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D2N055
aci
[doctor] karen nelson is a 3 -year-old female with no significant past medical history who comes in for evaluation of a new right eye twitch karen is accompanied by her father hi karen how are you [patient] i'm okay i guess [doctor] hey dad how are you doing [patient] hey doc i am okay yeah karen has been having this e...
CHIEF COMPLAINT Right eye twitch. SOCIAL HISTORY The patient plays soccer every Saturday, however she has noted that there is a girl that tries to kick her and pulls her hair. FAMILY HISTORY Patient's father reports that they do not have a family history of seizures or Tourette's syndrome. REVIEW OF SYSTEMS Cons...
D2N056
aci
[patient] alright thanks for coming in today i see on my chart here that you had a bunch of lower respiratory infections so first tell me how are you what's going on [doctor] you know i'm doing better now but you know last week i was really sick and i just have had enough like i was coughing a lot a lot of mucus even h...
CHIEF COMPLAINT Recurrent lung infections. SOCIAL HISTORY Patient reports he is a farmer. He denies smoking or living with anyone who smokes. ALLERGIES Patient denies history of seasonal allergies. REVIEW OF SYSTEMS Constitutional: Reports low-grade fever. Respiratory: Reports shortness of breath and productive ...
D2N057
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[patient] hi good afternoon joseph how are you doing today [doctor] i'm doing well but my my big toe hurts and it's a little red too but it really hurts okay how long has this been going on i would say you know off and on for about two weeks but last week is is when it really became painful i was at a a trade show conv...
CHIEF COMPLAINT Right great toe pain. HISTORY OF PRESENT ILLNESS Joseph Walker is a pleasant 58-year-old male who presents to the clinic today for the evaluation of right great toe pain. The onset of his pain began 2 weeks ago, however it worsened last week. He noticed the pain worsening when he was at a trade show ...
D2N058
aci
[doctor] russell ramirez is a 45 -year-old male with past medical history significant for cad status post prior status post prior rca stent in twenty eighteen hypertension and diabetes mellitus who presents for hospital follow-up after an anterior stemi now status post drug-eluting stent and lad and newly reduced eject...
CHIEF COMPLAINT Hospital follow-up after an anterior STEMI. MEDICAL HISTORY Patient reports history of CAD status post prior RCA stent in 2018, hypertension, and diabetes mellitus. SURGICAL HISTORY Patient reports history of RCA stent in 2018 and most recently underwent drug-eluting stent placement in the LAD. SO...
D2N059
aci
[doctor] okay [patient] good morning [doctor] good morning thanks doctor doctor cooper i'm i'm you know i'm a little i'm sad to be in here but you know thanks for taking me in i appreciate it [patient] sure absolutely what can i help you with today [doctor] so you know i've been dealing with my asthma and like i tried ...
CHIEF COMPLAINT Asthma. MEDICAL HISTORY Patient reports history of asthma. SURGICAL HISTORY Patient reports history of tonsillectomy. SOCIAL HISTORY Patient reports she is a student and enjoys playing water polo as well as being active with aerobics and running. ALLERGIES Patient reports history of seasonal al...
D2N060
aci
[doctor] hey jean how're you doing today [patient] i'm doing alright aside from this foot pain that i have [doctor] so i see here that you looks like you hurt your left foot here where you were playing soccer can you tell me a little bit more about what happened [patient] yeah so yeah i was playing in a soccer game yes...
CHIEF COMPLAINT Left foot pain. HISTORY OF PRESENT ILLNESS Jean Martinez is a pleasant 27-year-old female who presents to the clinic today for the evaluation of left foot pain. The patient sustained an injury to her left foot while playing soccer yesterday. She became entangled with another player, causing the play...
D2N061
aci
[doctor] hi virginia how're you today [patient] i'm good thanks how are you [doctor] good so you know you got that knee x-ray when you first came in but tell me a little bit about what happened [patient] i was playing basketball and jerry ran into me and the inside of my knee hurts [doctor] okay did you fall to the gro...
CHIEF COMPLAINT Right knee pain. HISTORY OF PRESENT ILLNESS Virginia Phillips is a pleasant 53-year-old female who presents to the clinic today for the evaluation of right knee pain. The onset of her pain began 7 days ago, when she was playing basketball and another player ran into her. She states that she fell to t...
D2N062
aci
[doctor] okay raymond it looks like you've been having some difficulty swallowing over for a period of time could you tell me like what's going on [patient] well i've been better for the last several weeks i've been noticing that it's been hard for me to swallow certain foods and i also have pain when i swallow down in...
CHIEF COMPLAINT Difficulty swallowing. HISTORY OF PRESENT ILLNESS Raymond Taylor is a pleasant 67-year-old male who presents to the clinic today for difficulty swallowing. The patient notes that the pain has been occurring for the last several weeks. The pain radiates to his chest when he swallows. He notes that he ...
D2N063
aci
[doctor] so gloria is a 46 -year-old female today with past medical history of diabetes and back pain and today here for shortness of breath with chf and copd also so gloria tell me what's going on [patient] i i i'm having a lot of trouble sleeping [doctor] okay and and how long has this been going on for [patient] rea...
CHIEF COMPLAINT Dyspnea. MEDICAL HISTORY Patient reports history of diabetes, back pain, congestive heart failure, and chronic obstructive pulmonary disease. SOCIAL HISTORY Patient reports living a sedentary lifestyle. MEDICATIONS Patient reports she is not consistent with taking Lasix and metformin. REVIEW OF ...
D2N064
aci
[doctor] hey matthew how're you doing [patient] hey doc i'm doing pretty good how are you [doctor] i'm doing pretty good hey i see here in the nurse's notes it looks like you hurt your left ankle can you tell me a little bit more about that [patient] yeah i did my wife and i were on a walk yesterday and i was just talk...
CHIEF COMPLAINT Left ankle pain. HISTORY OF PRESENT ILLNESS Matthew Murphy is a pleasant 20-year-old male who presents to the clinic today for the evaluation of left ankle pain. The onset of his pain began 2 days ago, when he stepped off of a curb and landed on his left ankle wrong. He denies hearing a pop at the ti...
D2N065
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[doctor] hey anna good to see you today so i'm looking here in my notes says you have you're coming in today for some right ankle pain after a fall so can you tell me what happened how did you fall [patient] yeah so i was taking out the trash last night and i ended up slipping on a patch of ice like and then when i fel...
CHIEF COMPLAINT Right ankle pain. HISTORY OF PRESENT ILLNESS Anna Diaz is a pleasant 31-year-old female who presents to the clinic today for the evaluation of right ankle pain. The onset of her pain began when she slipped on a patch of ice while taking out the trash. She states that she heard a pop at the time of th...
D2N066
aci
[doctor] hey gabriel i'm doctor scott good to see you today i know you've heard about dax is it okay if i tell dax a little bit about you [patient] sure [doctor] okay so gabriel is a 43 -year-old male today here for back pain evaluation and also has a past medical history of diabetes high blood pressure and high choles...
CHIEF COMPLAINT Back pain evaluation. MEDICAL HISTORY The patient has a history of diabetes, hypertension, and high cholesterol. SURGICAL HISTORY He denies previous back surgeries. MEDICATIONS The patient currently utilizes metformin 500 mg twice daily and Norvasc. REVIEW OF SYSTEMS Cardiovascular: Reports ank...
D2N067
aci
[doctor] hi elizabeth so i see that you were experiencing some kind of injury did you say that you hurt your knee [patient] yes i hurt my knee when i was skiing two weeks ago [doctor] okay skiing that sounds exciting alright so what happened what what's when did the injury like what sorry what happened in the injury [p...
