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Doctor: Any specific family medical history that I should be aware of?
Patient: No.
Doctor: Anyone in your family, even grandparents, if you know them, did they have diabetes or high blood pressure?
Patient: No.
Doctor: Anyone else sick at home?
Patient: No. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Noncontributory. No one else at home is sick. |
Doctor: What is your family medical history?
Patient: My mother has high blood pressure, and she had a stroke last year.
Doctor: Is your mother still with us after the stroke?
Patient: Yeah. She is doing well.
Doctor: Good. What about your father's medical history?
Patient: My father died in a car accident, when he was forty.
Doctor: I am so sorry to hear that.
Patient: Thank you. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Mother is alive and has a h/o HTN and stroke. Father died in motor vehicle accident at age 40 years. |
Doctor: Anyone in your family have a history of drug or alcohol abuse?
Patient: No.
Doctor: Any other medical conditions that might run in your family?
Patient: Nope. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Noncontributory. |
Doctor: Do you drink?
Patient: Like, every day?
Doctor: No, just in general.
Patient: No, I don't drink at all.
Doctor: Do you smoke?
Patient: No, I don't do that at all, either. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient does not smoke nor drink alcohol. |
Doctor: Any drug allergies?
Patient: Ah yes, I am allergic to... what's the name of the drug? It's called Napro-
Doctor: Naprosyn?
Patient: Yes, Naprosyn. | Section Header: ALLERGY
Summary: Naprosyn. |
Doctor: Hi, how old are you madam?
Patient: I am ninety three. I am a super duper old Swedish woman.
Doctor: Ha! Not so old okay!
Patient: I had vomiting episodes and I am feeling very nauseous.
Doctor: Oh I am so sorry to hear that.
Patient: I have pain in urination too, I think I might have the U T I?
Doctor: Let's see here. So you already have a right hip issue, bone disease, hypertension, depression, and heart rhythm disorder for a long time.
Patient: Yes that is correct.
Doctor: Let me see what we can do here.
Patient: Thank you doctor. | Section Header: PLAN
Summary: The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection. |
Doctor: Do you drink?
Patient: No, never!
Doctor: Did you ever smoke?
Patient: No.
Doctor: How about drugs? Marijuana or anything?
Patient: Well, I always stayed away from drugs.
Doctor: Good. And what is your living arrangement? Do you stay with your kids?
Patient: I live at my place. My kids visit me but mostly I live alone.
Doctor: Okay. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: No history of smoking, alcohol, or drug use. She lives at home. |
Doctor: Good afternoon, how old are you?
Patient: Hello Doctor, I'm fifty four years old.
Doctor: What gender do you identify with?
Patient: I identify as a female.
Doctor: Thank you. What symptoms are you experiencing in your right hand?
Patient: I have numbness and tingling in my right hand.
Doctor: Are there any specific fingers that you feel it in?
Patient: I really feel it in my fifth, fourth, and third fingers.
Doctor: What kind of treatments have you done for this pain?
Patient: I've taken antiinflammatories, stayed away from sports and stuff like that, and rested.
Doctor: Has this helped at all?
Patient: No, not at all, its still numb and tingling.
Doctor: This sounds like carpal tunnel, there's a quick, minimally invasive surgery I can do on this hand, since it hasn't responded to nonoperative treatments. I think that'll really help.
Patient: I'd like to do that, what's the name of the procedure?
Doctor: Its called a carpal tunnel release. | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management. |
Guest_family: Congestion and cough.
Doctor: Oh, how long?
Guest_family: It's been three weeks now.
Doctor: Okay.
Guest_family: He has been like this for so long, but nothing else.
Doctor: How about fever nausea vomiting diarrhea?
Guest_family: No fever, no vomiting, nothing else.
Doctor: Okay great. | Section Header: REVIEW OF SYSTEMS
Summary: He has been congested for about three weeks ago. Coughing now but no fevers. No vomiting. Review of systems is otherwise negative. |
Doctor: What do you do? Are you working or in school?
Patient: I am in school.
Doctor: Good.
Patient: Thanks. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient is currently in school. |
Doctor: Do you have any children, ma'am?
Patient: Yes, I have a wonderful baby girl at home.
Doctor: Wonderful, were there any complications with your pregnancy or delivery?
Patient: Nope, everything went very smooth. I'm thankful.
Doctor: Good, have you ever been hospitalized for any issue?
Patient: No, thankfully.
Doctor: Good, so I can assume you've never had surgery?
Patient: Correct, I never have. | Section Header: HISTORY of PRESENT ILLNESS
Summary: Pregnancy and delivery with no complications. He has no history of hospitalizations or surgeries. |
Doctor: Any past surgeries that I should know of?
Patient: I had a hip replacement years ago.
Doctor: Both hips?
Patient: My left.
Doctor: Total?
Patient: Yeah.
Doctor: Got it.
Patient: I also had my uterus and appendix removed. I was young when I had my appendix taken out.
Doctor: Do you happen to remember who did your most recent surgeries?
Patient: Wish I did. I'd have to look back at my records and get back to you. I have everything at home.
Doctor: That's no problem. I should be able to look it up from my end, too. | Section Header: PAST SURGICAL HISTORY
Summary: Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age. |
Doctor: Where do you live?
Patient: I live with my mother around the corner where the Whole Foods is. I have been there for a few years now.
Doctor: Are you the mother of the patient?
Guest_family: Yes, I'm the mother.
Doctor: How are you dealing with everything?
Guest_family: We just want what is best for him. We want to support him in every possible way. He has only one elder sister. She lives in Texas and she also wants the same for him. Before he started living with us, he has been living in the A B C D places and some were in very bad condition. He was not striving there. That's why we asked him to move in with us. | Section Header: REVIEW OF SYSTEMS
Summary: PSYCHIATRIC: The patient lives with his mother and has been staying with her for a few years now. We have talked to her. She is very supportive. His only sister is also very supportive of him. He has lived in the ABCD houses in the past. He has done poorly in some of them. |
Doctor: Are you taking any medications?
Patient: Yes, I am taking Accutane for my acne issues.
Doctor: Okay, any other medicines?
Patient: No, just that.
Doctor: Okay. | Section Header: MEDICATIONS
Summary: Accutane and takes no other medications. |
Doctor: Do you have any history of surgeries, sir?
Patient: The most recent was seven years ago. I had a craniotomy. I had a brain hemorrhage and there was bleed inside and outside the brain that they had to fix.
Doctor: How was the recovery for that?
Patient: I took a while but the doctors said I had a normal recovery time.
Doctor: That is good. Have you had any other surgeries?
Patient: I had surgery on my leg for a fracture. They put some pins in my leg.
Doctor: Okay.
Patient: I had some kind of surgery done on my stomach when I was a kid. I am not sure what the surgery was. All I know is that it was a very common procedure with no complications.
Doctor: Okay. Is that all?
Patient: Yep. That's it. | Section Header: PAST SURGICAL HISTORY
Summary: 1. He has a surgery on his stomach as a child. He does not know the type. 2. Surgery for a leg fracture. 3. Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma. |
Doctor: Do you have any past medical problems that I should know about?
Patient: Well, what exactly do you mean by that, doctor?
Doctor: Well, it could be anything from A D H D to depression to epilepsy.
Patient: Oh, no. I don't have anything like that. | Section Header: PAST MEDICAL HISTORY
Summary: No significant past medical problems. |
Doctor: So, lets talk about your family, anybody in your family have any neurological problems?
Patient: No, I don't think so, my parents did experience some memory loss but that was when they were in their nineties. And I am assuming it was mostly from the old age rather than any neuro problem.
Doctor: Yeah, that is true. And how about your brothers and sisters, do you have any?
Patient: Oh yeah, I have five siblings and they are pretty healthy! I mean all of them are doing good, no one has any memory issues as far as I know or any neuro related illness.
Doctor: Okay. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family. |
Doctor: Do you have any family history of heart disease?
Patient: My mother has coronary artery disease. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Mother with history of coronary artery disease. |
Doctor: Hello, miss X Y Z. Dr. X and I will go over your report with you to make sure everything is correct. Then, I will ask you a few questions.
Patient: Sounds good to me.
Doctor_2: Hi, ma'am. Could you confirm your age for me, please?
Patient: I'm seventy six years old. I'm also a resident of A S D F if that matters.
Doctor_2: Thank you, ma'am.
Doctor: Doctor A B C requested for you to see us, correct?
Patient: That's correct.
Doctor: Perfect. Doctor X, could you go over her previous diagnoses?
Doctor_2: She is diagnosed with hyperlipidemia, hypertension, and atherosclerotic cerebrovascular disease. Is this all correct, ma'am?
Patient: Sounds about right.
Doctor: I see she underwent a procedure. What was it, Doctor X?
Doctor_2: She underwent a decompression for L three and L four. Did Doctor Stanley Gertzbein perform this procedure for your back?
Patient: He did. He also did surgery on my lower legs.
Doctor_2: Thank you for confirming.
Doctor: I see after the surgery, you had some pain in your right L four distribution, correct?
Patient: That's correct.
Doctor: Doctor X, did the M R I report of the outside lumbar come in?
Doctor_2: It did. We also have a report of a lumbar C T myelogram, but no films came.
Doctor: What does the C T myelogram say?
Doctor_2: It says she has spondylolisthesis and L four and L 5 stenosis with right posterior surgical fusion changes at both levels.
Doctor: I see. There are some notes from Doctor Reitman. What does it say?
Doctor_2: It looks like she is being sent for an L four selective nerve root block to rule out if she would be a candidate for a T L I F at L four and L 5.
Doctor: I see. Could you review the M R I film as well?
