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Doctor: I am going write you a prescription for a stimulant. It is called Cylert.
Section Header: MEDICATIONS Summary: Cylert.
Doctor: Are you married? Patient: Yes. I have been married for twenty two years. Doctor: Are you working? Patient: No. I am unemployed. I have not completed my collage degree yet. I have been in school for the last two years. Doctor: Keep at it.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: unemployed. 2 years of college education. Married 22 years.
Doctor: Nurse, do you have a report on my patient? Guest_clinician: I do. She has a two year history of small cell lung cancer, which spread to both femurs, lower lumbar spine, and pelvis. Doctor: Oh, no. Did she get chemotherapy? Guest_clinician: She's had chemotherapy and radiation treatments multiple times. She can't remember how many times she had those treatments because she lost track. She also said she finished a series of ten radiation treatments for pain relief. Doctor: How are her symptoms now? Guest_clinician: She's currently having severe pain. Doctor: I see. Does she have any imaging done? Guest_clinician: She does. A C T scan was done to check for metastasis. Doctor: Thank you, Nurse. I'll go see her now. Guest_clinican: No problem. Doctor: Hello, ma'am. What is the reason for your visit today? Patient: I wanted to see if I could get some treatment for my pain. Doctor: What kind of pain are you having? Patient: I feel like it's a burning feeling? I don't know. I can feel it one spot and then it spreads down. Doctor: I see. Where do you feel the pain? Patient: I feel it mostly on my lower right side of my back. Doctor: Do you feel it anywhere else? Patient: The back of my right leg and knee. Doctor: Would you said the pain radiates down from your back to your knee? Patient: That's it. Radiating. I forgot the word. Doctor: No problem. On a scale from zero to ten, with zero being no pain and ten being the worst pain of your life, how would you rate your back and leg? Patient: They're both a ten. Doctor: Oh, wow. Do you feel pain anywhere else? Patient: Yes. Could you check my feet? Doctor: Let me check them. I'll feel around your left foot. Let me know what you feel. Patient: I feel like the bottom is numb. Ouch. It also feels sharp at times too. Doctor: I see. The nurse stated here that you had some pain spreading to your mid back too. Let me feel it really quick. Let me know how that feels. Patient: Ouch! It hurts a lot. I feel a sharp and dull pain. Most of the time, it's just aching. Doctor: I see. When do you feel like the pain in your body gets the worst? Patient: I'd say when I'm sitting in a car for a long time. Doctor: So, just sitting for long periods of time? Patient: Yeah. When I stand and walk, too. Doctor: Have you ever taken anything for the pain? Patient: I am on a load of narcotics for the pain.
Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is on my schedule today to explore treatment of the complaints. She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis. She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count. She says she has just finished a series of 10 radiation treatments for pain relief. She states she continues to have significant pain symptoms. Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee. She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times. She complains of some diffuse, mid back pain. She describes the pain as sharp, dull, and aching in nature. She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain. She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking. She is on significant doses of narcotics. She has had multiple CT scans looking for metastasis.
Doctor: Any fever, chills or rigors? Patient: No. Doctor: Any blurring of vision or history of glaucoma or cataract? Patient: No. Doctor: Did you experience any shortness of breath? Patient: No. Doctor: Any stomach discomfort? Patient: No. Doctor: Did you observe blood in your stool or in vomit? Patient: No, nothing like that. Doctor: Okay, good. Did you notice any increase in your urine frequency or urgency? Patient: No. Doctor: Do you feel any muscle weakness or tiredness? Patient: No, nothing of that sort. Doctor: Any known history of arthritis? Patient: Nope. Doctor: And no fever due to any fungal infection or anything, right? Like valley fever? Patient: No, nothing of that sort. Doctor: Any history of pneumonia? Patient: No. Doctor: And I am looking at your chart, so no history of stroke, C V A, or any seizure disorder. Patient: That's correct. Doctor: No thyroid or hormone related problem? Patient: No. Doctor: And you do not have any blood disorders, right? Patient: That is right.
Section Header: REVIEW OF SYSTEMS Summary: CONSTITUTIONAL: No history of fever, rigors, or chills. HEENT: No history of cataract, blurring vision, or glaucoma. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena. UROLOGICAL: No frequency or urgency. MUSCULOSKELETAL: No arthritis or muscle weakness. CNS: No TIA. No CVA. No seizure disorder. ENDOCRINE: Nonsignificant. HEMATOLOGICAL: Nonsignificant.
Doctor: Have you experienced any diarrhea? Patient: Yes. I have been having diarrhea. When I think about it, it started happening around the same time that the mouth sores started. I didn't have any diarrhea today though. Doctor: Have you experienced any episodes of nausea or vomiting? Patient: No. Doctor: Have you noticed any blood in your bowel movements? Patient: No. Doctor: Even though you have been taking the medications without any issue, for about ten years, the methotrexate may be the cause of the mouth sores and the inflammation in the small intestines. These are both common side effects from the use of methotrexate. I am not as familiar with NSAID's causing mouth sores. Aspirin use can cause gastrointestinal upset. I think the most likely cause of the sores is the methotrexate not the use of Aspirin.
Section Header: ASSESSMENT Summary: Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems. Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed. She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting. I am not as familiar with the NSAID causing an erosive stomatitis. I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis.
Doctor: Are you on insulin? Patient: Yes. Doctor: Are you on metformin as well? Patient: Yes. Doctor: How about glucotrol? Patient: Yes I take that. Doctor: Are you on lipitor? Patient: Yes.
Section Header: MEDICATIONS Summary: Insulin, metformin, Glucotrol, and Lipitor.
Guest_clinician: What was he given in the E R? Doctor: Epi one M G, zero point three M L subcutaneously along with fifty M G of Benadryl intramuscularly. In about fifteen to twenty minutes, he reported his itching had improved. The rash itself faded a little bit and he began to feel a lot more comfortable.
Section Header: EMERGENCY DEPARTMENT COURSE Summary: The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly. After about 15-20 minutes he states that itching started to feel better. The rash has started to fade a little bit and feeling a lot more comfortable.
Doctor: Hello, how are you? Patient: I am good, Doctor. Doctor: So, what brings you here today? Patient: Well, I have many medical issues and I see Doctor X for them, but I wanted a second opinion, so he referred me here. Doctor: Yeah, he is a good man! Don't worry we will take care of you. Patient: Thank you. Doctor: So, let me start by getting your medical history. Patient: Sure, I had skin cancer which was treated by removal of that part. Doctor: Okay. Patient: Other than that, I have anemia and an acid reflux problem. I also have history of C O P D. Doctor: Alright. Patient: I also suffer from sciatica which was caused mainly due to my arthritis. Doctor: I see.
Section Header: REVIEW OF SYSTEMS Summary: The patient has multiple medical problems, for which she is under the care of Dr. X. She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease. There is a history of anemia and there is a history of sciatica, which has been caused by arthritis. The patient has had skin cancers, which have been treated with local excision.
Doctor: Welcome back to Sample Clinic, Mister Sample. Patient: Good afternoon, doctor. Doctor: What seems to be the problem today, sir? Patient: I'm having a lot of pain in my right heel. Doctor: How long have you had this pain? Patient: Um, it's been about two weeks now. Doctor: When is the pain the worst? Patient: Honestly, it starts with the first step first thing in the morning. Doctor: Does it get worse throughout the day? Patient: Yes, it gets worse all day with activities. Doctor: What treatments have you had for this? Patient: Well, nothing to date. Doctor: Where is your heel pain? Patient: It's on the right heel, then it's on the inside bottom part of the heel and into the inside of the heel. Doctor: Do you have any change in your medical history since your last visit? Patient: No, it's the same old same old. Doctor: Do you have any flu like symptoms? Patient: Like fever or chills? Doctor: That, or vomiting or headaches. Patient: Oh, no I don't have anything like that. Doctor: What about chest pain or shortness of breath? Patient: Thankfully, no nothing like that.