CHIEF COMPLAINT Right knee injury. HISTORY OF PRESENT ILLNESS Elizabeth Ross is a pleasant 91-year-old female who presents to the clinic today for the evaluation of a right knee injury. The onset of her pain began 2 weeks ago, when she was downhill skiing. She states she ran into a tree and twisted her right knee. A...
D2N068
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[doctor] hi , brian . how are you ? [patient] hi , good to see you . [doctor] it's good to see you too . so , i know the nurse told you a little bit about dax . [patient] mm-hmm . [doctor] i'd like to tell dax about you , okay ? [patient] sure . [doctor] so , brian is a 58 year old male with a past medical history sign...
CHIEF COMPLAINT Follow-up of chronic problems. HISTORY OF PRESENT ILLNESS Brian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow-up of his chronic problems. The patient states he has been feeling out of sorts lately. He ...
D2N069
virtassist
[doctor] hi , ms. thompson . i'm dr. moore . how are you ? [patient] hi , dr. moore . [doctor] hi . [patient] i'm doing okay except for my knee . [doctor] all right , hey , Sarah , ms. thompson is a 43 year old female here for right knee pain . so tell me what happened with your knee ? [patient] well , i was , um , try...
CC: Right knee pain. HPI: Ms. Thompson is a 43-year-old female who presents today for an evaluation of right knee pain. She states she was trying to change a lightbulb on a ladder, and she twisted her knee when she stumbled and caught herself from falling yesterday. She has been applying ice and taking Ibuprofen wit...
D2N070
virtassist
[doctor] hi logan . how are you ? [patient] hey , good to see you . [doctor] it's good to see you as well . [doctor] so i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] so logan is a 58 year old male , with a past medical history s...
CHIEF COMPLAINT Back pain. HISTORY OF PRESENT ILLNESS Mr. Logan Walker is a 58-year-old male with a past medical history significant for diabetes type 2, hypertension, and osteoarthritis, who presents today with back pain. Mr. Walker reports that he was helping his daughter move some heavy equipment and lifted some...
D2N071
virtassist
[doctor] i know the nurse told you about dax . [patient] mm-hmm [doctor] i'd like to tell dax a little bit about you , okay ? [patient] sure . [doctor] so ralph is a 62-year-old male with a past medical history significant for depression and prior lobectomy as well as hypertension , who presents for his annual exam . s...
CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS The patient is a 62-year-old male with a past medical history significant for depression and prior lobectomy, as well as hypertension. He presents for his annual exam. The patient reports that he is doing relatively well. Over the summer, he moved his oldest d...
D2N072
virtassist
[doctor] hi , ms. brooks . i'm dr. baker . how are you ? [patient] hi , dr. baker . [doctor] is your , is your right finger hurting ? [patient] yes . [doctor] okay . hey , Sarah , uh , sharon brooks is a 48 year old female here for right finger pain . all right . so , tell me what happened . [patient] well , i was skii...
CC: Right finger pain. HPI: Ms. Brooks is a 48-year-old female who presents today for an evaluation of right finger pain. She states she was skiing on Sunday and hyperextended her finger when it became caught in a strap on a jump. She has tried applying ice and taking Ibuprofen, but it is still very painful. She has...
D2N073
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[doctor] today i'm seeing christina cooper . her date of birth is 07/01/1954 . uh , ms. cooper is a new patient who was referred by diane nelson for a long-standing iron deficiency anemia . [doctor] hello , how are you ? [patient] i'm good , thank you . [doctor] so tell me what brings you in today . [patient] recently ...
CHIEF COMPLAINT Iron deficiency anemia. HISTORY OF PRESENT ILLNESS Mrs. Christina Cooper is a 65-year-old female who presents with a long-history of iron deficiency anemia. The patient reports she has been living with anemia since she was 13 years old. She attempted to donate blood on 12/2019 but was unable to due ...
D2N074
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[doctor] patient , bruce ward . date of birth 5/21/1969 . please use my neuro consult template . this is a 52-year-old male with dia- newly diagnosed pituitary lesion . the patient is seen in consultation at the request of dr. henry howard for possible surgical intervention . mr . ward presented to his primary care pro...
CHIEF COMPLAINT Pituitary lesion. HISTORY OF PRESENT ILLNESS Bruce Ward is a 52-year-old male with a pituitary lesion. The patient is seen in consultation at the request of Dr. Henry Howard for possible surgical intervention. The patient presented to his primary care provider, Dr. Howard, on 03/01/2021 complaining ...
D2N075
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[doctor] next is betty hill , uh , date of birth is 2/21/1968 . she has a past medical history of uterine fibroids and anemia . she's a new patient with a referral from the er of esophagitis . um , i reviewed our records from the er , including the normal cardiac workup , and we're about to go in and see her now . good...
CHIEF COMPLAINT Esophagitis. HISTORY OF PRESENT ILLNESS Betty Hill is a 53 y.o. female who presents to clinic today for a new patient evaluation of suspected esophagitis. The patient was referred from the emergency department where she was seen in early 10/2020 following 4 days of chest pain. The pain has resolved b...
D2N076
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[doctor] hello . [patient_guest] hi . [doctor] i'm dr. evelyn , one of the kidney doctors . it's good to meet you guys . [patient_guest] it's nice to meet you also . [doctor] yeah . so i was reading about this syndrome that i actually have never heard of . [patient_guest] yeah , me too . [doctor] i do n't think it's ve...
CHIEF COMPLAINT Renal screening tests. HISTORY OF PRESENT ILLNESS Katherine Lopez is a 22-month-old female, born at 34 weeks +3 days gestation, diagnosed with the rare Smith-Magenis syndrome and associated global developmental delays. She was referred to nephrology by genetics who recommended renal screening tests. ...
D2N077
aci
[doctor] hey diana it's good to see you in here so i see that you injured your wrist could you tell me a bit about what happened [patient] yeah i was walking up and down the stairs i was doing my laundry and i slipped and i tried to catch myself and i put my arms out to catch myself and then all of a sudden i just my w...
CHIEF COMPLAINT Right wrist injury. HISTORY OF PRESENT ILLNESS Diana Scott is a pleasant 61-year-old female who presents to the clinic today for the evaluation of a right wrist injury. The patient sustained this injury yesterday morning, 05/12/2022, when she slipped on the stairs while carrying a laundry basket. She...
D2N078
aci
[doctor] hey philip good to see you today so take a look here at my notes i see you're coming in for some right knee pain and you have a past medical history of hypertension and we will take a look at that so can you tell me what happened to your knee [patient] yeah i was you know i was just doing some work on my prope...
CHIEF COMPLAINT Right knee pain. REVIEW OF SYSTEMS Cardiovascular: Denies chest pain. Respiratory: Denies shortness of breath. Gastrointestinal: Denies abdominal pain. Musculoskeletal: Reports right knee pain. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear bilaterally. No wheezes. Cardiovascular - Auscu...
D2N079
aci
[doctor] hi wayne how're you today [patient] i'm doing okay aside from this left shoulder pain that i've been having [doctor] okay and how long have you had this pain [patient] about i want to say a few weeks i think it's been about three weeks now [doctor] okay and do you remember what you were doing when the pain sta...
CHIEF COMPLAINT Left shoulder pain. HISTORY OF PRESENT ILLNESS Wayne Taylor is a pleasant 66-year-old male who presents to the clinic today for the evaluation of left shoulder pain. The onset of his pain began 3 weeks ago. He denies any specific injury. The patient states he is active and has been renovating his bas...