Doctor_2: The M R I reveal a grade two L four anterior spondylolisthesis without major canal stenosis. She does, however, have facet joint disease at this level and dorsal postoperative changes. She also has a foraminal disc protrusion on the right and a severely degenerated disc at L three and L four.
Doctor: Thank you for that. So, miss. Where are you feeling pain today?
Patient: I feel it in the font of my lower leg and right hip.
Doctor: What kind of pain are you feeling?
Patient: I told Doctor X about it. He could let you know.
Doctor_2: She claimed she had a burning, shooting, aching, and constant pain in nature.
Doctor: I see. Is it worse when you do certain activities?
Patient: Yes. When I walk and stand.
Doctor: Are you able to walk at all?
Patient: I can walk around a block before it gets to the point where I get weak.
Doctor: When does it feel better?
Patient: I feel more comfortable when I'm resting, sitting, sleeping, or getting a massage.
Doctor: From a scale of zero to ten, with ten being the worst pain, how would you rate the pain on average?
Patient: I'd say like a nine.
Doctor: That's the intensity on a daily level, correct?
Patient: Yeah, that's correct.
Doctor: What's the lowest pain you've ever felt?
Patient: I think it was a five.
Doctor: I see. Doctor X, did you ask her the series of questions about bowel function?
Doctor_2: I did. She denied any bowel or bladder dysfunction, saddle area hypoesthesia, numbness, tingling, weakness or Valsalva related exacerbation.
Doctor: Great. Have you taken any medication recently?
Patient: Uh. I think it starts with a T.
Doctor_2: It states here you took Tylenol, correct?
Patient: That's correct. | Section Header: HISTORY of PRESENT ILLNESS
Summary: Ms. XYZ is a 76-year-old resident of ASDF. She is seen at the request of Dr. ABC. She carries a diagnosis of hyperlipidemia, hypertension, and atherosclerotic cerebrovascular disease. She underwent an L3-4 decompression in Month DD, YYYY by Dr. Stanley Gertzbein for back and bilateral lower extremity pain. Shortly after surgery, she began having pain in the right L4 distribution and is seen today with an outside lumbar MRI only. I have a report of a lumbar CT myelogram as well, but no films. She has apparently spondylolisthesis and L4-5 stenosis with right posterior surgical fusion changes evident at both levels. According to Dr. Reitman's notes, she is being sent for an L4 selective nerve root block to rule out whether or not she would be a candidate for a TLIF at L4-5. Her MRI films are reviewed. These reveal grade 2 L4 anterior spondylolisthesis without significant canal stenosis, though she has facet joint arthropathy at this level and dorsal postoperative changes. She has a foraminal disc protrusion on the right, as well as a severely degenerated disc at L3-4. The patient complains essentially of pain along the anterior tibia and along the right hip, which his burning, shooting, aching and constant in nature. It is worse with standing and walking. She can walk about a block before her symptoms become debilitating. She is more comfortable in recumbency. She denies bowel or bladder dysfunction, saddle area hypoesthesia, numbness, tingling, weakness or Valsalva related exacerbation. She rates her pain as 9/10 in average and her daily level of intensity and 5/10 for her least level of pain. Alleviating factors include sitting, recumbency, sleeping, and massage. She treats her pain with Tylenol currently. |
Patient: Um, do I have to follow some special or soft diet?
Doctor: No, nothing like that. You can have a normal diet. Whatever you like to eat.
Patient: At this age, my diet is very limited. I am going to be eighty-two next month.
Doctor: Well, I don't think you need to restrict your diet. You can follow your regular diet.
Patient: Alright, thank you. | Section Header: PLAN
Summary: Regular for age. |
Doctor: Do migraine headaches run in the family?
Patient: My mother gets migraines and she told me that it runs on her side of the family.
Doctor: Any family history of blood clots?
Patient: No. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Migraine headaches on maternal side, including her mother. No family history of thrombosis. |
Doctor: Are you married?
Patient: I was, but my husband died thirty years ago.
Doctor: Are you working?
Patient: Nope.
Doctor: What is your highest degree?
Patient: I did high school. I was living alone for fifteen years until December of ninety four.
Doctor: How is your living situation now? Who is taking care of you?
Patient: My daughters have started taking care of me on a shareable basis.
Doctor: Do you smoke? Or drink or have ever used any drugs.
Patient: Nope. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use. |
Doctor: Do you smoke, or have you smoked in the past?
Patient: Yeah, I quit two years ago. But before that I used to smoke two packs per day. I first started smoking as a teenager.
Doctor: Do you drink at all?
Patient: I used to drink six packs of beer plus two additional drinks a day for many years. Good news is that I've been dry for two years now.
Doctor: Any illicit drug use, such as cocaine, marijuana or heroin?
Patient: No none of that. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: 2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use. |
Doctor: Hello, miss. How are you doing today? It looks like we are evaluating C O P D and emphysema.
Patient: Yes, the last time I was seen in Pulmonary Medicine Clinic was March two thousand and four.
Doctor: It has been quite some time. How are you feeling?
Patient: I have actually been hospitalized for psychiatric problems and now live in a nursing facility. Things have not been too great. I don't like living there.
Doctor: I understand the frustration. When you live in a nursing facility you lose a lot of your freedom.
Patient: I want to live back in my apartment, but I know I am too ill to care for myself.
Doctor: In spite of all of that how are your respiratory issues?
Patient: I feel pretty stable. I still have shortness of breath when I do activities, but with my condition I feel like that is something I will have to live with.
Doctor: Unfortunately, that is the nature of the disease. I am happy to see that the pulmonary disease has not changed significantly since your last visit.
Patient: The only thing that seems to have changed is that I have a small cough and produce some mucus.
Doctor: Okay. Do you have any fever or chills?
Patient: No, none of that.
Doctor: Do you experience any chest pains? I want to check especially since you have been coughing up some mucus.
Patient: No, I luckily do not have any chest pains. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient returns to the Pulmonary Medicine Clinic for followup evaluation of COPD and emphysema. She was last seen in the clinic in March 2004. Since that time, she has been hospitalized for psychiatric problems and now is in a nursing facility. She is very frustrated with her living situation and would like to return to her own apartment, however, some believes she is to ill to care for herself. At the present time, respiratory status is relatively stable. She is still short of breath with activity, but all-in-all her pulmonary disease has not changed significantly since her last visit. She does have occasional cough and a small amount of sputum production. No fever or chills. No chest pains. |
Doctor: You can continue working, I just want you to be careful.
Patient: Thanks Doctor. I will be.
Doctor: Great. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: He was released to regular work. |
Doctor: Can you confirm your age for me, ma'am?
Patient: Sure, I'm fifty six years old.
Doctor: Great, so what brings you in to see me today?
Patient: Um, I'm peeing a lot, and I'm having a little bit blood in that urine as well.
Doctor: Have you ever had a cystoscopy?
Patient: Yes, it was unremarkable, that's what they told me.
Doctor: When are your episodes for the most part?
Patient: Um, usually during the day. I don't usually have them at night.
Doctor: Are you having any pain with urination?
Patient: No, no pain.
Doctor: Aside from the little bit of blood, can you tell if there's any pus in your urine?
Patient: No, I don't have any of that, it's just the little bit of blood.
Doctor: Have you taken any medications for this?
Patient: Um, I had Ditropan, and it didn't do very well.
Doctor: Well, this ultrasound of the kidney is also unremarkable, so at this time I think we should try a different medication. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night. No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms. The patient had been previously on Ditropan and did not do nearly as well. At this point, what we will try is a different medication. Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease. |
Doctor: Any health issues on your mom or dad's side?
Patient: No, we're a pretty healthy family. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Noncontributory. |
Doctor: Hello sir, how are you?
Patient: I don't know, I don't know whether I am good, or my problem is getting worse and that is the reason I got myself to your clinic for a neurological consult.
Doctor: Hm, don't worry! We will take care of you, let me start by taking some details.
Patient: Sure!
Doctor: So were you referred by someone or-
Patient: Oh, no I referred myself to your clinic.
Doctor: Okay. And what is your age?
Patient: I am sixty four years young!
Doctor: Ah, that's clever, you certainly look very young. And which is your dominant hand? Are you left handed, or right?
Patient: I am right handed.
Doctor: So, tell me what is going on with you?
Patient: Well, lately I am having difficulty remembering names and phone numbers or even events.
Doctor: Well, it's not uncommon.
Patient: I know, but I am usually very good at remembering things. I would have not worried that much, but it was brought to my attention by my clerical staff.
Doctor: Oh, okay. What do you do?
Patient: Well, I was the catholic priest at my parish, like we have our own small administrative district and church.
Doctor: Okay, and when did you notice first that you are forgetting things?
Patient: Around twelve months back.
Doctor: And did it cause any problem at work or any mishaps?
Patient: No, not at all! No social or professional faux pas whatsoever.
Doctor: Okay, I have my notes let me put the date, oh what is the date-
Patient: It's twenty eighth of February.
Doctor: Thank you! | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral. |
Doctor: All right, you can go home now.
Patient: Thank you doctor.
Doctor: You can stay at your friend's place and make sure to take good care of yourself.
Patient: Yes.
Doctor: Make sure you follow up with Doctor X on Monday or Tuesday. I know that Doctor Y already discussed his plans. Continue taking your medicines except Prozac. Okay? | Section Header: DISPOSITION
Summary: She is being discharged to home. She will stay with a friend for a couple of days. She will be following up with Dr. X on Monday or Tuesday. Apparently Dr. Y has already discussed the situation and the plan with her. She will continue on her usual medications except for discontinuing the Prozac. |
Doctor: Do you smoke or drink?
