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0 | GENHX | The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago, when she fell at a ABC Store. The patient stated she received physical therapy, one to two visits and received mo... | Doctor: When did your pain begin?
Patient: I've had low back pain for about eight years now.
Doctor: Is there any injury?
Patient: Yeah, it started when I fell in an A B C store.
Doctor: How old are you now?
Patient: I'm twenty six.
Doctor: What kind of treatments have you had for this low back pain?
Patient: Yea... |
1 | ROS | As mentioned denies any oropharyngeal swelling. No lip or tongue swelling. No wheezing or shortness of breath. No headache. No nausea. Notes itchy rash, especially on his torso and upper arms. | Doctor: Hey, bud. What brings you in today?
Patient: A rash on my upper arms and torso.
Doctor: When did it start?
Patient: Bout a day or two ago.
Doctor: Any itchiness to the area?
Patient: Yes, a lot actually.
Doctor: Have you had episodes of shortness of breath or wheezing?
Patient: No.
Doctor: How about swe... |
2 | PASTMEDICALHX | Essentially unchanged from her visit of 04/15/2005. | Doctor: Has anything changed in your medical history since you last visit on April fifteenth two thousand five?
Patient: What do you mean by that?
Doctor: Have you been diagnosed with any new medical conditions, or are you experiencing any new symptoms?
Patient: Oh, no, nothing like that. |
3 | MEDICATIONS | Accutane. | Doctor: How've you been treating your acne?
Patient: The dermatologist started me on Accutane.
Doctor: How long have you been on Accutane?
Patient: About three months now.
Doctor: Have you noticed any improvements since starting it?
Patient: Yeah, kinda. |
4 | CC | Confusion and hallucinations. | 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. |
5 | GENHX | 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment. | Doctor: How is his birth history? Was he born normal? Or was there any abnormality?
Guest_family: He was born at thirty two weeks. He was my fourth pregnancy, and he was around four pounds and eleven ounces.
Doctor: Was he placed in an incubator?
Guest_family: Yes, he was there for three weeks. He had jaundice but t... |
6 | PASTSURGICAL | He has not had any previous surgery. | Doctor: Have you had any surgeries in the past?
Patient: Nope I have not.
Doctor: Anything?
Patient: No. |
7 | GENHX | Back pain after a fall. | Doctor: Hello. How are you doing today?
Patient: Not great. My back is killing me.
Doctor: What happened?
Patient: I fell down on it.
Doctor: I see. Let's do some tests to see if you damaged anything. |
8 | FAM/SOCHX | 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: When are you planning to quit your I V and inhalation drugs Mister X Y Z?
Patient: I am on treatment now. They are following me up for depression issues too.
Doctor: Okay yes, you are on methadone maintenance.
Patient: Yes.
Doctor: Who lives with you?
Patient: I have a roommate. |
9 | GENHX | The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and p... | Doctor: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: Before we begin, how old are you?
Patient: I'm fifty seven years old.
Doctor: Very well, and what seems to be the problem today?
Patient: So, I had surgery on these feet, um, like thirteen years ago to remove bunions, but they're back now.
Doc... |
10 | GENHX | She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth. | Doctor: Hi, I will ask about some birth related questions about your baby, okay?
Guest_family: Yeah, sure.
Doctor: Was she born normal or cesarian?
Guest_family: No cesarian, there was normal delivery. It was spontaneous too.
Doctor: Where was she born?
Guest_family: At the Women's.
Doctor: What was her weight at ... |
11 | FAM/SOCHX | He denies tobacco or alcohol. He has what sounds like a data entry computer job. | Doctor: So, where do you work?
Patient: Oh, I am a data operator for an I T company.
Doctor: Okay.
Doctor: Do you smoke or drink?
Patient: No, I don't! |
12 | DISPOSITION | To home with his son. | Doctor: Who are going to stay with?
Patient: I am going home with my son. I will stay with him. |
13 | FAM/SOCHX | He immigrated to this country in 1984, although he lists himself as having a green card still at this time. He states he lives on his own. He is a single male with no history of marriage or children and that he had high school education. His recreational drug use in the chart indicates that he has had a history of m... | Doctor: When did you move here from Philippines, sir?
Patient: I think somewhere around nineteen eighty four.
Doctor: Oh wow, it's been a while, do you have a green card?
