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Doctor: Can you tell me what problems you have had in the past. Or what medical issues are currently going on? Patient: You mean my heart problem and things? Doctor: Yes. Patient: Okay, I have hypertension and kidney problems since many years. Doctor: Okay. Patient: I get frequent urinary infections. Doctor: Your urine creatinine is normal. Patient: Okay. I also have severe aortic stenosis.

Section Header: PAST MEDICAL HISTORY Summary: Significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal).

Doctor: Does anyone else in your family have aneurysm problem? Patient: Well, my grandmother had it. She actually passed away due to brain aneurysm. Doctor: Oh, okay.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Grandmother died of cerebral aneurysm.

Doctor: What is wrong with your back honey? Patient: Oh, it all started off with a little pimple on the buttock. I was soaking it at home with hot water and stuff, but it did not improve. I hope this is not cancer. I am only twenty four. Doctor: Okay what exactly are you experiencing? Patient: I have pain. Doctor: So you came to the hospital on the first and they did an I and D in E D? Patient: Yes I was admitted to the hospitalist service with high blood sugars. My African American father was so scared. Doctor: Okay sugars high. Do you know the number? How high? Patient: No, I do not know that but they found positive bacteria or some sort of thing in my blood culture. Doctor: So today we are evaluating you for surgery? Patient: Yes.

Section Header: HISTORY of PRESENT ILLNESS Summary: This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation.

Doctor: Hi there! I have the results from your ultrasound. You have kidney stones in the ureter close to the bladder. Patient: Oh no. Doctor: This explains the pain you have been having on your left side. Are you still experiencing nausea and vomiting? Patient: Yes, I have been. Doctor: I would like to set you up with a consult with a consult with a surgeon. Patient: Okay.

Section Header: ASSESSMENT Summary: 1. Left flank pain. 2. Left ureteral stone. 3. Nausea and vomiting.

Doctor: Any known drug allergies? Patient: No.

Section Header: ALLERGY Summary: No known drug allergies.

Doctor: Your daughter had an exposure to the ant bait but we are not sure if she actually ingested any of it. Poison Control confirmed that even if she did ingest the small amount that she was found with, it is likely nontoxic. Do you have any questions? Guest_family: No.

Section Header: ASSESSMENT Summary: Exposure to ant bait.

Doctor: Hello, sir. How are you today? Patient: I am alright. I am here for a check up since I am feeling kind of dizzy lately. Doctor: That is not good. How long has this been happening? Patient: A few months. This happened to my sister too. I think she is still dealing with it. Doctor: Is there any other family medical history I should know about? Migraines or cancer? Patient: No. Not that I know of. The rest of my family seems pretty healthy.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Sister is dizzy but no other acute illnesses.

Doctor: Do you know anyone in your family whose had cancer? Patient: No one that I know.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Negative for cancer.

Doctor: Okay so your blood report is back and the cardiac enzyme we were looking for are negative. Patient: Okay. Doctor: Your blood urea nitrogen, also known as B U N, is within normal limits and hydrogen is stable. Creatinine is also within the normal range. Patient: Great!

Section Header: LABS Summary: First set of cardiac enzyme profile negative. H&H stable. BUN and creatinine within normal limits.

Doctor: Are you on any medications? Patient: No, not taking any medications.

Section Header: MEDICATIONS Summary: None.

Doctor: Hi, how are you doing today? Patient: I've been better. Thank you. Doctor: So, you are here for your follow up right? Remind me how often are you coming here? Patient: That's right. I'm coming around between a month or two. Doctor: Yeah, it's every four to eight weeks. Patient: I'm not taking any medicine now. I just wanted to let you know. Doctor: Yeah, I can see it in your record. It says that you are off of all the immunosuppression. So, just let me check. It says here that you do have mild chronic G V H D. It is not that bad that I should be worried about any therapy or anything else. How long ago did you get that transplant? Patient: I think it was around four and a half years ago. I'm feeling much better after that. I do have complaints of blood in my stool. But after you sent me to that doctor, that gastro doctor, I feel good. I know they said that they removed something, but I'm not sure, but after that it has been improved a lot. Doctor: Okay, let me see in my chart. You had some rectal bleeding issues because of which I referred you to the gastroenterologist. A complete endoscopy was performed, which was both on the upper and the lower side. There was no evidence of ulcers or any other abnormality. That's good news, right? Patient: Yeah, I agree. That was a relief. Doctor: They did find some polyps and they removed it. They turned out to be benign, so nothing to worry about there. Patient: Yeah, I remember this said they removed something, but I forgot the name. Doctor: Is there any other issue that I can help you with? Patient: I don't know. I feel a lot of fatigue and like I'm not able to do things like I used to do before. I get tired very easily. I don't know if it is related to something or not, but things have been weird. I'm not able to do even the minor things like I lift two boxes and I'm done for the day. Is it something that I should be worried about? Doctor: It looks like you have a mild iron deficiency. I will work on that with you, don't worry.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient comes to the clinic today for followup. I am seeing him once every 4 to 8 weeks. He is off of all immunosuppression. He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant. He has multiple complaints. He has had hematochezia. I referred him to gastroenterology. They did an upper and lower endoscopy. No evidence of ulcers or any abnormality was found. Some polyps were removed. They were benign. He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.