Patient: Nope, I've never touched a cigarette nor do I plan on ever doing so. Same goes for alcohol. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She does not drink or smoke. |
Doctor: Hi there! Welcome to the Neurology clinic, sir.
Patient: Hi! Thank you.
Doctor: What brings you in to the clinic today?
Patient: I was diagnosed with binocular diplopia twenty five years ago but I haven't had much of an issue with it until about a year ago.
Doctor: What did you notice as far as symptoms?
Patient: Suddenly, I started having double vision.
Doctor: Did the double vision happen more than one time?
Patient: It has been happening almost every day off and on through out the day.
Doctor: How long do the episodes last?
Patient: They last for only a few minutes at a time. When I was first diagnosed years ago it happened for a year and then it stopped happening. It was not happening as often as it is now.
Doctor: Did you ever receive any treatment for your binocular diplopia?
Patient: No. It spontaneously resolved and so I didn't need to seek any treatment. Back when all this was happening it had two episodes of a drooping eyelid. I thought I had myasthenia gravis but I was told that that was probably not the case.
Doctor: What eyelid was drooping?
Patient: I don't remember?
Doctor: What is your dominate hand?
Patient: I am right handed.
Doctor: And how old are you?
Patient: I am sixty seven.
Doctor: Involving the double vision, does it become worse when looking at distant objects?
Patient: Yes.
Doctor: When you look at objects off to either side of midline does it become worse?
Patient: Yes. That makes it worse too. When I put my hand over one eye is goes away.
Doctor: Do you have any other symptoms related to the vision issues?
Patient: No. | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia. |
Doctor: How old is your son?
Guest_family: He is almost five and a half years old now.
Doctor: What seems to be the problem?
Guest_family: He has a lot of pain about both feet, and if you look at it, it looks like his feet rotate inwards.
Doctor: Okay, let me see, okay, um, he has rocker bottom feet.
Guest_family: Okay.
Doctor: I believe he would benefit from a subtalar arthrodesis, possible autograft, and lengthening of the Achilles. I'll go over the details of that procedure right now.
Guest_family: Can we do the surgery soon?
Doctor: Yes we can. But we'll probably need to do another procedure until his foot matures some more. This is a stabilizing measure.
Guest_family: What are the risks of infection if we do the surgery?
Doctor: Historically, the risk of infection is very low, usually less than one percent.
Guest_family: How do you get the risk so low?
Doctor: We use prophylactic antibiotics to minimize the infection risk.
Guest_family: Will he be able to walk again right after the surgery?
Doctor: No, he'll need to stay off it for a while, we call this nonweightbearing. It will only be for some time after the procedure, it's not permanent.
Guest_family: What are the rest of the risks?
Doctor: The total risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. I would not worry about these risks, though. The risk is low.
Guest_family: Okay. Let's do the surgery. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 5-year-4-month-old male who presents for evaluation of feet. He has been having significant feet pain with significant planovalgus deformity. The patient was noted to have flexible vertical talus. It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening. This was explained to the mother in detail. This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature. Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. All questions were answered and the mother agreed to the above plan. |
Doctor: Welcome back to the clinic.
Patient: Thank you.
Doctor: I understand that we are doing an impairment rating exam today.
Patient: Yes, that's correct.
Doctor: And we are evaluating your right shoulder injury. Correct?
Patient: Yes.
Doctor: Was this a workrelated injury?
Patient: Yes. I was working as a C N A at the Veteran's House.
Doctor: How did the work injury happen?
Patient: I was transferring a patient from a wheal chair to a bed, and I hurt my shoulder.
Doctor: What is the date of the incident?
Patient: January first, two thousand and two.
Doctor: Are you currently working?
Patient: No. I have not been able to go back to work yet.
Doctor: I am required to ask some specific questions for the L and I paperwork. What is your ago, ethnicity and gender?
Patient: I am a thirty one year old, white, female.
Doctor: Have you ever had a prior injury to your right shoulder?
Patient: No.
Doctor: Are right or left hand dominant?
Patient: Right.
Doctor: Other then your shoulder injury, do you have any other chronic health problems?
Patient: No.
Doctor: Are you experiencing any fever, chills or illnesses?
Patient: No.
Doctor: Let discuss some of the previous treatments and test that you have been done for your shoulder.
Patient: Okey. I have done a lot of different treatments.
Doctor: What treatments have you done?
Patient: I tried physical therapy. They did a subacromion decompression treatment in November, two thousand and two.
Doctor: Did either of those treatments help?
Patient: Not much. I went and saw Doctor Lin and he said that I might have a nerve fiber injury. I forget what he called it.
Doctor: Brachial plexopathy?
Patient: Yes. That sounds right.
Doctor: Oh, I see his notes in your chart. It says that he felt like you had a right superficial radial neuritis and blocked this with resolution of your symptoms. Then it looks like he sent you to get E M G testing at Valley Medical. Let me look for those results.
Patient: Okey. They should be in my chart. I had Doctor Lin send over all my records.
Doctor: Here it is. It says that the right suprascapular neuropathy although a C5 radiculopathy could not be ruled out. MRI testing on the cervical spine was then done which was negative for disk herniation and underwent suprascapular nerve decompression of the scapular notch on December eighteenth, two thousand and three.
Patient: Whatever that means? I ended up getting a nerve block because I was still in pain. Doctor Lin did one in the frount of my shoulder and then another in the back.
Doctor: This has been a long drawn out course of treatments for you.
Patient: Yes, it has been. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a pleasant, 31-year-old, right-handed, white female who injured her shoulder while transferring a patient back on 01/01/02. She formerly worked for Veteran's Home as a CNA. She has had a long drawn out course of treatment for this shoulder. She tried physical therapy without benefit and ultimately came to a subacromion decompression in November 2002. She had ongoing pain and was evaluated by Dr. X who felt that she had a possible brachial plexopathy. He also felt she had a right superficial radial neuritis and blocked this with resolution of her symptoms. He then referred her to ABCD who did EMG testing, demonstrating a right suprascapular neuropathy although a C5 radiculopathy could not be ruled out. MRI testing on the cervical spine was then done which was negative for disk herniation and she underwent suprascapular nerve decompression of the scapular notch on 12/18/03. She finally went to an anterior axillary nerve block because of ongoing pain in the anterior shoulder again by Dr. X. She comes to me for impairment rating. She has no chronic health problems otherwise, fevers, chills, or general malaise. She is not working. She is right-hand dominant. She denies any prior history of injury to her shoulder. |
Doctor: Are you up to date on your vaccines?
Patient: I've actually never been vaccinated before. My parents don't believe in vaccines. | Section Header: IMMUNIZATIONS
Summary: None. |
Doctor: Hi there! Welcome in, sir.
Patient: Hi! Thank you.
Doctor: What is your past medical history?
Patient: No. I don't have any health problems.
Doctor: Do you have a primary care doctor?
Patient: No. I don't have health insurance right now. | Section Header: PAST MEDICAL HISTORY
Summary: The patient denies any previous past medical history. He currently does not have a primary care physician as he is uninsured. |
Doctor: Are you married, ma'am?
Patient: Yes.
Doctor: Do you smoke, use alcohol or use recreational drugs?
Patient: No. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She is married. She does not smoke, use alcohol or use illicit drugs. |
Patient: In the past I was very very fat! Actually, I was morbidly obese. I also had high blood pressure, but after my surgery it got resolved.
Doctor: So, everything is okay now?
Patient: Yeah. | Section Header: PAST MEDICAL HISTORY
Summary: Significant for hypertension and morbid obesity, now resolved. |
Doctor: So, you were referred by Doctor X.
Patient: Yeah.
Doctor: According to him, I see no changes or correction to your present illness, right?
Patient: Yeah, I think so. | Section Header: HISTORY of PRESENT ILLNESS
Summary: As per Dr. X without any changes or corrections. |
Doctor: Do you have any related family history?
Patient: You mean like heart issues in the family?
Doctor: Yeah, something like that.
Patient: My brother died of heart attack. It was sudden everyone was shocked.
Doctor: How old was he?
Patient: He was not that old; he was just in his fifties. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She states her brother died of an MI suddenly in his 50s. |
Doctor: So, tell me what's going on? What brings you to the emergency?
Patient: I felt like my heart will explode. I have never felt palpitations like this. I am feeling so weak.
Doctor: When did it start?
Patient: This afternoon.
Doctor: Hm, so your blood pressure is one ninety five by eighty three and your heart rate is one twenty one which is quite high.
Doctor: We have started you on I V Metoprolol. This will help to bring your heartrate down.
Doctor: And you said you are sixty six?
Patient: Yes.
Guest_family: My mom has stopped taking her medications.
Doctor: I can tell from her reports. Her blood pressure is quite high.
Guest_family: It's been several months since she last took her medicines.
Doctor: Well, that's not good!
Doctor: And does she drink and smoke?
Guest_family: Yes, both.
Doctor: How much do you drink Ma'am? Is it occasional?
Guest_family: She drinks a lot!
Patient: Well, I drink about four to five glasses of wine every day. I drank last night.
Doctor: Well, I think you need to cut down on it.
Patient: I am trying doctor and honestly these are all withdrawal symptoms. I have never felt like this before.
Doctor: Hm, I understand. For now I have put you on five M G of Metoprolol and looks like your blood pressure is under control and your heart rate has come down to seventy. | Section Header: HISTORY of PRESENT ILLNESS
Summary: This 66-year-old patient has history of hypertension and has not taken medication for several months. She is a smoker and she drinks alcohol regularly. She drinks about 5 glasses of wine every day. Last drink was yesterday evening. This afternoon, the patient felt palpitations and generalized weakness and came to the emergency room. On arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83. The patient received 5 mg of metoprolol IV, after which heart rate was reduced to the 70 and blood pressure was well controlled. On direct questioning, the patient said she had been drinking a lot. She had not had any withdrawal before. Today is the first time she has been close to withdrawal. |
Doctor: Hello, how are you today?
