/SOCHX Section text: His father died of coronary artery disease. "Doctor: Good morning, ma'am. Just to confirm, you're thirty two years old, correct? Patient: Yes, doctor, that's correct. Doctor: Good, so, have you been able to get a P C P yet? Patient: No, I haven't gotten one just yet. Doctor: Are you in the process of getting one? Patient: Yeah, Project Access is trying to find me one. Doctor: Good, um, what seems to be the problem today, then? Patient: Well, I was at Doctor X Y Z's office today, I had an appointment, but they cancelled me because I don't have the Project Access insurance yet. Doctor: I see, what were you going to see Doctor X Y Z for? Patient: I'm having a lot of pain in my foot. Doctor: Okay, have you seen Doctor X Y Z before? Patient: Yeah, I saw him on May fourteenth two thousand four. Doctor: But you still don't have a P C P, correct? Patient: Yes, that's correct. Doctor: Okay, we've seen you quite a few times in here. You were in here last week and saw Doctor X Y Z for some back pain, how did they treat you? Patient: Um, I got some pain medicines and muscle relaxers. Doctor: Okay, so, can you tell me more about your foot, please? Patient: Well, I have this pain in my foot, and I had surgery before so there's plates and screws in it. Doctor: Have you ever talked to anyone about removing this hardware? Patient: Well, I was supposed to see Doctor X Y Z about it, but since that appointment was cancelled, I came here. Doctor: I see, how long have you had this foot pain? Patient: Um, it started hurting a lot yesterday. Doctor: Is there any injury here? Patient: No, it's just chronically painful, honestly. Doctor: Do any activities bother it? Patient: Yeah, I can't exercise without a lot of pain. Doctor: I see, well, we've x rayed this before, and I see the hardware in there, but there's no apparent abnormality or evidence of loosening, at least from what I can see.","Section header: GENHX Section text: This 32-year-old female comes in again still having not got a primary care physician. She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect. She says that Project Access is trying to find her a doctor. She is not currently on Project Access, and so she is here to get something for the pain in her foot. I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004. She said she does not have a primary care physician. She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers. She has been in here multiple times for different kinds of pain. This pain she is having is in her foot. She had surgery on it, and she has plates and screws. She said she was suppose to see Dr. XYZ about getting some of the hardware out of it. The appointment was cancelled, and that is why she came here. It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her. She did not injure her foot in any way recently. It is chronically painful. Every time she does very much exercise it hurts more. We have x-rayed it in the past. She has some hardware there. It does not appear to be grossly abnormal or causing any loosening or problems on x-ray." "Doctor: Do you smoke or drink? Patient: No. Doctor: Any drugs? Patient: You mean like meth? Doctor: Yeah. Patient: No, never did it. Doctor: Okay.",Section header: FAM/SOCHX Section text: denied ETOH/Tobacco/illicit drug use. "Doctor: Hello, miss. How are you? What brings you to my office today? Patient: I am doing well. Just here for a refill on my medication. Doctor: Great. That should be easy. How has the stress management been going to control the acne? Patient: It is going well. My husband has been on board with my meditations and yoga. He is very supportive. Doctor: Wonderful. Are will still clean from drinking and smoking? That can interact with your medications. Patient: Yeah I know. I don't drink or smoke.",Section header: FAM/SOCHX Section text: The patient is married. She is a nonsmoker and nondrinker. "Doctor: So I have here that you're taking three different medications. Patient: Yeah. I've been taking them every day just like they told me to. Doctor: I see. That's good. Did you refill your prescriptions with the newly revised doses? It looks like they changed the dosing of your medications at the hospital. Patient: Um I've just been taking what I have at home. Doctor: I advise that you take the doses that they prescribed. If you'd like me to put in a new order, please let me know. Patient: Okay, yeah that's fine. I can pick it up on my way home. I didn't think the dosing mattered much as long as I took the meds every day.","Section header: MEDICATIONS Section text: I reviewed his medication list in the chart. He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription." "Doctor: Any major surgeries in the past? Patient: Not too many, but a catheter was put in my heart. Doctor: Oh, so cardiac catherization, correct? Patient: Yep.",Section header: PASTSURGICAL Section text: No major surgery except for prior cardiac catheterization. "Doctor: Hello, sir. I see you're being seen for an evaluation for your allergy. Can you please confirm your age? Patient: Yeah, that's right. Thirty four. Doctor: Let me take a look at your medical records. I see you were treated at the A B C Medical Center for an allergic reaction, correct? Patient: Yeah. I was rushed to the hospital that day. After, they told me to get checked for a follow up. Doctor: Who told you to have a follow up? Patient: One of the E R doctors and the kidney doctor. Doctor: I see. Your records indicate you had some swelling around the eye on May third of two thousand and eight. The cause was unknown. I see you were transferred from A B C Medical Center to X Y Z Medical center that day. Patient: Yeah, that sounds about right. Were there more details about that? Doctor: Yeah, there is. It says here you have a history of renal failure, so you needed dialysis. They believe the allergic reaction was due to this medicine called, Keflex, which was used during your dialysis treatment. Does that name ring a bell? Patient: Yeah, it does. I forgot why they gave it to me. Doctor: Usually, Keflex is used to treat a skin cellulitis dialysis shunt infection. Patient: Oh, I see. Doctor: I would like to ask you more about your allergies. What would you say you're allergic to? Patient: I've had a lot of problems with grass and sometimes pollen. Doctor: I see. I'll put that down as grass allergies, and environmental and inhalant allergies. Do you have any life-threatening allergic reactions? Patient: Nope. Never had that. Doctor: Have you ever had any swelling under the skin due to something you ate or touched? Patient: Nope. Never had that either. Doctor: That's great. I'm taking a look at your medications. I see you aren't taking anything for your allergies, but you are taking Atenolol. Do you have high blood pressure? Patient: Yeah, I do. Doctor: I see. All that's left from your report are the treatments they gave you before you were discharged from the hospital. Patient: What were the treatments they gave me? Doctor: Looks like they monitored you the whole time and gave you some corticosteroid therapy and antihistamine therapy. You didn't have any additional problems as well.","Section header: GENHX Section text: A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment. Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies. In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection. In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions. He currently is not taking any medication for allergies. He is taking atenolol for blood pressure control. No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring." "Guest_family: Doctor, you must tell her. She has stopped taking her medications. And her blood pressure is out of control, she is angry all the time and not looking after herself at all. Patient: That is not true! Doctor: Miss Tara, you need to take your medications on time. You are hypertensive and your readings don't look good. Patient: I don't want to take anymore medications. I want to try some natural remedies to treat my high blood pressure. I am not going to take any prescription meds that's it. Doctor: If that's the case then I will make note in your file that you are not complying.",Section header: PASTMEDICALHX Section text: Hypertension. The patient noncompliant "Patient: I think I got some allergy, my lips are swollen and its causing me difficulty in swallowing. Doctor: Oh, let me take a look.",Section header: CC Section text: Swelling of lips causing difficulty swallowing. "Doctor: Any medical history? Patient: Um I suffer from depression and high blood pressure. Doctor: Are you taking anything for either? Patient: Only for high blood pressure. Doctor: Have you had surgeries in the past? Patient: I had surgery to get a few hemorrhoids removed back in two thousand and ten.",Section header: PASTMEDICALHX Section text: Significant only for hemorrhoidectomy. He does have a history of depression and hypertension. "Doctor: Do you have a family history of any medical conditions, such as diabetes or heart disease? Patient: No, nothing.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: How's your family? Patient: They're doing well, thank you. My three boys are all grown up. Hard to believe they're living their own as young professionals. One of them is actually a G I doctor in San Diego, California. Doctor: You must be so proud of your boys. Patient: My wife and I always say how lucky we are. Doctor: I'm sure. And I have a few more questions before we wrap up. Patient: Go for it. Doctor: Do you drink or smoke? Patient: I smoke about a third of a pack a day and I drink every now and again, but nothing crazy.","Section header: FAM/SOCHX Section text: The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. The patient is married. She has three grown sons, all of which are very successful in professional positions. One son is a gastroenterologist in San Diego, California." "Doctor: How's it going, buddy? I haven't seen you in a long time Patient: Hey, Doctor. It's been a while. I've been doing well. Just here for my check up. Doctor: Nice. How's the family doing? Are they all well? Patient: Yeah, they're doing great. Nobody has been sick for a while. Doctor: That's great to hear. Nobody has new medical conditions either, right? Patient: Not that I know of. They're all doing good.",Section header: FAM/SOCHX Section text: Reviewed and unchanged. "Doctor: So, you and your husband live together, correct? Patient: Yes. It's a miracle we've lasted this long. Guest_family: Can't argue that. Doctor: Are you able to walk any distance without assistance? Guest_family: She's most comfortable in her wheelchair, but she usually walks with a walker if she's at home. Patient: Yeah, he's right. Doctor: And how often do you walk with your walker? Patient: If I were to guess, I'd say half the time. Doctor: Great. Guest_family: If I'm nearby, I like to keep any eye on her incase she feels unstable and needs help sitting back down. Doctor: It's good that you're both looking out for each other. Now moving onto the last few questions. Do you smoke or drink? Patient: No and no. Doctor: Did you smoke or drink in the past? Patient: No.","Section header: FAM/SOCHX Section text: She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows. No history of alcohol abuse or smoking." "Doctor: You do not look so well today. What seems to be the problem? Patient: Well‚ I am having a hard time. My whole body aches and I am in pain. Doctor: Do you have a history of drug use? Patient: Well yes. I am detoxing. Doctor: What kind of drugs have you been using? Patient: Heroin. Doctor: Okay. How long have you been using? Patient: I don't feel well. Maybe a year. I can't sleep or eat. Doctor: Have you had a fever, chills, vomiting or diarrhea? Patient: I think I have a fever. I feel chilled. I have had some diarrhea.",Section header: CC Section text: Detox from heroin. "Doctor: How would you rate your general health? Patient: I've been in reasonably good health at least physically. I try to go on frequent walks and eat a clean diet. However, there was one instance where I was not well mentally. After my husband died in nineteen seventy five, I had what I believe was a nervous breakdown. As a result of this, I was hospitalized for several weeks and treated with E C T. Doctor: I'm so sorry to hear about the loss of your husband. I can't imagine how difficult that must've been. I'm glad that you sought the care that you needed to feel better at that time. Did this happen when you were living in the United States or Korea? Patient: This all happened when I was living in Korea. I'm grateful that I had my family and friends to support me. Doctor: Social support is very important, especially when you are processing the loss of a loved one. Patient: Absolutely. Doctor: I have a few more questions before we move on. Any past medical problems? Patient: I used to have high blood pressure. Doctor: When you say used to, do you mean it's been resolved now? Patient: Yes. Doctor: Great news. How about surgeries? Have you had any in the past? Patient: None whatsoever. Doctor: Any alcohol or tobacco? Patient: No, I stay away from things like that.","Section header: PASTMEDICALHX Section text: The patient has generally been in reasonably good physical health. She did have a ""nervous breakdown"" in 1975 after the death of her husband. She was hospitalized for several weeks and was treated with ECT. This occurred while she was living in Korea. She does not smoke or drink alcoholic beverages. She has had no prior surgeries. There is a past history of hypertension, but this is no longer present." "Doctor: Are you experiencing any headaches, or do you have any history of migraine? Patient: No. Doctor: Any temporary loss of consciousness? Patient: No. Doctor: Any feeling of being off balance or fainting? Patient: No. Doctor: Any continuous sound you may hear? Patient: No. Doctor: Okay so no tinnitus. Any mouth sores or ulcers? Patient: Um, no. Doctor: Do you notice any change in your voice, any hoarseness? Patient: No, nothing like that. Doctor: Did you notice any swelling in and around your mouth? Patient: No, I did not. Doctor: Any history of goiter or swelling of your thyroid gland? Patient: Nope. Doctor: Okay.","Section header: ROS Section text: HEENT: No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter." "Doctor: Hello, miss. How can I help? Patient: Well, I just turned fifty seven this year and I would like to get rid of these wrinkles on my face. I don't like them one bit. Doctor: You look beautiful and actually have a lot of fullness in the face. It is great that you do not smoke and do not have history of skin disease. We can definitely help you with these minor issues.","Section header: GENHX Section text: This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds." "Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: Remind me, how young are you? Patient: Oh doctor, you flatter me. I'm sixty two years old. Doctor: Great, and you've had a rotator cuff repair before, correct? Patient: Yes, that's correct. Doctor: Good, well, what seems to be the problem today? Patient: I'm still having a lot of pain in this shoulder. Doctor: Oh no, have you had any recent imaging done on this shoulder? Patient: Yes, I had an M R I not too long ago, can you take a look? I have it right here. Doctor: Thank you, yes, um, this M R I shows that you've torn that rotator cuff again. Patient: Oh no, can we do another surgery to repair it again? Doctor: Yes, we'll have to. Patient: What's the risk of infection of the surgery? Doctor: Its less than one percent. We'll use antibiotics to control for infection the entire time. Patient: Will I be asleep again? Doctor: Yes, you won't feel a thing. Patient: Great, yes, I'd like to go forward with the surgery. I need to get back to playing tennis.","Section header: GENHX Section text: This is a 62-year-old female who previously underwent a repair of rotator cuff. She continued to have pain within the shoulder. She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff. She wished to proceed with a repair. All risks and benefits of the surgery were discussed with her at length. She was in agreement with the above treatment plan." "Doctor: What brings you in today? Patient: I dropped a glass and one of the broken pieces cut my foot pretty badly. There was a lot of blood. Doctor: Is the area still bleeding? Patient: I got it to stop bleeding while I was waiting for my ride. Doctor: Is there any pain in the area? Patient: No, it doesn't hurt. Doctor: Are you able to walk normally without pain or discomfort? Patient: Yes. Doctor: Are you experiencing any numbness or loss of strength in the area? Patient: No. Doctor: Do you have any other injuries on any other part of your body? Patient: No. Doctor: Have you had any recent illnesses? Patient: No. Doctor: Do you have any other concerns while you are here today? Patient: No.","Section header: GENHX Section text: This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints." "Doctor: What do you do for a living, sir? Patient: I'm actually retired, but I used to work as a dock hand. Doctor: That's great, congratulations on your retirement! Patient: Thank you so much, doctor. Doctor: I just need some background information on you, sir. Do you smoke? Patient: Sure, I smoke about a half a pack of cigarettes a day. Doctor: Do you drink, sir? Patient: Well, not anymore, but I used to be an alcoholic.","Section header: FAM/SOCHX Section text: 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand" "Doctor: Any surgical history? Patient: I had my thyroids taken out. Doctor: When did you have them taken out? Patient: Hm three years ago. Man, time flies. Doctor: Did you experience any complications post surgery? Patient: Nothing out of the ordinary. Doctor: Who was the surgeon who did your thyroidectomy? Patient: Doctor X. Doctor: What was the final diagnosis? Patient: I had a growth on my thyroids. Doctor: Was the growth cancerous? Patient: It was. I was initially reluctant to get them out, but I realized it was necessary. I didn't have much of a choice if I wanted to live ya know. Doctor: That's understandable. I'm sorry you had to go through that. Surgery is daunting, let alone surgery to remove cancer.",Section