Doctor: Are you feeling any pain? Patient: No, I feel great. Doctor: Is there any other medical issue that we should be worried about? Patient: No, it feels like I'm young again. I'm able to do all my activities.

Section Header: EMERGENCY DEPARTMENT COURSE Summary: COMPLICATIONS: None.

Doctor: Thank you for coming in to see us at A B C D General Hospital today. Patient: I wish I wasn't here right now. Doctor: I understand, before we begin, how old are you? Patient: I'm seventy seven years young. Doctor: Which race, and gender do you identify with? Patient: I'm an African American woman. Doctor: What's seems to be causing you pain today? Patient: I've had this bunion on my foot for as long as I can remember. Doctor: Is the pain worsening? Patient: Yes, it is so painful, I've tried to avoid surgery for so long, but I want this bunion gone. Doctor: How have you managed this bunion in the past? Patient: I've used antiinflammatories, rested, changed my activities, I've done everything, but this pain is getting worse and worse. I need it gone.

Section Header: HISTORY of PRESENT ILLNESS Summary: This 77-year-old African-American female presents to ABCD General Hospital. The patient states she has had a bunion deformity for as long as she can remember that has progressively become worse and more painful. The patient has attempted conservative treatment without long-term relief of symptoms and desires surgical treatment.

Doctor: Do you have diabetes or blood pressure problems? Patient: Yes, I have hypertension but no diabetes. Doctor: Alright.

Section Header: PAST MEDICAL HISTORY Summary: Hypertension.

Doctor: How are you dealing with your pain now? Patient: Oh no, I have no issues with my pain. Today I'm here for a different cause. I'm having this weakness all around on my left side, especially in my arm. I feel like I cannot lift anything like even a glass of water. It's hard for me to lift it up. I'm not able to walk properly, let alone the balancing and everything else. It's just that my whole left side seems to be weak.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient reports that the pain is not an issue at this time. The patient states that her primary concern is her left-sided weakness as related to her balance and her walking and her left arm weakness.

Doctor: Did you have any medical disorders previously, sir? Patient: I have diabetes. Also, I was quite overweight. Doctor: Are you taking any medications for that? Patient: Yes, I was still taking something called Zyprexa, but I stopped it after my last regular weight check. Also, I never took anything for diabetes. I also have chronic bronchitis for… I don't know… many years. Doctor: Do you smoke? Patient: Oh yes, I am a smoker. Doctor: How many cigarettes do you take in a day? Patient: Maybe up to sixty a day.

Section Header: PAST MEDICAL HISTORY Summary: He has a history of obesity and also of diabetes mellitus. However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa. The patient has chronic bronchitis. He smokes cigarettes constantly up to 60 a day.

Doctor: Lets talk about your ears. Any continuous ringing or thumping noises you may hear? Patient: No, nothing like that. Doctor: Any hearing problems? Patient: Um, no. Doctor: Any dizziness or spinning sensation? Patient: Nope.

Section Header: REVIEW OF SYSTEMS Summary: EARS: Negative tinnitus, negative vertigo, negative hearing impairment.

Doctor: Good morning, ma'am. You're eighty two years old, is that correct? Patient: Good morning, doctor. Yes, that's correct. Doctor: Good, and just one more piece of background information, which hand do you write with? Patient: I use my right hand for everything. Doctor: Good, so what seems to be the problem today? Patient: Doctor, I've had years of pain in this shoulder. Doctor: What kind of treatments have you had? Patient: Well, um, I've had antiinflammatories, and rested, and none of it has helped so far. Doctor: Can I assume the pain is impacting your daily life? Patient: Yes, it certainly is. The pain is unbearable now.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment.