Patient: I am here for a breast cancer screening.
Doctor: Have you gotten a mammogram before?
Patient: Yes, I have. I also try to keep up with my self examinations every few weeks.
Doctor: That is great. I am happy to see you on top of your preventative healthcare.
Patient: I try to be as careful as I can since my sister had breast cancer. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Her sister had breast cancer. |
Doctor: Good morning, sir.
Patient: Good morning, doctor.
Doctor: So, what seems to be the problem today, sir?
Patient: Well, I've had toe problems in the past.
Doctor: I see, what about the rest of the lower body, any problems there?
Patient: Actually, yes, I've had left knee issues in the past, too. | Section Header: PAST MEDICAL HISTORY
Summary: He has had toe problems and left knee pain in the past. |
Doctor: Do you have a history of any health conditions that I should be aware of, ma'am?
Patient: Um, yeah, I had a mastectomy, and chest tube placement.
Doctor: Oh, wow. Do you have any chronic conditions?
Patient: Yeah, I have chronic A F I B. | Section Header: PAST MEDICAL HISTORY
Summary: History of mastectomy, chest tube placement, and atrial fibrillation; chronic. |
Doctor: How have you been handing erectile dysfunction since your last visit, sir?
Patient: Well, I've been taking the Cialis, it's the, um, ten M G version.
Doctor: Have you seen any improvement?
Patient: Yes, I've had some, which is good.
Doctor: Have you had any side effects?
Patient: No, none yet.
Doctor: Good, can you describe your erections for me, sir?
Patient: Well, they're firm now, and I can penetrate again for about ten minutes.
Doctor: Good, are you having any chest pain?
Patient: No sir, I stopped using my nitroglycerin too.
Doctor: Good, are you having any fever or chills?
Patient: No, nothing like that.
Doctor: Are you having any pain with urination, or blood in the urine?
Patient: No, nothing like that, sir, everything is normal.
Doctor: How often do you urinate during the day?
Patient: I go about every three hours or so, I have a good stream and everything.
Doctor: Do you wake up at night to go to the bathroom?
Patient: No, I sleep through the night very well.
Doctor: Good, do you have any other conditions that I should know about?
Patient: Well, I have a history of elevated P S A, and I had a biopsy in June when I had a, um, high grade P I N.
Doctor: Do you know what that P S A value was?
Patient: It was eleven point six.
Doctor: Thank you, I see here on Doctor X's notes that there were two specimens that were too small to evaluate. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient presents today for followup, history of erectile dysfunction, last visit started on Cialis 10 mg. He indicates that he has noticed some mild improvement of his symptoms, with no side effect. On this dose, he is having firm erection, able to penetrate, lasting for about 10 or so minutes. No chest pain, no nitroglycerin usage, no fever, no chills. No dysuria, gross hematuria, fever, chills. Daytime frequency every three hours, nocturia times 0, good stream. He does have a history of elevated PSA and biopsy June of this year was noted for high grade PIN, mid left biopsy, with two specimens being too small to evaluate. PSA 11.6. Dr. X's notes are reviewed. |
Doctor: I am afraid, I don't have better news for you, your reports confirm cancer.
Patient: We were suspecting it all along, but now since it is confirmed it's just hard to accept.
Doctor: I am sorry, I totally understand. Do you want some time?
Patient: No, I am okay.
Doctor: Hm, you also have hypertension and diabetes.
Patient: Yeah, that I know.
Doctor: Did you have any chest pain or shortness of breath or uneasiness?
Patient: No, I don't have any heart condition.
Doctor: Okay and no dizziness or loss of consciousness or stroke like symptoms?
Patient: No.
Doctor: Okay. Well, your B M I looks fine, that means you are not overweight.
Patient: Hm. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Positive for hypertension, diabetes, and cancer. Negative for heart disease, obesity or stroke. |
Doctor: Are you married?
Patient: Yes. I am happily living together with my husband and my four kids.
Doctor: Oh, do you smoke?
Patient: Nope.
Doctor: What about alcohol or any other kind of drug use?
Patient: Nope. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use. |
Doctor: Anyone in the family had any medical issues?
Patient: Oh yes.
Doctor: Can you please elaborate?
Patient: So, my mother's side family had heart issues. My dad's sister had sugar problem. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: There was a history of coronary artery disease and diabetes mellitus in the family. |
Doctor: And you are not allergic to anything right?
Patient: That's right.
Doctor: Any drugs or pollens or anything?
Patient: Nope nothing.
Doctor: Good. | Section Header: ALLERGY
Summary: No known allergies. |
Doctor: Has the redness worsened over the last few days?
Guest_clinician: I think so. Her right big toe looks worse to me.
Doctor: Is she otherwise healthy?
Guest_clinician: Um besides her toe and some nasal congestion, she's doing fine. | Section Header: REVIEW OF SYSTEMS
Summary: She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness. Review of systems is otherwise negative. |
Doctor: You had a surgery on your breasts?
Patient: Yes, they removed lump from my left breast.
Doctor: Okay, and what other surgeries have you had?
Patient: I do not have a gall bladder, then I had a breast augmentation, I have had heart surgeries three times and they have removed half of my pancreas.
Doctor: Okay.
Patient: And knee surgery too, on the left side.
Doctor: Okay. What type of heart surgery did you have?
Patient: Cardiac ablation. | Section Header: PAST SURGICAL HISTORY
Summary: Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas. |
Doctor: What happened?
Guest_clinician: She was brought to emergency by her son. Apparently, she is doing fine, no distress. She is alert, and I was able to communicate with her and take her history, she was cooperative and calmy responded to all my questions.
Doctor: Okay, that's good. | Section Header: EXAM
Summary: GENERAL: Alert and in no apparent distress, calm, cooperative, and communicative. |
Doctor: What is your family medical history?
Patient: My family has high blood pressure and diabetes.
Doctor: Do you have any family history of nervous system disorder or disease such as multiple sclerosis, Alzheimer's disease, Parkinson's disease, epilepsy, or stroke?
Patient: No.
Doctor: Do you have any children, miss?
Patient: Yes. I have a son, he was born on October thirty first, two thousand and eight. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: There is a family history of diabetes and hypertension. There is no family history of a neuropathy or other neurological disease. She has one child, a son, born on October 31, 2008. |
Doctor: Have you ever had any heart problems in the past?
Patient: I remember I did have something heart related but I don't know what that was. I do not understand any medical terms.
Doctor: Okay that's fine, I completely understand. We will try to look for your past medical history.
Patient: I do have hypertension and diabetes, you know that right?
Doctor: Yes, type two diabetes. Do you know of any other things that you had in the past?
Patient: Yes, four years back I had lung embolism. I also get frequent urine infections.
Doctor: Okay. And I can see on the file that you have high cholesterol and a gastric ulcer too.
Patient: Yes, that's about right.
Doctor: Okay. What surgeries have you had in the past?
Patient: I have had my appendix taken out, then C Section, cataract surgery and hernia repair done in the past. | Section Header: PAST MEDICAL HISTORY
Summary: She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history. She states that she has underlying history of heart disease but is not able to elaborate to any significant extent. She also has a history of hypertension and type II diabetes but is not currently taking any medication. She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections. Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair. |
Doctor: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: So, are you married?
Patient: Yes, happily to my husband.
Doctor: That's wonderful, um, what do you do for a living?
Patient: I work as an office manager right now.
Doctor: Do you smoke?
Patient: Yes, I do. I've smoked a pack a day for the last twenty years.
Doctor: Do you drink?
Patient: Actually, yes, I drink daily.
Doctor: How much do you drink every day?
Patient: Well, it varies, but usually about anywhere from three to five drinks a day.
Doctor: Okay, do you do any illicit drugs?
Patient: No, absolutely not.
Doctor: What do you do for exercise?
Patient: Well, I go for walks, and like low impact cardio. But, I do like playing softball with my friends too.
Doctor: Very nice, how often do you exercise?
Patient: I work out a few times a month. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient is married. She is employed as an office manager. She does smoke cigarettes, one pack per day for the last 20 years. She consumes alcohol 3 to 5 drinks daily. She uses no illicit drugs. She exercises monthly mainly walking and low impact aerobics. She also likes to play softball. |
Doctor: I'm going to run down a list of symptoms and I'd like you to tell me if you've experienced any.
Patient: Okay.
Doctor: Headache?
Patient: No headaches.
Doctor: Are you coughing at all? And if yes, then are you bringing up any blood with your cough?
Patient: No cough.
Doctor: Any chest pain or shortness of breath that wakes you in the middle of the night?
Patient: Nope.
Doctor: Do you feel short of breath when you move around?
Patient: Nope.
Doctor: Any visual, hearing, or swallowing problems?
Patient: None.
Doctor: And finally any changes to your bowel movements or urinary habits?
Patient: Nope. All normal. | Section Header: REVIEW OF SYSTEMS
Summary: No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND, orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI. |
Doctor: Looking at your medical history now. Any changes since your last visit?
Patient: No changes. | Section Header: PAST MEDICAL HISTORY
Summary: Otherwise reviewed and noted. |
Doctor: Hello, sir. Looks like we are here for a general wellness check?
Patient: Yes, sir. In my seventy eight years on this Earth, I have learned to take my health more seriously. I need to start catching things before they come, not after.
Doctor: I could not agree more. From your last checkup notes, it looks like you had right knee surgery and back surgery about eighteen months ago. How is that going? Any pain?