header: PROCEDURES Section text: Total thyroidectomy. "Doctor: Welcome in. I am Doctor Welch. Guest_family: Thank you! It is nice to meet you. Doctor: How old is your daughter? Guest_family: She is three years old now. Doctor: Hi there! Patient: Hi! Doctor: Mom I would like to start off with some questions regarding pregnancy, childbirth, and prior children. Guest_family: Okay. Doctor: Do you have any other children? Guest_family: No. She is my only child. Doctor: Have you ever had any miscarriages or abortions prior to having your daughter? Guest_family: I had a very early miscarriage before getting pregnant again with her. Doctor: I am so sorry to hear that. Guest_family: Thank you. I was difficult but when I got pregnant again with her, we were so overjoyed. Doctor: Did you have any difficulties or problems during your pregnancy with her. Guest_family: I had the flu in my seventh or eighth month of pregnancy. Other than that I had no problems. Doctor: How far along were you when you gave birth? Guest_family: I was thirty six weeks. Doctor: Did you have a vaginal birth or a C section? Guest_family: I had a regular birth. Doctor: Were any tools used during the birth to help with the birthing process? Guest_family: No. Doctor: How long were you in labor for? Guest_family: I was in labor for eleven hours. Doctor: Were you given any anesthesia during the birth? Guest_family: They gave me a little bit of laughing gas but not much. Doctor: What was her birth weight? Guest_family: Seven pounds and ten ounces. Doctor: Do you recall her Apgars score? Guest_family: No. I am not sure. Doctor: How long did you stay in the hospital after the birth? Guest_family: Five days. Doctor: Let us move to questions regarding your daughter. Has she had any development problems? Guest_family: She did not walk until well after two years old. She only rolled from side to side at two. Doctor: Okay. How old was she when she spoke her first words? Guest_family: She was around one or two. Doctor: When did she start to feed herself, using her hands? Guest_family: She was two. Doctor: Has she been toilet trained yet? Guest_family: No. She is not interested but I have been trying.","Section header: GENHX Section text: Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother. Birth weight 7#10oz. No instrumentation required. Labor = 11hours. ""Light gas anesthesia"" given. Apgars unknown. Mother reportedly had the ""flu"" in the 7th or 8th month of gestation. Patient discharged 5 days post-partum. Development: spoke first words between 1 and 2 years of age. Rolled side to side at age 2, but did not walk. Fed self with hands at age 2 years. Never toilet trained." "Doctor: Okay and are you working? Patient: Oh yes, I am a farmer. I have a farmland and my wife, and I do farming. Doctor: Good, so you are one happy married couple working together. Patient: Ah, yes. Doctor: And how about tobacco, do you smoke or eat? Patient: Absolutely not. Doctor: Any use of drugs or alcohol? Patient: Drugs? Doctor: Yeah, like cocaine or anything like that. Patient: Oh that, no. No drugs. Patient: And I don't drink either. Doctor: Alright.","Section header: FAM/SOCHX Section text: Farmer, Married, no Tobacco/ETOH/illicit drug use." "Doctor: Well, looking at your hand x ray, the bone looks in alignment, and I don't see any effusion. Doctor: Any tenderness or pain? Patient: Ah, not really! Doctor: There is no asymmetry. Can you move your hand up and down? Now rotate it. Can you move your fingers? Patient: Yes, I can do all of that, no problem at all. Doctor: Can you bend your hand? Patient: Yes. Doctor: Perfect.","Section header: EXAM Section text: BONE: No misalignment, asymmetry, defect, tenderness or effusion. Capable of from of joint above and below bone." "Doctor: How about any surgeries in the past? Patient: Well, I had colon surgery in nineteen eighty nine or was it ninety, oh yeah in nineteen ninety. Doctor: Okay and anything else? Patient: Ah yes, I had three surgeries for my sinus one was the same year as my colon surgery, one was before that. So, the first one was in nineteen eighty seven I believe then nineteen ninety and the last one was in two thousand five. Doctor: Wow, you remember the years also. Patient: Yeah, surprisingly.","Section header: PASTSURGICAL Section text: Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005." "Doctor: So, do you drink or smoke, sir? Patient: I'd say I have the occasional drink, but I don't smoke. Doctor: What do you do for a living? Patient: I'm a nursing aid in a nursing home right now. Doctor: Do you work the normal day shift? Patient: No, I work the second shift, so I work some late nights and early mornings. Doctor: Are you back at Wichita State this semester? Patient: No, I decided to take some time off. Doctor: Is everything okay? Patient: Yeah, I'm just really tired, so I decided to step away for a little. Doctor: That's understandable. Are you dating right now? Patient: Yes, I've been dating my boyfriend for a while now. Doctor: Is there any significant stress in your relationship? Patient: No, everything is going really well.","Section header: FAM/SOCHX Section text: Only occasionally drinks alcohol and he is a nonsmoker. He currently is working as a nurse aid, second shift, at a nursing home. He states that he did not enroll in Wichita State this semester. Stating he just was tired and wanted to take some time off. He states he is in a relationship with one partner and denies any specific stress in the relationship." "Doctor: What brings you in today, miss? Patient: I haven't been feeling well since I went to the dentist. Doctor: When did you go to the dentist? Patient: It was in May last year. Doctor: What happened at the dentist? Also, sorry, but how old are you. Patient: It was after I left the dentist. I was driving home, and I got lightheaded. I was so lightheaded that I had to pull over. Doctor: How long did the episode last? Patient: About two to three minutes. Doctor: Is this the only time that this has happened? Patient: No. In November last year, I was in the middle of eating breakfast when I got dizzy. I was so dizzy that I was nauseous, and I threw up several times. I was so exhausted from the dizziness and throwing up that I went to my room and took a two hour nap. I felt better and back to normal after I woke up from my nap. Doctor: How long did the vertigo last? Patient: It lasted about two to three minutes. So, about the same amount of time. Doctor: Have you had any other dizzy episodes? Patient: No I didn't but in January on the thirteenth my right arm went numb. It lasted for about four to five hours. Doctor: Are you left handed, or right? Patient: I am right handed. Doctor: Have you experienced any slurred speech or trouble swallowing? Patient: No. Doctor: Have you had any continuing weakness other than the time in January? Patient: No. Doctor: Have you experienced any headaches or visual changes? Patient: No. Doctor: Any continuing vertigo or lightheadedness? Patient: No.","Section header: GENHX Section text: This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness." "Doctor: Oh wow, you got stung quite a few times. Patient: Yeah, you're right about that. In my seventy six years this i have never gotten stung. This is new. Guest_family: He got stung around noon while I was inside preparing lunch. Patient: Yeah, they got both my hands and right knee. Those little monsters. Doctor: Did you notice redness and swelling right away? Patient: Um not right away. Doctor: How long did it take for your body to react? Patient: Bout thirty minutes or so. Doctor: Did you experience any shortness of breath, itching, or hives? Patient: No, surprisingly. Doctor: And no tongue swelling or trouble swallowing? Patient: No. Doctor: Have you gotten stung in the past? Or is this your first time? Patient: I got stung about a month ago. No redness or swelling like I do now. I guess it could've been due to the Benadryl I took as soon as it happened. Doctor: Did you take Benadryl again today? Patient: No, I figured I'd be okay. Guest_family: He takes Metoprolol and Hydrochlorothiazide for his blood pressure. Patient: And a baby Aspirin in the mornings. Doctor: Did you take your daily medications today? Patient: Yeah.""","Section header: GENHX Section text: Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today. He did not note any immediate reaction. Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath. He denies any sensation of tongue swelling or difficulty swallowing. The patient states he was stung approximately one month ago without any serious reaction. He did windup taking Benadryl at that time. He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day." "Doctor: What is your family medical history? Patient: I was adopted. I don't know my family medical history.",Section header: FAM/SOCHX Section text: Unknown. "Doctor: Were you ever diagnosed with any blood or heart disease? Patient: Uh no. Doctor: Any other past medical issues? Patient: No.",Section header: PASTMEDICALHX Section text: None. "Doctor: Any major or minor surgeries done in the past? Guest_family: Sorry, I have no idea about it. Guest_family: I just started working for him.",Section header: PASTSURGICAL Section text: Unknown. "Doctor: I can see your medication list here. Doctor: Do you take Accutane and Ovcon? Patient: Yes, I do. Doctor: Okay. Patient: Okay.",Section header: MEDICATIONS Section text: Accutane and Ovcon. "Doctor: What are you taking? Patient: I take Tylenol. Doctor: Is that only for pain? Patient: Yes it is.",Section header: MEDICATIONS Section text: Tylenol. "Guest_clinician: Hello, doctor. Let me give you a run down as to what we are dealing with today. This patient was last seen in January two thousand and four. She is coming for a follow up on interstitial disease secondary to lupus pneumonitis. I will let her tell you more about what happened yesterday. Doctor: Thanks, nurse. How are you feeling today, miss? Welcome back to the Pulmonary Medicine Clinic. What happened yesterday? Patient: Well, I was doing fine since last time. My respiratory issues have been great and I have had no major difficulties breathing. Doctor: That's good to hear. What happened yesterday that caused you to want to come in so urgently? Patient: Yesterday I noticed that I have some back and joint pain. When I breathe deep my back hurts. Doctor: Are you experiencing any coughing? Patient: No, coughing at this moment. Doctor: Have you been producing any mucus the times that you do cough? Patient: No, I already said I didn't cough. Doctor: Okay. Any fevers or chills? Patient: Nothing so far. Doctor: Do you have any other symptoms currently? Patient: I do notice that I am more tired than usual. Doctor: During physical activity do you seem out of breath or more tired than usual? I want to see if your pulmonary system is inhibited. Patient: No. I don't have issues with breathing when I do daily activities.","Section header: GENHX Section text: The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. She was last seen in the Pulmonary Medicine Clinic in January 2004. Since that time, her respiratory status has been quite good. She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort. She denies any problems with cough or sputum production. No fevers or chills. Recently, she has had a bit more problems with fatigue. For the most part, she has had no pulmonary limitations to her activity." "Doctor: Hello sir, it's been a while since your last visit. How have you been? Patient: Hello doctor, yes, I have come a long way. I guess last time I was here was in two thousand and two if I am not wrong. Was does your system say? Doctor: You are right! It was August second of two thousand and two to be very precise. Doctor: Please confirm for the records, you are a white married man and must be forty nine years old now. Am I right? Patient: You got it all right doctor! Doctor: Are you still working in that airplane company? Patient: Yes sir, still with Alaska Airlines but I have been promoted and work as a plane mechanic. Doctor: That is so nice! Good for you man! So, tell me how can I help you today? What brought you to our dermatology department today? Patient: I'm having pain in my stomach on the right side and down here. Doctor: Is it only on the right side or anywhere else? Patient: It is on both sides and now I can feel it on the middle part of my left thigh as well. Doctor: Tell me more about it. How did it start? When did you first notice it? Patient: It's been going on and off. It was not there for a while, but now it is like back again mainly on my tummy, down here. It is painful when I touch it. At first, I thought maybe I'm having shingles. Doctor: When did you notice it? Patient: It all started before the holidays, I think one and a half months before the holidays. It is still going on for the past eight days in my tummy and the hips mainly on the right side. Doctor: Did you get any treatment for this? Any over the counter medicines? Patient: No, as I told you I thought it was shingles, but then there was no change in the skin, no rashes, nothing. I was not sure what to take. Doctor: Okay, do you bathe every day? Patient: Yes, I do but I try to use as little soap as possible. Doctor: Okay, here is what I think, all your symptoms are pointing towards hyperesthesia. I would like to run some tests to find the underlying cause and then we will start the treatment. A nurse will come and take you to the lab. Does this sound good to you? Patient: Yes.","Section header: GENHX Section text: This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. It cleared for awhile. This has been an intermittent problem. Now it is back again on his right lower abdomen. At first, it was thought that he may have early zoster. This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area. He has had no treatment on this; there are no skin changes at all. The patient bathes everyday but tries to use little soap. The patient is married. He works as an airplane mechanic." "Doctor: Are you finished with your cancer treatments? Patient: Yes. I am in remission now. Doctor: That is great! When was your last radiation treatment? Patient: It has been over two years since my last treatment.",Section header: IMAGING Section text: She has had no recent radiological procedures. "Doctor: Do you smoke? Patient: Yeah. I smoke about a pack a day. Doctor: Do you have any plans of quitting? Patient: Eh not really. Doctor: As your doctor, I'd advise that you consider nicotine patches and find ways to break your smoking habit. Patient: Okay. I'll see what I can do. Doctor: Do you drink? Patient: Socially. Doctor: Are you married? Patient: No, but I have two littles ones. Doctor: Aw, how old are they? Patient: I have a four year old and a six year old. Doctor: That's great. I'm sure they keep you busy. Any hobbies? Patient: They really do, especially the four year old. As for hobbies, I like fixing up computers. I also like fishing, hiking, and camping with the family.","Section header: FAM/SOCHX Section text: He smokes one pack of cigarettes per day. He is a social drinker. He is not married, but has two children. Hobbies: Computers, hiking, camping, fishing." "Doctor: Good morning, ma'am. Before we begin today, can you confirm your age for me? Patient: Good morning, doctor. Sure, I'm seventy nine years old. Doctor: Great, thank you. What seems to be the problem today, ma'am? Patient: Well, I have this arthritis, as you know. Doctor: Yes, how would you describe your arthritis? Patient: Well, at this point I'd say it's debilitating. Doctor: I see, so the antiinflammatories and rest haven't helped at all? Patient: No, I haven't had any improvement, doctor. It's still so bad. Doctor: I see, I believe you'd be a good candidate for a knee replacement. Patient: Yes, I thought so. What are the risks of infection for the surgery? Doctor: Um, it's less than one percent, we use prophylactic antibiotics to control for infection the entire time. Patient: That's great, what about anesthesia, will I be asleep for this? Doctor: Yes, you won't feel a thing. Patient: Great, yes, I'd like to do the surgery, doctor.","Section header: GENHX Section text: This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed with surgery as described below." "Doctor: Welcome to the clinic. Patient: Thank you. Doctor: Are you from the area? Patient: I was born and raised in Iowa. My husband and I moved here twenty years ago, and we have been here ever since. Doctor: It is a wonderful city. Do you have kids? Patient: Yes! We have two kids. Doctor: Do you have any history or present use of tobacco, alcohol and recreational drugs or substances? Patient: I have a glass of wine every once and a while but no to the rest.","Section header: FAM/SOCHX Section text: Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use." "Doctor: Any of your family members have issues like seizures? Patient: None on my father's side, but, yeah, on my mom's side some of the family members had seizures. Like, my mom had them during her childhood. I know that my great grandmother had it and so does my great aunt.",Section header: FAM/SOCHX Section text: There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt. There is no other significant neurological history on the paternal side of the family. "Doctor: Do you have a sore throat, cough or earache? Patient: No.","Section header: ROS Section text: Negative as far as sore throat, earache, or cough." "Doctor: Can you tell me what are the diseases you have been diagnosed with in the past? Patient: Sure, I have had hypertension, diabetes, asthma and cholesterol problem. Doctor: Ok, is there anything else? Patient: Nope. Doctor: And it is type two diabetes, right? Patient: Yes. Doctor: Thank you!","Section header: PASTMEDICALHX Section text: Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol." "Doctor: Good afternoon, sir. Do you remember the details of your surgery? Patient: No, can you remind me? Doctor: Well, um, we did a right orchiectomy due to your testicular cancer, when did you have that? Patient: Um, it was about eighteen years ago now, so that was about nineteen eighty nine. Doctor: Good, while you're here, do you have any other conditions that I should be aware of? Patient: Sure, I have G