Patient: Yes I do have G C. My apartment is not too far from there.
Doctor: Do you live by yourself? Or you married?
Patient: No, I live by myself. N... |
14 | GENHX | The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two MIs, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001. He states that... | Doctor: How old are you, sir?
Patient: I am sixty two year old African American.
Doctor: Do you have any relevant past medical history?
Patient: I do have diabetes, high blood pressure and I had a stroke in the year two thousand and two. I do have weakness on my right side after that. I also had two heart attacks. A... |
15 | CC | The patient does not have any chief complaint. | Doctor: Hi, how can I help?
Patient: No, I just came in for follow up.
Doctor: Okay so just a follow up today. No complaints?
Patient: Nope. Nothing.
Doctor: That's great. |
16 | ROS | Patient is hard of hearing. She also has vision problems. Denies headache syndrome. Presently, denies chest pain or shortness of breath. She denies abdominal pain. Presently, she has left hip pain and left shoulder pain. No urinary frequency or dysuria. No skin lesions. She does have swelling to both lower extr... | Doctor: Just to go over few things let me ask, any aches and pains?
Patient: Currently I just have left hip pain and shoulder pain.
Doctor: Oh, how bad is it?
Patient: Pretty bad.
Doctor: What else is going on?
Patient: I have this leg swelling from last couple weeks.
Doctor: Any new skin lesions on your legs from th... |
17 | FAM/SOCHX | lives with parents and attends mainstream 5th grade classes. | Doctor: Hi there! I am Doctor Frankland.
Patient: Hi. It is nice to meet you.
Doctor: How are you today?
Patient: I'm good.
Doctor: Do you live at home with both of your parents?
Patient: Yes.
Doctor: What grade are you in?
Patient: Firth grade.
Doctor: Mom, is he in public school?
Guest_family: Yes.
Doctor: Is ... |
18 | GENHX | The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up from the sitting position or ... | Doctor: What brings you here today, sir?
Patient: I'm feeling a lot of lightheadedness and I just cannot keep stable. I'm losing my balance all the time.
Doctor: Do you have any spinning sensation?
Patient: No, but I had it before when I had vertigo. I'm just feeling lightheaded.
Doctor: Is it happening after anything ... |
19 | MEDICATIONS | No medications other than recent amoxicillin. | Doctor: Are you taking any medication?
Guest_family: Yes, I am taking that antibiotic.
Doctor: Oh yes!
Guest_family: Yeah.
Doctor: Yes, you are taking amoxicillin.
Guest_family: That's right. |
20 | DIAGNOSIS | 1. Bipolar disorder. 2. Iron deficiency anemia. 3. Anxiety disorder. 4. History of tubal ligation. | Guest_clinician: I see that the patient was in yesterday.
Doctor: Yes, she's a frequent flyer.
Guest_clinician: What's her medical history?
Doctor: She suffers from bipolar disorder and anxiety. She's also anemic and not on any iron supplements. As for surgeries, she's had her tubes ligated. |
21 | FAM/SOCHX | He is a non-cigarette smoker and non-ETOH user. He is single and he has no children. He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical. | Doctor: Do you smoke?
Patient: No, I do not.
Doctor: How about alcohol.
Patient: No, I don't drink alcohol as well.
Doctor: Okay let me ask you, do you have any children or are you married?
Patient: No, I am single, thus no kids.
Doctor: Okay, where do you work?
Patient: I work as a payroll representative. I used to ... |
22 | EDCOURSE | The patient was seen in the urgent care and examined. At this time, her photophobia and nausea make migraine highly likely. She is well appearing and we'll try Tylenol with codeine for her pain. One day off school and follow up with her primary doctor. | Doctor: I looked over your report from urgent care.
Patient: They didn't do much other than tell me to follow up with you.
Doctor: Given that you're sensitive to light and feel nauseated, I believe a migraine is highly likely.
Patient: Can I take anything for it?
Doctor: I'm going to prescribe you Tylenol with cod... |
23 | MEDICATIONS | Include Cipro and Flagyl. | Doctor: Let me write you a prescription for Cipro and Flagyl.
Patient: Okay. |
24 | GENHX | This is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb. She was actually able to spontaneously trigger the thumb. She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley. All risks and benefits of the su... | Doctor: Hello, ma'am. How are you doing today?
Patient: My right hand hurts.
Doctor: Is that your dominant hand?