Doctor: Have you ever had surgery? Patient: What, like a joint replacement? Doctor: Well, anything from joint replacements, to appendix removal, or C sections? Patient: Yeah, I've had an appendectomy and hysterectomy, actually.

Section Header: PAST SURGICAL HISTORY Summary: The patient has a past surgical history of appendectomy and hysterectomy.

Doctor: Can you confirm your age for me, ma'am? Patient: Absolutely, I'm sixty six now. Doctor: Good, so it's been about five months since you last evaluation for type two diabetes and high blood pressure. Patient: Yes, and I have a few other problems today, too. Doctor: Sure, we can treat all of them. What seems to be the problem today? Patient: I'm having some right shoulder pain. Doctor: Can you remember an injury to this shoulder? Patient: No, not that I can remember. Doctor: What aggravates your symptoms? Patient: It hurts when I move the shoulder. Doctor: Do you have any weakness, numbness, or tingling? Patient: No, I don't have any of that. Doctor: Okay, back to diabetes, how has that been progressing? Patient: Well, I can only check it in the morning, and it's usually less than one hundred. Doctor: Have you been checking your blood sugar two hours after meals? Patient: No, doctor, I haven't been. When I check them, it's normal though. Doctor: Do you have any records to prove that? Patient: No, I don't have that with me today. Doctor: That's important, do you have any other issues or concerns today? Patient: No, I can't think of anything. Doctor: Okay. I'm looking at your charts, and I see you had a benign breast biopsy done on June eleventh two thousand four. Did you have a repeat done after six months like they asked? Patient: No, I never had that done, I need to.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension. While here she had a couple of other issues as well. She stated that she has been having some right shoulder pain. She denies any injury but certain range of motion does cause it to hurt. No weakness, numbness or tingling. As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100. She has not been checking any two hours after meals. Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her. No other issues or concerns. Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well.

Doctor: What is your family medical history? Patient: None, that I know of.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Unremarkable.

Doctor: Do you mind giving me a run down of his past medical history? I want to make sure it's all in his chart. Guest_family: Sure. I'll start with his surgeries. If I remember correctly, he had back surgery, a couple knee surgeries, and coronary artery bypass surgery with angioplasty. Doctor: I see. When did he have these done? Guest_family: I'd have to check, but I know he had back surgery in O nine. He has a history of high blood pressure and high cholesterol. He was recently diagnosed with B P H potentially linked to cancer. It's B P H, right? Or is it B H P? Doctor: If it's his prostate, then B P H is correct. Guest_family: Oh, he has high P S A levels, too. I think that's related to the prostate. Doctor: Is he currently experiencing any symptoms? Guest_family: He was complaining of pain earlier. He does have a history of fatigue, tiredness, and shortness of breath though. So far, he hasn't complained about the usual.

Section Header: PAST MEDICAL HISTORY Summary: Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer. Symptoms of shortness of breath, fatigue, and tiredness.

Doctor: How long have you been living with diabetes, sir? Patient: Oh, it's been about thirty five years now. Doctor: How long have you been taking insulin for this? Patient: Well, um, I've been taking insulin for about twenty years now. Doctor: Do you have any major medical conditions that I should know about? Patient: Yeah, um, prostate cancer. Doctor: How were you treated for this? Patient: I've had radiation. Oh, my P S A is zero point zero one, by the way.

Section Header: PAST MEDICAL HISTORY Summary: The patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years. He also has a history of prostate cancer, which was treated by radiation. He says his PSA is at 0.01.

Doctor: So, what stomach symptoms are you experiencing? Patient: I feel an intense burning in my throat. Doctor: When do you feel this? Patient: It really hurts after eating food, especially junk food. Doctor: That's pretty consistent with reflux disease. Patient: Ah, yes. Doctor: I got your survey results back as well, let's discuss them. Patient: Absolutely, please, what does it show. Doctor: According to your answers, it looks like you have depression as well.

Section Header: PAST MEDICAL HISTORY Summary: Significant for depression and reflux disease.

Doctor: Any difficulty in swallowing? Patient: No. Doctor: Any nausea, vomiting or blood in your vomit? Patient: No, no vomit at all. No problem there. Doctor: Okay, any stomach pain? Patient: No. Doctor: Okay.