D2N080
aci
[doctor] okay hi andrea well i [patient] hello [doctor] i understand you're you've come in with some right knee pain can you tell me about it what's going on [patient] it it's not the right knee it's the left knee [doctor] okay the left knee [patient] and it just happens occasionally less than once a day when i'm walki...
CHIEF COMPLAINT Left knee pain. HISTORY OF PRESENT ILLNESS Andrea Barnes is a 34-year-old female who presents today for evaluation of left knee pain. The patient has been experiencing intermittent episodes of pain and sudden instability with ambulation. Her pain is localized deep in her patella and occurs less than...
D2N081
aci
[doctor] so beverly is a 53 -year-old female with a recent diagnosis of stage three nonsmile cell lung cancer who presents for follow-up during neo agit chemotherapy she was diagnosed with a four . four centimeter left upper lobe nodule biopsy was positive for adenocarcinoma molecular testing is pending at this time al...
CHIEF COMPLAINT Follow up of stage III non-small cell lung cancer. MEDICAL HISTORY Patient reports history of stage III non-small cell lung cancer. SOCIAL HISTORY Patient reports having a good family support system and that some of her family has accompanied her to her chemotherapy sessions. MEDICATIONS Patient ...
D2N082
aci
[doctor] alright [patient] you're ready just [doctor] ready [patient] hi kyle how are you today [doctor] i'm doing well i'm just anxious about my pcp told me that i had some abnormal lab work and why she wanted me to be seen by you today [patient] yeah i bet that did make you nervous i i see that she referred you for a...
HISTORY OF PRESENT ILLNESS Kyle Lee is a pleasant 46-year-old male who presents to the clinic today for evaluation of low immunoglobulin A level. He was referred to our offices by his primary care physician after routine labs revealed abnormalities. The patient states he has been experiencing frequent infections. Duri...
D2N083
aci
[doctor] hey lawrence how're you doing [patient] i'm doing alright aside from this elbow pain [doctor] so it looks like here that you came in to see us today for an evaluation of that right elbow pain can you tell me can you can you tell me well first of all what do you think has been causing that pain [patient] so i r...
CHIEF COMPLAINT Right elbow pain. HISTORY OF PRESENT ILLNESS Lawrence Butler is a pleasant 45-year-old male who presents to the clinic today for the evaluation of right elbow pain. Over the past week, the patient has developed 6/10 pain in the "inside" of his right elbow. The pain may radiate into his forearm on oc...
D2N084
aci
[doctor] alright david so you were just in the emergency department hopefully you can hear me okay through the zoom meeting what happened [patient] well it seems that i was outside and i fell down i was walking a bit and i did have a pain in my chest but i did n't think anything of it and i just kept on going and then ...
CHIEF COMPLAINT Follow up. SOCIAL HISTORY The patient has been trying to limit his tobacco use for 2 years. He reports smoking once every week. MEDICATIONS Bumex 2 mg once daily. Cozaar 100 mg daily. Norvasc 5 mg once daily. REVIEW OF SYSTEMS Constitutional: Denies problems sleeping. Cardiovascular: Reports ches...
D2N085
aci
[doctor] hi russell how are you what's been going on [patient] well i've been having this sharp pain on the right side of my abdomen below my ribs for the last several days [doctor] i saw my doctor and they ordered a cat scan and said i had a kidney stone and sent me to see a urologist okay well does the pain move or o...
CHIEF COMPLAINT Right-sided abdominal pain MEDICAL HISTORY Patient reports history of kidney stones. FAMILY HISTORY Patient reports his father has a history of kidney stones. MEDICATIONS Patient reports use of Tylenol. REVIEW OF SYSTEMS Gastrointestinal: Reports right-sided abdominal pain and nausea. Denies vo...
D2N086
aci
[doctor] hey nicholas nice to see you today your pcp looks like he sent you over for a nonhealing foot ulcer on your right foot can you tell me about how long you've had that [patient] yeah i've had the boot for about six weeks i first noticed it when i put on a pair of shoes that were little bit too tight i felt some ...
CHIEF COMPLAINT Non-healing ulcer on his right foot. HISTORY OF PRESENT ILLNESS Nicholas Gutierrez is a pleasant 45-year-old male who presents to the clinic today for the evaluation of a non-healing ulcer on his right foot. The patient was referred from his primary care physician. The onset of his pain began 6 weeks...
D2N087
aci
[doctor] hi richard how are you the medical assistant told me that you have a tick bite is that what happened [patient] i really do n't know where i got it but i i had i do get out in the woods and i do spend a lot of time out in the yard but yeah i've got a tick bite around my knee and and it's been it's been over a w...
CHIEF COMPLAINT Tick bite. MEDICAL HISTORY Patient reports a history of arthritis, hypertension, and diabetes type 2. SOCIAL HISTORY Patient reports he enjoys spending time outside in the woods and working in the yard. He went hunting with his grandchildren a couple of weeks ago. MEDICATIONS Patient reports taki...
D2N088
virtassist
[doctor] hi , andrew . how are you ? [patient] hey , good to see you . [doctor] i'm doing well , i'm doing well . [patient] good . [doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] uh , so , andrew is a 59-year-old male with a past medical histor...
CHIEF COMPLAINT Upper respiratory infection. HISTORY OF PRESENT ILLNESS Andrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection. The patient reports that he has been doing a bit of work out...
D2N089
virtassist
[doctor] hi andrea , how are you ? [patient] i'm doing well . how are you ? [doctor] doing well . uh , so i know the nurse told you about dax . i'd like to tell dax a little bit about you . okay ? [patient] okay . [doctor] so , andrea is a 52-year-old female with a past medical history significant for rheumatoid arthri...
CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen. The patient states she is doing well. ...
D2N090
virtassist
[doctor] hi , albert . how are you ? [patient] hey , good to see you . [doctor] it's good to see you too . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] so , albert is a 62-year-old male , with a past medical history significant for depression , type ...
CHIEF COMPLAINT ER follow-up. HISTORY OF PRESENT ILLNESS Albert Powell is a 62-year-old male with a past medical history significant for depression, type 2 diabetes, and kidney transplant. He is here today for an emergency room follow-up. The patient states he was not staying on top of his blood sugar readings and ...
D2N091
virtassist
[doctor] hi jerry , how are you doing ? [patient] hi , good to see you . [doctor] good to see you as well . um , so i know that the nurse told you about dax . i'd like to tell dax about you . [patient] sure . [doctor] jerry is a 54 year old male with a past medical history , significant for osteoporosis and multiple sc...
CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS Jerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam. The patient states he has been traveling all over the country. He notes it has been a stressful summer and adjust...
D2N092
virtassist
[doctor] hello , mrs . martinez . good to see you today . [patient] hey , dr . gomez . [doctor] hey , Sarah , i'm here seeing mrs . martinez . she's a 43-year-old female . why are we seeing you today ? [patient] um , my arm hurts right here . kind of toward my wrist . this part of my arm . [doctor] so you have pain in ...
CC: Right arm pain. HPI: Ms. Martinez is a 43-year-old female who presents today for an evaluation of right arm pain after she hitting her arm on a pole while playing tennis. She had mild swelling at the time. There is pain with motion. She denies any numbness or tingling in her hand. She has a past medical history ...
D2N093
virtassist
[doctor] hey lawrence . how are you ? [patient] hey , good to see you . [doctor] it's good to see you too . so , i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] so , lawrence is a 62-year-old male , with a past medical history sig...