Patient: It is.
Doctor: I see. What seems to be the problem?
Patient: I feel like my right thumb just locks up, and I can't move it anymore.
Doctor: Does it stay locked?
Patient: No, it doesn't. It ju... |
25 | GENHX | The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. The patient requ... | Doctor: Are you keeping up with your food journal?
Patient: Yes, and I have it with me today.
Doctor: Good, and you're using calorie points, correct?
Patient: Yes, I range from twenty six to thirty.
Doctor: Good, are you exercising regularly?
Patient: Yes, I am. I'm also going to Overeaters Anonymous.
Doctor: How ... |
26 | FAM/SOCHX | Noncontributory. | Guest_clinician: Any significant family history of disease?
Doctor: None according to my records. |
27 | PASTSURGICAL | Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery. | Doctor: Have you ever had surgery?
Patient: One too many times.
Doctor: Which ones?
Patient: I had my appendix taken out and glaucoma surgery fairly recently. I also had my gallbladder taken out ten years ago and a partial colon resection due to colon cancer in nineteen sixty one.
Doctor: Any recurring episodes of... |
28 | PASTSURGICAL | The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative. | Doctor: What is your surgical history?
Patient: I had cataract surgery on both eyes. I also had knee replacement surgery on my left knee. |
29 | FAM/SOCHX | Family history is remarkable for heart disease, cerebrovascular disease, diabetes, and hypertension. | Doctor: Hi, there. How are you doing?
Patient: I think I have some sort of condition.
Doctor: Why do you say that?
Patient: My body has been feeling weird lately.
Doctor: I see. Is there anything that runs in your family?
Patient: I know a lot of my family has some sort of heart problem. We have high blood pressure ... |
30 | GENHX | This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse. | Doctor: Hi mister Jones. Do you remember me from the last time you were here? How old are you now?
Patient: I am fifty two. Yes doc. I remember you.
Doctor: What have you been using most recently? I need to know what kind of drugs we are dealing with.
Patient: I gotta kick the heroin. It's going to kill me this time... |
31 | FAM/SOCHX | Noncontributory. | Doctor: Anyone sick in your family?
Patient: No one.
Doctor: Okay.
Patient: Everyone is healthy. |
32 | FAM/SOCHX | His father died of colon and thyroid cancers at age 52. One brother died of stomach cancer at age 53 and one brother committed suicide. Five other siblings are all healthy. Negative for coronary heart disease, hypertension, diabetes, or kidney disease. | Doctor: Tell me a little more about your family. Are there any significant conditions that your parents or siblings had that you know of?
Patient: Um, my dad died a few years back. He had color cancer and thyroid cancer.
Doctor: I'm so sorry to hear that, sir. How old was he?
Patient: Thank you, he was only fifty two... |
33 | PLAN | 1. Take medications regularly. 2. PT, OT, speech therapist to evaluate and treat at Siskin Rehab Hospital. 3. Continue Cipro for an additional two days for his UTI. | Doctor: I have sent over your referral for physical therapy, occupational therapy and speech therapy. The patient coordinator at Siskin Rehab Hospital will give you a call within two days to see up your appointments. It is important to take your medications regularly. You need to continue the Cipro for an additional tw... |
34 | FAM/SOCHX | Mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old. | Doctor: Can you tell me about cancer in your family?
Patient: Yes, my mom had stomach cancer and she died at fifty nine.
Doctor: And father?
Patient: My dad died at ninety one years of age.
Doctor: Okay. |
35 | PASTMEDICALHX | Negative. Generally very healthy. | Doctor: Does she have any past medical history or health problems?
Guest_family: No. She is a healthy child. |
36 | LABS | All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122. Urine pregnancy test was negative. | Doctor: I looked at your labs. Everything looks normal for the most part. You do have abnormal levels for Sodium and Creatinine which are related to your kidneys. Then your thyroid levels are not normal as well.
Patient: How about my E K G? I had a negative pregnancy test.
Doctor: Oh yes that. Your E K G showed a high... |
37 | GENHX | The patient returns today for a followup. She was recently in the hospital and was found to be septic from nephrolithiasis. This was all treated. She did require a stent in the left ureter. Dr. XYZ took care of this. She had a stone, which was treated with lithotripsy. She is now back here for followup. I had wr... | Doctor: Good morning. So, you are here for your follow up today.