Section Header: HISTORY of PRESENT ILLNESS Summary: Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel. The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day. The patient states that he is currently doing no treatment for it. He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch. The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.
Doctor: What is your family medical history? Patient: My family has a high blood pressure. I have a family member that had colon cancer. My daughter has a twitch. They don't know what caused it? Doctor: Okay.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: HTN, Colon CA, and a daughter with unknown type of "dystonia."
Doctor: Hello Miss Long, I see that you have been referred today by A B C, D O, for a reevaluation. Are you having issues with your hand eczema again? Patient: Yes, it has been flaring. Doctor: Can you confirm your age for the records please? Patient: Sure, I'm twenty nine. Doctor: If I'm not wrong, you are from Vietnam, right? Patient: That's right. Doctor: Are you married? Single or with a partner? Patient: I'm single. Doctor: Are you working somewhere? Patient: No, currently I'm unemployed. Doctor: Okay, since you are an established patient here in our dermatology department, let me just update all your information into the records. Doctor: Okay according to my records we have last seen you here in our office on July thirteenth of two thousand and four. Patient: Yeah, I think so. Doctor: I have previously treated you with Aristocort cream and Cetaphil cream. I also ask you to increase your moisturizing cream and lotion and asked you to wash your hands in Cetaphil cleansing lotion. Patient: I've been doing all that, but now it looks like my eczema is flaring. I have these cracks in my hands and they feel very dry. Doctor: Have you been washing your hands with Cetaphil cleansing lotion? Patient: No, I was using soap. The Cetaphil cleansing lotion was not working. I had a lot of pain and burning sensation whenever I tried to use that. Doctor: It may be because of the fissures. I mean those cracks in your hands. Patient: I have been wearing gloves as much as I can. Doctor: Okay.
Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04. She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema. I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion. She comes in today for reevaluation because she is flaring. Her hands are very dry, they are cracked, she has been washing with soap. She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin. She has been wearing some gloves also apparently. The patient is single. She is unemployed.
Doctor: Have you been applying Triamcinolone zero point one percent three times a day to your rash? Patient: The one on my left wrist? Doctor: Yes. And Bactroban ointment is also three times a day as needed for your bug bites. Patient: Yep. Doctor: Are you still using Nystatin on your lips once a day as needed? Patient: Uh yeah. I've been using it much less now. Doctor: So let's see, your other medications are the same as of July thirtieth O four with the exception of Klonopin? Patient: Yeah, I mean I'm taking four M G in the morning and six M G at night instead of the six M G and eight M G that was recommended. I feel like I do better with the lower doses.
Section Header: MEDICATIONS Summary: She is currently on her nystatin ointment to her lips q.i.d. p.r.n. She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs. Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg.
Doctor: So, I am looking at your reports, you don't have anemia or any other blood disorders. Patient: Well, that's a relief! Doctor: Yeah. Doctor: Let me check your lymph nodes. They are nonpalpable. I don't see any swollen glands or anything. Patient: Great!
Section Header: REVIEW OF SYSTEMS Summary: HEMATOLOGIC/LYMPHATIC:: Normal; Negative for anemia, swollen glands, or blood disorders.
Guest_family: Hi, how are you? Doctor: I am well, how's the baby? I see that he is eight pounds and thirteen ounces, and he was born via…? Guest_family: Yes, C section. Yeah, he is he has never been hospitalized. He was born a week early. Doctor: Okay, I would like to ask you some questions about the pregnancy and other history. Guest_family: Yes, sure go ahead. Doctor: Great, have you had any infections during pregnancy like G B S or S T D infections? Guest_family: No, I haven't, I only had thumb and toenail infections and we treated that with rubbing alcohol. We have a history of boils in the family, so I am not afraid of minor infections like this. Doctor: Did you smoke during pregnancy? Guest_family: Yes, I did, but stopped after five months. Doctor: Sir, have you had any S T D while she was pregnant? Guest_family_2: No, I was not diagnosed with anything unusual. Doctor: Great, so looks like you were discharged in forty eight hours and no more hospital stays for you. Guest_family: That is correct.
Section Header: HISTORY of PRESENT ILLNESS Summary: The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section. Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family). GBS status was negative. Mom smoked up to the last 5 months of the pregnancy. Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions. Mom and baby were both discharged out of the hospital last 48 hours. This patient has received no hospitalizations so far.
Doctor: Welcome to the clinic, sir. I am Doctor Jones. Patient: Thank you. It is nice to meet you. Doctor: Do you use tobacco products? Patient: Yes. I smoke cigarettes. I am working on quitting. Doctor: I am glad you are attempting to quit. We have a lot of tools now to help with cravings. How much do you smoke per day now? Patient: I smoke about a pack a day. Doctor: Do you drink alcohol or use recreational drugs? Patient: I drink but I don't do any drugs. Doctor: How many alcoholic drinks do you consume per week? Patient: I drink about four drinks per night. I used to drink a lot more than that. I have cut back on my drinking. Doctor: Are you physically active? Do you exercise? Patient: I was very athletic when I was growing up. Now I don't exercise on a regular basis. Doctor: What do you do for employment? Patient: I am a network engineer. I work for Shepherd Pratt. Doctor: Are you married? Patient: Yes. I have been married to my wife for five years now. Doctor: Do you live at home with your wife and or is there anyone else living in your home? Patient: No. Just me and the wife.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He lives with his wife. He works at Shepherd Pratt doing network engineering. He smokes a pack of cigarettes a day and is working on quitting. He drinks four alcoholic beverages per night. Prior to that, he drank significantly more. He denies illicit drug use. He was athletic growing up.
Doctor: Are you married? Patient: I'm divorced. Doctor: So, do you live alone? Or do you have kids? Patient: I live with my girlfriend, and we have a kid together. I also have three other kids from my former wife. Doctor: Do you smoke? Patient: I used to smoke. But I, I've quit like fifteen years ago. Doctor: What about alcohol? Patient: Yeah, I drink beer. Around one to two beers a day. Doctor: Are you working? Patient: I'm retired right now, but I used to work in an iron company.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.
Doctor: Do you want to go home? Patient: Yes, I do. Can I? Doctor: Yes, you sure can.
Section Header: DISPOSITION Summary: To home.
Doctor: Are you studying? Patient: Yes. I'm doing my major in computer science. Doctor: Do you live alone? Patient: No, I live in my family. Mainly my parents and my sisters.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: lives with parents and sisters.
Doctor: Have you ever had surgery before? Patient: No, not that I know of. Doctor: So, no gallbladder removal, or joint replacements? Patient: Unless they did it while I was sleeping, but none that I can remember.
Section Header: PAST SURGICAL HISTORY Summary: No previous surgeries.
Doctor: I remember you had mentioned that one of your family members had bone cancer. Are there any other medical problems that run in your family? Patient: Sadly, yes. Stroke and dementia are the other two big ones. Doctor: I'm sorry to hear that.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: stroke, bone cancer, dementia.
Doctor: Are you allergic to any meds? Patient: Me? Doctor: Yes. Patient: No, I am not. Doctor: Are you sure? Patient: Yes, I am damn sure. Doctor: Okay great!
Section Header: ALLERGY Summary: None known to medications.
Doctor: What's bringing her in today? Guest_family: Oh, doctor. She hasn't been doing well at all. Guest_family: I think she's actually gotten worse. Doctor: I understand. I'm sorry to hear that she hasn't been feeling well. Let me see what we can do for her today. Guest_family: I haven't taken her temperature since this morning. It was one hundred and three degrees when she woke up. Doctor: What time did she wake up today? Guest_family: Um, around eight I believe. She also suffers from apnea. Doctor: It looks like she has an upper respiratory infection. Guest_family: Is she going to get better? Doctor: Yes, she should feel better once we start treating the infection. But I'm worried it may be pertussis.