CHIEF COMPLAINT Shortness of breath. HISTORY OF PRESENT ILLNESS Lawrence Walker is a 62-year-old male with a past medical history significant for type 1 diabetes, congestive heart failure, depression, and reflux, who presents with complaints of shortness of breath. The patient states he has had some shortness of br...
D2N094
virtassist
[doctor] hey , ms. james . nice to meet you . [patient] nice to meet you , dr. cooper . how are you ? [doctor] i'm well . hey , Sarah , i'm seeing ms. james . she's a 42-year-old female , and what brings you in today ? [patient] i hurt my , uh , finger when i was skiing this past weekend . [doctor] really ? [patient] y...
CC: Right index finger pain. HPI: Ms. James is a 42-year-old female who presents today for an evaluation of right index finger pain. She states she injured it while skiing. She states she fell and jammed her finger. She took Ibuprofen on but it did not help her. She denies any icing it or wearing a splint. She rates...
D2N095
virtassist
[doctor] hi , cheryl . how are you ? [patient] i'm doing well . how are you ? [doctor] i'm doing well . so i know the nurse told you a little bit about dax . i'd like to tell dax about you . [patient] okay . [doctor] cheryl is a 34-year-old female with a past medical history significant for hypertension , who presents ...
CHIEF COMPLAINT Back pain. HISTORY OF PRESENT ILLNESS Ms. Ramirez is a 34-year-old female with a past medical history significant for hypertension, who presents today with back pain. The patient reports she has been walking a lot lately, 30 minutes to an hour or so a day. While walking 6 days ago, she felt her back...
D2N096
virtassist
[doctor] um , hi mrs. anderson . right ? [patient] yeah . yes , doctor . [doctor] what brings you here today ? [patient] hi , doctor . um , i'm having this left shoulder pain lately , uh , and it's paining a lot . [doctor] okay . all right . hey , Sarah . i am seeing mrs. anderson , a 44-years-old female , uh , complai...
CC: Left shoulder pain. HPI: Ms. Anderson is a 44-year-old female who presents today for an evaluation of the left shoulder. She states that she was in gymnastics 1 week ago. The pain has been present since that time. She has pain with any type of movement of her left shoulder. She had taken Tylenol for 2 to 3 days ...
D2N097
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[doctor] elizabeth , how are you ? [patient] i'm doing okay . how are you ? [doctor] doing okay . so i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? [patient] okay . [doctor] all right . elizabeth is a 66-year-old female with a past medical history of significant for depressio...
CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS Elizabeth Peterson is a 66-year-old female with a past medical history significant for depression and hypertension, who presents for her annual exam. It has been a year since I last saw the patient. The patient reports that she is doing well. She has been to m...
D2N098
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[doctor] all right . today i am seeing jose james . uh , date of birth 9/29/1957 . mr . james is a new patient who's having pain in his left shoulder and elbow . he fell five months ago going up a stairs , and the pain has been present since . [doctor] hi mr . james , i'm doctor isabella . how are you doing ? [patient]...
CHIEF COMPLAINT Left shoulder and elbow pain. HISTORY OF PRESENT ILLNESS Mr. Jose James is a 64-year-old male who presents for left shoulder and elbow pain. The patient reports falling on his hand while going up stairs 5 months ago and has been experiencing constant pain since. He admits he was continuing to comple...
D2N099
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[doctor] next patient is randy gutierrez . date of birth , 8/10/2020 . please use review of symptoms . all text to write . physical exam , auto text uri . [doctor] hello , how are you doing today ? [patient_guest] we're okay , thank you . [doctor] that's good to hear . so , how many days has randy been feeling sick ? [...
CHIEF COMPLAINT Cough, nasal congestion, and rhinorrhea. HISTORY OF PRESENT ILLNESS Randy Gutierrez is a 9-month-old male who is being evaluated today for a cough, nasal congestion, and rhinorrhea. He is accompanied by his mother. Symptoms began yesterday around dinnertime with clear nasal drainage, pulling on his ...
D2N100
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[doctor] kayla ward , date of birth , 4/28/07 . mrn 3-8-4-9-2-0 . she's here for a new visit with her mother for acne located on the face , which started about two years ago and is present most every day . she has been using persa-gel and washing regularly , which is somewhat helpful . there are no associated symptoms ...
CHIEF COMPLAINT New acne evaluation. HISTORY OF PRESENT ILLNESS Kayla Ward is a 15-year-old female who presents for new patient evaluation of acne located on the face. She is accompanied by her mother today. Kayla states her acne started approximately 2 years ago and it is present almost every day. The patient’s mo...
D2N101
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[doctor] patient is julia jones , date of birth 5/16/1996 . she is a new breast reduction consult . hello , how are you doing today ? i'm dr. gonzalez . it's nice to meet you . [patient] nice to meet you , ma'am . how are you ? [doctor] i'm doing good , thank you . so you're here to discuss a breast reduction , correct...
CHIEF COMPLAINT Macromastia. HISTORY OF PRESENT ILLNESS Julia Jones is a 25-year-old female who presents for evaluation of macromastia. Ms. Jones reports this is her first visit in regard to a breast reduction and has been interested in getting a breast reduction for approximately 7 years. Currently she has Blue Cr...
D2N102
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[doctor] kelly wood . date of birth , february 15th , 1979 . established patient here for renal ultrasound because of hematuria . urine dipstick today . negative for leukocytes , nitrates , protein , ketone , bilirubin and glucose . color yellow and clear , urobilinogen 0.2 , ph 5.5 and specific gravity 1.020 . there i...
CHIEF COMPLAINT Hematuria. Chronic urolithiasis. HISTORY OF PRESENT ILLNESS Mrs. Kelly Wood is a 41-year-old female established patient with chronic urolithiasis who returns in follow up for renal ultrasound due to hematuria. The patient reports having intermittent episodes of gross hematuria over the past several ...
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[doctor] next patient is melissa sanchez . date of birth , 9/23/1962 . mrn : 5484367 . she is being seen in office today for status post mitral valve repair done on 8/3/2020 . at her previous follow-up on 9/17 , we felt that she was doing quite well from a cardiac standpoint , and so we recommended she continue with th...
CHIEF COMPLAINT Status post mitral valve repair. HISTORY OF PRESENT ILLNESS Mrs. Melissa Sanchez is a 58-year-old female being seen today for a status post mitral valve repair, completed on 08/03/2020. On 09/17/20 we saw Mrs. Sanchez in office, and she was doing well and thus we recommended maintaining her current ...
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[doctor] judy gomez , mrn 869723 . date of birth , 5 , 7 , 1961 . she's in office today for ongoing management of psoriatic arthritis . hello , judy , how are you doing today ? [patient] i'm doing good , thank you . how are you ? [doctor] i'm great , thanks . so how have you been since the last time ? i know the last t...
CHIEF COMPLAINT Psoriatic arthritis management. HISTORY OF PRESENT ILLNESS Judy Gomez is a 61-year-old female who presents to the clinic today for ongoing management of psoriatic arthritis. Ms. Gomez is currently taking methotrexate and prednisone 1 mg daily. She believes methotrexate has been relieving her joint p...
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[doctor] patient's name is diana scott . date of birth , 12/8/1920 . the date of service is 7/9/2021 . this is a new patient note . [doctor] good afternoon . how are you today ? [patient] i'm good , thank you . [doctor] good . well , what brings you in to see me today ? [patient] well , my doctor says that i have a hea...