Patient: Yes, sir.
Doctor: Update me what happened, why were you in the hospital?
Patient: I had a lot of back pain and less of urine output. I always had burning sensation whenever I used to go to the bathroom. So, I went to the doctor, and they said ... |
38 | FAM/SOCHX | Father died at age 85 of "old age," mother died at age 89 of "old age." Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease. Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma. | Doctor: I'd like to know more about your family's medical history.
Patient: Buckle up. This is a long one. My son is fifty eight and he suffers from glaucoma, high cholesterol, high blood pressure, and R A. My eldest brother passed away at ninety two due to old age and my two younger brothers followed in their seventi... |
39 | GENHX | 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: How are you related to the patient?
Guest_family: I am his friend; I work with him in a coffee shop. He works as a cook there.
Doctor: Can you tell me your age?
Patient: I'm forty one.
Doctor: Can you tell me what exactly happened?
Guest_family: He was cooking, and the hot oil splashed onto his arm.
Doctor:... |
40 | DISPOSITION | To home. | Doctor: Are you ready for home?
Patient: Yes.
Doctor: Who will help at home?
Patient: Just my family.
Doctor: That is great.
Patient: Thanks. |
41 | ASSESSMENT | 1. Multiple problems including left leg swelling. 2. History of leukocytosis. 3. Joint pain involving the left shoulder, probably impingement syndrome. 4. Low back pain, chronic with obesity. 5. Obesity. 6. Frequency with urination. 7. Tobacco abuse. | Doctor: It looks like your white blood cell count is normal according to your most recent labs. But, I do want to keep an eye on it given your history of high white blood cells.
Patient: That's good to hear. I'm glad that it's back to normal.
Patient: However, I must say that I've been having a lot of pain over the p... |
42 | PLAN | Activity is as tolerated. Diet is as tolerated. | Doctor: How are you feeling?
Patient: I feel good. I feel like I am getting stronger every day.
Doctor: Great! I would like you to continue your exercises at home but please take it slow. Try to stick to the diet we discussed for the next month. Do you have any questions?
Patient: No. |
43 | GENHX | 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... | Doctor: Hello, sir. What brought you in today?
Patient: Do you not see the swelling on my right hand and arm? I'm white. The swelling should be noticeable!
Doctor: Oh, wow! How did this happen?
Patient: I got stung by this huge Yellow Jacket Wasp yesterday. I usually see Doctor X Y Z, but he wasn't available.
Doctor... |
44 | EDCOURSE | The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction. | Doctor: Are you in pain?
Patient: Yes, I want something strong for this.
Doctor: We can give you a shot.
Patient: Yes please.
Doctor: Okay nurse, give her Dilaudid of 4 M G I M.
Patient: Thank you.
Doctor: How are you now? Any bad side effects?
Patient: No I feel much better. |
45 | FAM/SOCHX | The patient denies smoking cigarettes. The patient does drink alcohol and also uses illicit drugs. | Doctor: Do you smoke cigarettes?
Patient: No. No cigarettes.
Doctor: Do you drink alcohol or use recreational drugs?
Patient: I drink alcohol and I smoke weed from time to time. |
46 | FAM/SOCHX | The patient has been a smoker since the age of 10. So, he was smoking 2-3 packs per day. Since being started on Chantix, he says he has cut it down to half a pack per day. He does not abuse alcohol. | Doctor: Are you a smoker?
Patient: Yes. I do not drink if that is any constellation.
Doctor: How much do you smoke per day?
Patient: I just started taking Chantix and now I am down to a half a pack a day.
Doctor: How much did you smoke per day prior to starting Chantix?
Patient: I was smoking about two to three pac... |
47 | MEDICATIONS | Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily. | Doctor: Let me add Flagyl intra venously. It will be five hundred M G every eight hours and I would also like to add Levaquin five hundred M G daily.
Patient: Okay. |
48 | ROS | No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits. | Doctor: Any difficulty in hearing?
Patient: No.
Doctor: Difficulty swallowing?
Patient: Um no.
Doctor: Any double vision or blurred vision or difficulty seeing things properly?
Patient: No, no problem at all.
Doctor: Okay.
Doctor: How about headaches or migraine?
Patient: No headache.
Doctor: Did you notice any chang... |
49 | ROS | The remaining ROS is unremarkable. | Guest_clinician: I did a review of her systems, and everything looks normal other than what was mentioned earlier.