Section Header: DIAGNOSIS Summary: Upper respiratory illness with apnea, possible pertussis.
Doctor: And you've had recurring abscesses for the past two years, correct? Patient: Unfortunately, yes. Doctor: Where have they been located? Patient: Um in the public area and my thighs. Doctor: Have you ever needed to get an abscess drained? Patient: Yeah. I've gotten about four I and D's.
Section Header: CHIEF COMPLAINT Summary: Recurrent abscesses in the thigh, as well as the pubic area for at least about 2 years.
Doctor: How's your overall health? Patient: Fine, I guess. I'm being treated for I B S by my G I. Last time I was in, they told me that my white blood cell levels aren't where they were supposed to be.
Section Header: PAST MEDICAL HISTORY Summary: Episodic leukopenia and mild irritable bowel syndrome.
Doctor: Do you have any family history of chronic illnesses that I should know about? Patient: What do you mean by that? Doctor: Well, it could be anything from depression, to arthritis, to cancer. Patient: Oh yeah, my mom has arthritis.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Patient admits a family history of arthritis associated with mother.
Doctor: How are you moving around? Are you able to perform your day to day activities? Patient: Little bit, not so much. Doctor: So just listen to your body and go around as much as you can. Patient: Okay. Doctor: Do not overstress yourself. Patient: Okay I can do that.
Section Header: PLAN Summary: As tolerated.
Doctor: Are you allergic to anything? Patient: No, I am not allergic. Doctor: Okay. Patient: Yeah.
Section Header: ALLERGY Summary: No known drug allergies.
Doctor: Remind me, how did he hurt himself? Guest_family_1: He was riding quads on October tenth two thousand seven when he got thrown off. Doctor: Yes, and we did O R I F on his fracture dislocation of the left elbow. Guest_family_1: Yes, he also fractured the neck of his right glenoid, um, if I remember correctly. Doctor: Which hand does he write with? Guest_family_1: He writes with his right hand. Doctor: Okay. That fracture appears to have healed very well; kids generally heal pretty well. How does it feel today? Guest_family_1: Yes, he's only ten. He's been pretty stiff, so he's been going to P T, and using his Dynasplint. Doctor: That's good that he is already in P T. His left elbow fracture is healed, so we should do another surgery in order to remove that hardware. That may help decrease some of the irritation with elbow extension. He looks neurologically intact in terms of movement and reflexed in his wrist and hand. Guest_family_1: Yes, I agree. What is the risk of infection of this surgery? Doctor: Historically, the risk of infection is less than one percent. Guest_family_1: Oh, wow, that's low, how is that possible? Doctor: We'll use prophylactic antibiotics, this controls for infection, and helps keep everything clean. Other Risks include bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, and continued postoperative stiffness. Guest_family_1: Wow, that's great, will be he asleep the entire time? Doctor: Yes, we'll use anesthesia, he won't feel a thing. Guest_family_1: Will this fix his pain, for sure? Doctor: I can't guarantee it, he may still be in some pain. Guest_family_1: Okay, what about you, dear? What do you think? Guest_family_2: Yeah, I think we should do it, boys should be playing sports with their friends.
Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007. The patient underwent open reduction and internal fixation of his left elbow fracture dislocation. The patient also sustained a nondisplaced right glenoid neck fracture. The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint. The patient is neurologically intact distally. Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware. Risks and benefits of the surgery were discussed. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness. All questions were answered and the parents agreed to the above plan.
Doctor: Since you have a family history of coronary heart disease, let me check you for its risk factors. Patient: Yeah, my father had it. Doctor: Any history of high blood pressure or diabetes? Patient: No. Doctor: How about smoking, do you smoke? Patient: No, I don't smoke. Doctor: And in the past, did any other Doctor mention that you might have sign or symptom indicating that you may have coronary artery disease? Patient: No. Doctor: Okay.
Section Header: HISTORY of PRESENT ILLNESS Summary: CORONARY RISK FACTORS: No history of hypertension or diabetes mellitus. Active smoker. Cholesterol status, borderline elevated. No history of established coronary artery disease. Family history positive.
Doctor: Who all are there in your family? Guest_family: It's me, my husband, my two older kids and this little baby. Doctor: Everyone living together? Guest_family: Yes Doctor: Is she going to any daycare? Guest_family: No, she's at home all the time.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Currently lives with her mom, dad, and two siblings. She is at home full time and does not attend day care.
Doctor: Do you drink? Patient: Oh, I do but occasionally. Who doesn't like a nice cocktail! Doctor: Okay. How about cigarettes, do you smoke? Patient: No, I don't smoke.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient does not smoke. She does have an occasional alcoholic beverage.
Doctor: I am okay. Patient: I have bad nausea. Doctor: Oh, so sorry. Patient: And I feel very dizzy like I am going to faint. Doctor: Okay let me see what is going on. Patient: Okay.
Section Header: CHIEF COMPLAINT Summary: Nausea and feeling faint.
Doctor: What brings you into the office today? Patient: I had a stroke about a month ago. The right side of my face is still not moving. Doctor: Is it only the right side of the face that is affected by paralysis? Patient: Yes. It has improved a little bit since I was in the hospital. Doctor: That is a good sign. It can take up to six months see how much movement you will regain.
Section Header: CHIEF COMPLAINT Summary: Right-sided weakness.
Doctor: Do you use tobacco? Patient: What, like smoke cigarettes? Doctor: Yes ma'am, do you? Patient: Oh, no. I don't do anything like that.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is a nonsmoker.
Doctor: Have you ever had surgery, ma'am? Patient: Yes, I had it for melanoma some time ago. Doctor: I see here that you had a hysterectomy as well, is that correct? Patient: Oh, yes, that's true. I had that done too.
Section Header: PAST SURGICAL HISTORY Summary: Surgery for melanoma and hysterectomy.
Doctor: So, let's see here. You don't recall anyone in your family having a history of neuromuscular diseases, correct? Patient: No, no one I can think of. Doctor: Do you know of anyone who has had foot deformities or neuropathy in their arms or legs? Patient: No, not one person comes to mind. Doctor: Great. Does anyone in your immediate family have a high arch? Patient: No, at least no one that I know of. Doctor: And you said that your aunt or sister has type two diabetes? Patient: My aunt. She's had it for some time now.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: There is no family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases. His aunt has a history of type II diabetes.
Doctor: So, what I feel is you might have short term memory loss due to high stress, but I also feel it's probably due to your current situation. The other impression I have is that you have anxiety issues and again it's stress related. Patient: Yeah, I do have anxiety issues.
Section Header: ASSESSMENT Summary: 1. Short-term memory loss, probable situational. 2. Anxiety stress issues.
Doctor: Who's my patient today? Guest_family: Today, it's my brother. Doctor: What seems to be the problem today? Guest_family: Well, he's a vegetarian but he has high cholesterol and he's on a medication to control it. Doctor: Has he changed his diet? Guest_family: Yes, he did when he got a letter saying that his fat levels were high in the blood. Doctor: What kinds of foods did he eliminate? Patient: Oh, you know, all of the fun ones. Like cappuccino, quiche, crescents, candy, vending machines, all of that stuff. Doctor: Do you take your lunch to work? Patient: Yes, I do about three or four times a week instead of eating out so much. Doctor: Are you exercising right now? Patient: Yes, I do about six or seven days a week. Doctor: What kind do you like to do? Patient: Well, I do just about everything. I swim, I bike, run and then I lift weights. Doctor: How long do you workout per day? Patient: Usually, it's about one and a half to two and a half hours every day. Doctor: Good, are you training for anything specific? Patient: Actually, yes I'm going to do a triathlon. Doctor: Can I assume you're losing weight? Patient: Yes, I am.