CHIEF COMPLAINT Heart murmur. HISTORY OF PRESENT ILLNESS Diana Scott is a 100-year-old female who presents today for evaluation of a heart murmur. Ms. Scott has been recently diagnosed with a “new, worrisome” heart murmur. She denies chest pain, syncope, palpitations, fevers, or chills. She reports shortness of bre...
D2N106
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[doctor] hey charles i'm using this cool new recording device to help me with my documentation is that okay with you [patient] sure [doctor] awesome how are you doing today [patient] well i could be better you know i moved out in the city [doctor] about two years ago bought this big plot of land [patient] oh [doctor] i...
CHIEF COMPLAINT Shortness of breath. HISTORY OF PRESENT ILLNESS Charles Sullivan is a pleasant 45-year-old male who presents to the clinic today for the evaluation of shortness of breath. The onset of his symptoms began 2 years ago. He has noticed that his breathing is not what it used to be. He describes an increase...
D2N107
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[doctor] so bryan it's nice to see you again in the office today what's going on [patient] i was in my yard yesterday and i was raking leaves and i felt fine and then when i got into my house about two hours later my back started tightening up and i started getting pins and needles in my right foot [doctor] alright hav...
CHIEF COMPLAINT Low back pain. HISTORY OF PRESENT ILLNESS Bryan Brooks is a pleasant 39-year-old male who presents to the clinic today for the evaluation of low back pain. He is accompanied today by his partner. Approximately 2 hours after he finished raking leaves yesterday, the patient began to feel a tightening ...
D2N108
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[doctor] hey gregory good to see you today so take a look at my notes and i see that you're here you've had a nonhealing foot ulcer so can you tell me how you're doing how long have you had it what's going on with it [patient] sure so i've had it for about two months now and it's recently become red and is draining so ...
CHIEF COMPLAINT Right foot ulcer. HISTORY OF PRESENT ILLNESS Gregory Hernandez is a pleasant 40-year-old male who presents to the clinic today for the evaluation of a non-healing right foot ulcer. Onset of ulcer was approximately 2 months ago after walking barefoot on the beach. He reports the ulcer has recently bec...
D2N109
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[doctor] so stephanie morales is a 36 -year-old female today complaining of her ankle pain and she also has a history of diabetes and high blood pressure so stephanie tell me what's going on with your ankle [patient] well we had a long spring and the other day we got some snow and ice i was walking to my car and i slip...
CHIEF COMPLAINT Left ankle pain. MEDICAL HISTORY Patient reports history significant for type 2 diabetes and hypertension. MEDICATIONS Patient reports taking metformin and Norvasc. REVIEW OF SYSTEMS Musculoskeletal: Reports left ankle pain and swelling.\ Denies left calf pain, lower left leg pain, or left knee p...
D2N110
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[doctor] okay hi wayne well i understand you're here for you've got a sore on your foot that's not healing is that right [patient] yes [doctor] so can you tell me about that how are you doing [patient] well i've been doing okay but i've had this wound on my right foot for a couple of weeks and it's not getting better i...
HISTORY OF PRESENT ILLNESS Wayne Jenkins is a pleasant 43-year-old male who presents to the clinic today for the evaluation of a right foot wound, onset 2 to 3 weeks ago. He was seen by his primary care physician who referred him to our office. His last visit with a podiatrist was 2 years ago, however they moved, and ...
D2N111
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[doctor] hey william so i see that you injured your knee could you tell me a bit about what happened [patient] yeah i thought it was a good idea to go to the trampoline park with my wife and heard a snap and instant pain when i was on the trampoline [doctor] okay alright and so do do you go to the trampoline park often...
CHIEF COMPLAINT Right knee injury. HISTORY OF PRESENT ILLNESS William Russell is a pleasant 57-year-old male who presents to the clinic today for the evaluation of a right knee injury. He has a past medical history significant for hypertension and type 2 diabetes. Approximately 1 week ago, the patient sustained an ...
D2N112
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[doctor] hey matthew i see here that you've had some back pain for a while and your pcp sent you over to see me how're you doing today [patient] pretty good i'm feeling pretty good do n't like the weather you know i've been sitting in the waiting area for you know thirty minutes and that definitely makes the symptoms w...
HISTORY OF PRESENT ILLNESS Matthew Hill is a pleasant 44-year-old male who presents to the clinic today for the evaluation of back pain. The patient was referred from his primary care physician. The onset of his pain began 30 years ago, when he fell off of a roof. He endorses that it was very bothersome and he was una...
D2N113
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[doctor] hi jacqueline how are you doing today [patient] i'm doing okay i'm just really anxious about my recent blood work that my pcp did and said that i have hepatitis c i'm just really surprised because i've been feeling fine [doctor] okay so were you ever told in the past that you have hepatitis c [patient] no neve...
CHIEF COMPLAINT Hepatitis C. SOCIAL HISTORY Patient reports personal history of intravenous drug use over 15 years ago. She is currently smoking 1-2 cigarettes per day, previously 1 to 1.5 packs per day. She also has a history of heavy alcohol use, but now drinks approximately 1 beer per day, more on the weekends. ...
D2N114
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[doctor] alright [patient] good morning Julie how are you doing today [doctor] i'm doing okay i'm just a little nervous about what's been going on with my headaches [patient] okay so i know you were sent here by your your pcp what was your understanding of why you were sent here [doctor] yeah so i actually have been so...
CHIEF COMPLAINT Headaches. HISTORY OF PRESENT ILLNESS Julie Jenkins is a pleasant 33-year-old female who presents to the clinic today for the evaluation of headaches. The patient was referred from her primary care physician. The patient states that she was seen by Dr. White a few years ago and was going to obtain an...
D2N115
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[doctor] alright so hey it's nice to see you jack i know you've been experiencing some neck pain could you tell me what happened [patient] yeah so i was in a a car accident [doctor] mm-hmm [patient] and i hit in the back and like my my neck went forward and my head went forward really quick and so i've been having some...
CHIEF COMPLAINT Neck pain HISTORY OF PRESENT ILLNESS Jack Torres is a pleasant 40-year-old male who presents to the clinic today for the evaluation of neck pain. The onset of his pain began 1 week ago after he was involved in a motor vehicle accident. He states that he was hit in the back and experienced whiplash. F...
D2N116
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[doctor] hey hi bobby how are you doing [patient] i'm doing good how are you [doctor] i'm doing fine so i understand you're here having some left or some right shoulder pain that you've had for a few weeks now [patient] yeah it was i was doing some work in my backyard and a lot of different projects going on and you kn...
CHIEF COMPLAINT Right shoulder pain. HISTORY OF PRESENT ILLNESS Bobby Flores is a 56-year-old male, right-hand-dominant, male who presents to the clinic today for the evaluation of right shoulder pain. The onset of his pain began a few weeks ago, when he was performing different projects in his backyard. He states ...
D2N117
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[doctor] mister jackson is a 45 -year-old male who has a history of diabetes type two and mild intermittent asthma and he is here today with right elbow pain so hey there mark nice to see you again listen sorry you're having some elbow pain let's talk about it but i would like to record this conversation with this cool...
CHIEF COMPLAINT Right elbow pain. MEDICAL HISTORY Patient reports history of type 2 diabetes and mild intermittent asthma. SURGICAL HISTORY Patient reports history of cholecystectomy 10 years ago by Dr. Nelson. SOCIAL HISTORY Patient reports he has been playing tennis since high school. ALLERGIES Patient repor...