Doctor: Okay, thanks for your help.
Guest_clinician: No problem. |
50 | PLAN | Daily applications of Acticoat, pressure relief, at least getting out of the chair for half of the time, at least eight hours out of the chair, and we will see her in one week. | Doctor: Okay, so let's go over the plan again. I'd like you to apply Acticoat dressing daily and make sure you're spending at least eight hours out of the chair for pressure relief. Any questions?
Patient: That sounds doable. I'll try my best. No questions about the plan.
Doctor: I'd also like you to come back in a we... |
51 | ASSESSMENT | Substance abuse. | Doctor: When are you planning to quit?
Patient: I always plan to do it.
Doctor: Okay let me refer you to a substance abuse clinic because you need it.
Patient: Okay, I will look at it.
Doctor: Sure. But please try to stop your substance abuse. It is a bad habit.
Patient: Yes. |
52 | FAM/SOCHX | Denies history of Tobacco/ETOH/illicit drug use. | Doctor: Do you have a history of tobacco, alcohol or recreational drug use?
Patient: No. |
53 | GENHX | A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache. Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved. She is having some left-sided sinus pressure and actually went to the dentis... | Doctor: How are you Miss G?
Patient: I am good doctor, thank you for asking.
Doctor: So, tell me what is going on?
Patient: I have this ear pain and headache for some time. It's better than before but I still want to get it checked.
Doctor: Okay, when exactly did it start?
Patient: Um, almost three weeks ago. I am h... |
54 | ROS | PSYCHIATRIC: See psychiatric evaluation. | Doctor: So, I have the evaluation report from your psychiatrist.
Patient: Ah, okay and what does it says?
Doctor: Well, he thinks you are doing really good.
Patient: Nice! |
55 | GENHX | Daily headaches for 6 months in a 57-year-old. | Doctor: How are you today?
Patient: I am doing okay.
Doctor: Just to confirm, you are fifty seven years old?
Patient: Yes.
Doctor: What brings you to see me today?
Patient: I have been having these headaches every day for the last six months.
Doctor: That is a long time. I am sorry that you have been experiencing... |
56 | FAM/SOCHX | Ms. A had difficulty providing information on familial medical history. She reported that her mother died three to four years ago from lung cancer. Her father has gout and blood clots. Siblings have reportedly been treated for asthma and GI tumors. She was unsure of familial history of other conditions such as hype... | Doctor: Welcome to the office, Miss A. I am Doctor Luna.
Patient: Thank you. It is nice to meet you.
Doctor: What is your family medical history?
Patient: My mother died about three or maybe it is four years ago?
Doctor: I am so sorry to hear that. How did she pass?
Patient: She had lung cancer. My mom didn't talk... |
57 | MEDICATIONS | None. | Doctor: Are you taking any medications?
Patient: No.
Doctor: Any over the counter drugs or anything?
Patient: None.
Doctor: Okay. |
58 | FAM/SOCHX | Non-contributory | 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. |
59 | GENHX | This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. At the time of my exam, he states that his left lower extremity pain has improved considerably. He apparent... | Doctor: Hi sir, let me start by getting your age.
Guest_family: He is fifty three!
Doctor: So, tell me what's going on?
Guest_family: He is complaining of so many things but-
Patient: But I have a lot of pain from my hernia. That's the number one complaint, but I am also having pain in my lower legs.
Guest_family: He h... |
60 | PASTSURGICAL | Back surgery, shoulder surgery, and appendicectomy. | Doctor: Do you have any prior history of surgeries?
Patient: I had surgery on my back and shoulder after a bad skiing accident.
Doctor: How long ago did you have those surgeries?
Patient: About three to four years ago. Oh, I had my appendix removed when I was a teenager. |
61 | ALLERGY | She has hay fever, eczema, sinus, and hives. She has no melanoma or skin cancers or psoriasis. Her mother had oral cancer. The patient is a nonsmoker. No blood tests. Had some sunburn in the past. She is on benzoyl peroxide and Daypro. | Doctor: So, ma'am, what brings you in for a visit today?
Patient: Well, a few things, I have hay fever, um, eczema, sinus problems, and hives.
Doctor: Wow, that's quite a lot. Do you have any history of melanoma, or skin cancer?
Patient: No, just the eczema.
Doctor: How about psoriasis?