Section Header: REVIEW OF SYSTEMS Summary: GASTROINTESTINAL: Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.

Doctor: Hello, ma'am. How are you feeling today? Patient: I'm sad and depressed. Doctor: I'm sorry to hear that. Why do you feel that way? Patient: My cancer came back.

Section Header: PAST MEDICAL HISTORY Summary: Significant for cancer. She also has a depression.

Doctor: What's going on with you? What brings you here today? Patient: I am having loose watery stools for more than two weeks now. I feel very lethargic. I also have pain in my tummy.

Section Header: DIAGNOSIS Summary: Diarrhea.

Doctor: Are you allergic to anything? Patient: No.

Section Header: ALLERGY Summary: He has no known drug allergies.

Doctor: Are you a smoker? Patient: I used to smoke. I quit in nineteen sixty eight. Doctor: Excellent! Have you weighed your self recently? Patient: I weighed myself this morning. I am at one hundred and eighty three pounds. Doctor: And how tall are you? Patient: I used to be five foot ten but I think I have been shrinking. Doctor: That is definitely a possibility. We do shrink as we go through life. I can have the nurse get your height after we do your exam. Patient: Okay.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He quit smoking in 1968. His current weight is 183 pounds. His tallest height is 5 feet 10 inches.

Doctor: Do you smoke? Patient: No, I have never smoked in my entire life.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is a nonsmoker.

Doctor: Welcome to the clinic, sir. Patient: Thank you. Doctor: Let us start with your medical history. Patient: I used to have seizures, but they have stopped now. Doctor: Was there a cause of the seizures? Patient: About seven years ago I had a traumatic stroke. They told me I had bleeding in the brain. After the stroke I was left with this weakness on my right side. Doctor: What part of your body is affected by the weakness? Patient: My arm, hand, and my face. Doctor: Do you have any other health problems? Patient: My liver is falling. It is because of all the alcohol that I have consumed over the years. I am not drinking anymore. Doctor: Are you being treated for your liver disfunctions? Patient: No. I just stopped drinking. I think I have diabetes. Doctor: What makes you feel like you have diabetes? Patient: I have been really thirsty, and I have been having numbness and tingling in my feet. Doctor: Oh okay. We can definitely do some test today to find out if you are diabetic or not.

Section Header: PAST MEDICAL HISTORY Summary: 1. Liver cirrhosis caused by alcohol. This is per the patient. 2. He thinks he is diabetic. 3. History of intracranial hemorrhage. He said it was subdural hematoma. This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis. 4. He said he had a seizure back then, but he does not have seizures now.

Doctor: Hi miss. How old are you? Patient: I am sixteen. Doctor: What race do you identify as? Patient: White. Doctor: Are you okay? You have a headache? Patient: No I have a really bad migraine. Doctor: Okay can you point to where you are feeling it the most? Patient: Here, since Monday. Doctor: Okay so mostly on the right frontal side and it's been forty eight hours now? Patient: Yes, I am feeling a lot of pressure. Doctor: I can understand the discomfort. Is it continuous or throbbing? Patient: It is throbbing. Doctor: On the scale of one to ten, ten being the worst, how would you rate it? Patient: Nine or more. Doctor: Have you ever experienced similar symptoms in the past? Patient: No I haven't. Doctor: Did you hit your head buy any chance? Patient: No no. Doctor: Okay can you tell me if you have any fever or chills, congestion, cough cold like symptoms? Patient: No. Doctor: Any nausea, vomiting, diarrhea or trauma anywhere? Patient: No nothing like that. Doctor: Anything from head to toe? Patient: No everything else is fine.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache. She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago. Indicates pressure type of discomfort with throbbing component. It is as high as a 9 on a 0 to 10 scale of intensity. She denies having had similar discomfort in the past. Denies any trauma. Review of systems: No fever or chills. No sinus congestion or nasal drainage. No cough or cold symptoms. No head trauma. Mild nausea. No vomiting or diarrhea. Other systems reviewed and are negative.

Doctor: Has the patient signed a do not resuscitate order? Guest_family: Yes, she has. Doctor: Does she have a healthcare proxy or durable power of attorney? Guest_family: Yes, she has both.

Section Header: EXAM Summary: CODE STATUS: DNR, healthcare proxy, durable power of attorney.