E R D, and um, I B S. Doctor: Thank you, what about allergies, do those bother you? Patient: Yeah, unfortunately I have those. Doctor: Do you have them in the spring, or in the fall? Patient: Actually, I have them in both. It's really annoying. Doctor: What allergy symptoms do you have usually? Patient: Um, another doctor called it a postnasal drip. Doctor: Okay, yes, I'm familiar with that. Have you ever had any other surgeries? Patient: Yeah, um, I had a hernia removed and repaired some time ago. Doctor: I see, what about any other major medical conditions? Patient: I've had carpal tunnel before. Doctor: Which hands did you have it in? Patient: I've had it in both.","Section header: PASTMEDICALHX Section text: Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia." "Doctor: Good morning, Miss X Y Z, correct? Patient: Yes, that's me, good morning doctor. Doctor: Before we begin, I just need a few pieces of information. How old are you? Patient: I'm forty four years young, doctor. Doctor: Good, thank you. Next, which hand do you write with? Patient: I write with my right hand. Doctor: Finally, what do you do for a living? Patient: I'm an aircraft mechanic. Doctor: Very nice, so, how did you get hurt? Patient: Um, I was working on repairing an airplane at work when I fell between the plane and one of the stands. Doctor: How big was the gap that you stepped in? Patient: Um, it was about a foot and a half. Doctor: Which knee did you hurt? Patient: It was my left knee. Doctor: Did you have surgery after the accident? Patient: Yes I did, I had two arthroscopies, and an, um, patellar replacement after those. Doctor: Okay, yes, I see. Patient: Then, I had a left knee replacement on Month D D, Y Y Y Y. Doctor: Do you have any imaging of this knee? Patient: I didn't have any x rays done, but I have an MRI report and notes from Doctor A B C D. Doctor: Can I see that report? Patient: Yes absolutely, here. Doctor: Okay, so this M R I from September two thousand six shows some nonspecific edema anterior to the patellar tendon, but thankfully there's no evidence of fracture of ligamentous avulsion or abnormality. Patient: What does that mean? Doctor: There's some bleeding in the bone there, but nothing is broken or out of alignment. Patient: Oh, thank you, that's good. Doctor: Oh certainly, yes, it is. What treatments have you had for this knee, aside from surgery? Patient: I've done a full course of PT for this. Doctor: Where is your knee pain? Patient: Mostly, it's here in the front of the knee, and then on both sides, like the inside and outside. Doctor: Does the pain go down your leg at all? Patient: Yes, it goes down my, is this the femur? Doctor: Yes, that's the femur. Patient: Then this must be my tibia, it goes down the front of that too. Doctor: Does it go into your thigh at all? Patient: Yes, it goes into the back of my thigh. I feel numbness and tingling back there. Doctor: Do you feel anything in the feet? Patient: Nope, my feet are completely normal, thankfully. Doctor: Are you having any back pain? Patient: A little, I feel something in my lower back, I'm not sure if it's related. Doctor: Does anything make your knee pain worse? Patient: Yeah, I can hardly walk anymore, it hurts so bad. Doctor: What kind of symptoms do you see when you walk on this? Patient: I feel popping and grinding, and my knee swells up. Doctor: That numbness and tingling you feel in the thigh, do you feel that in the knee at all? Patient: Actually yes, it feels like pins and needles there. Doctor: What about this, when I touch the knee do you feel any abnormal discomfort or pain over the rest of the knee? Patient: No, nothing out of the ordinary there. Doctor: What about this, this is the fibular head, which is where you feel the pins and needles. I'm applying pretty heavy pressure here, how would you describe what you're feeling? Patient: Um, numbness, tingling, and then that same pins and needles feeling. Doctor: Is there any instability? Patient: Yes, and there's pain with it too. Doctor: Are you working right now? Patient: No, I'm not right now. Doctor: Any allergies I should know about? Patient: Yes, actually, I'm allergic to a lot of pain medications. Doctor: Okay, have there been any changes in how you're walking? Patient: Yes, I had to change my walking pattern to take weight off my knee, and I think that has to do with my back pain. Doctor: That's certainly a possibility. How would you describe your pain? Patient: I'd say its constant, shooting, cramping, aching, throbbing, feels like it's being pulled, sharp, and , um, stabbing. All of those words seem fitting. Doctor: Okay, does the pain wake you up at night? Patient: Yeah, it does occasionally. Doctor: Does anything make this feel better? Patient: Yeah, it gets a little better if I lay down or if I keep my leg elevated. Doctor: Out of ten, with ten being the worst pain ever, how would you describe your pain on average? Patient: Um, I'd say six out of ten. That's how it is right now, too. Doctor: What about at its worst? Patient: Easily, its ten out of ten. Doctor: Finally, what about when the pain is at its least? Patient: Um, when it's not too bad, I'd say it's a three out of ten. I also have this other M R I report from September of O six, here. Doctor: Thanks. I see. They said that there is nonspecific edema anterior to the patellar tendon, but there is no acute fracture or any ligament abnormalities. That's good.","Section header: GENHX Section text: Ms. XYZ is an otherwise fairly healthy 44-year-old right-handed aircraft mechanic. On her date of injury, she reports that she was working on an aircraft when she fell between the airplane and a stand with about an 18-inch gap in between. She injured her left knee and underwent two arthroscopic procedures followed by patellar replacement and subsequently a left total knee arthroplasty in Month DD, YYYY. The patient is seen with no outside images, but an MRI report of the left knee and office notes from Dr. ABCD. The patient reports that she has undergone a full course of physical therapy and complains primarily of pain in the anterior aspect of the left knee and primarily over the medial and lateral tibial components with pain extending proximally to the distal femur and distally down into the anterior tibial plateau area. She has intermittent numbness and tingling in the posterolateral thigh and no symptoms at all into her feet. She has axial low back pain as an ancillary symptom. Her pain is worse with walking and is associated with swelling, popping and grinding. She complains of pins and needles sensation over the area of the common peroneal nerve overlying the fibular head. She has no dysesthetic or allodynic symptoms with light touch over the remainder of the knee and the femoral nerve area. Heavy pressure and light percussion of the fibular head produce painful numbness, tingling, and pins and needles sensation. The patient underwent a left knee MRI in September of 2006 revealing nonspecific edema anterior to the patellar tendon, but no evidence of an acute fracture or a femoropatellar ligament avulsion or abnormality. She has continued to complain of persistent instability and pain. She is not working. She has a number of allergies to different pain medications and feels that her back has been bothersome mostly due to her gait disturbances relating to her knee. Her pain is described as constant, shooting, cramping, aching, throbbing, pulling, sharp, and stabbing in nature. It occasionally awakens her at night. It is better in recumbency with her leg elevated. Exacerbating factors include standing, walking, pushing, puling. VAS pain scale is rated as 6/10 for her average and current pain, 10/10 for worst pain, and 3/10 for her least pain." "Doctor: How old are you? Patient: I'm eighty six years old. Doctor: What gender do you identify with? Patient: I identify as a female. Doctor: How long have you had this back and buttock pain? Patient: Its been a while, now. I know I have a fracture in my lower back. Doctor: How have you been managing this? Patient: Another doctor called this conservative treatment. I've been resting a lot, and using antiinflammatories. Doctor: Has there been any improvement? Patient: Its been several months at this point, and honestly no, there's been no improvement. I'm still in a lot of pain. Doctor: This C T Scan you had recently shows sclerosis, with some healing of a L five compression fracture, but if you look here, the healing is not complete. Patient: What can we do about this? I'm in so much pain. Doctor: I believe you'd be a candidate for a bilateral L five kyphoplasty. Patient: What's that? Doctor: It's a small procedure on that L five vertebra. Its minimally invasive, and we can actually do it as an outpatient procedure. Patient: Oh, wow, that's good to hear. What are the risks of infection? Doctor: Very low, historically, they're less than one percent. Patient: How is this possible? Doctor: We'll use antibiotics in order to control for infection. Patient: That's great, will I be under anesthesia? Doctor: Yes, you'll be asleep for the whole thing. Patient: Great, yes, I'd like to have this done, I can't keep living in this pain. Doctor: Awesome, I agree. Do you have control over your bladder and bowel movements? Patient: Yes, thankfully, I have complete control over everything like that still. Doctor: Do you wear a brace or corset normally? Patient: Yes, I usually wear both. Doctor: Okay, last question, can you notice any weakness in your body? Patient: No, I'm still very strong, even at my age.","Section header: GENHX Section text: The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture. The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was treated conservatively over several months, but did not improve. Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing. The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty. She denies bowel or bladder incontinence. She does complain of back pain. She has been wearing a back brace and corset. She does not have weakness." "Doctor: Good afternoon, sir, and who's the patient today? You, or your daughter? Guest_family: Not me today, its my daughter. Doctor: And how old are you, dear? Patient: I'm eighteen. Doctor: What seems to be the problem today? Patient: I hurt my right knee while playing tennis, um, it was about three days ago now. It really hurts. Doctor: I see, tennis, huh? Was there any contact involved? Patient: No, I took a step wrong when I went for an awkward shot. Doctor: Are you able to stand on this knee? Patient: Not well, it feels unstable, like I'm going to fall over. Doctor: Have you ever hurt this knee before? Patient: Yeah, tore my ACL in two thousand eight. Doctor: I assume you had surgery for that? Patient: Yeah I did, um, with Doctor X. He called it an, um, A C L reconstruction. Doctor: How did you recover from this? Guest_family: She didn't do well, she didn't do what we or the others doctors suggested, and the knee never really got the same tightness back. Doctor: What did they do about that? Guest_family: I have it in my notes here, they did an, um, A C L revision. That was done by Doctor Y. Doctor: When was that done? Guest_family: Looks like it was at the end of two thousand eight. Doctor: Following the revision, how did you cover? Patient: I did everything they said, I did it exactly as they wanted, and I did fine until this last injury. Doctor: Good, was there any instability following the revision? Patient: Nope, I was really stable.","Section header: GENHX Section text: The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. At this time, she complains of pain and instability in the knee. The patient's past medical history is significant for having had an ACL injury to the knee in 2008. She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008. The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury." "Doctor: How're you feeling today? Patient: Much better. The antibiotics seemed to really help. Doctor: Are you still experiencing any symptoms? Patient: Um no, thankfully. I had some wheezing when I first started the antibiotics, but it's improved a ton. I don't think the wheeze is even there anymore. Doctor: Good, good.",Section header: PASTMEDICALHX Section text: He has had some wheezing in the past but nothing recently. "Doctor: Any medical problems that run in the family? Patient: No, nothing that comes to mind.",Section header: FAM/SOCHX Section text: Unremarkable. "Doctor: Hi Mister B, nurse tells me you had a fall? Patient: Yes, a pretty bad one. Doctor: Okay, tell me what happened? Patient: Well, I was running to catch a taxi and stumbled upon a piece of rock, lost my balance and fell. Patient: I fell face down and my head hit the sidewalk. The next thing I remember is I am all dazed and people trying to help me. Doctor: I see, did you lose consciousness after the fall? Patient: No. Doctor: So, is your head hurting? Patient: Only the right forehead where I have the scrape and my chin. Doctor: Okay, any neck or back pain? Patient: No. Doctor: Any stomach pain? Patient: No. Doctor: Pain anywhere else, in extremities, hand or leg? Patient: No. Doctor: Okay, and how old are you? Patient: I am forty two. Doctor: Okay.","Section header: GENHX Section text: Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a while after it happened. He complains of pain over the chin and right forehead where he has abrasions. He denies neck pain, back pain, extremity pain or pain in the abdomen." "Doctor: Let's talk about your family history. Patient: Okay. Doctor: Can you tell me about any kind of medical traits that run in your family? Patient: I think my family has been blessed or I don't know if any. Doctor: What about any heart disease? Patient: Nope. No heart disease or diabetes or any other kind of issues that I'm aware of.",Section header: FAM/SOCHX Section text: Negative. "Doctor: Hello, Nurse. Could you give me a run down on the eleven month old patient? Guest_clinician: The patient was presented with stage two neuroblastoma on the left when he was six weeks old. It was completely resected. It was shown not to be N Myc amplified and had some favorable Shimada histology. Doctor: Great. Did he have a follow up after? Guest_clinician: He did. There was a second primary in his right adrenal gland. They performed a biopsy, which was consistent with neuroblastoma with favorable Shimada histology. Doctor: Did he receive any chemotherapy? Guest_clinician: He is now being treated with it per protocol P nine six four one and not on study. His last chemotherapy appointment was on May twenty first two thousand and seven. They used carboplatin, cyclophosphamide, and doxorubicin. Doctor: What did they do after chemotherapy? Guest_clinician: He received G C S F daily because he had neutropenia that delayed his second cycle. Doctor: Thank you, Nurse. I'll go talk to the mother. Guest_clinican: No problem, Doctor. Doctor: Hello, ma'am. It's nice to see you again. How is your little boy doing? Guest_family: Not so well. Since out last visit, he had a stuffy nose for a couple of days. Doctor: Is it getting worse? Guest_family: I think it's getting better now. It isn't as stuffy. Doctor: That's good to hear. Has he been sick or had any fevers? Guest_family: Nope. Just the stuffy nose. Doctor: Has he been able to eat anything? Guest_family: At times, he didn't want to eat. It seemed like he wasn't hungry. Doctor: Does he still have a reduced appetite? Guest_family: Not anymore. He's starting to eat again. Doctor: Did he have any nausea or vomiting after he ate? Guest_family: Thankfully, no. I would have made my husband clean up the vomit. Doctor: That's great. Is he able to pee and poop fine? No diarrhea, right? Guest_family: His poop has been solid. I haven't seen anything bad about his pee either. Doctor: Great. Would you be able to open his mouth for me? I just want to check if everything's fine inside. Guest_family: Of course. Say ah. Patient: Ah. Doctor: Thank you. Oh, wow. It looks like he's showing some symptoms of thrush again. Guest_family: Oh, no. Should we restart fluconazole? Doctor: It's just a fungal infection inside the mouth. I'll prescribe him fluconazole. It should get rid of it. Guest_family: Thank you so much. You all have been so helpful. My little boy is slowly getting better.","Section header: GENHX Section text: The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected. It was felt to be stage 2. It was not N-Myc amplified and had favorable Shimada histology. In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology. He is now being treated with chemotherapy per protocol P9641 and not on study. He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin. He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle. In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving. He is not acted ill or had any fevers. He has had somewhat diminished appetite, but it seems to be improving now. He is peeing and pooping normally and has not had any diarrhea. He did not have any appreciated nausea or vomiting. He has been restarted on fluconazole due to having redeveloped thrush recently." "Doctor: So, how are long have you had pain in this hip? Patient: It's been about eight or ten years now. It began while I was working in construction. Doctor: How old are you now? Patient: I'm thirty two now, so I've been in pain since I was in my twenties. Doctor: Have you seen another doctor for this, or am I the first? Patient: Yeah, um, I've actually seen several doctors before, the last I saw was Doctor A B C a few weeks ago. Doctor: What did those doctors tell you? Patient: They thought it was low back pain, and something called, um, radiculopathy. Doctor: Does your pain radiate into your legs? Patient: Yes. Doctor: Has your pain been present for the eight years, or did it come and go? Patient: It's been persistent, and I've had difficulties on and off since then. Doctor: Okay. The x rays from Doctor A B C show severe degenerative changes as well as avascular necrosis of the femoral head. What else did the Doctor do for you? Patient: He gave me some pain medicine, and we talked about going to another specialist for surgery. Doctor: Do you remember the names of the procedures suggested? Patient: Something about resurfacing