D2N118
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[doctor] alright so how're you doing today angela [patient] i'm doing pretty well [doctor] alright so looking here at your appointment notes it says you're you're here you think you have a kidney stone you had some in the past so we're gon na take a look at that and then you also have a past medical history of hyperten...
CHIEF COMPLAINT Kidney stone. MEDICAL HISTORY Patient reports history of hypertension, diabetes, and kidney stones. MEDICATIONS Patient reports taking Norvasc 2.5 mg and metformin 500 mg. REVIEW OF SYSTEMS Constitutional: Reports insomnia. Cardiovascular: Denies chest pain. Gastrointestinal: Denies abdominal pai...
D2N119
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[doctor] hey betty how are you doing [patient] i'm doing okay i just been really frustrated because with my asthma and it just seems like i can never catch a break never get better i'm always it seems like i'm always coughing and wheezing [doctor] i'm sorry to hear that what normally triggers your asthma type symptoms ...
CHIEF COMPLAINT Asthma. MEDICAL HISTORY Patient reports history of asthma. SOCIAL HISTORY The patient denies the use of any type of cigarette or tobacco product, as well as marijuana. Occasionally, she will be at a bar that allows smoking inside, which does bother the patient. She enjoys being outside and hiking. ...
D2N120
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[doctor] hello larry how are you doing today [patient] i've been better my primary care doctor wanted me to see you for this back pain that i've been having for a couple of years now [doctor] okay [patient] and i have tried so many things and just nothing seems to work [doctor] i'm sorry to hear that now do you remembe...
HISTORY OF PRESENT ILLNESS Larry Garcia is a pleasant 41-year-old male who presents to the clinic today for the evaluation of back pain. The onset of his pain began 2 years ago, after moving furniture. He denies any specific injury. The patient describes his pain as sharp and stabbing. He locates his pain to his lowe...
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[patient] hi kenneth how are you the medical assistant told me that you had some knee pain yeah i was getting ready for the holiday weekend and i was out on my boat skiing and i i did a jump and kinda twisted when i landed and my knee has been hurting me ever since [doctor] okay so that was about five days ago then [pa...
CHIEF COMPLAINT Right knee pain. MEDICAL HISTORY Patient reports history of hypertension. SURGICAL HISTORY Patient reports history of tonsillectomy. SOCIAL HISTORY Patient reports that he has a boat on Lake Martin. He is frequent water skier. MEDICATIONS Patient reports taking lisinopril 20 mg once a day. REV...
D2N122
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[doctor] hey kyle it's nice to see you today can you tell me a little bit about what brought you in [patient] yeah i went to see my pcp for a cough which they diagnosed as bronchitis but then they did that chest x-ray to make sure i did n't have pneumonia and they found this lung nodule i went for a cat scan that confi...
CHIEF COMPLAINT Cough. MEDICAL HISTORY Patient reports a history of rheumatoid arthritis. He denies any previous history of lung infections or pneumonia. SOCIAL HISTORY Patient reports he stopped smoking tobacco 7 years ago and has felt better since doing so. He notes that he enjoys biking. FAMILY HISTORY Patien...
D2N123
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[doctor] so tyler is a 56 -year-old male who presents today complaining of difficulty swallowing and has a past medical history of diabetes and high blood pressure so tyler tell me what's going on with your swallowing problem [patient] well it's just been something that i have noticed over the last you know four to fiv...
SUBJECTIVE Difficulty swallowing. Tyler Green is a 56-year-old male who presents today complaining of difficulty swallowing. The patient noticed the difficulty swallowing approximately 4 to 5 weeks ago. He describes it as something stuck in his throat. He states that it bothers him a little bit throughout the day as ...
D2N124
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[doctor] so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened [patient] hey doctor michael yeah so my son sean i think you met in the past he he started playing basketball and there we do multiple seasons and so we're kinda getting ready for the next season that starts in in april ...
CHIEF COMPLAINT Right ankle injury. HISTORY OF PRESENT ILLNESS Jerry Cook is a 45-year-old male who presents today with a right ankle injury. The patient sustained an injury to the right ankle while playing basketball with his son. He reports he landed awkwardly and twisted his right ankle after jumping to make a l...
D2N125
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[patient] miss edwards is here for evaluation of facial pain this is a 54 -year-old male [doctor] how're you doing doctor cruz nice to see you today [patient] good to see you mister edwards i'm doctor [doctor] tell me what's been going on yeah so i've got this stabbing shooting pain i've had for a while you know and it...
CHIEF COMPLAINT Right-sided facial pain. REVIEW OF SYSTEMS Eyes: Denies vision changes or weakness in right eye. HENT: Reports right sided facial pain. Denies left sided facial pain. Neurological: Reports headaches. Denies sensory loss, numbness, or tingling in the right cheek. Denies right sided facial weakness. P...
D2N126
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[doctor] hi michelle what's been going on the medical assistant told me that you injured your knee [patient] yeah i'm gon na have to keep this my favorite story is that i had a sandra who injured her knee cold dancing so that would immediately came up to mine but let's try skiing so i was skiing in vermont last weekend...
CHIEF COMPLAINT Right knee injury HISTORY OF PRESENT ILLNESS Michelle King is a pleasant 44-year-old male who presents to the clinic today for the evaluation of a right knee injury. Her injury was sustained while skiing in Vermont last weekend after she caught her ski when coming off of the lift and fell. She report...
D2N127
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[doctor] hey brandon you know glad to see you in here today i see on your chart that you're experiencing some neck pain could you tell me a bit about what happened [patient] yeah i was in a car crash [doctor] wow okay when was that [patient] well which car crash [doctor] okay so multiple car crashes alright so let's se...
CHIEF COMPLAINT Neck pain. HISTORY OF PRESENT ILLNESS Brandon Green is a pleasant 46-year-old male who presents to the clinic today for the evaluation of neck pain. His pain began when he was involved in a motor vehicle accident in 02/2022 when he was on his way home from a pain clinic. The patient notes that he has...
D2N128
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[doctor] hi , carolyn . how are you ? [patient] good . how are you ? [doctor] i'm good . you're ready to get started ? [patient] yes , i am . [doctor] so carolyn is a 49-year-old female here for follow-up of her chronic problems . so , how are you doing , carolyn ? [patient] i'm doing okay . um , my osteoarthritis has ...
CHIEF COMPLAINT Follow-up of chronic problem. HISTORY OF PRESENT ILLNESS Ms. Carolyn Garcia is a 49-year-old female who presents to the clinic today for follow-up of her chronic problem. The patient reports her osteoarthritis has been flaring up a little lately, and she would like to talk about that, primarily in h...
D2N129
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[doctor] good afternoon , beverly . good to see you . [patient] nice to see you too . [doctor] so , i know my nurse told you a little bit about dax . um , now , if you do n't mind , i'd like to tell dax a little bit about you . [patient] go for it . [doctor] great . um , beverly's a 24 year old female patient , and i k...
CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS Beverly Ortiz is a 24-year-old female patient with a history of type 2 diabetes and high blood pressure. She is here today for her yearly exam. The patient states she has been doing well. She has recently began working at a bakery this summer. The patient sta...
D2N130
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[doctor] hi , anna , how are you ? [patient] i'm doing okay . how are you ? [doctor] i'm doing well . uh , so i know the nurse told you a little bit about dax . i'd like to tell dax a little bit about you . [patient] okay . [doctor] all right . so , uh , anna is a 26-year-old female with a past medical history , signif...