Doctor: How are you doing today? Patient: I have a long history of lung disease. COPD to be exact. Recently, I was experiencing a lot of coughing and shortness of breath even on walking from one room to another. All the time I felt sleepy, tired, or confused. Doctor: How is it now? Patient: It is getting better. Doctor: What else? Patient: I was also diagnosed with pneumonia; I was on trip and there they found it. It is also getting a lot better now, but doctor said to continue taking oxygen for some more time. Doctor: Oh wow! Patient: With everything going on, I felt weak and tired and it looks like I have lost all my strength and muscle. Patient: I also felt very instable and had a fall. I did not call for any assistance but now I think I should have called someone. Everyone including my family and nurses all tell me all the time to call for assistance. I was just being stubborn and hurt myself. Doctor: Did you use a wheelchair? Patient: No. Doctor: You know I would agree with everyone else; you should call for assistance if you need help like getting out of bed or need to use the restroom.

Section Header: ASSESSMENT Summary: 1. Acute on chronic COPD exacerbation. 2. Community acquired pneumonia both resolving. However, she may need home O2 for a short period of time. 3. Generalized weakness and deconditioning secondary to the above. Also sustained a fall secondary to instability and not using her walker or calling for assistance. The patient stated that she knew better and she should have called for assistance and she had been told repeatedly from her family members and staff to call for assistance if she needed to get out of bed.

Doctor: Were there any medical issues in the past? Patient: Oh, I have a list. I have asthma and sinus issues. I also had hives at some point and psoriasis. Doctor: How about allergies? Patient: I don't know of any.

Section Header: ALLERGY Summary: The patient has asthma, sinus, hives, and history of psoriasis. No known drug allergies.

Doctor: Do you use tobacco products, alcohol, or recreational drugs, miss? Patient: I have a drink every once and a while. Doctor: How many drinks do you consume in a week? Patient: I don't even drink that often. I probably have one drink per month. Doctor: Are you married? Patient: I was engaged but that is not happening anymore. It is a long story. Doctor: I am sorry the hear that. What do you do for work? Patient: I am a metal grinder.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: works as a metal grinder and was engaged to be married. She denied any tobacco or illicit drug use. She consumed 1 alcoholic drink per month.

Doctor: Now that you're eighteen, I have a big question to ask you. Do you smoke? Patient: Never have, never will. Doctor: That's what I like to hear. You have a good head on your shoulders, bud. Patient: Thanks. I'd like to think so, too. I have some friends who smoke weed, but stay clear of tobacco.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: None.

Doctor: Have you ever been diagnosed with any illnesses? Patient: No, I do not have any diseases. Doctor: How about any issues with B P, thyroid, diabetes? Patient: Nope none.

Section Header: PAST MEDICAL HISTORY Summary: No significant past medical history.

Guest_clinician: Any history of drug or alcohol use? Doctor: He was a former smoker and tested positive for cocaine during his last visit in January O eight.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.

Doctor: I just quickly wanted to check few things, let's go over them together? Patient: Sure. Doctor: Any heart condition like heart failure or anything? Patient: No. Doctor: Any heart catheterization? Patient: Um, no. Doctor: Any history of chest pain, palpitation, or irregular heartbeat? Patient: No. Doctor: Do you have high blood pressure? Patient: No. Doctor: Any history of high cholesterol? Patient: No. Doctor: Any excessive or abnormal sweating? Patient: Not really, no. Doctor: Any stress test or heart tests done recently? Patient: No. Doctor: Okay, thank you for answering these questions. Patient: No problem.

Section Header: REVIEW OF SYSTEMS Summary: CARDIOVASCULAR: No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.

Doctor: Hello Miss Sherry, how are you doing today? Patient: I have seen worse days. Doctor: Ha, I will take that as a positive answer then. I have my resident here with me, Doctor Helm, she will be representing your case today. Guest_clinician: Hello. Patient: Hello Doctor Helm. Doctor: Doctor Helm. Guest_clinician: The patient is a sixty one year old female. She was diagnosed with non small cell lung cancer stage one A in the upper right lobe. She was treated with CyberKnife and the treatment was completed one month ago. This is her first visit after the CyberKnife treatment. Doctor: Thank you Doctor Helm. So, Miss Sherry, how are you doing after the treatment? Patient: I feel nauseous. Doctor: How would you define it mild, moderate, or severe? Patient: I would say mild. Doctor: What about vomiting? Patient: No, only nausea is there. If I try to take deep breaths, then I still have pain. Doctor: How is your dysphagia? Are you able to swallow and eat your food and drink now? Patient: It has been better now. I won't say I am all good but as I said I have seen the worst days. Doctor: Is there any heartburn or rash? Patient: No. Doctor: Are you coughing up blood, or just cough? Patient: No, none of them. Doctor: Let me exam for any rib pain, okay? Patient: Okay. Doctor: Any pain if I touch you here or here? Patient: No.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer. CyberKnife treatment was completed one month ago. She is now being seen for her first post-CyberKnife treatment visit. Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting. She continues to have pain with deep inspiration and resolving dysphagia. She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.