the hip, or a hip replacement. I'm here for another opinion on that. Doctor: I saw you come in with a cane, do you have groin pain as well? Patient: Yes, and I can't do any of the activities I used to. Doctor: Besides the pain medication, have you had anything else? Patient: I've taken antibiotic steroids before. Doctor: Okay. Do you drink? Patient: Yes, a lot.","Section header: GENHX Section text: The patient is a 32-year-old male seen by Dr. ABC several weeks ago for persistent left hip pain. He has a long eight to ten year history of pain into the left hip. He has been worked up by several specialists and evaluated. He was thought initially to have low back pain with radiculopathy. He does have a history of antibiotic steroid use as well as heavy drinking. He reports his symptoms started approximately eight years ago when he was doing some construction at which time he began to have left hip pain. He has had difficulties on and off ever since then. On the last visit, radiographs revealed severe degenerative changes of the left hip joint with apparent AVN of the left femoral head. He was given some pain medication and discussion took place regarding referring him to a specialist for evaluation of possible hip resurfacing versus conventional total hip replacement. He came for a second opinion in the area and we discussed his problems further. He continues to have primarily groin pain, which limits his daily activities. He has used a cane in the past for a short period and he continues to have difficulty with the left hip." "Doctor: Let me examine your skin. Patient: Sure. Doctor: It looks normal and well hydrated. Any excessive sweating? Patient: No, not really. Doctor: I don't see any injury or wounds. Patient: Yeah. Doctor: Its just a normal protocol to ask these questions for every new patient. Patient: I understand. Doctor: Thank you for your cooperation.",Section header: EXAM Section text: SKIN: Inspection within normal limits. Well hydrated. No diaphoresis. No obvious wound. "Doctor: Hi there! I am Doctor Kirkland. Patient: Hi. Doctor: How are you feeling? Patient: I feel weird. Like I feel confused. I don't know how I got here. Doctor: That's okay. Do you remember what happened to you before you came here? Patient: No. Doctor: Can you tell me about your past medical history? Patient: Um. Doctor: Take your time. Patient: I can't think of what it is called. It's something to do with my brain. Doctor: Okay. Patient: My doctor knows what it is. Doctor: What is the name of your doctor? Patient: Doctor Frank. Doctor: Doctor X? Across the street? Patient: Yes, that is his name. I don't know if that is across the street or not. Doctor: I will have your nurse give him a call and get some background information from him. Patient: Okay. Doctor: Can you please give Doctor X a call and get mister Jones' medical history? Guest_clinician: Yes, of course. Doctor: Thank you.",Section header: GENHX Section text: The patient himself is not able to give a good history. History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor. "Doctor: Any issues from head to toe? Patient: No, everything is fine.",Section header: ROS Section text: Noncontributory. "Doctor: Hello, it's been two months already? Patient: I know right? Doctor: Just feels like yesterday.",Section header: CC Section text: The patient is here for two-month followup. "Doctor: Tell me about your family medical history. Patient: No one in my family has any health problems.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: And are you working? What do you do? Patient: Oh, I am a catholic priest! Doctor: Oh wow! Patient: Yes. Doctor: And if you don't mind me asking, do you drink alcohol? Patient: Maybe that is something for my confession box but jokes apart I don't drink. Doctor: Sorry I need to ask these questions it's a protocol. Patient: I understand. Doctor: And can I put down here that you don't smoke or use any kinds of drugs? Patient: Yes, I don't do those either. Doctor: Cool.",Section header: FAM/SOCHX Section text: Catholic priest. Denied Tobacco/ETOH/illicit drug use. "Doctor: Okay, so where do you live? Patient: I live at an old age nursing home.",Section header: FAM/SOCHX Section text: Not available. The patient lives at a skilled nursing facility. "Doctor: So, he is Arjun, and he is thirty seven years old and was complaining of chest pain. Patient: Hi Doctors, how are you? Doctor: We are good thanks for asking. Guest_clinician: Hi there Arjun, I am doctor J and I am assisting Doctor Wilson today. So, chest pain huh? Patient: Yep. Guest_clinician: And I see here no cardiac excretion was mentioned. Doctor: Yeah. I am suspecting coronary spasm but that's questionable. Guest_clinician: Okay. Doctor: I did run a cardiac enzyme profile and it was negative. Guest_clinician: Alright. And he also has hyperlipidemia? Doctor: Yes, he does. Guest_clinician: Okay and did you order an E K G? Doctor: I did, it is normal too. Guest_clinician: Don't worry Arjun, we will take of you. Patient: Thank you.","Section header: ASSESSMENT Section text: 1. Chest pain in a 37-year-old gentleman with negative cardiac workup, questionably right coronary spasm. 2. Hyperlipidemia. 3. Negative EKG and cardiac enzyme profile." "Doctor: So, do you live in the area? Patient: Yes, my husband and I have lived here for a long time. He died a few years back. Doctor: I'm sorry to hear that. Patient: It's alright. Doctor: Do you smoke or drink? Patient: No, I don't. Doctor: Do you use any illicit drugs or substances? Patient: No, I don't do anything like that.",Section header: FAM/SOCHX Section text: The patient lives locally. She is a widow. She does not smoke cigarettes or use illicit drugs. "Patient: Um, I take the generic for Ultracet. Sometimes I take as many as four times a day. Doctor: Does this help the pain? Patient: No, I'm still in pretty significant pain, doctor. Doctor: Good morning, sir. My nurse's chart says that you're thirty four years old. Is that correct? Patient: Yes, doctor, that's correct. Doctor: How long have you had this back pain? Patient: Well, it's been a while now. Doctor: Does the pain go into your legs? Patient: Yes, into the left leg, more towards the outside of my leg. Doctor: Is there any injury that started this pain? Patient: Yeah, I was lifting at work on August twenty seventh two thousand three when I lifted something and felt a pretty sharp pain from my back down into my left leg. Doctor: Have you had back pain or surgeries before this injury? Patient: No, I haven't. Doctor: Are you having weakness in the legs? Patient: Yes, I am. Doctor: Okay, I believe you are a good candidate for surgery, sir. It seems like you have a lot of weakness and pain in the S one nerve root distribution. Patient: Okay. What are the risks of infection for this surgery? Doctor: Overall, the risk of infection is very low, less than one percent. We use antibiotics to control for infection the entire time. Patient: Will I be asleep for the surgery? Doctor: Yes, you'll be under anesthesia. You won't feel a thing. Patient: Okay, yes. I'd like to do the surgery.","Section header: GENHX Section text: This is a 34-year-old male with history of back pain with radiation into the left leg in the S1 nerve root distribution. The patient was lifting at work on 08/27/03 and felt immediate sharp pain from his back down to the left lower extremity. He denied any previous history of back pain or back surgeries. Because of his intractable pain as well as severe weakness in the S1 nerve root distribution, the patient was aware of all risks as well as possible complications of this type of surgery and he has agreed to pursue on. After an informed consent was obtained, all risks as well as complications were discussed with the patient." "Doctor: Hello, miss. Doctor X and I will be going over your medical history with you. Before we begin, could you confirm your age for me? Patient: I'm twenty five years old. Doctor: Thank you. Doctor X, could you go over the diagnosis of erythema nodosum? Doctor_2: She was diagnosed in two thousand and four after a biopsy was done that confirmed erythema nodosum, but the detail from the Netherlands is not that specific. Doctor: What kind of procedures were done to address it? Doctor_2: She had undergone a colonoscopy to address secondary diseases that may have been present because of the erythema nodosum, correct miss? Patient: Yeah, that's correct. Doctor: Were there any findings, Doctor X? Doctor_2: The findings were uncertain if the terminal ileum had abnormal biopsies. However, the skin biopsy mentioned some fibrosis, basal proliferation, and inflammatory cells in the subcutis. Doctor: I see. Her report states something about a tibia and fibula fracture on her right leg before the erythema nodosum. Are these skin lesions due to the fracture? Doctor_2: The skin lesions are not associated with the fracture, correct ma'am? Patient: That's correct. The cuts in my skins are on both legs too. Not just the right. Doctor: Thank you. Did anything occur before the skin lesions? Doctor_2: She had cosmetic surgery done on her jaw. Doctor: Ma'am, I see you visited our clinic and the Dermatology several times, correct? Patient: Yeah, that's correct. I had a rash that I wanted to get checked. Doctor_2: I remember that. I was here when she presented the rash. We suggested the rash in her lower extremities and ankles was erythema nodosum. She also had discomfort, which could have been inflammatory arthritis. Doctor: Doctor X, did you confirm with any tests? Doctor_2: Yes. There was an initial S E D above one hundred and ten and her C P R was increased. Doctor: Great. In the visits after, were there any other problems found? Doctor_2: The reports says that no other abnormalities were found. However, I do see something about her first visit. Doctor: Could you explain what it says? Doctor_2: She has some M T P detected, which could have been signs of erythema nodosum. However, the Dermatology did not agree, and they believed it to be venous stasis. Doctor: The venous stasis could have been related to the fracture, right? Doctor_2: That is correct. Doctor: Her initial visit reports suspicion of I B D, sarcoid inflammatory arthropathy, and lupus. Why was that? Doctor_2: She had a questionable rheumatoid fracture even though her C C P was negative. Her A N A was positive at one to four zero. There was a persistent speckled pattern. However, the rest of the lupus serologies were negative. Doctor: What lupus serologies were used? Doctor_2: Double stranded D N A, R N P, Smith, R O, and L A were used. Doctor: How did her cardiolipin antibodies panel look? Doctor_2: They were all negative. We made sure I g M, I g G, and I g A were less than ten. Doctor: I see. Was there anything else in the report? Doctor_2: She had her beta 2 glycoprotein one or R V V T tested. Doctor: That seems important because of the livedo pattern. Doctor_2: Exactly. That's why they concluded it was an onset of lupus and not rheumatoid arthritis because the arthritis couldn't be associated with erythema nodosum. Doctor: Why did she undergo a C T scan? Doctor_2: We feared she had lymphoma. The scan of her chest, abdomen, and pelvis were done to rule out sarcoid. Doctor: I see. The results came out normal, right? Doctor_2: That's correct. Doctor: Did you change some of you habits to help your bowels, ma'am? Patient: I tried my best to. Doctor: That's good. What was found Doctor X? Doctor_2: There was evidence of B twelve deficiency with a high methylmalonic and high homocystine levels along with a low normal B twelve in addition to iron studies consistent with iron deficiency and an initially low M C V. Doctor: That gives the possibility of inflammatory bowel disease, right? Doctor_2: Correct. That's stated in the report. Doctor: Were there any tests done to confirm this? Doctor_2: She underwent a colonoscopy, which showed nothing. Her endoscopy was also normal. Recently, she underwent a second coloscopy, and no evidence of inflammatory bowel disease was seen after viewing it microscopically. Doctor: Nothing was seen microscopically? Doctor_2: Actually, we determined there were aggregates of eosinophils. Doctor: That sounds important. That could be due to an allergic reaction or an emergence of Crohn Disease. I will have to discuss with Doctor Y from Gastroenterology to see the significance. Patient: Could I interrupt for a second? I don't think my B twelve and iron deficiency were looked at while I stayed in the United States. Doctor: Is that correct, Doctor X? Doctor_2: That is. I think these details were from somewhere else. Doctor: At least we are aware of it. What medication was provided during her first visit? Doctor_2: It looks like she was placed on forty milligrams of prednisone. The strength was reduced over time. Doctor: This may be a reason to her acne. Was she taken off this medication? Doctor_2: Yes, she was. There were too many adverse effects. Doctor: What was she places on after? Doctor_2: It looks like she started a point six m g colchicine, which she took daily. Doctor: How were her inflammatory markers after taking it? Doctor_2: Her markers were under control and positive. She also didn't have any evidence of erythema nodosum. Doctor: That is great. How did you like that medication, ma'am? Patient: My ankle would swell up and hurt. There were also some sensitive rashes on the skin of my legs. Doctor: I see. Is that stated on the report, Doctor X? Doctor_2: It is. I also see that she was reevaluated by Dermatology. Doctor: Did they find anything apparent? Doctor_2: No, they didn't. They didn't find any evidence of erythema nodosum. Doctor: What was the plan following that? Docotr_2: It looks like we proceeded with a D E X A scan and checked her vitamin D levels. Doctor: Was there any medication prescribed? Doctor_2: We ordered vitamin D and calcium to be bought over the counter so that her bones were protected. However, they use of them was stopped until we figured out the underlying cause of her disease. Doctor: I see. Other than the fracture and jaw surgery, was there anything else? Doctor_2: It shows she had Varicella and Mononucleosis, correct ma'am? Patient: Yeah, that's correct. Doctor: That's good. Our recent physical exam with you from last August showed changes in your venous stasis and diffuse periarticular ankle edema. Fortunately, we did not find any erythema nodosum, but the livedo patter was still present. Patient: I see. Did you find anything else? Doctor: We did find a heart murmur, so we will conduct an echocardiogram. Doctor X, could you confirm all the details form the workup, please? Doctor_2: Of course. Her A C E levels were normal. Her sed rate was around 30, which was high. Before that, it was around one ten, which is even higher. Her R V V T was normal. The rheumatoid factor was negative. The urinalysis was also normal. She had a C R P level of two point three, which was high. Her C C P came out negative. Her C B C displayed microcytosis and hypochromia with hematocrit levels of thirty seven point seven. Her hematocrit levels improved to forty point three later on, and she did not have any hypochromia, microcytosis, or anemia present. Doctor: Thank you for all that information. Does all this information and history seem to be correct, ma'am? Patient: Yes. Thank you for going over that in front of me. Doctor: No problem. I see you're here today regarding some mild but intense skin rashes. You mentioned that you thought it was erythema nodosum, correct? Patient: Yeah, that's correct. I think it's on my ankles. I also feel some joint stiffness. Doctor: I will take note of that. You also mentioned something about a rash before. Did you have a rash that was sensitive to U V light, like sunlight? Patient: That's right. I had it twice when I was in Europe. Doctor: When did you notice the rashes? Patient: I was skiing, and my face started to swell up. Doctor: I see. Do you think it had to do anything with your acne? Patient: No. My acne was stable after I stopped taking that one medicine and started the other. Doctor: The prednisone and colchicine we mentioned earlier, correct? Patient: That's correct. Doctor: Is there anything else you would like to ask? Patient: I am trying to get pregnant and would like to know if the medication has any effects on pregnancy. Doctor: I'll discus that with you right now. Patient: Actually, could you provide me with a pamphlet? I need to go study for my psychology classes. I have a big test tomorrow.","Section header: GENHX Section text: This is a 25-year-old woman who is attending psychology classes. She was diagnosed with presumptive erythema nodosum in 2004 based on a biopsy consistent with erythema nodosum, but not entirely specific back in Netherlands. At that point, she had undergone workup which was extensive for secondary diseases associated with erythema nodosum. Part of her workup included a colonoscopy. The findings were equivocal characterizes not clearly abnormal biopsies of the terminal ileum. The skin biopsy, in particular, mentions some fibrosis, basal proliferation, and inflammatory cells in the subcutis. Prior to the onset of her erythema nodosum, she had a tibia-fibula fracture several years before on the right, which was not temporarily associated with the skin lesions, which are present in both legs anyway. Even, a jaw cosmetic surgery she underwent was long before she started developing her skin lesions. She was seen in our clinic and by Dermatology on several occasions. Apart from the first couple of visits when she presented stating a recurrent skin rash with a description suggestive of erythema nodosum in the lower extremities and ankle and there is discomfort pointing towards a possible inflammatory arthritis and an initial high sed rate of above 110 with an increased CRP. In the following visits, no evident abnormality has been detected. In the first visit, here some MTP discomfort detected. It was thought that erythema nodosum may be present. However, the evaluation of Dermatology did not concur and it was thought that the patient had venous stasis, which could be related to her prior fracture. When she was initially seen here, a suspicion of IBD, sarcoid inflammatory arthropathy, and lupus was raised. She had an equivocal