Section Header: HISTORY of PRESENT ILLNESS Summary: His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it. The patient started improving his diet when he received the letter explaining his lipids are elevated. He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc. He has started packing his lunch three to four times per week instead of eating out so much. He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time. He is in training for a triathlon. He says he is already losing weight due to his efforts.
Doctor: The patient has possible free air in their diaphragm. Guest_clinician: How old is the patient? Doctor: Seventy six. Guest_clinician: Past medical history? Doctor: Unknown as of now.
Section Header: CHIEF COMPLAINT Summary: Possible free air under the diaphragm.
Doctor: Out of ten, ten being the worst pain imaginable, how would you rate your pain today? Patient: Today it's about a six or seven, and it's usually pretty constant there. Doctor: Does the pain change with the weather? Patient: Yes, when it's cold out it turns to ten out of ten. It's better when it's warm out. Doctor: Does the pain change throughout the course of the day? Patient: Yes, it progressively gets worse and worse as the day goes on, but I also have a pretty hard time getting out of bed in the morning, too. Doctor: Out of ten, how would you rate your pain at night? Patient: Oh, it's ten out of ten. Doctor: Does the pain wake you up at night? Patient: If I sleep at all. I'm not sleeping well at all, and when I do it's for less than an hour at a time. Doctor: Are there any activities that really aggravate the pain? Patient: Yes, if I sit for more than about twenty minutes, or if I lay flat on my back. Doctor: Does anything alleviate the pain? Patient: Laying on my side helps a little.
Section Header: HISTORY of PRESENT ILLNESS Summary: The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather. The patient states that pain is dramatically less, when the weather is warmer. The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning. The patient states that she does not sleep at night well and sleeps less than one hour at a time. Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back. Easing factors include side lying position in she attempts to sleep.
Guest_family: For as long as I have been taking care of her, she has had this tracheal tube and she barely speaks. She mostly signals if she needs anything. Doctor: Okay. It's mentioned in her report that she has a history of smoking. Guest_family: She is nodding yes. Doctor: Well, it's alright. I think it's going to be difficult taking any past medical information from her.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient had been previously a smoker. No other could be obtained because of tracheostomy presently.
Doctor: Have you been taking anything for high blood pressure? Patient: Yeah, I started taking Toprol and uh the one that starts with an A. I forget what it's called. Doctor: Hm are you talking about Avalide? Patient: Oh right, yeah that's the one.
Section Header: MEDICATIONS Summary: Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned.
Doctor: Good afternoon, ma'am. Before we begin, may I ask how old you are? Patient: Good afternoon, doctor. I'm fifty six years old, now. Doctor: Great, thank you. What seems to be the problem today, ma'am? Patient: Well, I need some support for dietary recommendations for healthy eating for my husband and me. Doctor: Why would that be, ma'am? Patient: Um, I have a lot going on, high cholesterol, high blood pressure, acid reflux, and I just want to lose some weight. My husband has high cholesterol too. Doctor: Tell me more about your eating habits, please. Patient: Well, we live by ourselves now that our children are gone, but I'm used to cooking really large portions. Doctor: Are you struggling to make food for just two people? Patient: Yes, that's a good way to put it. I'd like to just make less food, that way we're not so tempted to eat so much. Doctor: I understand, are you busy, do you work? Patient: Well, I start a new job this week.
Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction. The patient states that her husband has been diagnosed with high blood cholesterol as well. She wants some support with some dietary recommendations to assist both of them in healthier eating. The two of them live alone now, and she is used to cooking for large portions. She is having a hard time adjusting to preparing food for the two of them. She would like to do less food preparation, in fact. She is starting a new job this week.
Doctor: Hello! What brings you into the office today? Patient: Hi! I have not been able to go pee, and I have had this sharp pain in my left side. Doctor: Have you recently had any surgical procedures? Patient: No. Doctor: Do you have a history of an enlarged prostate or kidney stones? Patient: No. Doctor: I would like to get some imaging done. Patient: Okay.
Section Header: CHIEF COMPLAINT Summary: Left flank pain and unable to urinate.
Doctor: Has he ever had any mental retardation problems in the past? Guest_family: No. Doctor: Did he go through mainstream education? Guest_family: Yes, he graduated high school last year. He had an I E P. He has a job now. Doctor: Oh really. That's great. Guest_family: We went through a program for the disabled to find him the job. He is doing well. Doctor: What is the job? Guest_family: He works at cardboard shop. Doctor: So, he is ambulatory. No issues with performing the work. Guest_family: No! His boss said he is doing very well.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled.
Doctor: And you are- Guest_family: Hi, I am her nurse. Doctor: So, do you know about her past medical history? Guest_family: I have very limited information, as I very recently started working with her. She does have dementia and that's the main reason why I was hired. Her family wanted someone to look after her twenty four seven. Doctor: Oh, I see. Guest_family: But I do have her medical records. You can have a look. Doctor: Yeah, that will be nice. Let me check her reports quickly. She has a history schizophrenia, chronic anemia and hypothyroidism and she also suffers from asthma. Guest_family: Yes. Doctor: Oh, I also see here she tested positive for P P D, was she diagnosed with tuberculosis? Guest_family: I honestly don't know, but I wasn't told that. Doctor: Okay.
Section Header: PAST MEDICAL HISTORY Summary: Actually quite limited, includes that of dementia, asthma, anemia which is chronic, hypothyroidism, schizophrenia, positive PPD in the past.
Doctor: Your last visit was on April seventh two thousand five, correct. Patient: Ah no, it was on April eighth two thousand five, doctor. Doctor: That's right. So, has anything changed since then? Patient: No, everything is the same really.
Section Header: PAST MEDICAL HISTORY Summary: Essentially unchanged from my visit of 04/08/2005.
Doctor: Any nausea, vomiting or diarrhea? Patient: Nope.
Section Header: REVIEW OF SYSTEMS Summary: No nausea, vomiting, or diarrhea.
Guest_family: What do you think doctor, what does she have? Doctor: Well, I think she has hay fever. Otherwise she looks like a healthy two year old. Guest_family: Hm, okay.
Section Header: ASSESSMENT Summary: Allergic rhinitis. Otherwise healthy 2-year-old young lady.
Doctor: Hello, sir. I'll be your doctor today. How are you feeling? Patient: Um uh who? Where am I? Doctor: You're in the emergency room. Patient: I'm where? Doctor: The police found you outside of the local bar. Do you remember what happened prior to your arrival here? Patient: I'm no longer at the bar? Doctor: No, you're here because someone was worried you may need medical attention. Patient: I don't know what's going on. Can you call my girlfriend? She was there with me before we got into a fight.
Section Header: REVIEW OF SYSTEMS Summary: Not obtainable as the patient is drowsy and confused.
Doctor: How's your husband doing? Patient: He's good. He usually comes with me to my appointments, but he had to run some errands this morning. Doctor: Happy to hear that he's also doing well. Patient: Me too. Doctor: I just have one more question for you regarding your social history. Do you smoke? Patient: No, never. Doctor: Okay, so no changes.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is married. She is a nonsmoker.
Doctor: How are you feeling today? Patient: I am doing good, considering. Doctor: Are you sleeping well? Patient: Yes. I was able to get some good sleep last night. Doctor: Have you been able to eat without any trouble? Patient: Yes. I ate a little bit of breakfast this morning. Doctor: Have you been able to have a bowel movement yet? Patient: Yes, I did this morning. Doctor: Did you experience any difficulties with your movement? Patient: It was still a little difficult and hard. Doctor: Okay. Continue the high fiber diet that we discussed, and it should improve. Please let me or one of the nurses know if it has not improved or becomes worse.