Doctor: Around what time did the car crash take place? Patient: About forty five minutes ago. I think someone called nine one one shortly after it happened. Doctor: Do you happen to remember how fast you were driving at the time of the crash? Patient: I was driving about forty miles an hour. Doctor: What kind of car were you driving? Patient: A minivan. The car in front of me stopped suddenly and I hit them right from behind. The front of my car is pretty wrecked. Doctor: Were you wearing a seatbelt? And did the airbag deploy? Patient: Yes and yes. Doctor: Any passengers in the car with you? Patient: No, just me. Doctor: Did you hit your head anywhere? Patient: No, but I do have some pain on the left side of my neck. Doctor: Do you think you lost consciousness at any point in time? Patient: Actually, I do. Right after the crash. Doctor: Any pain elsewhere? Patient: Um I'm having some pain in my lower stomach area. I think it could be due to slamming into the airbag or steering wheel. Doctor: How would you rate this pain, ten being the worst pain ever? Patient: Um I'd give it a five out of ten right now. Doctor: Any knee, ankle, or foot pain? Patient: No. Doctor: How about pain in your shoulders, elbows, or wrists? Patient: Uh no, but I guess I do have a little bit of pain in my pelvic area. Doctor: Do you remember walking before or after the ambulance arrived? Patient: I don't think so. Someone told me that I was placed on the stretcher after they got me out of the car. Doctor: Just to confirm, no chest pain or difficulty breathing? Patient: No. Doctor: Have you noticed any cuts on your skin? Patient: No. Doctor: Any headache, nausea, or vomiting? Patient: No. Doctor: Fever or chills? Patient: No. Doctor: Any chance of pregnancy? Patient: No, I've been good at taking my birth control and I also have an I U D. Doctor: When was your last period? Patient: Um end of May I believe. Doctor: Are you taking anything besides birth control? Patient: Accutane for my pimples.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance. The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago. The patient states that she was driving her vehicle at approximately 40 miles per hour. The patient was driving a minivan. The patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her. The patient states that she was wearing her seatbelt. She was driving. There were no other passengers in the van. The patient states that she was restrained by the seatbelt and that her airbag deployed. The patient denies hitting her head. She states that she does have some mild pain on the left aspect of her neck. The patient states that she believes she may have passed out shortly after the accident. The patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag. The patient denies any pain in her knees, ankles, or feet. She denies any pain in her shoulders, elbows, and wrists. The patient does state that she is somewhat painful throughout the bones of her pelvis as well. The patient did not walk after this accident. She was removed from her car and placed on a backboard and immobilized. The patient denies any chest pain or difficulty breathing. She denies any open lacerations or abrasions. The patient has not had any headache, nausea or vomiting. She has not felt feverish or chilled. The patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan. There were no oblique vectors or force placed on this accident. The patient had straight rear-ending of the vehicle in front of her. The pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10. The patient states that her last menstrual cycle was at the end of May. She does not believe that she could be pregnant. She is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on Accutane.

Doctor: Any known allergies? Patient: No. Doctor: Any allergy to any drug? Patient: No.

Section Header: ALLERGY Summary: She has no known drug allergies.

Doctor: Let's talk about your family history. Did anyone in your family have any medical issues that you were aware of? Patient: I don't think so. My family has been pretty healthy. Both my parents died of old age. Doctor: What about your siblings? Any kind of thyroid issue or diabetes or blood pressure issue there? Patient: I have one older brother. He's into weightlifting and all. I would say he's pretty healthy.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.