rheumatoid fracture, but her CCP was negative. She had an ANA, which was positive at 1:40 with a speckled pattern persistently, but the rest of the lupus serologies including double-stranded DNA, RNP, Smith, Ro, La were negative. Her cardiolipin panel antibodies were negative as well. We followed the IgM, IgG, and IgA being less than 10. However, she did have a beta-2 glycoprotein 1 or an RVVT tested and this may be important since she has a livedo pattern. It was thought that the onset of lupus may be the case. It was thought that rheumatoid arthritis could not be the case since it is not associated with erythema nodosum. For the fear of possible lymphoma, she underwent CT of the chest, abdomen, and pelvis. It was done also in order to rule out sarcoid and the result was unremarkable. Based on some changes in her bowel habits and evidence of B12 deficiency with a high methylmalonic and high homocystine levels along with a low normal B12 in addition to iron studies consistent with iron deficiency and an initially low MCV, the possibility of inflammatory bowel disease was employed. The patient underwent an initially unrevealing colonoscopy and a capsule endoscopy, which was normal. A second colonoscopy was done recently and microscopically no evidence of inflammatory bowel disease was seen. However, eosinophil aggregations were noted in microscopy and this was told to be consistent with an allergic reaction or an emerging Crohn disease and I will need to discuss with Gastroenterology what is the significance of that. Her possible B12 deficiency and iron deficiency were never addressed during her stay here in the United States. In the initial appointment, she was placed on prednisone 40 mg, which was gradually titrated down this led to an exacerbation of her acne. We decided to take her off prednisone due to adverse effects and start her on colchicine 0.6 mg daily. While this kept things under control with the inflammatory markers being positive and no overt episodes of erythema nodosum, the patient still complains for sensitivity with less suspicious skin rash in the lower extremities and occasional ankle swelling and pain. She was reevaluated by Dermatology for that and no evidence of erythema nodosum was felt to be present. Out plan was to proceed with a DEXA scan, at some point check a vitamin D level, and order vitamin D and calcium over the counter for bone protection purposes. However, the later was deferred until we have resolved the situation and find out what is the underlying cause of her disease. Her past medical history apart from the tibia-fibular fracture and the jaw cosmetic surgery is significant for varicella and mononucleosis. Her physical examination had shown consistently diffuse periarticular ankle edema and also venous stasis changes at least until I took over her care last August. I have not been able to detect any erythema nodosum, however, a livedo pattern has been detected consistently. She also has evidence of acne, which does not seem to be present at the moment. She also was found to have a heart murmur present and we are going to proceed with an echocardiogram placed. Her workup during the initial appointment included an ACE level, which was normal. She also had a rather higher sed rate up to 30, but prior to that, per report, it was even higher, above 110. Her RVVT was normal, her rheumatoid factor was negative. Her ANA was 1:40, speckled pattern. The double-stranded DNA was negative. Her RNP and Smith were negative as well. RO and LA were negative and cardiolipin antibodies were negative as well. A urinalysis at the moment was completely normal. A CRP was 2.3 in the initial appointment, which was high. A CCP was negative. Her CBC had shown microcytosis and hypochromia with a hematocrit of 37.7. This improved later without any evidence of hypochromia, microcytosis or anemia with a hematocrit of 40.3. The patient returns here today, as I mentioned, complaining of milder bouts of skin rash, which she calls erythema nodosum, which is accompanied by arthralgias, especially in the ankles. I am mentioning here that photosensitivity rash was mentioned in the past. She tells me that she had it twice back in Europe after skiing where her whole face was swollen. Her acne has been very stable after she was taken off prednisone and was started on colchicine 0.6 daily. Today we discussed about the effect of colchicine on a possible pregnancy." "Doctor: Anyone sick in your family? Patient: Nope. Doctor: So, everyone is healthy? Patient: That's right.",Section header: FAM/SOCHX Section text: Unremarkable. "Doctor: Mister Sunil, your blood pressure is high, and I am noticing this from past two-three times you have been here. It's been constantly high, you are not taking it seriously. Patient: No, nothing like that Doctor! It's been well under control. I have been monitoring at home. Doctor: Are you noting your readings? Did you bring it with you? Patient: No. I did not get the readings with me but I assure you I am taking care and my B P is normal. Doctor: Well, it's up and I am little bothered by it.","Section header: GENHX Section text: His blood pressure up. The last two to three times he has been in here, it has been up. He has assured me before that his blood pressure is under good control at home, but he does not bring any blood pressures in with him this time, which bothers me." "Doctor: What is your family medical history? Patient: My dad had colon cancer. Doctor: Did your dad pass from colon cancer? Patient: No. They caught it early. He passed away from old age. My mom passed away when she was in her nineties from a stroke. Doctor: I am sorry. Do you have any family history of any neurological disorders like, M S, Alzheimer's, Parkinson's or epilepsy? Patient: Other then my mom having a stroke, I know of nothing else.",Section header: FAM/SOCHX Section text: His mother died of a stroke in her 90s. His father had colon cancer. He is unaware of any family members with neurological disorders. "Doctor: Hello. I see you're here for a follow up. Did you get your blood work done? Patient: I did. Here are the results. Doctor: Let me take a look. Oh, wow. It looks like your blood sugar is high. Are you exercising every day? Patient: Not really. Is that bad? Doctor: You are at risk of developing type two diabetes.",Section header: PASTMEDICALHX Section text: Adult-onset diabetes. "Doctor: Have you had ever had surgery? Patient: Yeah, I had my gallbladder removed a few years ago. Doctor: Thank you, what about any other parts of the body, like your eyes, ears, or nose? Patient: Oh yeah, I forgot. I had eye surgery too. Doctor: Thank you, think hard, any other surgeries you can remember? Patient: Let me look at my notes, um, it looks like I had a dilation and curettage done some time back, too. Doctor: I see. Thank you for sharing that with me.","Section header: PASTSURGICAL Section text: Cholecystectomy, eye surgery, D&C." "Doctor: Hi there! How are you doing? Patient: Um. I am feeing really strange. Doctor: Strange how? Patient: I took Ecstasy over the weekend and I feel weird still. My heart is racing. I feel agitated and have been having waves of sadness. I cannot shake this feeling. Doctor: When did you take the Ecstasy? Patient: On Saturday.","Section header: CC Section text: ""I took Ecstasy.""" "Doctor: Do you live alone? Patient: I do. I lost my husband to prostate cancer last year. Doctor: Oh wow. I'm so deeply sorry for your loss. Losing a loved one is incredibly difficult. I lost my sister to cervical cancer two years ago. It was one of the hardest experiences of my life. Patient: I'm sorry for your loss as well. It helps to remember the positive memories you had with them. Doctor: Yes, definitely. How have you been doing otherwise? Patient: Not bad. I've been keeping myself busy with gardening. Doctor: Gardening is a great hobby. Patient: Yes, I enjoy it very much. It brings me a lot of peace. Doctor: And as your doctor I have to ask, but any history of alcohol or drug use? Patient: No.","Section header: FAM/SOCHX Section text: She is a widow, lives alone. Denies any tobacco or alcohol use." "Doctor: Hello. How are you doing today? Patient: I feel depressed. Doctor: I'm sorry to hear that. What's been happening? Patient: My parents were fighting for a long time, and I think they're not together anymore. Doctor: That must be really hard. I'm sorry to hear that they're divorced. Who do you live with right now? Patient: I usually hop houses. I'll go to my dad's house the first half of the week and spend time with his family. Then, I'll go to my mom's house during the last half of the week. Doctor: That's nice. Now you can ask for more gifts during Christmas. Patient: You know what? I never thought about that. That's a really good idea.",Section header: FAM/SOCHX Section text: The patient's parents continued to undergo a separation and divorce. The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week. "Doctor: What do you do for a living? Patient: I'm a real estate agent. Doctor: How long have you been working in the real estate business? Patient: Almost twenty years. Doctor: Wow. I know who to go to when I'm looking to buy a house. Patient: Happy to help. Doctor: So let's see here. Do you drink or smoke? Patient: I drink socially, but it's very infrequent. Doctor: And I have to ask, but any drug use? Patient: Nope. Not now, not ever.","Section header: FAM/SOCHX Section text: No tobacco use, occasional EtOH, no known drug use, works as a real estate agent." "Doctor: Welcome back in, Miss A. Patient: Thank you, doctor. Doctor: Do you remember the information about your operation? Patient: No, not really. Can you remind me? Doctor: Sure, you had a lap band replacement in January of O nine, and you had a band adjustment. Patient: Thank you. Doctor: How are you feeling today? Patient: Well, I've been under a lot of stress lately, and I had problems with my adjustments before. Doctor: Has anything changed since the operation? Patient: Actually, doctor, I was in a car accident a couple weeks ago, and I'm having problems. Doctor: What symptoms are you experiencing? Patient: I don't feel full. Doctor: How is your appetite? Patient: I'm not really hungry, but I also don't feel full. When I get hungry at night I can't wait until the morning to eat. I get so hungry. Doctor: Do you eat anything when you feel like this? Patient: Yeah, I usually have a candy bar, and that helps some.","Section header: GENHX Section text: Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment. Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress. She was in a car accident a couple of weeks ago and she has problems, she does not feel full. She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better." "Doctor: So, where do you live? Patient: Ah, I now live in an assisted nursing facility. Doctor: Okay, and do you drink or smoke? Patient: No, neither.",Section header: FAM/SOCHX Section text: She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility. "Doctor: Any specific medical traits in the family? Patient: What do you mean by that? Doctor: I meant does anyone in your family or extended family have any medical problems that they were treated for? Patient: I'm not aware of any such thing in my family.",Section header: FAM/SOCHX Section text: Unremarkable. "Doctor: Welcome in! I am Doctor Madison. Patient: Thank you. It's nice to meet you. Doctor: Are you married? Patient: Yes. We just got hitched last year. Doctor: Congratulations! Patient: Thank you. Doctor: Do you drink alcohol? Patient: No, I don't drink. Doctor: Do you smoke cigarettes? Patient: Yes. I know it's bad for me. Doctor: How much do you smoke per day? Patient: About a pack a day. Doctor: Okay. I have a lot of tools to help you quit smoking that we can discuss. Patient: Okay.",Section header: FAM/SOCHX Section text: Marital status: Married. The patient smokes 1 pack of cigarettes per day. Denies use of alcohol. "Doctor: We have you scheduled for a follow up and to have the staples removed in one week with Doctor X Y Z. Do you have your wound care instructions? Patient: Yes. Doctor: Do you have any questions? Patient: No. Doctor: If you do have questions or concerns that may come up, please don't hesitate to call the office. Patient: Okay. Doctor: If you develop a fever greater than one hundred and one point four, chills, nausea, vomiting, or continuing diarrhea please call the office. Also if your incision site becomes red, warm to the touch or has any drainage, call the office. Patient: Okay.","Section header: PLAN Section text: The patient was instructed to contact us with any questions or concerns that may arise. In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site. He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time." "Doctor: Have you had sinus issues before? Patient: I am not sure, maybe on and off. Doctor: Because this is more allergic. Patient: Okay. Doctor: So, we call it allergic rhinitis. Patient: Is it different than sinus infection? Doctor: Yes, it's it is different. Patient: Okay.",Section header: ASSESSMENT Section text: I think this is still his allergic rhinitis rather than a sinus infection. "Doctor: She has a rare case of thrombocytopenia. I'd like her to come in for a consult. Guest_clinician: Any other medical history? Doctor: No, just the thrombocytopenia.",Section header: CC Section text: Thrombocytopenia. "Doctor: Hi there how are you? Patient: I am good no problem at all other than the usual. Doctor: And what is that? Patient: You know, some discomfort I have on my right side. I have been feeling that since I had a stroke five years back. Doctor: Right, right. We did an E M G right? Patient: Yes. Doctor: And none of the medications we tried are helping? Patient: No, I also saw a neurologist, but nothing is helping Doctor: Okay, and are you monitoring your sugar regularly? Patient: Oh yes, Everyday at least two to three times a day. Doctor: And how bout insulin dose? Patient: Oh, that I kind of adjust myself. Doctor: Well, I have rechecked all the symptoms and everything looks fine. I don't see anything out of order, but we will keep monitoring. Patient: Okay. Doctor: And you are not smoking or drinking again are you? Patient: No, not since I had the stroke. Doctor: In the past you had a history of heavy usage of both alcohol and smoking, you need to be careful. You are seventy years old. Patient: Yeah, I am taking care of it. Doctor: Alright take care then.",Section header: GENHX Section text: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage. "Doctor: What is the strength of your Omeprazole? Patient: It is forty M G and I take it just once a day. Doctor: Any herbal medication? Patient: No I do not take anything like that.",Section header: MEDICATIONS Section text: Omeprazole 40 mg once a day. Denies herbal medications. "Doctor: So, to double check, you have a history of hay fever and asthma, correct? Patient: Yes. I was also recently diagnosed with cervical dysplasia. I found out shortly after my last O B G Y N visit. Doctor: And are you planning to follow up with your O B G Y N in the upcoming months? Patient: Yeah, the next visit is scheduled and everything.","Section header: PASTMEDICALHX Section text: Significant for asthma, allergic rhinitis and cervical dysplasia." "Doctor: So, do you have any family history of arthritis? Patient: Fortunately, no, not that I know of. Doctor: So, as far as you know, no one has had a joint replacement? Patient: No, it doesn't ring any bells.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Please, tell me about your medical history. Patient: I've been dealing with depression and anxiety for some time now. Doctor: I'm sorry, that must be difficult. Patient: Thank you, it is, but I manage. Doctor: What about your joints? How do you move? Patient: Oh yes, I have arthritis as well. I also had sciatic pain a long time ago, and a herniated disk. Doctor: Have you ever had neurological symptoms, like headaches, blurry vision, or weakness? Patient: Actually yes, I have migraines when I'm having my period. Doctor: Thank you, and have you had any surgery in the past? Patient: Yes, I had my appendix out.","Section header: PASTMEDICALHX Section text: Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy." "Doctor: Do you have any past history of psychiatric treatment of struggles? Patient: I had some extreme fatigue back in nineteen ninety one. I was in therapy for six years. They had me on Prozac. I took in for that whole six years while I was in therapy. When I started the Prozac, I had just started working again. The stress at work was overwhelming. Doctor: Was this the first time that you had feelings for fatigue and depression? Patient: No. I have always had a little sadness or depressed time in my life but it had been manageable before all the work stress started happening. Doctor: How are you feeling these days? Patient: I get somewhat sad from time to time but I don't dwell on things anymore. Doctor: Do you ever have thoughts of selfharm or suicidal thoughts? Patient: No.","Section header: GENHX Section text: The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue. She was also taking Prozac during that time. She then began taking Prozac again when she started working at secondary to stress with the work situation. She reported a chronic history of mild sadness or depression, which was relatively stable. When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things. She denied any history of suicidal ideation or homicidal ideation." "Doctor: How many other children do you have? Guest_family: My husband and I have three children, your patient today, and another boy, and girl. Doctor: How is everyone else doing? Guest_family: They're all doing very well, thank you for asking. Doctor: Do you live here in Easton? Guest_family: Yes, born and raised. Doctor: Good, do you have any pets? Guest_family: We have four dogs, three cats, and three mules. Doctor: What, no deer? Guest_family: No, no deer, at least not anymore. Doctor: What grade are you in, young man? Patient: I'm in the second grade, doctor. Doctor: Good, how do you like P E? Are you able to play no problem? Patient: Yes, I love P E. I don't have any problems there.","Section header: FAM/SOCHX Section text: He lives