Patient: Yes, I had a right knee replacement. I am doing great so far. Nothing to complain about. I can do almost anything I desire now. It is such a good lifestyle change from before surgery.
Doctor: What do you do with your new body?
Patient: I travel every chance I get. I just got back from a cruise.
Doctor: I hope to be as agile as you when I get to retirement. Now let's check the other systems. Do you feel any type of chest pain? Any heaviness, tightness or pressure?
Patient: No, nothing like that.
Doctor: How about shortness of breath?
Patient: I only get short of breath when I walk up the stairs.
Doctor: That is decently normal. I get out of breath when walking from floor to floor in this hospital too.
Patient: I thought so. I remember being young and still struggling with stairs.
Doctor: Unfortunately, some things are just with us for life. Do you have any coughing fits or irregular heart beating?
Patient: No.
Doctor: Great! You are getting a clean bill of health from me today. On the notes it says you have Crohn's disease. Are you getting regularly checked for that?
Patient: Yes. Doctor Ferguson takes care of me for that.
Doctor: Excellent. Are you scheduled for a prostate check?
Patient: Yes, I go to Doctor Roszhart.
Doctor: You are wonderfully on top of it. What a breath of fresh air. From all of your travelling, how are your ankles? Have you noticed any swelling?
Patient: Surprisingly, from all the walking I do, I do not have any swelling. After quitting smoking ten years ago I had to get addicted to something else and that was walking and travelling. | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago. He has done well with that. He does most of the things that he wants to do. He travels at every chance he has, and he just got back from a cruise. He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations. He sees Dr. Ferguson. He is known to have Crohn's and he takes care of that for him. He sees Dr. Roszhart for his prostate check. He is a nonsmoker and denies swelling in his ankles. |
Doctor: And when did you had your last tetanus shot?
Patient: Um, I don't remember correctly, but it should be in my reports. I did have one sometime back, just don't remember when exactly.
Doctor: Ah, no problem. I see it here in your reports and it's up to date. So that's good.
Patient: Cool. | Section Header: IMMUNIZATIONS
Summary: Up-to-date. |
Doctor: So where do you stay?
Patient: I stay nearby in my apartment.
Doctor: Alone?
Patient: No, I stay with my boyfriend.
Doctor: Okay, and do you smoke and drink?
Patient: Both.
Doctor: And how much would say you smoke per day?
Patient: Well, I smoke a lot. Seven to eight packs per day.
Doctor: Oh! And for how many years?
Patient: I don't remember exactly but for many, many years, I have a long history of chain smoking.
Doctor: Hm. And alcohol?
Patient: Same, I drink heavily. I have been drinking for many years.
Doctor: Hm. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She lives with her boyfriend. The patient has a history of heavy tobacco and alcohol abuse for many years. |
Doctor: How are you, sir?
Patient: One less than sixty.
Doctor: So, what happened?
Patient: I was visiting my son in Cheyenne, Wyoming, then I on October tenth when I was taking a shower, I felt a pop in my head. I don't know what happened after that.
Guest_family: We thought he was having a long shower that day. Then about one and a half hours later my son suspected something is not right and we went up to check. There we found him unconscious on the shower floor. Our son, he then drove us back to Iowa and since then he is complaining of these headaches and that he's not feeling well. He gets unconscious or falls asleep I don't know but it is happening a lot of the time. We got him to local hospital today in the morning. It is three days after that shower incident.
Doctor: Yeah, his report says he got a hemorrhage, I mean, blood clot in his brain.
Guest_family: Yeah, after that report they transferred us to this hospital. | Section Header: HISTORY of PRESENT ILLNESS
Summary: 59y/o male experienced a "pop" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC. |
Doctor: Is this your first surgery or have you had other surgeries in the past?
Patient: This will be my second. I had a hernia repair back in O ten. | Section Header: PAST SURGICAL HISTORY
Summary: Hernia repair. |
Doctor: Where do you work?
Patient: I work at the Hilton as a head chef.
Doctor: Do you smoke or consume any form of tobacco?
Patient: Nope.
Doctor: Do you drink or have ever used any illegal drug?
Patient: No, none of that. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Employed cook. Denied ETOH/Tobacco/illicit drug use. |
Doctor: Where do you feel the most pain?
Patient: I'd have to say at the heels of my feet. I spend a lot of time on my feet at work.
Doctor: I see. What kind of shoes do you normally wear to work?
Patient: Regular tennis shoes.
Doctor: Are they cushioned?
Patient: Eh not really, but they're pretty durable.
Doctor: I'd advise getting an orthotic for your shoes to help with the heel pain and resting your feet when you're home. In the meantime, I'd like for you to see a specialist to make sure nothing else is going on.
Patient: Alright, I'm good with that plan.
Doctor: Are you having any other problems? Joint pain, difficulty walking, nausea, vomiting, or other symptoms?
Patient: No, just heel pain for now. | Section Header: REVIEW OF SYSTEMS
Summary: Positive findings of the foot that have been recorded. All other systems reviewed were negative. |
Doctor: I'm here to take your social history. So, tell me about yourself.
Patient: I was taking drugs. I tried all the methods, mainly I was using inhalation and I V drugs.
Doctor: Right now, you are on methadone, right?
Patient: Yes. I'm also going to the psychiatry department for my depression and these drug issues.
Doctor: What is your living status?
Patient: I live with my roommate. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: The patient has a history of inhalation on intravenous drug abuse. She is currently on methadone maintenance. She is being followed in Psychiatry for depression and substance abuse issues. She lives with a room-mate. |
Doctor: I will ask you a few questions about your family history, sir.
Patient: That's okay.
Doctor: Does anyone in your family ever have any medical problems?
Patient: Both of my parents had diabetes. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: His father and mother had diabetes. |
Doctor: Are you aware of any medical issues in your family?
Patient: I don't know.
Doctor: What about your paternal family?
Patient: I don't know my father. No idea about his family.
Doctor: What about your mom? Maternal family?
Patient: I have no idea. I'm not in contact with her. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She did not know her father and was not in contact with her mother. |
Doctor: Good morning, sir. Before we begin, how old are you?
Patient: Good morning, doctor. I'm forty one.
Doctor: Thank you, and how long have you had this left knee pain?
Patient: It's been about two years now.
Doctor: Is there an injury?
Patient: Yeah, I sprained my MCL while playing hockey back then.
Doctor: What kind of symptoms have you had in this knee since then?
Patient: Well, the knee locks up on me, I can't extend it all the way, and it just hurts really bad if I try to.
Doctor: Do you feel any instability?
Patient: No, not at all. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain. He has had a positive symptomology of locking and pain since then. He had no frank instability to it, however. |
Doctor: I see here that you've been feeling more short of breath.
Patient: Yes, for three days now.
Doctor: Is it worse when you exert yourself?
Patient: Um no, not really. I've had a terrible cough along with frequent headaches and chest congestion. I have also had a low fever.
Doctor: Did these symptoms start around the same time?
Patient: I think so.
Doctor: Where does your chest feel most congested? And how would you rate the pain right now? Ten being the worst.
Patient: Both sides. I'd say it's at a three currently.
Doctor: Does it send pain or numbness or tingling down your arms? How about any jaw pain as a result?
Patient: No, but it does get worse whenever I cough.
Doctor: Is this your first time experiencing this type of congestion?
Patient: Oh no. I had something like it about ten months ago.
Doctor: Did that improve on its own?
Patient: It would come and go, but over the past few days it's gotten worse. I am a strong German man so I held out coming to the doctor as long as I could.
Doctor: You are very strong! You are sixty nine though, so I don't think anyone would see it as weak if you came to the doctor more often. | Section Header: HISTORY of PRESENT ILLNESS
Summary: 69-year-old Caucasian male complaining of difficulty breathing for 3 days. He also states that he has been coughing accompanying with low-grade type fever. He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing. Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since. |
Doctor: Are you aware of any medical problems in your family?
Patient: No.
Doctor: Anyone with any heart disease or diabetes?
Patient: No. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: Unremarkable. |
Doctor: Besides pain in your left eye, are you having any other problems?
Patient: No.
Doctor: Do you happen to have a history of eye problems?
Patient: None. | Section Header: REVIEW OF SYSTEMS
Summary: Focal left eye pain without any changes in visual acuity or photophobia. He has no prior ophthalmologic problems. Review of systems for cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine, immunologic systems is negative. |
Doctor: Hello, sir how can I help you? Looks like we are talking about snoring today.
Patient: Yeah, I need to get this loud and obnoxious snoring under control. I keep waking up my partner. I have a C P A P right now because I was told I have almost severe sleep apnea.
Doctor: Yes, I see on your chart that you were given ten centimeters of H two O nasal pressure and that you predominately suffer from hypopnea. Hypopnea is shallow breathing. How has the device been working?
Patient: It definitely has reduced my snoring, but my partner keeps waking me up in the middle of the night because the mask pops off. I wear it around five to seven nights a week, but for some reason it falls off or I take it off randomly in the night. My wife usually must remind me to put it back on.
Doctor: So what is your sleep pattern now? When do you usually go to bed and wake up?
Patient: Usually I sleep around eleven or eleven thirty and wake up at six or seven on the weekends. I'll sleep in until eight or nine on the weekdays. On Saturday's I might go to sleep around midnight because I usually watch a show with my family. I feel good when I wake up though. Much less tossing and turning. The sheets are always on the bed still.
Doctor: That's some good news. I see you have lost a bit of weight too. Around fifteen to eighteen pounds is something to be proud of.
Patient: Thanks. It has been a lot of exercising and dieting. I am motivated because I want to stop snoring.
Doctor: How has work been? Do you think it has been stressful at all?