CHIEF COMPLAINT Joint pain. HISTORY OF PRESENT ILLNESS The patient is a 26-year-old female with a past medical history significant for epilepsy, depression, and peptic ulcer disease who presents with some joint pain. The patient reports that her left elbow has really been bothering her. She states that she sits at ...
D2N131
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hi , susan , how are you ? [patient] good . how are you ? [doctor] good . are you ready to get started ? [patient] yes , i am . [doctor] so , susan is a 26-year-old female here for a high blood pressure check . susan , what's going on with your blood pressure ? [patient] so , i've always struggled with , um , high bloo...
CHIEF COMPLAINT High blood pressure check. HISTORY OF PRESENT ILLNESS Ms. Susan Watson is a 26-year-old female who presents to the clinic today for a high blood pressure check. The patient reports she has always struggled with high blood pressure, but it is seems out of control recently. She notes that she has inte...
D2N132
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[doctor] hello mrs. lee , i see you're here for back pain . [patient] yes . [doctor] hey Sarah , i'm seeing mrs. lee today for , uh , back pain . she's a 40-year-old female . so can you tell me what happened to you ? [patient] yes . i was at a birthday party and it was surprise party . so we were all like crunched behi...
CC: Back pain. HPI: Ms. Lee is a 40-year-old female who presents today for an evaluation of back pain. She states she was at a birthday party and she ran her back into the railing of the staircase and twisted her back. She denies any pain radiating down her legs. Lying flat and twisting motions aggravate the pain. S...
D2N133
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[doctor] good morning rebecca , nice to see you . [patient] nice to see you too . [doctor] so , my nurse told you a little bit about dax , now i'm wondering if i can tell dax a little bit about you . [patient] go for it . [doctor] okay , so rebecca is a 27-year-old female patient . um , you have a history of carpal tun...
CHIEF COMPLAINT Joint pain HISTORY OF PRESENT ILLNESS Ms. Thompson is a 27 y.o. female with a history of carpal tunnel release done a couple years ago, chronic back pain, and depression. She presents today for joint pain. Ms. Thompson reports that over the course of the month she has begun swimming more regularly a...
D2N134
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[doctor] we're gon na go right to the front- . so when you touch that- hi , michelle , how are you ? [patient] i'm good . how are you ? [doctor] i'm good . so i know the nurse told you about dax . i'd like to dax a little bit about you , okay ? [patient] okay . [doctor] all right . so , michelle is a 31-year-old female...
CHIEF COMPLAINT Abnormal labs. HISTORY OF PRESENT ILLNESS The patient is a 31-year-old female with a past medical history significant for type 2 diabetes, and hypertension who presents with abnormal labs. She had an insect bite at her last visit after hiking in the woods. We drew a Lyme titer which came back positiv...
D2N135
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[patient] um , i have high blood sugar . yeah , osteoarthritis , arterial fibrillation , and reflux . [doctor] hi , hannah . how are you ? [patient] good , how are you ? [doctor] i'm good . you ready to get started ? [patient] yes , i am . [doctor] so , hannah is a , uh , 52-year-old female here for evaluation of a hig...
CHIEF COMPLAINT Evaluation of high blood sugar. HISTORY OF PRESENT ILLNESS Ms. Hannah Phillips is a 52-year-old female who presents for evaluation of high blood sugar. The patient admits to dietary indiscretion. She notes that she has been eating more sweets during the holidays. She reports that this past week, she ...
D2N136
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[doctor] hi janet , how are you ? [patient] good , how are you ? [doctor] i'm good . uh , are you ready to get started ? [patient] yes . [doctor] okay . so , janet is a 33-year-old female , here for some , some joint paint . what , what joint's been bothering you , janet ? [patient] it's been mostly , um , my knees , a...
CHIEF COMPLAINT Joint pain. HISTORY OF PRESENT ILLNESS Ms. Janet Sullivan is a 33-year-old female who presents to the clinic today for evaluation of joint pain. She localizes the joint pain to her bilateral knees. The patient reports she has been doing stair workouts, which she thought was building muscle on her kn...
D2N137
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[doctor] morning christine , nice to see you . [patient] nice to see you too . [doctor] so i know my nurse told you a little bit of- ... um , about dax and i'm gon na tell dax a little bit about you , if that's okay ? [patient] go for it . [doctor] okay , great . um , uh , this is christine . she's a 63-year-old female...
CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS Christine Flores is a 63-year-old female presenting for her yearly exam. She has a history of high blood pressure and depression in the past. She also had a right carpal tunnel release done about 2 years ago. The patient states that she has been doing well wit...
D2N138
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[doctor] next patient is emily hernandez . date of birth , march 26 2001 . this is a 20 year old female being seen today for our yearly follow-up for asthma , allergic rhinitis and food allergy . due to insurance changes since our last office appointment in april 2020 , she was switched from symbicort to wixela . she a...
CHIEF COMPLAINT Follow-up for asthma, allergic rhinitis, and food allergy. HISTORY OF PRESENT ILLNESS Emily Hernandez is a 20-year-old female presenting today for an annual follow-up for asthma, allergic rhinitis, and food allergy. Due to insurance changes during the interim of our last office appointment from 04/20...
D2N139
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[doctor] all right , new patient , jordan roberts . date of birth : 3/2/1972 . he's a 49 year old , uh hm , with hypertension and palpitations . please copy forward his thyroid profile from march 1st , 2021 . [doctor] hello mr. roberts , how are you doing today ? [patient] i'm fine , thank you . [doctor] good . good . ...
CHIEF COMPLAINT High blood pressure and palpitations. HISTORY OF PRESENT ILLNESS Jordan Roberts is a 49-year-old with a long history of hypertension and an acute episode of palpitations. In March, Mr. Roberts went to the emergency room for palpitations and hypertension. He attributed this to a panic attack, but als...
D2N140
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[doctor] brittany edwards , 07 , 1898 . she is a return visit for ibs with functional abdominal pain , nausea , vomiting . ms. edwards is a pleasant , 32-year-old female who was last seen in august of 2019 with flares of abdominal pain , who was diagnosed with irritable bowl that was treated with bentyl . [doctor] she ...
CHIEF COMPLAINT Follow up irritable bowel syndrome (IBS). HISTORY OF PRESENT ILLNESS Ms. Brittany Edwards is a pleasant 32-year-old female who returns in follow up for irritable bowel syndrome (IBS) with functional abdominal pain, nausea, and vomiting. Ms. Edwards was last seen in August 2019 with flares of abdomin...
D2N141
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[doctor] okay , so our next patient is christopher watson . date of birth 04/12/1934 . mr . watson is- is an 86-year-old male who returns in follow-up for adult hydrocephalus . this is his first visit since undergoing sh- shunt surgery , excuse me , on august 1st , 2020 . [doctor] i have followed mr . watson since may ...
CHIEF COMPLAINT Follow up adult hydrocephalus, 3 months status post shunt surgery. HISTORY OF PRESENT ILLNESS Mr. Christopher Watson is an 86-year-old male who returns in follow up of adult hydrocephalus. This is his first visit since undergoing shunt surgery 08/01/2020. He is accompanied by his daughter, Theresa, t...
D2N142
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[doctor] amanda taylor , birth date october 31st 1949 . patient is a 72 year old woman who comes for followup for hypertension . her history includes significant alcohol use disorder and mi- mild hypercholesterolemia . at last visit on april 16th her blood pressure was 130 over 90 . after presenting at 150 over 100 she...