Section Header: REVIEW OF SYSTEMS Summary: The patient has been eating fairly well, sleeping well, doing well with her sprints. A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.
Doctor: Our records show that he is up to date with his vaccinations. Guest_family: Okay.
Section Header: IMMUNIZATIONS Summary: Up-to-date.
Doctor: Are you allergic to any medications? Patient: No
Section Header: ALLERGY Summary: None.
Doctor: So, do you remember when your last pap smear was? Patient: I have it written down right here in my notes. It was in October of two thousand one. Doctor: Great, do you have any children? Patient: Yes, I have a beautiful daughter. Doctor: That's wonderful. Have you only been pregnant once? Patient: Yes, I've just pregnant once and it was with my daughter.
Section Header: GYNECOLOGIC HISTORY Summary: Last pap performed 10/2001. Gravida: 1. Para: 1.
Doctor: Have you undergone any surgeries? Patient: I had both my tubes tied in O one and I had a polyp removed when I was fourteen. Doctor: And that was a- Patient: Oh, sorry I didn't mean to interrupt. Doctor: It's alright. I just wanted to know if that polyp was found in your colon? Patient: Yes, it was.
Section Header: PAST SURGICAL HISTORY Summary: Bilateral tubal ligation in 2001, colon polyp removed at 14 years old.
Guest_family: Doctor can you check my baby boy? Doctor: Yes for sure. Guest_family: He has a fever.
Section Header: CHIEF COMPLAINT Summary: Fever.
Doctor: Where's your rash? Patient: All over my torso and arms. Doctor: When did you first notice it? Patient: Well, it started on my back and then it made its way to my torso and arms. Doctor: Have you found yourself itching it? Patient: Yes. Doctor: Any potential triggers for the rash, such as dietary changes, new medications, or unfamiliar exposures? Patient: Nope. I mean I did remove some insulation in my basement a few days ago, but I didn't feel itchy that day. Doctor: Any shortness of breath, wheezing, facial swelling, tongue or lip swelling, or other associated symptoms? Patient: No.
Section Header: HISTORY of PRESENT ILLNESS Summary: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms. No facial swelling. No tongue or lip swelling. No shortness of breath, wheezing, or other associated symptoms. He cannot think of anything that could have triggered this off. There have been no changes in his foods, medications, or other exposures as far as he knows. He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.
Doctor: Are you allergic to anything? Patient: As in drugs? Doctor: Yes, sorry. I was referring to drug allergies. Patient: Oh yeah. I'm allergic to Sulfa drugs. Doctor: What happens when you take Sulfa drugs? Patient: Break out in a terrible rash. I remember I had to go to the E R the first and last time I took it. Doctor: Wow, I'm sorry. Rashes can be very uncomfortable and sometimes require immediate attention. Patient: Yeah, so no more Sulfa drugs for me. That's for sure.
Section Header: ALLERGY Summary: Sulfa.
Doctor: Do you smoke? Patient: Yes. Doctor: How much do you smoke? Patient: Honestly, I smoke every day.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient current smokes.
Doctor: Does any of your family member have any major medical problems? Patient: Yeah, my mother died of heart attack. She was seventy years old. My father died of cancer; it was prostate cancer. He was around eighty. Doctor: Anything anyone else? Patient: Hm, my brother had both heart disorder and prostate cancer and he died around seventy four.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother died of MI, age 70. Father died of prostate cancer, age 80. Bother died of CAD and prostate cancer, age 74.
Doctor: Where's your pain? Patient: Right above my belly button. It's been bothering me for three weeks now. Doctor: Does the pain come and go? Patient: Um it's pretty constant, but it does seem to get worse at night. Doctor: Do you find that sitting or laying down in certain positions helps the pain? Patient: Eh not really. I can't seem to really get comfortable since it started. Doctor: Have you taken any medicine for the pain? Patient: I uh- Doctor: Yes? Patient: Um I took Pepto Bismol a few times, but that didn't do much. Doctor: Did they already take you back for your C T scan? Patient: Yeah. Doctor: We should be getting the results of your scan fairly soon then. In the meantime, I'm going to put in some additional orders.
Section Header: CHIEF COMPLAINT Summary: Abdominal pain and discomfort for 3 weeks.
Patient: Good morning, doctor. Doctor: So, I've reviewed your past notes, are there any other diagnoses I should know about? Patient: Well, I've had depression for a while now. Doctor: Thank you for sharing that with me.
Section Header: PAST MEDICAL HISTORY Summary: Depression
Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: So, what do you do for a living? Patient: Right now, actually, I'm not working. Doctor: That's okay, I'm not here to judge. Are you married? Patient: No, I'm happily single right now. Doctor: Good for you, do you have any kids? Patient: No, I don't have any, its just me. Doctor: Do you drink or smoke? Patient: No, I don't do any of that. Doctor: Good, and do you use anything harder? Like illicit drugs? Patient: No, I absolutely do not. Doctor: Good, and with ten being the most stressful day every, how would you rate your stress level out of ten? Patient: Today, I'd say its about an eight out of ten.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is not working. Rates her stress level as an 8/10. She is single with no children. Does not smoke, drink, or utilize illicit substances.
Doctor: Hello. How are you doing today? Patient: My head has been hurting a lot. Doctor: I see. Did the nurse come in and ask you questions about past medical history? Guest_clinician: Sorry, Doctor. I was looking for you. I reviewed his history with him, and nothing has changed. Doctor: Perfect. Let's do some tests to see why your head has been hurting. Patient: I'm ready for less pain. Let's go.
Section Header: PAST MEDICAL HISTORY Summary: otherwise unchanged.
Doctor: We're going to check around your knee now. Patient: Okay, sounds good. Doctor: Looks like your deep tendon reflexes are the same on both legs. Sensation seems great and intact.
Section Header: EXAM Summary: NEUROLOGIC: Deep tendon reflexes were symmetrical at the patellar area. Sensation was grossly intact by touch.
Doctor: Can you tell me something about your family? Any illnesses in family? Patient: My dad's mom has diabetes and hypertension and my dad's dad had emphysema and he was a smoker. Doctor: Okay. Patient: Yeah. Doctor: Is there any history of death of child who was less than a year maybe? Patient: No, there isn't. Doctor: Okay. That's great. No illnesses for small children? Patient: No.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker. There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.
Doctor: Alright, I am looking at your urine report and it confirms what I was suspecting. You have a urinary tract infection. Patient: I kind of knew it was a U T I. I have had it before, but nothing this painful and severe. I feel like I am going to die! Doctor: Oh yes, it is because you got something called as acute cystitis and its usually very painful and can cause some serious complications. Patient: Well, is it because of my diabetes? Doctor: I am afraid I don't have better news for you, but your diabetes is out of control. It's way too high and you must be really careful. Are you taking your medicines? Patient: Yes! Doctor: How bout diet? Patient: Yeah, sometimes I don't care about my diet. Doctor: Well, you must watch your diet, you can't just be careless. I am going to change your diabetes medication. And let's start you on the antibiotic that should give you relief. Also stay hydrated drink plenty of fluids it will help you flush the infection out. Patient: Alright, thank you! Doctor: Take care.
Section Header: ASSESSMENT Summary: Diabetes type II uncontrolled. Acute cystitis.
Doctor: Good morning, ma'am. Patient: Good morning, doctor. Doctor: Before we begin, I just have a few questions. Do you remember what illnesses you had as a child? Patient: Yes, I got a few. I had strep throat, mumps, and, um, chickenpox growing up.