Patient: I still work at Smith Barney in downtown Baltimore. I work from around eight or eight thirty to five or five thirty. I deal with training on how to sell managed funds and accounts. I do not think I have been stressed because I am able to stay awake through my shift and even when I come home at night. I may get a little tired during hay fever season, but that is rare.
Doctor: Yes, I see that you have hay fever. Fatigue is a common symptom from the allergy. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient initially presented with loud obnoxious snoring that disrupted the sleep of his bed partner. He was found to have moderate-to-severe sleep apnea (predominantly hypopnea), was treated with nasal CPAP at 10 cm H2O nasal pressure. He has been on CPAP now for several months, and returns for followup to review his response to treatment. The patient reports that the CPAP has limited his snoring at night. Occasionally, his bed partner wakes him in the middle of the night, when the mask comes off, and reminds him to replace the mask. The patient estimates that he uses the CPAP approximately 5 to 7 nights per week, and on occasion takes it off and does not replace the mask when he awakens spontaneously in the middle of the night. The patient's sleep pattern consists of going to bed between 11:00 and 11:30 at night and awakening between 6 to 7 a.m. on weekdays. On weekends, he might sleep until 8 to 9 a.m. On Saturday night, he might go to bed approximately mid night. As noted, the patient is not snoring on CPAP. He denies much tossing and turning and does not awaken with the sheets in disarray. He awakens feeling relatively refreshed. In the past few months, the patient has lost between 15 and 18 pounds in combination of dietary and exercise measures. He continues to work at Smith Barney in downtown Baltimore. He generally works from 8 to 8:30 a.m. until approximately 5 to 5:30 p.m. He is involved in training purpose to how to sell managed funds and accounts. The patient reports no change in daytime stamina. He has no difficulty staying awake during the daytime or evening hours. The past medical history is notable for allergic rhinitis. |
Doctor: How are you feeling today?
Patient: I have a lot of anxiety.
Doctor: Anything else?
Patient: I have a lot of pain in my chest as well.
Doctor: Do you drink?
Patient: Yes, I cannot stop myself. I have tried many times but it's hard to control. | Section Header: CHIEF COMPLAINT
Summary: Anxiety, alcohol abuse, and chest pain. |
Doctor: So, do you smoke?
Patient: No.
Doctor: How about alcohol?
Patient: I drink, but just normal. I don't have any alcohol problem.
Doctor: Okay. So, no history of any drug or alcohol abuse, right?
Patient: No, not at all.
Doctor: Okay. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: He is a nonsmoker. He has been drinking alcohol today, but has no history of alcohol or drug abuse. |
Doctor: Hi, how can I help you?
Patient: I am here for a follow up on my heart rhythm problem. I think it is atrial fibrillation.
Doctor: Oh yes. You are not on Cardizem and your heart rate is up just a little bit today.
Patient: That's right. I misplaced it.
Doctor: Okay. Let me see. What symptoms are you experiencing right now?
Patient: I am feeling very dizzy. I do have some vertigo and lightheadedness.
Doctor: You are on blood thinners, right? That is Coumadin therapy? Or am I wrong here?
Patient: No, you are right but please stop the Coumadin. I am tired of these regular blood draws.
Doctor: See, I understand it is hard to control it. It is difficult to regulate that.
Patient: Yes exactly. That is why I don't want it. Give me something simple.
Doctor: Okay I will investigate it. Are you experiencing any chest pain or shortness of breath?
Patient: Oh no, I am not feeling that.
Doctor: Okay great!
Patient: Actually, I am moving around a little bit better now and my arm does not hurt.
Doctor: How about your back pain?
Patient: Um, it is improving as well.
Doctor: Okay, cool.
Patient: Yeah. | Section Header: HISTORY of PRESENT ILLNESS
Summary: ABC is in today for a followup of her atrial fibrillation. They have misplaced the Cardizem. She is not on this and her heart rate is up just a little bit today. She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy. She is very adamant that she wants to stop the Coumadin. She is tired of blood draws. We have had a difficult time getting her regulated. No chest pains. No shortness of breath. She is moving around a little bit better. Her arm does not hurt her. Her back pain is improving as well. |
Doctor: Good morning, young man.
Patient: Good morning, doctor.
Doctor: Who is this young lady, is this your grandmother, or sister?
Guest_family: Oh doctor, yes, I am his grandmother.
Doctor: Good, my chart says that you're fourteen years old. Is that correct?
Patient: Yes sir.
Doctor: Good, so what seems to be the problem today?
Patient: I've been having pain in this knee for about a month now.
Doctor: Can you remember a specific injury to this knee?
Patient: Um, yeah, I was playing basketball when I jumped, and then when I landed I felt this knee pop.
Doctor: Do you remember the date of your injury, young man?
Guest_family: Um, it was on December twenty second two thousand seven.
Doctor: Good, so how have you been treated for this so far?
Patient: We went to another clinic first, and they put me in a splint.
Guest_family: Yeah, and then they referred us over to Children's.
Doctor: Have they taken x rays yet?
Patient: Yes, I got back a few minutes ago.
Doctor: Let's have a look. Well, you broke your leg.
Patient: What, where? Can you show me?
Doctor: Right here, this is a tibial tubercule avulsion fracture with patella alta.
Guest_family: What does that mean, doctor?
Doctor: Well, he's broken his leg, and pulled some bone off by doing so. We'll need to do surgery on this.
Guest_family: Oh no, what's the name of the procedure?
Doctor: It's called an O R I F. We'll go in there with some hardware to put everything back together, and he can get on the road to healing.
Guest_family: Let me call his father while we discuss this. What's the risk of infection from this surgery?
Doctor: Historically, it's less than one percent. We use antibiotics to control for infection.
Guest_family: Okay, will he be asleep for this?
Doctor: Yes, he won't feel a thing.
Guest_family: That's good too. Will he need this hardware out in the future?
Doctor: We can remove everything once he has healed up nicely. Other risks include bleeding, changes in the sensation of the leg, hardware failure, need for post op rehab, need for hardware removal, and failure to restore extensor mechanism tension. But I would not worry about these things. I have been doing these surgeries for years and things like this rarely happen.
Guest_family: Yes, his father agrees. We're going to do the surgery. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 14-year-old male who reported having knee pain for 1 month. Apparently while he was playing basketball on 12/22/2007 when he had gone up for a jump, he felt a pop in his knee. The patient was seen at an outside facility where he was splinted and subsequently referred to Children's for definitive care. Radiographs confirmed comminuted tibial tubercle avulsion fracture with patella alta. Surgery is recommended to the grandmother and subsequently to the father by phone. Surgery would consist of open reduction and internal fixation with subsequent need for later hardware removal. Risks of surgery include the risks of anesthesia, infection, bleeding, changes on sensation in most of the extremity, hardware failure, need for later hardware removal, failure to restore extensor mechanism tension, and need for postoperative rehab. All questions were answered, and father and grandmother agreed to the above plan. |
Doctor: Good afternoon, ma'am. Can you confirm your age for me, please?
Patient: Sure, good afternoon, doctor. I'm sixty one years old.
Doctor: Great, what brings you in for a visit today?
Patient: I have some notes here with me, but I have a history of polyarteritis nodosa mononeuritis multiplex.
Doctor: Is this in your legs, or arms?
Patient: Um, it's in my legs.
Doctor: I see here that you have sleep apnea too.
Patient: Yeah, I was involved in an overnight sleep study on C P A P and oxygen.
Doctor: Why did they do this?
Patient: It was in order to determine why I had difficulty falling asleep and staying asleep.
Doctor: Have You had any other treatments?
Patient: Yeah, I had a review done while I was in the hospital about two weeks ago, I have the results right here.
Doctor: Thank you, so, how is your leg pain been managed?
Patient: Um, I take pretty substantial doses of opioids in order to control it.
Doctor: Do you have any swelling?
Patient: Yes, I take Lasix for my leg swelling.
Doctor: How do you sleep with the C P A P?
Patient: I can fall asleep with it, but I usually rip my mask off because I toss and turn.
Doctor: How would you rate your quality of sleep?
Patient: I'd, um, say it's pretty terrible. | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep. She returns today to review results of an inpatient study performed approximately two weeks ago. In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex. She also takes Lasix for lower extremity edema. The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has "terrible quality sleep." |
Doctor: Hi there, what's going on?
Guest_family: I am her daughter. I brought her to the emergency. She lives in a skilled nursing home. Today, when I went to meet her, I found her with the right side of her face drooping. I immediately rushed her here.
Doctor: Oh, you did the right thing. Ma'am, how are you feeling?
Guest_family: She has dementia, most of the time she doesn't even remember me.
Doctor: Oh, okay.How old is she?
Guest_family: She is eighty three. She also has a history of stroke after which she developed this condition where she knows what she wants to speak but is unable to make the word or sentence.
Doctor: Oh, I see. She has expressive aphasia, correct?
Guest_family: Yes, that.
Doctor: Okay, let me check her. She does have a droop to her right side of the face. Ma'am, do you feel any weakness on the right side of your body?
Guest_family: She says yes.
Doctor: She had her C T scan earlier today and I have the report. It does not show any acute attack or anything.
Guest_family: Okay!
Doctor: But it does show that she has a new onset of a stroke.
Guest_family: Is there anything to worry?
Doctor: I think we need to admit her for observation. We need to monitor her. We will also get her a proper treatment for her urinary infection which is not getting better due to resistance to the oral medicines.
Guest_family: Yeah, sounds good!
Doctor: Yeah, let me talk to the nurse.
Guest_family: Thank you. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation. While in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop. The CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications. |
Doctor: Hello, are you translating for the patient today? I am sorry, but I do not speak Spanish.