CHIEF COMPLAINT Hypertension. Alcohol use disorder. HISTORY OF PRESENT ILLNESS Amanda Taylor is an 72-year-old woman who presents for a follow-up for hypertension. History includes significant alcohol use disorder and mild hypercholesterolemia. At last visit on April 16, BP was 130/90. After presenting at 150/100 sh...
D2N143
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[doctor] next patient is grace ross . date of birth 8-23-97 . ms. ross is a new patient . she's here today for a full spectrum std testing . the patient states that she's having symptoms of discomfort , a change in discharge , and odor in her vaginal region . she says that the right side of her vagina is starting to be...
CHIEF COMPLAINT Full-spectrum sexually transmitted disease testing. HISTORY OF PRESENT ILLNESS Ms. Ross is a 23-year-old female who presents today as a new patient for full-spectrum STD testing. The patient states that she is having symptoms of discomfort, a change in discharge, and an odor in her vaginal region. S...
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[doctor] tyler nelson , date of birth : 3 , 6 , 1949 , mrn , 385729 . he is here today for ongoing management of rheumatoid arthritis . last time he was here , he received a steroid injection in his right knee . hello mr. nelson , how are you ? [patient] um , about the same as last time . my knee is still swollen . [do...
CHIEF COMPLAINT Rheumatoid arthritis management. HISTORY OF PRESENT ILLNESS Mr. Nelson is a 72-year-old male who presents today for ongoing management of rheumatoid arthritis. He was last seen by me on 03/04/2021, where he received a steroid injection to his right knee. He continues to experience right knee pain and...
D2N145
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[doctor] uh , mrn49282721 . patient's name is jacqueline miller . use last visit exam where appropriate . [doctor] hi , how are you doing , jacqueline ? [patient] i'm pretty . good . how are you ? [doctor] good as well . so it sounds like we're , um , under good control right now . [patient] yes . it's doing much bette...
CHIEF COMPLAINT Follow-up for perioral dermatitis. HISTORY OF PRESENT ILLNESS Jacqueline Miller is a 40-year-old female who is being seen today for a follow-up skin exam for perioral dermatitis. She also has a history of rosacea, including ocular rosacea. Today, she states that her perioral dermatitis is well-contro...
D2N146
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[doctor] hey good morning bobby how are you [patient] i'm doing okay i as you're aware doctor miller sent me over for this pain in my belly that i've had for several weeks they did he did an ultrasound and and said i had gallstones and they recommended i stay several way from some high fat food but i'm just still havin...
CHIEF COMPLAINT Abdominal pain. MEDICAL HISTORY Patient reports history of type 2 diabetes. SOCIAL HISTORY Patient reports enjoying nature photography. FAMILY HISTORY Patient reports family history of cholelithiasis. Both of his parents have had cholecystectomies. REVIEW OF SYSTEMS Constitutional: Reports low-...
D2N147
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[doctor] hi matthew how are you the medical assistant told me that you injured your shoulder [patient] hey yeah i'm i'm hanging in there [doctor] what happened [patient] yeah so well when i was younger i used to be a little bit more active with my friends with the playing [doctor] pick up football and so you know me be...
CHIEF COMPLAINT Right shoulder injury. HISTORY OF PRESENT ILLNESS Matthew Allen is a 67-year-old male, right-hand-dominant, male who presents to the clinic today for the evaluation of a right shoulder injury. The patient sustained this injury 4 days ago, when he was tackled a couple of times playing pick up football...
D2N148
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[doctor] hi jeremy how are you the medical assistant told me that you injured your back [patient] yeah i was moving some boxes when my son was moving out of his college dorm and i really hurt my lower back [doctor] okay how long ago did that happen [patient] this was about four months ago [doctor] about four months ago...
HISTORY OF PRESENT ILLNESS Jeremy Adams is a pleasant 57-year-old male who presents to the clinic today for the evaluation of low back pain. The onset of his pain began 4 months ago, when he was moving boxes out of his son’s college dorm. At that time, he noted tingling in his right toes, which resolved after approxim...
D2N149
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[doctor] so dennis is a 57 -year-old male today complaining of shortness of breath he has also got a history of diabetes high blood pressure and history of asthma so dennis tell me what's going on how're you doing [patient] not too good [doctor] okay how long have you been feeling not too well [patient] about a couple ...
CHIEF COMPLAINT Shortness of breath with hemoptysis. MEDICAL HISTORY Patient reports history of diabetes, hypertension, and asthma. He also has a long history of knee pain. MEDICATIONS Patient reports taking metformin and Norvasc. REVIEW OF SYSTEMS Constitutional: Denies fever. HENT: Denies bleeding gums. Respir...
D2N150
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[doctor] alright scott so so i understand that you you had some right knee injury can you tell me a little bit about what happened [patient] yeah i was trying to go out and play some pickup soccer games over the weekend and went to go plank kick the ball and and just felt a pop in my right knee [doctor] okay and and ho...
CHIEF COMPLAINT Right knee injury. HISTORY OF PRESENT ILLNESS Scott Miller is a pleasant 36-year-old male who presents to the clinic today for the evaluation of a right knee injury. The injury occurred 3 days ago, when he was playing pickup soccer games and felt a pop in his right knee. He reports swelling at the ti...
D2N151
aci
[doctor] alright teresa i see here in your chart that you seem to be experiencing some elbow pain could you tell me where it hurts [patient] yeah so it's hurting on the inside of my elbow [doctor] mm-hmm [patient] and when i i i've been doing some pottery i've been creating you know i have a pottery wheel and i've been...
CHIEF COMPLAINT Right elbow pain. HISTORY OF PRESENT ILLNESS Teresa Sullivan is a pleasant 33-year-old female who presents to the clinic today for the evaluation of right elbow pain. Her pain began 4 days ago, without any improvement. She denies any specific injury; however, she has recently increased her usage of a...
D2N152
aci
[doctor] good morning noah tell me a little bit about why you are here today [patient] hi document i'm i'm just had you know the back pain you know and i've i've had it for you know about a week and [doctor] oh [patient] you know i mean i tried some you know i mean medications but you know some over the counter stuff b...
CHIEF COMPLAINT Back pain. MEDICAL HISTORY Patient reports history of diabetes. SOCIAL HISTORY The patient's family owns and runs a bakery. MEDICATIONS Patient reports taking metformin twice daily. REVIEW OF SYSTEMS Musculoskeletal: Reports back pain. Neurological: Denies numbness or tingling in feet. PHYSICA...
D2N153
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[patient] i hope i did n't hurt it again [doctor] hi gregory how are you i the medical assistant told me that you injured your knee [patient] yeah yeah i heard it stepping off a curb [doctor] how long ago did that happen [patient] about two and a half weeks ago [doctor] two and a half weeks ago and what what knee is bo...
HISTORY OF PRESENT ILLNESS Gregory Price is a pleasant 68-year-old male who presents to the clinic today for the evaluation of a right knee injury. The onset of his pain began 2.5 weeks ago, when he stepped off of a curb and turned over his ankle. He locates his pain to the lateral aspect of his right knee. The patien...
D2N154
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[doctor] hi dennis how are you today [patient] good [doctor] so what what brings you into the office i do n't believe i have ever seen you before here [patient] the i'm training for a triathlon and the back of my heel hurts typically after a workout or when i first get up in the morning it will really hurt in the back ...
HISTORY OF PRESENT ILLNESS Dennis Martin is a pleasant 46-year-old male who presents to the clinic today for the evaluation of right heel pain. The onset of his pain began 10 days ago while training for a triathlon. He locates his pain to the posterior aspect of his heel, which radiates proximally into his calf. His p...