Patient: No, that doesn't r... |
62 | GENHX | Ms. ABC returns today for followup regarding her cervical spinal stenosis. I have last seen her on 06/19/07. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several ... | Doctor: Hello, this is my assistant, and she will be working with me today for your care. Can you please represent the patients case?
Guest_clinician: This is Miss A B C. She's here for her follow up regarding her cervical spinal stenosis. She was seen by you on nineteenth June. She had an incident on fourth of June, ... |
63 | ROS | Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies. He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities. | Doctor: How is everything else?
Patient: Fine.
Doctor: Anything from head to toe?
Patient: I have a shoulder issue. Can you check?
Doctor: Okay, just to check back you do not have any heart, lung, stomach, hormonal issues?
Patient: Nope.
Doctor: Any other muscles or bone problems?
Patient: None.
Doctor: Okay. So, I thi... |
64 | PASTSURGICAL | Significant for his trauma surgery. | Doctor: Did you had any surgery in the past?
Patient: Yes, I had this major trauma surgery some time back. |
65 | GENHX | The patient is a 19-year-old male who was involved in a fight approximately an hour prior to his ED presentation. He punched a guy few times on the face, might be the mouth and then punched a drinking glass, breaking it and lacerating his right hand. He has three lacerations on his right hand. His wound was cleaned ... | Doctor: How old are you young man?
Patient: I am nineteen.
Doctor: What happened? How did you get hurt?
Patient: I was in a fight. Some people are just rude.
Doctor: Oh, that's bad! How did you hurt your right hand?
Patient: Ah, I punched that other guy in face or maybe his mouth, I don't remember exactly but he got ... |
66 | ALLERGY | She has hay fever, eczema, sinus, and hives. She has no melanoma or skin cancers or psoriasis. Her mother had oral cancer. The patient is a nonsmoker. No blood tests. Had some sunburn in the past. She is on benzoyl peroxide and Daypro. | Doctor: Hello, miss. How are you doing today?
Patient: My skin has been going crazy.
Doctor: Could you describe to me what's happening?
Patient: I can't really describe it, but I can show you. Here's a report from my local doctor.
Doctor: I see. It says you have hay fever, eczema, sinus problems, and hives, correct... |
67 | PASTSURGICAL | Unknown. | Doctor: Has she had any surgeries in the past?
Guest_family: I couldn't tell ya even if I wanted to. I have no clue, sorry.
Doctor: Is there someone we could call who might know?
Guest_family: I can't think of anyone off the top of my head. Maybe her daughter? But she's outta town right now. |
68 | PASTSURGICAL | Cholecystectomy without complication | Doctor: Do you have a history of any surgical procedures?
Patient: I had my gallbladder removed.
Doctor: Did you have any complications with the surgery?
Patient: No. |
69 | ROS | The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities. | Doctor: Any fever, chills?
Patient: No.
Doctor: How about cough cold symptoms?
Patient: Nope no problems like that.
Doctor: Okay. Any chest pain or breathlessness?
Patient: No, I don't have chest issues.
Doctor: Any problems with bowel or bladder?
Patient: No.
Doctor: Pain in neck or head or hand, feet or anywhere?
Pat... |
70 | ALLERGY | None. | Doctor: Are you allergic to anything, food or medicines?
Patient: No allergies that I know of. |
71 | ROS | HEENT: See has had headaches, and some dizziness. She denies any vision changes. CARDIAC: She denies any chest pain or palpitations. RESPIRATORY: She denies any shortness of breath. GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis. NEUROLOGICAL: She denies any neurological defi... | Doctor: How many days has it been since your headaches started?
Patient: About two days now.
Doctor: How long do they normally last?
Patient: A couple hours.
Doctor: Any nausea or vomiting with the headaches? Any vision changes?
Patient: Yeah, it's been pretty consistent. No vision changes.
Doctor: Have you tried t... |
72 | PASTMEDICALHX | Hypertension, depression, and osteoporosis. | Doctor: Do you have any medical conditions that I should know about?
Patient: Actually yes, I have high blood pressure and, um, depression.
Doctor: That's good to know, thank you. What about your bones?
Patient: Um, yes, I have osteoporosis too. |
73 | FAM/SOCHX | She lives with her husband. She is a nonsmoker and no history of drug or alcohol abuse. She does drink two to three drinks daily. She completed 12th grade. | Doctor: Hello, I will ask you a few basic questions, okay?