Guest_family: Yes doctor.
Doctor: My chart says this man is fifty two years old, is all of that correct?
Guest_family: Yes doctor, that's correct.
Doctor: Good, so, what seems to be the problem today?
Guest_family: He hurt himself a while back when he slipped on a grape while he was at the grocery store.
Doctor: Oh no, when was this?
Guest_family: It was on October second two thousand eight.
Doctor: Which knee did he injure?
Guest_family: Doctor, it was his left knee.
Doctor: How has he been treated for this so far?
Guest_family: He went straight to the E D immediately, and then he saw his P C P.
Doctor: What did the P C P recommend?
Guest_family: He only referred him to P T, and gave him a knee brace. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 52-year-old male, who was referred to Physical Therapy, secondary to left knee pain. The patient states that on 10/02/08, the patient fell in a grocery store. He reports slipping on a grape that was on the floor. The patient states he went to the emergency room and then followed up with his primary care physician. The patient was then ultimately referred to Physical Therapy. After receiving a knee brace, history and information was received through a translator as the patient is Spanish speaking only. |
Doctor: Do you smoke cigarettes?
Patient: I smoke about three packs in a month.
Doctor: Do you drink alcohol or use recreational drugs?
Patient: No.
Doctor: What do you do for work?
Patient: I am an editorial assistant at the local newspaper. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs. |
Doctor: Have you had any adverse reactions to medications you've taken in the past?
Patient: No, thankfully. | Section Header: ALLERGY
Summary: He has no allergies. |
Doctor: Are you okay?
Patient: Yeah, yeah, I am fine.
Doctor: I am asking this as you look a little pale.
Patient: No I am okay. I have always been healthy my whole life. Just a little fatigued now.
Doctor: Okay that won't be something we can't fix.
Patient: Yeah, but I am okay.
Doctor: Yes, I do not see any issues with your past history.
Patient: As I said, I am healthy. | Section Header: PAST MEDICAL HISTORY
Summary: Otherwise, reviewed. Fairly healthy. |
Doctor: Hello today I have my assistant with me, and she will be representing your case. Tell me who do we have today?
Guest_clinician: Patient has been cared by Doctor X since two thousand and two. She had a Codman Hakim shunt set at ninety M M H two O. She last came to our clinic in January two thousand and eight. At that time, she was recommended to follow up with Doctor Y for the medical management of her chronic headaches. She was also recommended to see a psychiatrist for her depression.
Doctor: Did you go and see a psychiatrist?
Patient: I did. It was okay.
Doctor: What brings you here today?
Patient: My headaches are back. They are very severe this time. It all happened that, after that scan.
Doctor: When did she have her scan?
Guest_clinician: She had her stunt adjusted which was after the M R I on April eighteenth.
Patient: Yes, and after that I'm having these very bad headaches.
Doctor: Are you able to sleep in the night properly?
Patient: No, these headaches wake me up in the night. I haven't had a proper sleep in like ages.
Doctor: Is there anything that elevates this pain? Or decreases it?
Patient: Everything seems like increasing it. It just gets worse with coughing, straining, sneezing, even when I'm trying to stand. I tried all the medications, but nothing is helpful. There was Imitrex and I also tried Motrin eight hundred M G twice a day, but nothing seems to be like effective. Actually, it helps a bit when I lie down.
Doctor: Is it like specific to any particular area of your head?
Patient: It is like all over but, uh, very much intense in the forehead.
Doctor: Is there any nausea associated with the headaches?
Patient: No.
Doctor: Anything else that happens along with these headaches?
Patient: Yeah, I get that ringing sound in my ears, and I just don't feel well.
Doctor: Any changes in your vision?
Patient: Yeah, it gets blurry, and I feel like lights are dimming. I will be meeting Doctor Y tomorrow.
Doctor: Any other thing you want to add?
Patient: No, that's it. | Section Header: HISTORY of PRESENT ILLNESS
Summary: Dr. X has cared for her since 2002. She has a Codman-Hakim shunt set at 90 mmH2O. She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches. We also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself. Today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04/18/08. She states that since that time her headaches have been bad. They woke her up at night. She has not been able to sleep. She has not had a good sleep cycle since that time. She states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up. She states that they feel a little bit better when lying down. Medication shave not helped her. She has tried taking Imitrex as well as Motrin 800 mg twice a day, but she states it has not provided much relief. The pain is generalized, but also noted to be quite intense in the frontal region of her head. She also reports ringing in the ears and states that she just does not feel well. She reports no nausea at this time. She also states that she has been experiencing intermittent blurry vision and dimming lights as well. She tells me that she has an appointment with Dr. Y tomorrow. She reports no other complaints at this time. |
Doctor: Tell me about the medical issues you had in the past or still do.
Patient: Well, I have asthma, sinus. I also have hives and there is a history of psoriasis.
Doctor: Wow, okay. Any known allergies?
Patient: Nothing that I have known. | Section Header: ALLERGY
Summary: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies. |
Doctor: Any known allergies?
Patient: No. | Section Header: ALLERGY
Summary: None. |
Doctor: Hello there, how are you doing?
Patient: Sorry, I'm just not feeling well. Something is wrong.
Doctor: Don't worry, I will check you up. We will figure it out. Do you remember when you had your last physical?
Patient: It was sometime in early May in two thousand and eight.
Doctor: Okay, I'm going through your chart. It looks like you have not been feeling well for about two weeks now.
Patient: That's right.
Doctor: Tell me what is happening exactly.
Patient: In the beginning I was thinking that it was just the stress and anxiety, but then I become worried that it might be something really different or something bad.
Doctor: What are you experiencing exactly? What are your symptoms?
Patient: It started with a lot of palpitations at first. My heart was beating so fast it looks like it was ready to go out. I was having this fluttering feeling in my chest.
Doctor: Were you feeling tired or fatigued?
Patient: Yes, very much for the last two weeks. I am worried it's my job. It is really getting to me.
Doctor: What else are you feeling?
Patient: Feeling very nervous an anxious actually.
Doctor: Have you noticed anything that you are doing or anything else that kind of increasing these symptoms?
Patient: Oh yeah, whenever I'm stressed. I feel like I have more palpitations and to the level that it causes a lot of chest pain.
Doctor: Is it the same when you are doing a lot of physical stuff like physical activities or something like that?
Patient: Nope. Haven't noticed it with the exertion part.
Doctor: Do you have any history of any heart issues in the past?
Patient: I had the same kind of symptoms like nine or ten years ago.
Doctor: Okay. What did you do that time? How did you recover?
Patient: Well, at that time a full work up was done but everything came out to be negative, so they just gave me something for my nerves. It kind of helped.
Doctor: Do you remember what they gave you? Like name or anything of the medicine.
Patient: No. It was many years ago, I don't remember.
Doctor: Anything else going on?
Patient: Yeah, for the last three days and I am having these tummy issues. I'm having on and off nausea and also, my stools are coming loose.
Doctor: Have you seen any color change in your bowel movements?
Patient: Yeah, it's been some really funny green color. I don't know what's going on inside.
Doctor: Have you ever noticed blood in the stools?
Patient: Nope.
Doctor: Is there any pain in your tummy?
Patient: Nope, it's just some nausea.
Doctor: How's your appetite?
Patient: Not as good as before.
Doctor: Do you smoke?
Patient: I never did. | Section Header: HISTORY of PRESENT ILLNESS
Summary: This patient presents to the office today because he has not been feeling well. He was in for a complete physical on 05/02/2008. According to the chart, the patient gives a history of feeling bad for about two weeks. At first he thought it was stress and anxiety and then he became worried it was something else. He says he is having a lot of palpitations. He gets a fluttering feeling in his chest. He has been very tired over two weeks as well. His job has been really getting to him. He has been feeling nervous and anxious. It seems like when he is feeling stressed he has more palpitations, sometimes they cause chest pain. These symptoms are not triggered by exertion. He had similar symptoms about 9 or 10 years ago. At that time he went through a full workup. Everything ended up being negative and they gave him something that he took for his nerves and he says that helped. Unfortunately, he does not remember what it was. Also over the last three days he has had some intestinal problems. He has had some intermittent nausea and his stools have been loose. He has been having some really funny green color to his bowel movements. There has been no blood in the stool. He is not having any abdominal pain, just some nausea. He does not have much of an appetite. He is a nonsmoker. |
Doctor: So just to double check, you're not on any medications?
Patient: You got it. Nothing since last year. | Section Header: MEDICATIONS
Summary: None. |
Doctor: What brings you in today?
Patient: I have this nasty cough and my nose has been super stuffy.
Doctor: Are you bringing anything up when you cough?
Patient: Not really, no.
Doctor: Are you having any other symptoms, such as chest pain, headaches, nausea, or vomiting?
Patient: No. I did have a slight headache last night but I took Advil and it's since gotten better.
Doctor: Are you taking anything for the cough or stuffy nose?
Patient: Just drinking tea and taking cough drops here and there.
Doctor: Okay. Let's take a look at you. Hm it appears that you have a U R I. | Section Header: ASSESSMENT
Summary: Upper respiratory infection. |
Doctor: How are you feeling today, sir?
Patient: I feel pretty weak right now, but I am doing okay at the moment.
Doctor: I reviewed the chart notes that was sent to me by the nursing home. They also sent me your medical history. You have been going through a lot recently.
Patient: Yes, I have. They moved me into the nursing home after I was released from the hospital. I hope that it is just temporary.
Doctor: I understand that you had a seizer and that is why you were taken to the hospital.
Patient: I had multiple seizures. After I was stabilized from the last seizure this side of my body in not working right.
Doctor: Okay so you are having some partial weakness on this side?