Doctor: Can you tell me more about your parents, please? How are they doing? Patient: Thank you for asking, they're both doing very well. They're very healthy. Doctor: That's great to hear. How old are they? Patient: My mom is fifty, and my dad is forty. Doctor: Wonderful, do you have any siblings? Patient: Yeah, I have two sisters, one is a half sister, and the other we have the same mom and dad. Doctor: How old are they? Patient: My half sister and I have the same mom, and she's thirty four. My other sister is ten. Doctor: Do they have any history of medical conditions that you know about? Patient: My half sister, um, no. My other sister has had some yeast infections.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother is 50 and healthy. Dad is 40 and healthy. Half-sister, age 34, is healthy. She has a sister who is age 10 who has some yeast infections.

Doctor: Hello sir, what brings you here today? Also, please confirm your age for the records. Patient: I am seventy years old. I am here for nothing particular but I just have discomfort on the right side. Doctor: We did electromyography study. This was to assess the health of muscles and the nerves in your body. When did you first notice this discomfort? Patient: About five years ago. After my stroke. I've been to a neurologist before. Doctor: Yeah, I can see that you have taken different kinds of medications, but nothing seems to help you. Patient: That sounds right. Nothing seems to help me to get rid of this discomfort. Doctor: How often do you check your sugar levels? Patient: I do it at home. Mainly two to three times a day. I increase or decrease the amount of insulin that I take based on my numbers. Doctor: Don't you consult anyone before doing that? Patient: It's been so many years now. I do it all by myself. Doctor: We did reevaluations of your symptoms. It turned out to be all negative. Do you smoke? Patient: I used to chew tobacco a lot and then there were drinks. I used to drink at least half a bottle of single malt in one night. I quit everything five years ago after my stroke.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage.

Doctor: It is nice to see you again, miss. We are following up on a few things today. How is your arm feeling? Patient: My arm is all better. It is not in pain at all anymore. Doctor: How has your mood been? Are you feeling any relief from your symptoms since you have been on the Lexapro? Patient: It's helping a little bit. Doctor: How much Lexapro are you taking now? Patient: I am taking ten M G. Doctor: How long have you been taking the full dosage? Patient: About a week ago. I don't take it every day. I don't feel like I need it some days. Doctor: I want you to take the full dosage every day. This might be why you have not had much relief with your symptoms yet. Patient: Okay. Doctor: Your hands are a little shaky. Is this a normal occurrence for you? Patient: I didn't even notice. Doctor: It is very subtle. We will keep an eye on it for now. Your blood pressure is a little better today. Have you experienced any worsening joint or bone pain? I want to check on your osteoporosis and osteoarthritis. Patient: No.

Section Header: ASSESSMENT Summary: 1. Hypertension, better reading today. 2. Right arm symptoms, resolved. 3. Depression probably somewhat improved with Lexapro and she will just continue that. She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it. 4. Perhaps a very subtle tremor. I will just watch that. 5. Osteoporosis. 6. Osteoarthritis.

Doctor: Do you have any past medical history? Patient: No.

Section Header: PAST MEDICAL HISTORY Summary: Negative.

Doctor: How long it has been since these psychotic periods are going off and on? Patient: It has been around twenty years. Doctor: So, you were taking Clozaril and some other medications? Patient: Yes. Doctor: Were you feeling better with them, sir? Patient: Yes. It was better for some years. Doctor: These antipsychotics, they were good on you, right? Patient: They were at times, but eventually there was a new episode.

Section Header: HISTORY of PRESENT ILLNESS Summary: As mentioned before, this patient has been psychotic off and on for about 20 years now. He has had years in which he did better on Clozaril and also his other medications. With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.

Doctor: Does anyone in your family ever have any neurological disorder? Patient: Not anything specific but, many of my family members had lazy eyes. Doctor: Who is in your family? Patient: My parents and my two little sisters. Doctor: How old are your sisters? Patient: One is nine, another one is five. Doctor: How are they both health wise? Patient: They both are healthy.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Many family members with "lazy eye." No other neurologic diseases declared. 9 and 5 year old sisters who are healthy.

Doctor: I have their surgical history if you'd like to go over it. Guest_clinician: Go ahead. Doctor: So they had an exploratory laparotomy in nineteen sixty seven. Guest_clinician: Okay. Doctor: They had a number of surgeries in nineteen seventy five, which include an L five S one lumbar laminectomy, anal fissure surgery, tonsillectomy, and adenoidectomy. Guest_clinician: Got it. Any complications that you know of? Doctor: None were mentioned by the patient or their spouse.

Section Header: PAST SURGICAL HISTORY Summary: L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.