Patient: Okay.
Doctor: What is your living status? Do you live alone or with family?
Patient: I am with my husband.
Doctor: What is your education level?
Patient: I cleared my twelfth grade but never joined college after that.
Doctor: Um, did you ever take a... |
74 | GYNHX | She does not bleed. She has both ovaries, as well as her uterus and cervix. She is on no hormonal therapy. | Doctor: Hello, miss. What brings you into the practice today?
Patient: I have been missing a lot of periods and I am not sexually active. I do not bleed. Is something wrong with me?
Doctor: What is your history with your reproductive parts? Have you had any surgeries?
Patient: I have everything still. I have both ovar... |
75 | ASSESSMENT | 1. Serous otitis. 2. Atopic dermatitis. | Doctor: How long have you been having this pain in your ear?
Patient: It's been three or four days.
Doctor: Okay, let me check your ears, which side is in pain?
Patient: The left one.
Doctor: Okay let me check both ears. Well, you have lot of fluid accumulated in your left ear, which has caused infection in your middl... |
76 | FAM/SOCHX | There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes. | Doctor: When were you diagnosed with type two diabetes?
Patient: Two years ago.
Doctor: Does diabetes run in the family?
Patient: Nope. I believe I'm the only one who has it.
Doctor: How about heart disease, stroke, cancer, or high blood pressure?
Patient: Nope. My family is pretty healthy for the most part. |
77 | FAM/SOCHX | Not obtainable. | Doctor: Can you tell me some illness that might run in your family?
Patient: No I don't know.
Doctor: Are you sure?
Patient: Yes. |
78 | FAM/SOCHX | ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92) | Doctor: Do you drink or smoke? Or take any other kind of drugs?
Patient: I used to smoke and drink, but I quit years ago. Maybe it was like in ninety two.
Doctor: How many cigarettes were you smoking then?
Patient: You see that is a tough one to remember. It was anywhere around thirty packs per year. |
79 | MEDICATIONS | loratadine beclomethasone nasal fluticasone/salmeterol inhaled Montelukast cephalexin hydrocodone | Guest_clinician: Has she taken anything for her symptoms?
Doctor: She's tried Loratadine Beclomethasone Nasal Fluticasone and Salmeterol Inhaled Montelukast Cephalexin Hydrocode.
Guest_clinician: Has she noticed any relief with these medications?
Doctor: Um some relief. |
80 | PASTSURGICAL | None. | Doctor: Any past surgeries?
Patient: Nah. |
81 | GENHX | This is a 58-year-old white female suffering increasing right knee pain for number of years prior to surgical intervention. She was completely refractory to conservative outpatient therapy. She had undergone two knee arthroscopies in the years preceding this. They were performed by myself. She ultimately failed thi... | Doctor: I hear someone just had a birthday! How young are you now, ma'am?
Patient: Hello, doctor. I just turned fifty eight.
Doctor: That's wonderful. You identify as white as well, correct?
Patient: Yes, that's correct.
Doctor: Is this right knee still bothering you?
Patient: Yes, and it's been going on for years ... |
82 | ROS | Otherwise negative. | Doctor: I reviewed all your systems, everything looks fine.
Patient: Nice. |
83 | EDCOURSE | The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort. | Doctor: Let me give you some medication in your I V.
Patient: Please make this all go away. I am feeling really sick like I am going to throw up.
Doctor: Sure, sure. Nurse, please give him Norflex sixty M G, Zofran four M G, morphine sulfate four M G.
Patient: Will I feel better after that?
Doctor: Yes.
Patient: I am ... |
84 | CC | Diarrhea, vomiting, and abdominal pain. | Doctor: It seems like you are not feeling very well today?
Patient: Yeah. I have had diarrhea and pain in my stomach.
Doctor: Have you experienced any vomiting?
Patient: Yes. I threw up this morning. |
85 | FAM/SOCHX | unknown. | Doctor: Do you know about any medical problems running in your family?
Patient: No, I don't know anything. I was never close to my family. |
86 | ROS | Please see history of present illness. Psychiatric: She has had some suicidal thoughts, but no plans. She denies being suicidal at the current time. Cardiopulmonary: She has not had any chest pain or shortness of breath. GI: Denies any nausea or vomiting. Neurological: No numbness, weakness or tingling. | Doctor: Have you had any thoughts of harming yourself or others?