Section Header: PAST MEDICAL HISTORY Summary: Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox
Doctor: Hi there! I am Doctor Sherman. Patient: Hello! It is nice to meet you. Doctor: It looks like your P C P sent you to us for a possible prostate problem. Patient: Yes. I am nervous. Doctor: Do not be nervous. We will start with discussing the symptoms you have been experiencing, a physical exam and then we will get a urine sample if you are able. Patient: Okay.
Section Header: CHIEF COMPLAINT Summary: Urology.
Doctor: What are you taking for allergies? Patient: Claritin. Doctor: Okay. Patient: For my allergic rhinitis.
Section Header: MEDICATIONS Summary: Claritin for allergic rhinitis.
Doctor: Do you have any known allergies to medication? Patient: Nope. None that I know of.
Section Header: ALLERGY Summary: None.
Doctor: What is your family medical history? Patient: My dad had a heart attack and passed away at sixty one. Doctor: I am so sorry to hear that. Patient: Thank you. Doctor: Do you know of any other major health conditions in your family? Patient: No. None that I know of. Everyone is relatively healthy. Doctor: That's good.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father died, MI age 61.
Doctor: Hello, sir how are you feeling today? Patient: I feel terrible. Very sick and I can barely move. I feel so weak.
Section Header: HISTORY of PRESENT ILLNESS Summary: The patient states that he feels sick and weak.
Doctor: So, we looked at your previous blood work results, now let me see what these reports say from today's C B C exam. Patient: Sure. Doctor: Okay so your hemoglobin levels look within range, white counts are thirteen point three, then seven point six lymphocytes and twenty six thousand platelets. Doctor: Okay? Patient: Okay.
Section Header: IMAGING Summary: The patient's CBC results from before were reviewed. Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.
Doctor: Welcome back. Patient: Thank you. Doctor: You are back for a follow up on your right arm pain, right? Patient: Yes. It has been almost a year since the pain first started. Doctor: How has your arm been feeling? Patient: I still have this dull pain in my upper outer area of my arm. Doctor: How long does the pain last? Patient: It was coming and going, but now the pain is more persistent since I last saw you. It is still happening every day. Doctor: Remind me again. You are right handed. Right? Patient: Yeah. It makes is hard to do things with the persistent pain. Doctor: I bet it does. Are you experiencing any numbness or tingling sensation in your arm or hand? Patient: No, but I have had this achy sensation in my hand radiating down to my fingers. Doctor: Do you have a history of any other neck or shoulder injuries? Patient: It is not from a specific injury but I have had this neck pain for thirty years. Doctor: Did you see anyone for the neck pain? Patient: Yes. I saw someone for it in two thousand and six, and then I developed this ear pain. They could not figure out what was going on so eventually I was sent to have an M R I of my neck and upper spine, which showed some degenerative changes. Then I was referred to Doctor X who was treating me for neck pain. He gave me steroid injections. Doctor: Are you still seeing Doctor X for the epidural injections? Patient: Yes. I have been seeing him since two thousand and seven. Doctor: How old are you? Patient: I am fifty eight. Doctor: Are you experiencing any symptoms from receiving the injections? Patient: Those are for neck pain. My arm pain recent. I have been having the injections for a while now, without any trouble. Doctor: What medications have you been taking for the pain? Patient: There are a few of them that I take. I gave the list to the nurse. Doctor: Okay. Patient: I also have taken several Medrol packs. They make my blood sugars to increase so I try not to take it. Doctor: Okay. Does the pain prevent you from doing your daily activities or decrease your quality of life? Patient: No. I can do everything like normal, but constant nagging pain does get to me at times.
Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain. He states that a little less than a year ago he developed pain in his right arm. It is intermittent, but has persisted since that time. He describes that he experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm. He has had a 30-year history of neck pain. He sought medical attention for this problem in 2006, when he developed ear pain. This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes. He was then referred to Dr. X for treatment of neck pain. He has been receiving epidural injections under the care of Dr. X since 2007. When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain. He also has taken several Medrol dose packs, which has caused his blood sugars to increase. He is taking multiple other pain medications. The pain does not interfere significantly with his quality of life, although he has a constant nagging pain.
Doctor: What type of surgery have you had in past? Anything big or small? Patient: I had a C section for my kiddo and one D and C. Doctor: Okay.
Section Header: PAST SURGICAL HISTORY Summary: C-section and D&C.
Doctor: Are you currently taking any medications? Patient: No.
Section Header: MEDICATIONS Summary: None.
Doctor: So are you allergic- Patient: To any medications? No allergies here.
Section Header: ALLERGY Summary: No known medical allergies.
Doctor: Hello again! Patient: Hi! Doctor: The results from you M R I showed nothing concerning. The growth factors were normal with normal cell function and no signs of decreased blood supply to the brain. Patient: That's great news. Doctor: Yes it is.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: GF with CAD, otherwise unremarkable.
Doctor: So, I understand that you had a fall. Patient: Yes. I did fall. Doctor: What happened? Patient: I don't really know. I have balancing problems. I have been to my P C P for this issue a few days ago. I saw her about a week and a half ago because I had another fall. Maybe around late December since today is January seventh. I have been having trouble with my right hand. It is like I am clumsy on my right side. I ended up falling because my right hand missed the railing when I grabbed it to head up the stairs. Doctor: Are you left or right handed? Patient: Right. Doctor: Can you tell me a little bit more about the trouble that you are having with the right hand? Is it localized to the right hand? Patient: Yes, it is only on my right side. It is like the right side of my body is weak and it has been getting worse. Doctor: How long has this issue been progressing for? Patient: About two years. Doctor: Have you experienced any blurred vision or visual disturbances? Patient: Yes. Every once and a while. Doctor: How old are you? Patient: I just turned fifty eight last week. Doctor: Happy belated birthday! Patient: Thank you! Doctor: Did your P C P have any bloodwork or imaging done? Patient: Yes, she did. She did both. She said she would send my records over. Doctor: Oh. I see it here! Did Doctor Madison discuss the results of your H C T and the M R I yet? Patient: No. Doctor: Okay. The results showed clinoid masses. This explains that problems that you have been having with your right side, your balancing problems, and the visual disturbances. With only the M R I I cannot tell if the masses are malignant or not. Patient: So, are the masses cancer? Doctor: I don't know yet. I will have to run some more tests and potently have to do a biopsy. Patient: Okay.
Section Header: HISTORY of PRESENT ILLNESS Summary: This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses.
Doctor: Do you smoke? Patient: Yes, I do. Doctor: How much? I mean can you tell me approximate amount? Patient: Yes sure, I smoke half a pack a day. Doctor: How about alcohol and drugs? Patient: No, I do not drink or use. I have a five month old baby.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She had a baby five months ago. She smokes a half pack a day. She denies alcohol and drug use.
Doctor: With ten being the worst pain imaginable, how would you rate your pain today out of ten, ma'am? Patient: Well, out of ten, I'd say it's about a seven. Doctor: How would you describe your pain? Patient: Um, I'd say it's deep, and it really aches. Doctor: Where is your pain located? Patient: It's in my right lower back, and then into my butt. Doctor: What activities make your surgery worse? Patient: I can't go up and down stairs without a lot of pain, and it hurts when I sit for a long time, like when I drive. Doctor: Before this pain, how would you describe your activity level? Patient: I was very active before all this started. Doctor: Are you able to do any of your prior activities? Patient: Not really, I'm having a lot of problems with stuff around the house, like all the chores and projects I used to be able to do.
Section Header: HISTORY of PRESENT ILLNESS Summary: The patient rates her pain at 7/10 on a Pain Analog Scale, 0 to 10, 10 being worse. The patient describes her pain as a deep aching, primarily on the right lower back and gluteal region. Aggravating factors include stairs and prolonged driving, as well as general limitations with home tasks and projects. The patient states she is a very active individual and is noticing extreme limitations with ability to complete home tasks and projects she used to be able to complete.