with mom, dad, brother, sister, and everybody is healthy. They live in Easton. They have 4 dogs, 3 cats, 3 mules and no deer. At school, he is in second grade and he is doing PE without any limitation." "Doctor: So let's start from the beginning. Patient: Okay. Doctor: You're seventy nine years old, correct? Patient: Yes. Doctor: Right or left handed? Patient: Right. Doctor: Do you remember when you had your first fall? Patient: Hm about a year and a half ago I fell while trying to walk from my bed to the living room. Doctor: Did you feel lightheaded prior? Patient: Uh yeah I did have some lightheadedness and I was a bit confused. I was aware of my surroundings though. My legs just gave out and the next thing I knew I was on the floor. Doctor: I see. Did you lose consciousness? Patient: No, thank goodness. Guest_family: He got up by himself and felt fine afterwards. The strangest thing. Patient: Yeah. I was good until my legs gave out on me July third of O eight. Doctor: Did you experience the same lightheadedness as before? Patient: Not this time. Guest_family: We had to rush him to the hospital after that. Patient: I was later diagnosed with pneumonia. The fall was blamed on the pneumonia. Doctor: Got it. Patient: To be on the safe side, I started using a walker from then on. Doctor: Did you need any type of walking assistance prior to your falls? Patient: Nope. I used to walk about two miles a day before all of this stuff started happening to me. This isn't even the end of it. My legs gave out on me again August O eight. No lightheadedness beforehand, but they did find that I had pneumonia again. Guest_family: They admitted him to the hospital and later sent him for rehab. Doctor: Did rehab help? Patient: Yeah. I was able to use my walker after that. Doctor: Did you return to your previous health? Patient: Uh not really, no. I had another fall in October O eight. Doctor: Did they diagnose you with pneumonia again? Patient: Yeah. I also had shingles. Doctor: Are you currently living at home? Patient: I'm living in a Chronic Rehab Unit. I can't use my walker anymore. I'm confined to a wheelchair. Doctor: I'm sorry to hear that. Patient: On top of that, I've noticed that my hands have been numb for the past three weeks. Doctor: Is it all of your fingers or only some? Patient: All. Doctor: Are you noticing any other symptoms along with the numbness in your fingers? Patient: Yes. I feel like I've lost quite a bit of muscle in my hands. They're also much weaker than before. My strength hasn't been the same since July O eight. It's definitely getting worse. Doctor: I see. Patient: I've had muscle twitching in my legs since August O eight. Doctor: Fasciculations? Patient: Yes. In my lower legs and thighs. Doctor: Any cramping or problems swallowing? Patient: No. Doctor: Any difficulty breathing? Patient: No. Doctor: Any constipation or diarrhea? Patient: Both actually. It tends to alternate. Doctor: But no loss of bowel or bladder control? Patient: No. I've noticed that my blood pressure has been out of whack. I also feel like I'm about to faint anytime I stand. Doctor: Okay. Patient: I don't think I have much feeling in my feet. They feel like sponges. Doctor: How long has that been going on? Patient: Uh nine months or so. I lost joint position sense in my feet around that time, too.","Section header: GENHX Section text: The patient is a 79-year-old right-handed man who reports that approximately one and a half years ago, he fell down while walking in the living room from the bedroom. At that time, he reports both legs gave away on him and he fell. He reported that he had some lightheadedness just before he fell and was slightly confused, but was aware of what was happening around him. He was able to get up shortly after falling and according to the patient and his son, subsequently returned back to normal. He was then well until the 3rd of July 2008 when his legs again gave way on him. This was not preceded by lightheadedness. He was rushed to the hospital and was found to have pneumonia, and the fall was blamed on the pneumonia. He started using a walker from that time, prior to that he was able to walk approximately two miles per day. He again had a fall in August of 2008 after his legs gave way. Again, there was no lightheadedness associated with this. He was again found to have pneumonia and again was admitted to hospital after which he went to rehabilitation and was able to use his walker again after this. He did not, however, return to the pre-July baseline. In October of 2008, after another fall, he was found to have pneumonia again and shingles. He is currently in a Chronic Rehabilitation Unit. He cannot use a walker and uses a wheelchair for everything. He states that his hands have been numb, involving all the fingers of both hands for the past three weeks. He is also losing muscle bulk in his hands and has noticed some general weakness of his hands. He does, however, note that strength in his hands has not been normal since July 2008, but it is clearly getting worse. He has been aware of some fasciculations in his legs starting in August 2008, these are present both in the lower legs and the thighs. He does not report any cramps, problems with swallowing or problems with breathing. He reports that he has had constipation alternating with diarrhea, although there has been no loss of control of either his bowel or bladder. He has had some problems with blood pressure drops, and does feel presyncopal when he stands. He also reports that he has no feeling in his feet, and that his feet feel like sponges. This has been present for about nine months. He has also lost joint position sense in his feet for approximately nine months." "Doctor: Are you still doing water aerobics? Patient: Yeah, I've been hitting the pool five days outta the week. Doctor: How're you feeling? Have you noticed any changes in energy and strength? Patient: I feel a bit stronger now compared to when I first started. I'm also way, way more energized.",Section header: PLAN Section text: As tolerated. Continue water exercise five days a week. "Doctor: Do you have any history of chronic pain? Patient: I got into a car accident a long time ago and I have always had neck pain. Doctor: Okay. Any other pain throughout the body? Patient: Sometimes I have back pain. Doctor: Okay.",Section header: GENHX Section text: Back and neck pain. "Doctor: How is your pain today? Patient: Eh it's been a rough few days that's for sure. The pain started almost instantly. Doctor: I'm sorry to hear that. Have you been taking anything for it? Patient: I actually saw a chiropractor the other day. My neck pain has been unbearable. Doctor: Is the pain localized to one area? Patient: Yeah. Doctor: And it hasn't radiated to any other part of your body? Patient: Nope. Doctor: Are you experiencing a pins and needles sensation at all? Patient: Not yet. Doctor: Any back pain? Patient: Oh yeah. I'd say it's even worse than my neck pain. The pain starts in my lower back and radiates down both legs. Doctor: Any pins and needles as a result of this back pain? Patient: No, no pins and needles. Doctor: Are you experiencing stiffness in your back? Patient: The stiffness seems to worsen when I exert myself during activities. Doctor: Has it impacted your sleep at all? Patient: Honestly, I haven't gotten much sleep since the accident. It's been so difficult to find a comfortable position to sleep in. I've never had back problems until now. Doctor: This accident sure did a number on you. Patient: No kidding. Doctor: You had mentioned experiencing stiffness during strenuous activity. Is it mostly during the day or does it progress into the night? Patient: Yeah, it's mostly during the day. Doctor: I see. Patient: The pain does improve a bit when I lay flat or sit up in a chair. Doctor: But despite this, your activity continues to be restricted, correct? Patient: Yeah, correct. Doctor: I meant to ask if you felt better after chiropractic treatment? Patient: A little bit, but not much. Doctor: And would you say your pain has overall gotten worse or remained the same? Patient: It's stayed more or less the same. Doctor: And to confirm, you didn't have neck or lower back problems prior to the accident? Patient: Yeah.","Section header: GENHX Section text: The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias. Stiffness is provoked by attempts at strenuous activity. The patient also reports difficulty sleeping, unable to find a comfortable position. The patient denies any previous back problems. During the day, the pain is exacerbated by strenuous activities. Pain may be eased by resting or recumbency and sitting. The patient's activity level has been significantly restricted. Some improvement has been noted with chiropractic treatment. Since the onset of the problem, the pain has continued at more less the same level. The patient reports that, prior to the present problem described above, there had been no episodes of neck or lower back pain." "Doctor: I have reviewed your x rays from your emergency room visit. I agree with Doctor Jones that your lungs show no signs of infection or decreased lung capacity. Patient: Okay.","Section header: IMAGING Section text: Chest x-ray ordered by ER physician is unremarkable, but to me also." "Doctor: Hello, how are you doing? What brings you here? Patient: I think I have allergies. I used to live in Seattle. I had allergies there, but I think they're getting worse after moving here. You see, I'm twenty three and I am a white female. I was in Seattle, I thought that the weather there is not for me. That's why I plan to move on here, but my allergies are not leaving me here either. Doctor: What did you take for your allergies before? Patient: Claritin and Zyrtec. Doctor: How effective were they? Patient: They seemed to be working for some time, but now I feel like nothing is effective anymore. Doctor: Have you ever tried Allegra? Patient: Yes, I tried that last summer and I've started it again like two weeks ago. But again, the story is the same. They work for some time and now it doesn't seem to be working anymore. Doctor: Have you tried sprays? Patient: I did use some over the counter ones. But I never got any prescribed nasal spray. Doctor: Any other medically related history that I should be aware of? Patient: I do have asthma if that counts. Doctor: Are you taking any medications for your asthma? Patient: Nope, nothing on the regular basis. Doctor: Do you think it is your asthma that is flaring up? Patient: I don't think so. I think, I still think it is just some allergies. I want to get tested.","Section header: GENHX Section text: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up." "Doctor: Good afternoon, ma'am. Patient: Good afternoon doctor. Doctor: So, do you have any medical conditions I should know about. Patient: Actually, yes. I have a few. I have hyperthyroidism, and I've had gallbladder issues for some time now. Doctor: I see. How's your blood pressure? Patient: Oh, um, I have high blood pressure too.","Section header: PASTMEDICALHX Section text: The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties." "Doctor: Are you a smoker, sir? Patient: Yes, I've been smoking about a pack, to about a pack and a half a day for more than forty years now. Doctor: What about alcohol, do you drink? Patient: Yeah, I drink a six pack of beer a day, doctor. Doctor: What about drugs? Do you use any illicit substances? Patient: No, I never used anything like that.",Section header: FAM/SOCHX Section text: The patient smoked 1-1/2 packs for more than 40 years. He consumes 6 beers per day. He denies any drug use. "Doctor: I'd like her to come see you for a consult tomorrow. Guest_clinician: How long has she been suffering from migraines with aura? Doctor: About five years now. Guest_clinician: Does she have a neurologist she sees regularly? Doctor: Not since moving here.",Section header: DIAGNOSIS Section text: Migraine with aura. "Doctor: So, sir, are you married? Patient: Yes, I'm married to my lovely wife. Doctor: That's great, so, what did you do for a living? Patient: I was a Pepsi Cola truck driver, but thankfully, I'm retired. Doctor: Congratulations on your retirement. What seems to be the problem today then? Patient: Thank you, it's nice to be done with that. The years took their toll though, I have a lot of pain in my back and knees. Doctor: Ah, yes, those years of sitting and lifting eventually catch up to everyone.","Section header: FAM/SOCHX Section text: Married. He is retired, being a Pepsi-Cola driver secondary to his back and knees." "Doctor: Tell me about your family medical history. Patient: The only thing that I know about is that my grandma has diabetes.",Section header: FAM/SOCHX Section text: Positive for diabetes mellitus in the maternal grandmother. "Doctor: Hello, Mister G, how are you today? Patient: I am good doctor thank you for asking. I am here to talk to you about my will. Doctor: Yeah, nurse informed me. So, tell me how can I help you? Patient: As you know I have terminal cancer. I have decided I do not want to be resuscitated. I have appointed my daughter as my legal healthcare proxy and she respects my wish. Doctor: Tell me what I can do to make you comfortable? Patient: Honestly doctor you have done enough and I am so thankful for that. I just wish to spend my last days at home surrounded with loved ones. I have my nurse, she takes care of me. I think I am fine! Doctor: Alright my friend.","Section header: EXAM Section text: CODE STATUS: Do not resuscitate, healthcare proxy, palliative care orders in place." "Doctor: Do you smoke? Patient: Nope. Doctor: What about alcohol? Or any kind of drugs? Patient: Nope.",Section header: FAM/SOCHX Section text: No smoking or drinking. No drugs. "Doctor: History of any illnesses, surgeries, or hospitalizations? Patient: I dislocated my wrist when I was a kid but that's all.",Section header: PASTMEDICALHX Section text: Surgeries: None. Injuries: Dislocated wrist. Illnesses: None. "Doctor: Any pain while peeing? Patient: No. Doctor: Any change in frequency or feeling the urgency to pee? Patient: No. Doctor: And what about bladder control, any accidents? Patient: No. Doctor: Any history of syphilis or any other S T D? Patient: No, never. Doctor: Okay.","Section header: ROS Section text: GENITOURINARY: Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs." "Doctor: Is there any history of heart disease in your family? Patient: Yes, my dad and brother had heart vessel blockage type of disease in their forties.",Section header: FAM/SOCHX Section text: Positive for coronary artery disease in her father and brother in their 40s. "Doctor: If I'm understanding correctly, you sustained an elbow injury during a fight with some other kids in Juvenile Hall? Patient: Yeah. My left elbow is killing me. Doctor: How old are you? Patient: Seventeen. Doctor: Are you having pain anywhere else? Patient: Yeah. My left ankle also hurts. Doctor: Are you able to walk without difficulty? Patient: Yeah. Doctor: Any knee pain? Patient: Not right now, but I've had left knee pain in the past. Doctor: Did you pass out or hurt your neck in any way? Patient: I didn't pass out. I hit my head against the floor when one of the kids tried to pin me down. Doctor: Do you have a headache, nausea, or blurry vision? Patient: No. Doctor: And no chest or abdominal pain? Patient: No. Doctor: Were there any weapons like knives or guns used during the fight? Patient: No.","Section header: GENHX Section text: This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He denies any passing out, any neck pain at this time even though he did get hit in the head. He has no chest or abdominal pain. Apparently, no knives or guns were involved." "Doctor: Hello. Before we begin your visit, I noticed some information missing. Could I verify the information with you? Patient: Of course. Doctor: Does your family have a history of any health related problems? Patient: Oh, yeah. A lot of my family have heart problems and cancer. Doctor: I see. Do you know what kind of cancer? Patient: I'm not completely sure, but my wife may know. She's here with me right now. Doctor: Great. I'll bring her in. Guest_family. Hello. I'm his wife. Doctor: Do you know what type of cancer runs in his family? Guest_family: I do. I believe it's carcinoma. Doctor: Thank you. Sir, are there any other health related problems I should be aware of? Patient: High blood pressure and food allergies run in my family too.","Section header: FAM/SOCHX Section text: Strong for heart disease, carcinoma, and a history of food allergies, and there is also a history of hypertension." "Doctor: Okay I am looking at you for multiple issues today. One of the biggest being swelling on your left leg. Can you tell me more about that? Patient: Yes sure. I got this swelling for almost three years now, and it has been worse for the past two to three months. Sometimes it gets better in the morning when I get up, but then throughout the day it begins to swell again. Lately it is staying bigger, and it feel uncomfortable with it being so large. The right leg also swells, but not nearly like the left leg. Doctor: How old are you, miss? Patient: I am forty four. My biggest problem is this pain in my left shoulder. I feel as if this low back pain is due to a poor mattress. Doctor: Did you hurt your shoulder? Patient: No, I don't remember hurting shoulder, but gradually I am losing some mobility. It is hard for me to get my hands behind my back or behind my head. I am losing strength in the left shoulder gradually for the last year. Doctor: Ok let's look at your labs. Patient: So far white counts are high. In April two thousand five Doctor X Y Z was asked to look at my high white count, but she thought it wasn't a problem and asked me to come for follow up. Doctor: Any other complaints? Patient: I have a lot of frequency with urination, and I get up to pee at night at least two to three times. Also, I have gained weight, I think about twelve pounds since March. Right now, I am two eighty four pounds. Doctor: Okay. So, I can see that your blood pressure is staying stable. You do take Atenolol twelve point five M G per day and Lasix as needed. Patient: Yes, that's correct. It makes me pee so much. I