Patient: Yes. That is why they moved me to the nursing home. I can't stand up. I am too weak. I can't take care of myself. The nurses have to help me do everything.
Doctor: I am going to try to help you get back to doing things on your own.
Patient: After being in the hospital I got an infection in my intestines. They put me on some antibiotic that I have never heard of and a probiotic.
Doctor: Okay. I see here in the chart that you had two surgeries on July sixth.
Patient: Yes, and then I had a radiation treatment too.
Doctor: Oh yes. On August seventh.
Patient: That sounds right.
Doctor: Your surgeries may have been the reason for the C diff.
Patient: What is C diff?
Doctor: It is an infection in the large intestine. It is often caused by overuse of antibiotics, and you have been on them for a while due to the surgeries that you have had. Or it could be from the surgery itself.
Patient: That make since. | Section Header: HISTORY of PRESENT ILLNESS
Summary: He said he has had two surgeries in 07/06 followed by radiation and then again in 08/07. He then had a problem with seizures, hemiparesis, has been to the hospital, developed C-diff, and is in the nursing home currently. He is unable to stand at the moment. He is unable to care for himself. I reviewed the information that was sent down with him from the nursing home which includes his medical history. |
Doctor: How is your sleep? Are you sleeping well?
Patient: Yes, without any disturbance. I sleep like a log!
Doctor: Good. Any mood swings or did you feel your emotions are out of control?
Patient: Nah, just the normal mood swings around my periods otherwise no problem at all.
Doctor: Any depression like feeling, sudden mood changes or feeling sad or hopeless?
Patient: Nope!
Doctor: Okay. | Section Header: REVIEW OF SYSTEMS
Summary: PSYCHIATRIC: No history of emotional lability, depression or sleep disturbances. |
Doctor: How's he doing today?
Guest_family: I think he might have fifth disease with sinusitis. It's been running rampant at his school.
Doctor: Oh, wow. Let's see what we can do. | Section Header: ASSESSMENT
Summary: Fifth disease with sinusitis. |
Patient: Help! I need help! I need to see the doctor!
Doctor: Yes, what's wrong? Where's your pain?
Patient: My stomach! It hurts so much! I've never had this type of pain before!
Doctor: When did it start?
Patient: At ten! I don't know. It started hurting out of nowhere. One second I'm driving home and the next thing I know I had to call-
Doctor: Yes?
Patient: The pain is so bad! It's hard for me to even think straight. | Section Header: CHIEF COMPLAINT
Summary: Abdominal pain. |
Doctor: Just want to ask you few routine questions, let me know if any of this is positive.
Patient: Sure, go ahead.
Doctor: Do you have any problems like headache, fever, rash, oral ulcer?
Patient: None.
Doctor: Any problem with vision? Like unable to see or double vision?
Patient: Um no, I can see everything.
Doctor: Okay. Do you get palpitations, like are you aware of your own heart?
Patient: No, nothing like that.
Doctor: How about breathlessness while lying down or do you have to get up in the middle of the night to catch a breath?
Patient: No I don't feel anything like that.
Doctor: That's great. Any diarrhea, constipation, or red blood come out in stool? Or pale stool? Like any change in the color of stool?
Patient: No, it is fine.
Doctor: Okay. Any jaundice recently?
Patient: No. No jaundice.
Doctor: Do you have problems with appetite?
Patient: Yeah, I mean you can say my appetite is decreased.
Doctor: Because of that have you noticed any weight loss?
Patient: Oh no.
Doctor: Okay sounds good.
Patient: Sure. | Section Header: REVIEW OF SYSTEMS
Summary: No rashes, headache, photophobia, diplopia, or oral ulcers. No palpitations, orthopnea or PND. No diarrhea, constipation, melena, bright red blood per rectum, or pale stool. No jaundice. Decreased appetite, but no weight loss. |
Doctor: Good morning, ma'am. What seems to be the problem with your knee?
Patient: I've had pain in this knee since I tripped on some ice on March tenth two thousand three.
Doctor: How old are you now?
Patient: I'm forty seven.
Doctor: What kind of symptoms have you had since the fall?
Patient: It's hard for me to stand up without significant pain, and it feels like my knee is going to give way.
Doctor: Has this knee given out before?
Patient: It has.
Doctor: Is there any swelling in this knee?
Patient: Yes, I also feel a popping, like when I go up the stairs.
Doctor: What kind of treatments have you had for this knee?
Patient: I've had antiinflammatories and P T, but I didn't respond well at all.
Doctor: Have you had surgery on this knee in the past?
Patient: Yes, but I can't remember the name of the operation. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice. The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure. |
Doctor: How're you doing today, sir?
Patient: Uh I'm hanging in there.
Doctor: I see that you've recently celebrated your seventy second birthday.
Patient: Yep. My kids and grandkids threw me a surprise party. It was really nice.
Doctor: Aw surprises are always fun. However, I'm sorry to hear that you're not doing that well today.
Patient: Yeah, me too. The other day, I had a lot of difficulty getting up from my chair because of weakness all over and a lightheadedness I can't seem to explain.
Doctor: Is this new for you?
Patient: Um I mean I've had falling spells several times a month for the past year, but I've always been able to get myself up one way or another.
Doctor: Do you remember losing consciousness during any of those episodes?
Patient: Not that I recall. I've noticed I'm a lot weaker than before so maybe that's why I keep falling more frequently.
Doctor: I see. Do you experience room spinning dizziness at all?
Patient: No. I also forgot to mention that four hours after not being able to get up from my chair, my left hand became numb for about two hours.
Doctor: Are you right or left handed?
Patient: Right handed.
Doctor: And besides what you've mentioned to me so far, no other symptoms of concern?
Patient: No. | Section Header: HISTORY of PRESENT ILLNESS
Summary: On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo. He had been experiencing falling spells without associated LOC up to several times a month for the past year. |
Doctor: And where do you live?
Patient: Well, I live in this small town called Fayetteville in Tennessee.
Doctor: Ah, I see. And do you have lot of friends there?
Patient: I have few.
Doctor: Okay, and do you drink?
Patient: No.
Doctor: How about smoking?
Patient: Never did! | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: She does not drink or smoke. Lives in Fayetteville, Tennessee. |
Doctor: How are you feeling?
Patient: I am feeling better now.
Doctor: What happened last night?
Guest_family: She went out to a party last night. She came home drunk and high.
Doctor: What did you take?
Patient: I took Ecstasy. I only had two drinks.
Doctor: How much Ecstasy did you take?
Patient: I didn't take them all at once. I think I took six tabs.
Doctor: What time did you start taking the tablets?
Patient: We started taking it kind of late. I think it was midnight.
Guest_family: When she came home, she was agitated and physically shaking. She was pacing all over the house. Then she threw up. That is when I got nervous and called nine one one.
Doctor: Mom, did you notice any blood, or any yellow or green color in the vomit?
Guest_family: No.
Doctor: Are you still feeling nauseous?
Patient: No. I feel fine. Well, I feel weird but not nauseous.
Doctor: Are you experiencing any pain at all?
Patient: No.
Doctor: Did you or do you feel depressed?
Patient: No.
Doctor: Do you or have you ever had suicidal thoughts?
Patient: No.
Doctor: Are you seeing or hearing things that are not real?
Patient: No.
Doctor: Do you or have you ever had thoughts of harming yourself?
Patient: No. I was not trying to harm myself or anyone else. I just wanted to have a little fun.
Guest_family: She seems to be back to her usual self now.
Doctor: Just one more question. Prior to last night have you had any recent illnesses or injuries?
Patient: No. | Section Header: HISTORY of PRESENT ILLNESS
Summary: This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecsasy tablets. The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis. Mother called the EMS service when the patient vomited. On arrival here, the patient states that she no longer has any nausea and that she feels just fine. The patient states she feels wired but has no other problems or complaints. The patient denies any pain. The patient does not have any auditory of visual hallucinations. The patient denies any depression or suicidal ideation. The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself. The patient denies any homicidal ideation. The patient denies any recent illness or recent injuries. The mother states that the daughter appears to be back to her usual self now. |
Doctor: Do you have any support system?
Patient: No, I am single.
Doctor: Okay so live alone at home?
Patient: Yes.
Doctor: Do you smoke or drink?
Patient: Nope I do not. | Section Header: PAST SURGICAL HISTORY
Summary: The patient is single. Living at home. No smoking or alcohol. |
Doctor: So, are you married?
Patient: No, my wife and I got divorced a while ago. We have three children together, though.
Doctor: Okay, and do you have someone who is managing your case?
Patient: Yes, I have an lawyer handling everything.
Doctor: Do you smoke or drink?
Patient: No, I never really smoke or drink. | Section Header: FAMILY HISTORY/SOCIAL HISTORY
Summary: He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney. |
Doctor: Have you ever had surgery?
Patient: No, not that I can remember.
Doctor: No gallbladder or appendix removal, c sections, or joint replacements?
Patient: Nope, never had anything done. | Section Header: PAST SURGICAL HISTORY
Summary: Otherwise, negative. |
Doctor: I just need to confirm a few pieces of information from my nurse before we begin today, sir.
Patient: Sure, no problem, doctor.
Doctor: Great, so it says here that you are forty five years old, and you identify as Caucasian. Is that correct?
Patient: Yes, that's correct.
Doctor: Thank you, so, what seems to be the problem today?
Patient: Well, I have this pain in my right knee, sir.
Doctor: Where is your pain?
Patient: It's right here, on the inside of my right knee.
Doctor: Is there an injury associated with this pain?
Patient: Actually, yeah. I twisted it while I was at work. | Section Header: HISTORY of PRESENT ILLNESS
Summary: The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain. He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee. |
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