Doctor: Welcome in! Patient: Thank you. Doctor: Let us get a little background. What is your medical history? Patient: I have some memory loss problems. Doctor: What kind of memory problems? Patient: Well, I have seizures. Doctor: Do you know what kind of seizures that you have? Patient: I have temporal lobe seizures. Doctor: Do you have any other health conditions? Patient: I also have high blood pressure. Doctor: Okay.
Section Header: PAST MEDICAL HISTORY Summary: Significant only for hypertension and left temporal lobe epilepsy.
Doctor: Did you have any medical issues? Patient: Nope. Doctor: What about surgery. Patient: No, I never had a surgery.
Section Header: PAST SURGICAL HISTORY Summary: She has undergone no surgical procedures.
Doctor: How old are you? Patient: I am seventy three. Doctor: Are you right handed or left handed? Patient: Right. Doctor: So, I see the chief complaint is memory loss and cognitive decline. Tell me what exactly happened, and how did you notice the symptoms? Let me document that today is January twelfth of nineteen ninety five. Guest_family: We noticed it the week prior to Thanksgiving last year in nineteen ninety four. We have a family tradition where we play a game and this time, we were taking her to Vail, Colorado to play "Murder She Wrote" at one of our family gatherings. She was chosen to be the assassin. Doctor: Okay. Guest_family: Kids played a trick with her and they hid a plastic gun, a toy gun in her luggage. As she walked through the security, the alarm went off and like within seconds she was all surrounded, and everyone was like panicked. There was so much panic, they searched her and interrogated her and what not. Eventually she and her family made it to the flight, and she seemed unusually frustrated and disoriented by all that. Previously, if any such incident would have happened in the past, she would just have like chuckled and brushed it off. And we all would have sat together and laughed about it. This time it was different. Doctor: I can see why she was frustrated. Anyone can be in such situations. Guest_family: When we were in Colorado, she seemed slow. She had difficulty reading her lines to her part when we were playing that game. She needed assistance to complete the whole game. Doctor: Was she slurring? Guest_family: Nope. Doctor: Was there any difficulty with vision? Or any weakness? Guest_family: Nope. Nothing that we noticed. Doctor: How was it after returning from there? Guest_family: She returned to work. She used to work in a local florist shop. She returned on the Monday following Thanksgiving. And she had difficulty. Patient: I was not able to take on with my usual task of flower arrangements or dealing with the cash at the cash register. Guest_family: She quit the next day, and she never went back. Doctor: How was it after that? Guest_family: She seemed to be doing fine and stable throughout November and December, and we were visiting a local neurologist as well, who was evaluating her. He did a few blood tests and did uh, M R I of the brain. He gave us all clear. He said there's nothing there. Doctor: Yeah, I see the working diagnosis of dementia of the Alzheimer's Type. When did these symptoms increase? Like when did you started noticing them more? Guest_family: One or two weeks ago, so end of December nineteen ninety four, she got lost in her own home. She was getting more sensitive and started saying that she is becoming a liability for everyone, which is not at all like her. Her walking was affected. She started walking like a bended form and also started veering to the right. She also did not recognize the location of where people were talking to her.
Section Header: HISTORY of PRESENT ILLNESS Summary: This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94. Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play "Murder She Wrote" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the "assassin." Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a "chuckle." While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing "Murder She Wrote." She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time. She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back. Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was "Dementia of the Alzheimer's Type." One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her.
Doctor: You are not allergic to anything? Patient: No, I am not. Doctor: Any food or other pollen? Patient: No, I am not allergic to anything. Doctor: Great!
Section Header: ALLERGY Summary: None.
Doctor: April twenty two three we checked your list of medications. Doctor: We saw that it lifts up in the morning and evening. Doctor: Yeah. Patient: Yeah.
Section Header: MEDICATIONS Summary: Her list of medicines is as noted on 04/22/03. There is a morning and evening lift.
Doctor: How old is the baby? Guest_family: He is twenty one months old. Doctor: What brings you here today? Guest_family: I have concerns about his motor development. Many times he seems to have lazy eyes and sometimes I can notice his jaw quivering. Doctor: How was your pregnancy? Guest_family: I had no complications in my pregnancy with him. My labor was very spontaneous, and it was a normal delivery. Doctor: Is this the only child? Guest_family: No, I have two more kids. Doctor: How much did he weigh at birth? Guest_family: He was around eight pounds and ten ounces. Doctor: Did you remember his milestones? Guest_family: Yes, I have all of it written down for all of my three kids and I brought this with me. He sat on his own by seven months. He was able to stand by eleven months and crawled around sixteen months but he was not walking until eighteen months. Doctor: What issues are he facing right now? Guest_family: He falls a lot. He cannot walk properly. He is kind of in toeing on his left. He's able to feed himself properly. He also throws, um, he picks up the things and throws them. His upper body looks strong. Doctor: How about his speech? How many words do you think he knows? Guest_family: He knows more than twenty words for sure. Doctor: Is he able to speak two word phrases? Guest_family: Yes. He says things like ,”give me,” and, “come here.” Doctor: Any other unusual behavior that you noticed? Any seizures or just the quivering movement of the jaw? Guest_family: No, it was only this and we have noticed this since birth. I don't know if it is related but I did notice that his left eye deviates outside.
Section Header: HISTORY of PRESENT ILLNESS Summary: This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months. He currently cannot walk and easily falls. His gait is reportedly marked by left "intoeing." His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases. No seizures or unusual behavior were reported except for "quivering" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.
Doctor: What brings you back into the clinic today? Patient: I have been having some severe bruising. I have been taking Coumadin for three months now. Am I taking to much Coumadin? Doctor: You are taking a normal start dose. Some people do not metabolize the medication as well as others. I would like to get you tested for hypersensitivity. After we get the test results back, we will be able to adjust your dosage accordingly. Patient: Okay.
Section Header: CHIEF COMPLAINT Summary: Probable Coumadin hypersensitivity.
Doctor: Let me examine you. Tell me, did you have any fever or chills, any sweating or that sort of thing? Patient: Um no. Doctor: How about abnormal weight loss or weight gain? Patient: No. Doctor: Are you experiencing any chest pain on exertion or shortness of breath normally or when you try to sleep? Patient: No, no chest pain and shortness of breath. Doctor: Let me see your legs. They look good I don't see any pedal edema. Usually that happens due to excess water retention. Any palpitations? Patient: No. Doctor: Any feeling of numbness or tingling? Did you faint or lose consciousness anytime? Patient: No and no. Doctor: Okay, good! Doctor: Any double and or blurred vision? Patient: No. Doctor: Any difficulty hearing or any wired continuous sound you may hear? Patient: No. Doctor: Okay, um tell me if you had any um, allergies, or sneezing, or runny nose? Patient: No, no really. Doctor: Okay, got it. Doctor: Any indigestion, or heart burn? Did you notice any blood in stool or black stool? Patient: No. Doctor: Any diarrhea or vomiting? Patient: Nope. Doctor: Are you feeling thirsty frequently? Patient: No, just normal. Doctor: Okay. Doctor: And I see you got a urine test, so no pus cells or blood present. Patient: Yes. Doctor: Any pain while passing urine though? Any blood? Patient: No. Doctor: And how is the urine frequency? Do you have to wake up at night to urinate? Patient: Well, my frequency is normal. I don't have to wake up at night for urinating. Doctor: How bout the stream while passing urine? You think it's normal or somewhat slow? Patient: No, it's absolutely normal. Doctor: Okay, so any cough or cold like symptoms any sputum? Patient: Nope. Doctor: No wheezing, right? Patient: Yes, no wheezing. Doctor: I don't see any lesions, that's good. Any mood swings, feeling depressed or have anxiety? Patient: No. Doctor: Any joint pain in the legs, back or anywhere? Patient: Um no. Doctor: Okay, so no erythema in the joints. Any heat or cold intolerance? Patient: No. Doctor: Okay, any difficulty swallowing? Let me check here, lymph nodes look fine. And do you bleed easily and does the bleeding stop normally? Patient: Oh yes! Doctor: Do you bruise easy? Patient: No, not really. Doctor: Okay. Any abnormal skin lesions? Patient: No.