Patient: I've had thoughts of not wanting to be alive anymore but no plans of actually hurting myself. And absolutely no desire to hurt others.
Doctor: Are you feeling suicidal right now?
Patient: No, not right now.
Doctor: Do you see a therapist or p... |
87 | CC | Non-healing surgical wound to the left posterior thigh. | Doctor: So, tell me what is going on?
Patient: Well, I have this wound on my thigh from my surgery and its not healing and honestly, I am a little worried.
Doctor: Okay, let me have a look, which side?
Patient: It's on the back of my left thigh. |
88 | ALLERGY | There is no known drug intolerance in the past. | Doctor: Any medication intolerances?
Patient: No. |
89 | GENHX | 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 ... | Doctor: Good morning, young man.
Patient: Hello, doctor.
Doctor: So, before we get started here, how old are you?
Patient: I'm seventeen, sir.
Doctor: Thank you, um, what happened?
Patient: Um, so I got into a fight at juvie, and I hurt my left elbow during it.
Doctor: I see, do you have any other pain?
Patient: We... |
90 | FAM/SOCHX | Denies the use of alcohol or tobacco. | Doctor: Do you drink alcohol or smoke cigarettes?
Patient: No, I do not.
Doctor: Are you sure?
Patient: Yes. |
91 | EXAM | CHEST: The chest examination is unremarkable. | Doctor: I will do some examinations on you. I will check your chest and then I will talk to you as I move forward, okay?
Patient: I'm okay with that.
Doctor: So, let's see what we have here. Hm, Yeah, just looks good. I do not find anything abnormal. |
92 | PASTMEDICALHX | History of migraine. | Doctor: And you mentioned that you have a history of migraine?
Patient: Yes, that's correct. |
93 | MEDICATIONS | His only medications are Ziac and Remeron. | Doctor: What medications are you taking currently?
Patient: Well, I'm taking Remeron for depression and Ziac for high blood pressure. |
94 | OTHER_HISTORY | Reviewed. There are no changes, otherwise. | Guest_clinician: Did you get a chance to review patient's chart?
Doctor: Yes, I reviewed his past medical history and family and social history.
Doctor: There are no changes, right Mister Jay?
Patient: Yes, nothing changed.
Guest_clinician: Okay, sounds good. |
95 | PROCEDURES | Permanent pacemaker placement after temporary internal pacemaker. | Doctor: How are you feeling?
Patient: I am well.
Doctor: So, we have placed a permanent pacemaker and removed your temporary internal pacemaker.
Patient: Yes. |
96 | ROS | The patient prior to today has been very well without any signs or symptoms of viral illness, but yesterday he began to experience symptoms of nausea, had an episode of vomiting last night. Has low appetite. There were no fevers, chills, or malaise. No headache. No congestion or cold. No coughing. He had no sore throat... | Doctor: How has our little man being doing?
Guest_family: Before today he has been doing well, but yesterday he threw up at night and has been very nauseous. He did not complain of stomach issues prior. He is not eating either.
Doctor: How is his appetite?
Guest_family: Low. He has no fever, chills, or weakness.
Doc... |
97 | IMAGING | EKG shows sinus tachycardia, no acute ST changes. | Doctor: Well, I have your E K G report, shows you have sinus tachycardia. In other words, your heart is beating faster than normal due to rapid firing of sinus node.
Patient: Okay.
Doctor: Well, there are no S T changes.
Patient: Hm. |
98 | IMMUNIZATIONS | Up-to-date. | Doctor: Good news! No need for any shots today. He is up to date on his immunizations.
Guest_family: Good! He hates shots. |
99 | ASSESSMENT | Chronic atrial fibrillation, the patient has been restarted back on aspirin 81 mg at the time of discharge. Aspirin should be continued with Nexium 40 mg once daily in order to prevent any future occurrence of upper GI bleed. If the patient has any occurrence of upper GI bleed such as coffee-ground emesis or melena t... | Doctor: I'm glad to hear that your Afib is under control. I'd like for you to start taking baby aspirin again.
Patient: Should I continue taking Nexium?
Doctor: Yes, I'd like you to also take Nexium forty M G once a day in order to reduce the risk of an upper G I bleed.
Patient: Sounds good.
Doctor: And I ask that... |
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