do not take it. Doctor: How about chest pain or shortness of breath? Patient: No chest pain, but I am gradually feeling short of breath. Doctor: What work you do? Patient: I work for the city of Wichita as bus dispatcher. My work demands sitting a lot, and just really does not move around much. But towards the end of the day my leg swells up. Doctor: Okay that's okay. Patient: I need cholesterol check right? Doctor: Yes, you do, but all the other labs are normal.","Section header: GENHX Section text: The patient is a 44-year-old white female who is here today with multiple problems. The biggest concern she has today is her that left leg has been swollen. It is swollen for three years to some extent, but worse for the past two to three months. It gets better in the morning when she is up, but then through the day it begins to swell again. Lately it is staying bigger and she somewhat uncomfortable with it being so large. The right leg also swells, but not nearly like the left leg. The other problem she had was she has had pain in her shoulder and back. These occurred about a year ago, but the pain in her left shoulder is of most concern to her. She feels like the low back pain is just a result of a poor mattress. She does not remember hurting her shoulder, but she said gradually she has lost some mobility. It is hard time to get her hands behind her back or behind her head. She has lost strength in the left shoulder. As far as the blood count goes, she had an elevated white count. In April of 2005, Dr. XYZ had asked Dr. XYZ to see her because of the persistent leukocytosis; however, Dr. XYZ felt that this was not a problem for the patient and asked her to just return here for follow up. She also complains of a lot of frequency with urination and nocturia times two to three. She has gained weight; she thinks about 12 pounds since March. She now weighs 284. Fortunately, her blood pressure is staying stable. She takes atenolol 12.5 mg per day and takes Lasix on a p.r.n. basis, but does not like to take it because it causes her to urinate so much. She denies chest pain, but she does feel like she is becoming gradually more short of breath. She works for the city of Wichita as bus dispatcher, so she does sit a lot, and just really does not move around much. Towards the end of the day her leg was really swollen. I reviewed her lab work. Other than the blood count her lab work has been pretty normal, but she does need to have a cholesterol check." "Doctor: What do you do for living? Patient: I am an officer at United States Marine office, artillery repair specialist. Doctor: Do you drink alcohol? Patient: I use to drink socially but stopped two years back. Doctor: How about smoking and drugs? Patient: No not that.","Section header: FAM/SOCHX Section text: He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs." "Doctor: How are you today? Patient: I am good. Doctor: What is your past medical history? Patient: I don't have any health problems. Not yet at least. Doctor: Let's keep try to keep it that way. Patient: Yes please.",Section header: PASTMEDICALHX Section text: Essentially noncontributory. "Doctor: Well, I am looking at your ultrasound report and honestly the only significant finding of this area is that it shows to be related to bone. Patient: Oh okay.",Section header: LABS Section text: The only significant finding in the ultrasound of the area is that it shows this to be related to bone. "Doctor: Tell me about your family. Did anyone have any medical issues? Patient: My father is alive. He is sixty nine right now. He did have some strokes in the past. My mom on the other hand died at the age of sixty two of many kinds of heart diseases. Doctor: What about your grandparents? Patient: My maternal grandfather he also had heart issues and he died of a heart attack. Both he and my maternal grandma had some heart diseases. Their heart use to beat pretty fast.","Section header: FAM/SOCHX Section text: Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT." "Doctor: Hi there! What brings you back to see me so soon? Patient: Hi! I have had these sores in my mouth. Doctor: How long have you had the sores? Patient: They started about ten to twelve days ago. Doctor: We have been currently treating your rheumatoid arthritis with methotrexate. How much have you been taking? Patient: Yes, we have tried lots of different treatments and methotrexate has been working well. I have been on it for ten years now. I have been taking about twenty or twenty five M G of per week. Doctor: Did we recently increase your dosage? I see in your chart that we have changed your dosage a few times. Patient: About a year ago we lowered the dosage for twenty five M G to twenty but my arthritis flared up so we went to twenty two point five. Doctor: Have you ever had any side effects from the methotrexate in the past? Patient: No. I don't think so. Doctor: Are you taking any other medications? Patient: I had a sinus infection and the doctor put me on an antibiotic. That was about two weeks ago. Doctor: Do you know what the antibiotic the doctor gave you? Patient: I don't remember the name of the antibiotic, but I know that I have taken antibiotics before and I didn't have a problem. Doctor: How long was your antibiotic course? Patient: It was three or four days long. I had to take it three times a day. Doctor: Have you ever had any allergic reactions to medications? Patient: No. Doctor: Any history of mouth sores? Patient: No. Doctor: Are you taking anything to help with the pain of the mouth sores? Patient: I took Aspirin a month ago. I started taking it again because my mouth was sore. Doctor: Have you had any other problems with your skin? Any new rashes? Patient: No. Doctor: Sorry to side track, but where is your accent from? My family is Cuban and my mom and you speak the same. Patient: What a surprise! I am Cuban. A proud fifty seven year old Cuban.","Section header: GENHX Section text: The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days. The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments, but over the past ten years she has been treated with methotrexate quite successfully. Her dosage has varied somewhere between 20 and 25 mg per week. About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of the flare of the rheumatoid arthritis, it was increased to 22.5 mg per week. She has had no problems with methotrexate as far as she knows. She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth. About two weeks ago, just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection. She does not remember the name of the antibiotic. Although she claims she remembers taking this type of medication in the past without any problems. She was on that medication three pills a day for three to four days. She notes no other problems with her skin. She remembers no allergic reactions to medication. She has no previous history of fever blisters." "Doctor: Hello, miss. How are you feeling today? Patient: Terrible. My allergies are killing me right now. Doctor: Do you have a history of allergies? Patient: Yeah, I do. I had them all the time when I lived in Seattle, but they got a lot worse when I moved here. I am a strong German woman and I hate how something as little as allergies gets the best of me. Doctor: Why did you move here? Patient: I wanted to experience different cities since I'm only twenty three. Doctor: That sounds exciting. Back to your allergies now. Do you take any medication to relieve your symptoms? Patient: Here's a list of past and current medications I'm taking. Doctor: Thank you. Let me take a look. I see you took Claritin and Zyrtec in the past, correct? Did those help you? Patient: Yeah, that's correct. They were working for a bit, but then they stopped working after a while. Doctor: I see. Your notes say you took Allegra after, correct? Patient: Correct. I tried out Allegra last summer, but I don't know if it was doing its job. I tried it again two weeks ago because my allergies were getting bad, but it still didn't work. Doctor: I see. Your notes state you've tried some nasal sprays, correct? Patient: Yeah, I did. I wanted to see if they would work. Doctor: Were you prescribed these nasal sprays? Patient: Nope. I bought them at my local pharmacy. Doctor: Sounds good. I'm looking at your medical history, and it sates here you have asthma too, correct? Patient: Yeah, I've had it for a long time, but it hasn't gotten worse. Doctor: I see. Do you think you need any medication to help alleviated your asthma? Patient: No. It doesn't bother me as much as my allergies.","Section header: GENHX Section text: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but doest not require daily medication for this and does not think it is flaring up." "Doctor: How are you doing young man? Patient: I'm good. Thank you. Doctor: Let's see how your chest is doing. Patient: Okay. Doctor: Chest measurements look nice. No issue there. The outline also looks great. Also, there is no hunchback?",Section header: EXAM Section text: CHEST: Normal AP diameter and normal contour without any kyphoscoliosis. "Doctor: I see here that Doctor- Patient: Yes, Doctor X referred me. My thyroid is an absolute mess. I have never been in so much pain in my seventy one years. Doctor: I'm so sorry to hear that. I hope we're able to get you the care that you need. Patient: I've been coughing up a storm. It's gotten to be way too enlarged. Doctor: It's good that you're here today to get the surgery rolling. Patient: I signed the paperwork and everything. Doctor: I'll go over the risk and benefits one more time. Any questions for me? Patient: When is the earliest I can get this done again? Doctor: Given your symptoms, I'd like to get you in in the next few days.","Section header: GENHX Section text: Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. She presented now after informed consent for the procedure, understanding the inherent risks and complications and risk-benefit ratio." "Doctor: Are you allergic to any medications? Patient: No, I am not allergic to any drugs. Doctor: Okay. Are you sure? Patient: Yes.",Section header: ALLERGY Section text: No drug allergies. "Doctor: I see here that you're allergic to grapefruit and peanuts. Do you happen to be allergic to any medications you've taken in the past? Patient: Nah, just allergic to grapefruit and peanuts. Doctor: Gotcha. Do you carry an Epi pen around with you? Patient: I try to bring it with me everywhere I go.",Section header: ALLERGY Section text: There are no known allergies. "Doctor: So, tell me about your family, any illness or anything that runs in the family. Patient: Um, not that I know of. Doctor: Okay.",Section header: FAM/SOCHX Section text: Unremarkable. "Doctor: Any medical issues in the past? Patient: No, I have a very clean history. Doctor: That's good for you. Any kind of surgery or hospitalization? Patient: No.",Section header: PASTMEDICALHX Section text: Noncontributory. "Doctor: Let's talk a little bit about your family, okay? Doctor: Does anyone in your family had any medical issues? Patient: Yeah, my parents died of cancer. Doctor: Which cancer? How old were they? Patient: I don't know which cancer they had, but my mother was forty two and dad was sixty two. Doctor: Who else is there in the family? Patient: Oh, I have a big family. I have four sisters, one brother and two half brothers. One of my half brother's has asthma.","Section header: FAM/SOCHX Section text: Mother died age 42 of unknown type cancer. Father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. One of the half-brothers has asthma." "Doctor: So, tell me something, does asthma run in your family? Patient: No, I think I am the only one who has it. Even my parents were surprised when I developed it, as no one else has it. Doctor: Yeah, it happens.",Section header: FAM/SOCHX Section text: No significant family history. "Doctor: Welcome in, sir. I am Doctor Gray. Patient: Thank you. It's nice to meet you. Doctor: What is your past medical history? Patient: I had surgery on my shoulder thirteen years ago and after the surgery I lost my sense of smell. I still can't smell. I also can't see very well in my right eye. Doctor: How old are you? Patient: I am seventy six. Doctor: Do you get headaches? Patient: No. Doctor: Do you have any nasal drainage? Patient: No. Doctor: Do you ever experience any weakness or numbness throughout or localized to an area of the body. Patient: No. Doctor: Have you had any resent weight loss? Patient: No.","Section header: GENHX Section text: 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge." "Doctor: Do thyroid problems run in your family? Patient: No.",Section header: FAM/SOCHX Section text: Noncontributory. "Doctor: Are you taking any medicines? Patient: Just Tylenol for my pain. Doctor: Okay.",Section header: MEDICATIONS Section text: Tylenol for pain. "Doctor: Good afternoon, sir. Did you see the nurse already? Patient: Yes, I just saw her. Doctor: Great, you're seventy eight years old, correct? Patient: Yes, I'm not as young as I used to be. Doctor: Who is? What seems to be the problem today, sir? Patient: I have right hand pain, and it's been there for a while now. Doctor: Are you having numbness sir? Patient: Yes, and I can't move it very well, either. Doctor: Which fingers are you having these symptoms in? Patient: Well, I told you it's all in the right hand, but it's in the index and middle fingers. Doctor: Are your fingers catching? Patient: What does that mean, doctor? Doctor: Are you having any problems extending your fingers? Patient: Yes, they seem to lock up when I try to extend my fingers. Doctor: Have you seen another doctor for this? Patient: Yes, I had an E M G and it showed, um, carpal tunnel on both hands. Doctor: It's in both hands, but the right is worse than the left, correct? Patient: Yes, that's correct. Doctor: What treatments have you had for this? Patient: I only had an injection so far. Doctor: Did this help at all? Patient: Well, some, but it was really only temporary relief. Is there surgery for this? Doctor: Yes, I think you'd be a good candidate for surgery. Patient: What are the risks of infection from the surgery? Doctor: It's less than one percent. We use prophylactic antibiotics to control for infection the entire time. Patient: Even though it's on my hand, will I be asleep for this procedure? Doctor: Yes, you won't feel a thing. Patient: Okay, yes. I'd like to do the surgery.","Section header: GENHX Section text: This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking. The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left. He had positive EMG findings as well as clinical findings. The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure. All risks as well as complications were discussed with the patient and consent was obtained." "Doctor: Hi are you married? Patient: Yes, I am. Doctor: Do you have kids? Patient: Yes, I had a son, but unfortunately, he died in a car accident. It was five years ago. Doctor: Where do you work? Patient: I work in a pharmaceutical company as a salesperson. Doctor: Do you smoke or drink or at any time tried any illicit drug? Patient: No, I've never smoked. I have tried a beer once, but I never liked it. Doctor: What about drugs? Patient: No, never did that.",Section header: FAM/SOCHX Section text: Married. One son deceased. Salesperson. Denied tobacco/ETOH/illicit drug use. "Doctor: Are you going to visit rehab? Patient: Yes, what choice do I have? Doctor: Yes, please do visit Mercy Manor for P T and Rehab. Patient: Yes, I will. Doctor: That will help your right side hip pain. Patient: I think so too.","Section header: ASSESSMENT Section text: Right hip pain, the patient to undergo physical therapy and rehabilitation at Mercy Manor." "Doctor: Can you tell me about your Immunizations? Patient: Yeah, I had them all. Doctor: Good, looks like you are up to date.",Section header: IMMUNIZATIONS Section text: Up-to-date. "Doctor: Welcome back to the clinic. How are you feeling today? Patient: Thank you. I am doing better. Doctor: It looks like we are following up on your severe osteoarthritis in both knees. And you also have been experiencing some flexion contracture limitations. Patient: Um hum. Doctor: How is your physical therapy going? Patient: It is going really well. She kicks my butt but it seems to be helping. Doing my exercises at home is really helping. Doctor: Were you not doing them in the beginning? Patient: No, I wasn't. She got on me to start doing them and I have definitely seen the difference. Doctor: Have you experienced any worsening of pain since you were last seen? Patient: Well, the right knee is worse than the left? It mostly hurts after physical therapy. Doctor: Can you describe what the pain feels like? Patient: It feels achy. Doctor: Is it a continuous pain, or? Patient: No. It is not all the time. Every once and a while. It feels stiff all the time. Doctor: Any weakness or instability? Patient: No. Doctor: Any burning sensations associated with the pain? Patient: No. Doctor: How long have you been dealing with this? Patient: Several months. Doctor: Have you had any trouble sleeping? Patient: No. When I sit down or lie down at night there's no pain. Doctor: So, the pain is when you are weight bearing, right? Patient: Yeah. And it hurts when I move around. It makes it difficult to do things. Doctor: Have you noticed any pain with the cold weather change? Patient: No, I have not noticed anything. Doctor: I am just going to take a look here. Patient: Okay. Doctor: I don't see any swelling or redness. And I don't feel any warmth coming from the area. Have you noticed any of these symptoms? Patient: Nope. Doctor: Any radiating pain through the knees here? Patient: No. Doctor: Any pain any where else in the body? Patient: No, just the knees. Doctor: So, no pain in the hips or back? Patient: Nope.","Section header: GENHX Section text: The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left. Pain: Localized to the bilateral knees right worse than left. Quality: There is no swelling, no redness, or warmth. The pain is described as aching occasionally. There is no burning. Duration: Months. Associated symptoms: Includes stiffness and weakness. There is no sleep loss and no instability. Hip Pain: None. Back pain: None. Radicular type pain: None. Modifying factors: Includes weight bearing pain and pain with ambulation. There is no sitting, and no night pain. There is no pain with weather change." "Doctor: Hi, what is going on? Guest_family: She was doing well until this morning, but now she can barely move her right arm and is having speech issues. She can't seem to comprehend words. I think it is a stroke. Doctor: We see this a lot at A B C Medical Center. I am glad you came. You just saw Doctor H, right? Guest_family: Yes. We did a C T head scan and labs. Doctor: Okay. Where is she living? With you? Guest_family: No. She is at the Life Care Center. Doctor: Ma'am, do you have headache or chest pain? Patient: What? What? Huh? Guest_family: She has not complained of anything like that. Doctor: Ma'am. Do you have vision issues? Patient: What? I can see. Of course I can see. Doctor: Any shortness of breath? Guest_family: She is breathing fine. Doctor: Have your symptoms improved at all? Or have they worsened since this morning? Guest_family: No. They have stayed constant.","Section header: GENHX Section text: The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors." "Doctor: I think you have a muscular strain. Patient: Yeah. Doctor: So right side shoulder strain and maybe a little bit of nerve compression. Patient: Oh really! Doctor: Maybe. I will do further evaluation and treatment. Patient: Okay.","Section header: ASSESSMENT Section text: Right shoulder pain, most likely secondary to muscular strain. He does have a very mild evidence of impingement." "Doctor: Can you tell me more about your daughter, ma'am? Guest_family: Sure, well she's fourteen now, um, she's right handed, and she just started high school. Doctor: Has she ever had surgery? Guest_family: Yeah, she had an, um, lipomyomeningocele repair when she was about three days old, and then again when she was three and a half years old. Doctor: When was her last surgery? Guest_family: Um, it was in March of nineteen ninety five. Doctor: How did she do following the second surgery? Guest_family: She did well, honestly. Doctor: So, what brings you in for a visit today? Patient: Well, I've been having some leg pain on the side of my legs. Doctor: How long have you had this pain? Patient: It's been several months at this point. Doctor: When is your pain the worst? Patient: Um, it's the worst at night, I have to take medicine for the pain. Doctor: What do you take? Guest_family: She takes Advil, Motrin, and Tylenol P M. Doctor: Wow, that's a lot. Looks like you have some patch sensory loss in the L four to S one region. Are you going to the bathroom regularly? Patient: Yeah, there's no problems there. I do have some loss of feeling in my big toe and calf though.","Section header: GENHX Section text: Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 03/95. She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM. Denies any new bowel or bladder dysfunction or increased sensory loss. She had some patchy sensory loss from L4 to S1." "Guest_clinician: How is the patient's condition now? Doctor: Well, he has improved clinically but would require acute care. Guest_clinician: Oh, I see.","Section header: DISPOSITION Section text: Clinically improved, however, requiring acute care." "Doctor: Good morning, ma'am. Can you confirm your age for me, please? Patient: Good morning, I'm sixty five years old, doctor. Doctor: How are you recovering from your operation? Patient: I'm doing okay. Can you remind me what operation I had? Doctor: Um, we did a left upper lobectomy for your stage I A non small cell lung cancer. Patient: Thank you, doctor. Doctor: Absolutely, do you have the results of your pelvic C T? Patient: Yes, I have the report right here. Doctor: Thank you, so this shows an enlarging simple cyst of the left kidney. Patient: What can we do about this? Doctor: Well, that's why we did the barium swallow, which showed a small hiatal hernia with minimal reflux. Patient: Oh, yeah, I remember that. Doctor: So, I have your x rays from November twenty third two thousand nine here, we did an A P and lateral view, and they're normal. Patient: Oh, well that's good too. Doctor: Are you having any pain with swallowing food? Patient: Yes, I get some chest pain, but I'd say it's pretty mild. Look at my calf, doctor, it's much bigger than the right one. Doctor: Chest pain is probably due to tertiary contractions with some delayed emptying. Is it tender? Patient: No, there's no real tenderness. Doctor: How long has this calf been enlarged? Patient: Um, it's been several months at this point. Doctor: Have you ever had D V T? Patient: Yes, um, in nineteen seventy five, and in nineteen eighty five. Doctor: Are you having any abnormal weight loss? Patient: No, everything is normal there, and I'm eating normally. Doctor: What about any cold or flu symptoms? Any fever or chills? Patient: No, that's all fine too. Doctor: Any new aches or pains? Patient: No, all my muscles feel pretty good. Doctor: Have you had a cough, or coughed up any blood. Patient: That's a negative, doctor. Doctor: What about shortness of breath while at rest or difficulty breathing with exercise? Patient: No, that's normal too. I'm breathing just fine.","Section header: GENHX Section text: The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer. She returns for a routine surveillance visit. She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney. She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux. She has a minimal delayed emptying secondary tertiary contractions. PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates. Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia. This most likely is secondary to tertiary contractions with some delayed emptying. She has also had increased size of the left calf without tenderness, which has not resolved over the past several months. She has had a previous DVT in 1975 and 1985. She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion." "Doctor: Let's talk about your family's medical history. Patient: Hm, well both my father and my brother had colon cancer. My daughter was detected with breast cancer. Doctor: Do you remember what her age was? Patient: Yeah, she was forty. Doctor: I see. Anything else? Patient: Well, I have a heart condition and high blood pressure. I also had a stroke. Doctor: Okay.","Section header: FAM/SOCHX Section text: Positive for heart disease, hypertension and cerebrovascular accidents. Family history is positive for colon cancer affecting her father and a brother. The patient has a daughter who was diagnosed with breast cancer at age 40." "Doctor: Any fever? Patient: No. Doctor: No nausea and vomiting or black stool? Did you notice any blood in your stools? Patient: Nope, nothing like that. Doctor: Did you notice any blood in urine or painful urination? Patient: No. Doctor: Okay, any chest pain? Patient: Um, no. Doctor: Any shortness of breath, cough or cold like symptoms? Patient: Nope. Doctor: No diabetes or thyroid problem, right? Patient: Absolutely not! Doctor: Looks like you have no history of C V A or stroke. Patient: Correct. Doctor: Everything else looks fine. Patient: Cool. Doctor: Your eyes, nose, and throat look good.",Section header: ROS Section text: CONSTITUTIONAL: No fever. ENT: Not remarkable. RESPIRATORY: No cough or shortness of breath. CARDIOVASCULAR: The patient denies chest pain. GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed. GENITOURINARY: No dysuria. No hematuria. ENDOCRINE: Negative for diabetes or thyroid problems. NEUROLOGIC: No history of CVA or TIA. Rest of review of systems is not remarkable. "Doctor: How are you doing miss? How are your sugar numbers coming along? Patient: I'm doing good. Thank you. Sugar has consistently been one hundred and thirty five or under it. Doctor: How are you checking it? Patient: I have a glucose monitor at home I'm using that only. Doctor: Nice. Did you eat anything in the morning today? Patient: No, I'm fasting for my test. Doctor: Okay, let's see. We have an Accu Chek here in our office. I will do a quick sugar test for you, and this will be a fasting sugar test. It will be just a quick prick on your finger. Patient: Don't worry doctor. I'm used to poking my finger all the time. Doctor: Let's see what we got here. Your reading says one hundred and twenty. I will write it down for my record. Are you being active? Patient: Yes, I'm exercising as a rule three times every week. I don't miss it. Doctor: Do you feel any tingling or numbness or any kind of cramps? Patient: Nope. Doctor: Any kind of blurry vision? Patient: Nope. Doctor: Any weight loss? Patient: Not that I notice.","Section header: GENHX Section text: Overall, she has been doing well. Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek. She is exercising three times per week. Review of systems is otherwise unremarkable." "Doctor: How did your last visit go with the cardiologist? Patient: Good. Doctor: It looks like they diagnosed you with sick sinus syndrome. Do you have any questions about this new diagnosis? Patient: No, she explained everything to me. I'm planning to follow-up with her in the next two weeks. Doctor: Great. So it looks like your past medical history is the same? Nothing new other than the sick sinus syndrome.",Section header: DIAGNOSIS Section text: Sick sinus syndrome. The rest of her past medical history remained the same. "Doctor: So Mister J, where do you stay? Patient: Oh, I stay at a care facilit. It's very near to your clinic. Have you heard about this place called South Valley Care Center? Doctor: Oh yes, I have heard of it.",Section header: FAM/SOCHX Section text: The patient has been residing at South Valley Care Center. "Doctor: How are you Mister James? Patient: I have been better! Doctor: Oh, tell me what's going on with you? Patient: I have this leg pain on my left side. Doctor: Hm, left leg pain? Patient: Yeah.",Section header: CC Section text: Left leg pain. "Doctor: Have you ever had an allergic reaction to drugs you've taken in the past? Patient: More than once. I've reacted poorly to sulfa drugs, penicillin, and some mycins. I also think I'm allergic to contrast medium.","Section header: ALLERGY Section text: She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins." "Doctor: Hey, do you smoke cigarettes? Patient: Yes I do smoke. Do you? Doctor: Nope. Are you planning on quitting? Patient: No, I just smoke one pack per day, it's not bad. Doctor: Oh my God. No. It is bad. You should think about quitting. Patient: Okay I will think about it. Doctor: Where do you work? Patient: I work at local christmas tree farm.",Section header: FAM/SOCHX Section text: The patient works at a local Christmas tree farm. He smokes cigarettes approximately one pack per day. "Doctor: Are you still working? Patient: Retired some time ago. Doctor: What was your profession? Patient: I used to work at a car repair shop called Champion Automotive Company. Doctor: Nice. How did you enjoy the work? Patient: I liked it a lot, but there came a time where I knew it was the end of the road for me. I'm really enjoying retirement. Doctor: I bet. I have cousin who owns a car repair shop. He's almost always busy. Patient: Yeah, it can be a lot sometimes. Doctor: Any smoking, drinking, or hard drugs? Patient: I can confidently say no to each one. Doctor: Great to hear.",Section header: FAM/SOCHX Section text: Retired employee of Champion Automotive Co. Denies use of TOB/ETOH/Illicit drugs. "Guest_clinician: Do you have his full medical history? Doctor: Yes, I confirmed with his wife. He had a CABG done in ninety one. He has a history of radical prostate cancer for which he underwent a radical prostatectomy and nephrectomy. Guest_clinician: Any additional surgeries? Doctor: Yes. He had lumbar surgery twice before. He suffered from lumbar stenosis many years ago in the sixties and seventies. He's actually due for another lumbar surgery with Doctor Y. He takes Percocet daily for his back pain. He also has a history of hypertension and hyperlipidemia. Guest_clinician: I think I got it all down.","Section header: PASTMEDICALHX Section text: Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia. Note that due to back pain, he had been taking Percocet daily prior to his hospitalization." "Doctor: Do you have any history of major surgeries? Patient: No. Nothing major.",Section header: PASTSURGICAL Section text: Nothing significant. "Doctor: Good morning, sir. Patient: Good morning, doctor. Doctor: Before we begin, have you ever had surgery? Patient: Yes, I had a vasectomy some time ago.",Section header: PASTSURGICAL Section text: Vasectomy. "Doctor: Okay, so let's go over your medications. I'd like you to take these to help your muscle spasms. Patient: Sounds good. Doctor: I've prescribed eight hundred milligrams of Ibuprofen to be taken every eight hours as needed along with Tylenol number three every six hours as needed. Patient: What does the number three stand for? Doctor: Tylenol number three is combined with Codeine. Patient: Okay, I see. Doctor: And finally, I'm prescribing Methocarbamol seven fifty milligrams which needs to be taken four times a day for maximum relief. Do you have any questions for me? Patient: No, I think you answered them all.","Section header: MEDICATIONS Section text: Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid." "Doctor: How are you doing today, sir? Patient: Honestly, I'm pretty sick today. I've got a lot going on. Doctor: How long have you been feeling this way? Patient: Well, it's been off and on for about a month now. Doctor: Has it been getting worse recently? Patient: Yeah, it has over the last couple weeks. Doctor: What are your symptoms? Patient: Well, I'm coughing up this yellow phlegm. It feels like everything is in my chest. Doctor: What medications have you been taking for this? Patient: I've been taking Allegra D sometimes, but I'm almost out. I need a refill. Doctor: What other problems are you having? Patient: My foot keeps breaking out. Doctor: Has this improved at all? Patient: Well, it was for a while, but now it's really bad again. Doctor: Have you been diagnosed with any conditions before? Patient: I had, um, tinea pedis before. Doctor: How was this treated? Patient: They gave me Nizoral cream. Doctor: It has been getting warmer recently, I don't think that this isn't necessarily a coincidence that you're having these symptoms now. Patient: Yeah, I work in the flint and it's really hot and humid down there. Doctor: What else are you dealing with, sir? Patient: I have this wart on my right middle finger, are you able to freeze it off? Doctor: Have you ever done that before? Patient: Yeah, you have done it before, and it went away. Doctor: If we've done it before, we can do it again. Patient: Cool, can we do blood work, too? I want to check on my prostate. Doctor: Well, that's called P S A. Patient: Can I have that done? I'm concerned. I am fifty after all. Doctor: Sure, we can check your cholesterol too. I know you have history of it being high. Patient: You know, I've been working on that. I quit smoking for a while, but I got back into it. Doctor: That's good, it's really hard to quit. Patient: Yeah, I tried chewing tobacco, but it's not the same. Doctor: Be sure to keep trying to quit smoking.","Section header: GENHX Section text: This patient presents to the office today for a checkup. He has several things to go over and discuss. First he is sick. He has been sick for a month intermittently, but over the last couple of weeks it is worse. He is having a lot of yellow phlegm when he coughs. It feels likes it is in his chest. He has been taking Allegra-D intermittently, but he is almost out and he needs a refill. The second problem, his foot continues to breakout. It seems like it was getting a lot better and now it is bad again. He was diagnosed with tinea pedis previously, but he is about out of the Nizoral cream. I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence. He works in the flint and it is really hot where he works and it has been quite humid lately. The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger. He is interested in getting that frozen today. Apparently, he tells me I froze a previous wart on him in the past and it went away. Next, he is interested in getting some blood test done. He specifically mentions the blood test for his prostate, which I informed him is called the PSA. He is 50 years old now. He will also be getting his cholesterol checked again because he has a history of high cholesterol. He made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking. He says it is difficult to quit. He tells me he did quit chewing tobacco. I told him to keep trying to quit smoking." "Doctor: Hi, how's it going? Patient: Not too bad, can't complain. Doctor: It looks like the weather's been warming up, which is nice. Patient: Yeah, I can't wait to spend some time with my kids this afternoon. Doctor: Aw, how many kids do you have? Patient: Two. Doctor: And are you single, dating, married? Patient: I've been married to my wife for about ten years now. Doctor: Congratulations! That's a decade, my friend. Patient: Hah, it sure is. Doctor: Are you from the area? Patient: I was actually born in Oklahoma. Doctor: How long- Patient: Moved up here in O seven. Doctor: Awesome. I moved here in O nine, so two years after you. Patient: No way! How funny. Where from? Doctor: I'm originally from Kentucky. And I have to do the routine ask, but any drinking, smoking, or illicit drug use? Patient: No to all of the above. Doctor: Got it.","Section header: FAM/SOCHX Section text: No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children." "Doctor: Looks like the nurse came in and asked you everything. Ah, she has everything documented here, but I will ask one more time. So, tell me, where do you live? Patient: Oh, it's a senior citizen house. They have many nursing aids there. Doctor: Do you smoke? Patient: No. Doctor: Do you work? Patient: Ah, right now I can't because of this disability, but I used to work as the security guard.","Section header: FAM/SOCHX Section text: He does not smoke. He lives in a senior citizens building with daily nursing aids. He previously was a security guard, but is currently on disability."