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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 urin... | Section Header: PAST MEDICAL HISTORY
Summary: 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: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 unde... |
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 wi... | Section Header: ASSESSMENT
Summary: 1. Left flank pain. 2. Left ureteral stone. 3. Nausea and vomiting. |
Doctor: Any known drug allergies?
Patient: No. | Section Header: ALLERGY
Summary: 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
Summary: 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 med... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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
Summary: 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
Summary: 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 ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 postt... |
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: EMERGENCY DEPARTMENT COURSE
Summary: 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: ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 with... |
Doctor: Do you have diabetes or blood pressure problems?
Patient: Yes, I have hypertension but no diabetes.
Doctor: Alright. | Section Header: PAST MEDICAL HISTORY
Summary: 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 ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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... | Section Header: PAST MEDICAL HISTORY
Summary: 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: REVIEW OF SYSTEMS
Summary: 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 toda... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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: PAST SURGICAL HISTORY
Summary: 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... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 pai... |
Doctor: What is your family medical history?
Patient: None, that I know of. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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 hav... | Section Header: PAST MEDICAL HISTORY
Summary: 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?
Pa... | Section Header: PAST MEDICAL HISTORY
Summary: 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 ... | Section Header: PAST MEDICAL HISTORY
Summary: 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: REVIEW OF SYSTEMS
Summary: 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: PAST MEDICAL HISTORY
Summary: 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
Summary: Diarrhea. |
Doctor: Are you allergic to anything?
Patient: No. | Section Header: ALLERGY
Summary: 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... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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 th... | Section Header: PAST MEDICAL HISTORY
Summary: 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 s... |
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 th... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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. ... |
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
Summary: 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.
Doct... | Section Header: ASSESSMENT
Summary: 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 w... |
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
Summary: 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 h... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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: PAST MEDICAL HISTORY
Summary: 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: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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 y... | Section Header: REVIEW OF SYSTEMS
Summary: 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:... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 under... |
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 c... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 approxi... |
Doctor: Any known allergies?
Patient: No.
Doctor: Any allergy to any drug?
Patient: No. | Section Header: ALLERGY
Summary: 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? ... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 medicatio... |
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 ... | Section Header: ASSESSMENT
Summary: 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. Perh... |
Doctor: Do you have any past medical history?
Patient: No. | Section Header: PAST MEDICAL HISTORY
Summary: 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 antipsy... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 psycho... |
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: Ho... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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 surg... | Section Header: PAST SURGICAL HISTORY
Summary: 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
Summary: 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 ... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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
Summary: No known medical allergies. |
Doctor: Are you taking any medications?
Patient: Yes I am taking thyroid meds and Lipitor. | Section Header: MEDICATIONS
Summary: 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: PAST MEDICAL HISTORY
Summary: 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... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 orthop... |
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
Summary: 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: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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 shephe... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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, accor... |
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... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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 ... | Section Header: PAST MEDICAL HISTORY
Summary: 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 ... | Section Header: PAST MEDICAL HISTORY
Summary: 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 t... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 an... |
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 t... | Section Header: PAST SURGICAL HISTORY
Summary: 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: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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
Summary: 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
Summary: 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 te... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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... |
Doctor: Are you on any medications at this time?
Patient: None whatsoever.
Doctor: Got it. | Section Header: MEDICATIONS
Summary: 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: CHIEF COMPLAINT
Summary: 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
Summary: 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
Summary: 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 h... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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 denie... |
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 ... | Section Header: CHIEF COMPLAINT
Summary: 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... |
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 pai... | Section Header: CHIEF COMPLAINT
Summary: 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
Summary: 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: PAST MEDICAL HISTORY
Summary: 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 pinn... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 ... |
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: H... | Section Header: CHIEF COMPLAINT
Summary: 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 ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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... |
Doctor: Have you ever had jaundice?
Patient: Um, no.
Doctor: Any rash or anything?
Patient: Nope. | Section Header: REVIEW OF SYSTEMS
Summary: 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?
... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 mo... |
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 waiti... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 s... | Section Header: REVIEW OF SYSTEMS
Summary: 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 ea... |
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 ... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 ... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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 an... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 ... |
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: HISTORY of PRESENT ILLNESS
Summary: 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
Summary: 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 H... | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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? ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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 t... |
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: FAMILY HISTORY/SOCIAL HISTORY
Summary: 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 ... | Section Header: HISTORY of PRESENT ILLNESS
Summary: 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... |
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