Section Header: REVIEW OF SYSTEMS Summary: General: No fevers, chills, or sweats. No weight loss or weight gain. Cardiovascular: No exertional chest pain, orthopnea, PND, or pedal edema. No palpitations. Neurologic: No paresis, paresthesias, or syncope. Eyes: No double vision or blurred vision. Ears: No tinnitus or decreased auditory acuity. ENT: No allergy symptoms, such as rhinorrhea or sneezing. GI: No indigestion, heartburn, or diarrhea. No blood in the stools or black stools. No change in bowel habits. GU: No dysuria, hematuria, or pyuria. No polyuria or nocturia. Denies slow urinary stream. Psych: No symptoms of depression or anxiety. Pulmonary: No wheezing, cough, or sputum production. Skin: No skin lesions or nonhealing lesions. Musculoskeletal: No joint pain, bone pain, or back pain. No erythema at the joints. Endocrine: No heat or cold intolerance. No polydipsia. Hematologic: No easy bruising or easy bleeding. No swollen lymph nodes.
Doctor: Are you allright? Patient: Yes I am fine. Doctor: That's great. Patient: Thanks. Doctor: I think you can go home now.
Section Header: DISPOSITION Summary: Stable.
Doctor: I'm reviewing my notes from your last visit. Your last visit was on May tenth two thousand four, correct? Patient: Yes, that's right. Doctor: Has there been any change since your last visit? Patient: Well, I'm having some increased paranoia. Doctor: Have you been treated, and are you taking medicine for this? Patient: Yes, and it's actually gotten a lot better with the medicine another doctor gave me.
Section Header: PAST MEDICAL HISTORY Summary: Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications.
Doctor: I just met with one of my patients whom I believe has pertussis. Guest_clinician: Second case of the day. What's their name and date of birth? Doctor: Hm give me a second to pull up their information.
Section Header: CHIEF COMPLAINT Summary: Public Health Department was notified of a case of suspected pertussis.
Doctor: Have you ever had psychiatric or psychological treatment? Patient: Uh no, no treatments whatsoever. I mean I do find myself in low moods every now and again when I'm dealing with certain stressors, but the decreased moods rarely ever long lasting.
Section Header: HISTORY of PRESENT ILLNESS Summary: The patient denied any history of psychological or psychiatric treatment. He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.
Doctor: Do you remember when your last flu vaccine was? Patient: I don't remember what month, but it was in nineteen ninety nine. Doctor: Good, and do you remember your last pneumonia vaccine? Patient: Let me look at my notes here, um, it was in nineteen ninety six. Doctor: Thank you, now, tell me more about your parents. Do you know their medical histories? Patient: Let me think, my dad is still around, he had a stroke. Oh yeah, and he has high blood pressure. Doctor: How old is your father? Patient: He's seventy nine now. Doctor: Good, what about your mother? Patient: She died when she was seventy four, she had heart failure and emphysema. Doctor: I'm sorry to hear that. Do you have any brothers or sisters? Patient: Thank you doctor, no, its just me and my Dad now.
Section Header: IMMUNIZATIONS Summary: Last flu vaccine was given on 1999. Last pneumonia vaccine was given on 1996. Family Medical History: Father age 79, history of cerebrovascular accident (stroke) and hypertension. Mother history of CHF and emphysema that died at the age of 74. No brothers and sisters.
Doctor: How are you doing today, ma'am? Patient: I'm doing just fine. Doctor: Any kind of alcohol consumption? Patient: Nope. Doctor: Have you ever taken any kind of illegal drugs? Patient: Nope. Doctor: What about smoking? Patient: No. Doctor: Are you still working? Patient: No, sir. I had issues with my knees, and they had to put in the new ones. I was kind of disabled and that's why I retired.
Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is retired on disability due to her knee replacements. She does not smoke, drink or use any illicit drugs.
Doctor: Do you have any chest pain? Patient: No, I don't. Doctor: Any breathlessness? Patient: Yes, I do get breathless only when I have to do some form of exertion like walking a long time or running. Doctor: Okay. How about any bowel issues? Patient: No, I don't have any stomach problems except I have to go frequently to use a bathroom. Doctor: Okay frequency. How about any prolonged bleeding issues or anything like that sort? Patient: No nothing like that.
Section Header: REVIEW OF SYSTEMS Summary: He denies any chest pain. He admits to exertional shortness of breath. He denies any GI problems as noted. Has frequent urination as noted. He denies any bleeding disorders or bleeding history.
Doctor: Does she lives with anyone? Guest_family: Yes, we all stay together, so just the immediate family. My parents, me and my sister. Doctor: Okay.
Section Header: HISTORY of PRESENT ILLNESS Summary: She lives with her parents.
Doctor: Hi, the weather outside is beautiful, did you get some sunshine? Patient: Yes in fact I came in walking. Doctor: Great way to get some exercise in. Doctor: ok so what's going on? Patient: I am having a bellyache. Doctor: Since when? Patient: Oh, it's been a while now. Doctor: Can you tell me more about your pain like how did it start and what exactly are you feeling? Patient: Ok so the pain started as dullache but it is constant right here in the middle upper part of my stomach. And sometimes it is moving to the back. Doctor: Can you tell me if it is stabbing pain and if it is related to any specific time of the day? Patient: Sure, so i do get episodes of stabbing pain but they are not related to meals. Once the wave comes it lasts for only a minute or so. Doctor: Can you tell me when exactly you noted it? Patient: Approximately six months back. I took over the counter antacids and got some relief so i did not go to doctor. But two months back it got worse, I do get occasional nausea and vomiting. Doctor: I can see that they found H pylori positive infection and treated you with triple drug therapy for two weeks and then gave you antacid omeprazole. But it did not improve your pain. Patient: Yeah that's right. Patient: Do you know I lost twenty pound of weight since all these symptoms began but i have been also admitted for poor appetite. Doctor: Ok tell me how are your bowel movements and if you see any blood in stools? Patient: I get two to three loose bowel movements a day but no blood in stool or anywhere. Doctor: Are you taking any pain medication over the counter? Do you drink alcohol and maybe you are vomiting blood? Patient: No no, nothing like that. Doctor: Can you tell me if any change in position changes the quality of pain? do you have any fever? Patient: No position changing have no effect, no fever or anything. Doctor: Have you been exercising before all this? Patient: Yes I have had very active and healthy lifestyle.
Section Header: HISTORY of PRESENT ILLNESS Summary: 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unrelated to meals lasting only minutes. Patient noted that the pain started approximately six months prior to this presentation. He self medicated "with over the counter" antacids and obtained some relief so he did not seek medical attention at that time. Two months prior to current presentation, he had worsening of his pain as well as occasional nausea and vomiting. At this time the patient was found to be H. pylori positive by serology and was treated with triple therapy for two weeks and continued on omeprazole without relief of his pain. The patient felt he had experienced a twenty-pound weight loss since his symptoms began but he also admitted to poor appetite. He stated that he had two to three loose bowel movements a day but denied melena or bright red blood per rectum. Patient denied NSAID use, ethanol abuse or hematemesis. Position did not affect the quality of the pain. Patient denied fever or flushing. He stated he was a very active and healthy individual prior to these recent problems.