Doctor: How is your foot feeling? Patient: It feels good. Doctor: Any pain or discomfort when you walk around on it? Patient: No. I am good doc.

Section Header: DISPOSITION Summary: Stable.

Doctor: Are you married? Patient: Yes, for almost twenty two years now. Doctor: That is amazing! And are you working? Patient: Ah yes, I drive a delivery truck in the town. Doctor: Okay. So, tell me do you smoke or drink? Yes, I do both. Doctor: And how much would you say you smoke per day? Patient: I smoke about two packs a day. Doctor: Hm, how much do you drink? Patient: I drink three, oh wait, I drink two beers every day. Doctor: And do you do any drugs like coke or anything? Patient: No.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is married. He works as a truck driver and he drives in town. He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs.

Doctor: Are you married? Patient: No sir, I'm happily single. Doctor: Where do you work? Patient: I am a press worker, I work in a newspaper printing. Doctor: Do you smoke? Have you ever taken any Illicit drug? Patient: No, none of them. Doctor: What about alcohol? Patient: I don't take any now. I was a heavy drinker, but I quit in the seventies.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Single. Works as a newpaper printing press worker. Denies tobacco, ETOH or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit.

Doctor: Ever reacted poorly to any medications taken in the past? Patient: Hm I don't think so. No reactions so far.

Section Header: ALLERGY Summary: No known medical allergies.

Doctor: Are you taking any medications? Patient: Yes I am taking thyroid meds and Lipitor.

Section Header: MEDICATIONS Summary: Synthroid and Lipitor.

Doctor: Any past medical history like any diabetes or high blood pressure or any heart disease? Patient: No, I don't remember any such thing. Doctor: How about any surgeries in the past? Patient: No. No surgeries at all.

Section Header: PAST MEDICAL HISTORY Summary: Otherwise nondescript as is the past surgical history.

Doctor: Good morning, young lady, how old are you? Patient: Good morning, doctor. I'm thirteen. Doctor: Good, and what seems to be the problem today? Mom, can you explain for me? Guest_family: Well, if you look, doctor, her back posture is very rounded. Doctor: I think, it's rounding about the thoracic spine. Is there a family history of this problem? Guest_family: Yes, on my side, my aunt and grandfather had, um, kyphosis. Doctor: Yes, that's what this is. This is thoracic kyphosis to be specific. Has she seen another doctor for this? Guest_family: Yes, we saw another orthopedist. Doctor: What did they recommend? Guest_family: They recommended we come in for further observation, so we're here for a second opinion. Doctor: Good, is there any back pain, numbness or tingling? Patient: No, I don't have any of that. Doctor: Is there any weakness, numbness or tingling in your legs and arms, my dear? Patient: No, I'm very strong, especially for my age. Doctor: Are you going to the bathroom with no problem? Patient: Yes, doctor, everything is regular there.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis. The patient has a family history in a maternal aunt and grandfather of kyphosis. She was noted by her parents to have round back posture. They have previously seen another orthopedist who recommended observation at this time. She is here for a second opinion in regards to kyphosis. The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities. No problems with her bowels or bladder.

Doctor: Are you allergic to anything? Patient: No, I am not allergic to anything. Doctor: Okay so no drug allergies. Patient: Yeah.

Section Header: ALLERGY Summary: No known drug allergies.

Doctor: Are you married, ma'am. Patient: Yes, to my husband, I can't even remember how long my husband and I have been married. Doctor: That's wonderful. Do you drink or smoke? Patient: Absolutely not, I've never have used that stuff.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is married, retired. Denies tobacco or ethanol use.

Doctor: Uh let's see here. Are there any diseases that run in your- Patient: Family? Doctor: Yes. Patient: Nope.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: unremarkable.

Doctor: What happened to you? How did you get involved in this accident? Patient: I was just trying to adjust cable that my brother's dog was tied to. All of a sudden, he attacked me out of nowhere. The injury to my leg is V shaped and the V is pointing towards my foot. Doctor: What kind of dog? Patient: German shepherd. But he is up to date on his shots, and he is completely healthy. Patient: He bit me on my foot, and it looks like his teeth went into my skin. I went to my P C P. Doctor: What did you do there? Patient: They cleaned the wound and did some bandage along with it he gave me a tetanus shot. Doctor: And he sent you to us? Patient: Yes. Doctor: Okay let me examine your wound. Patient: Sure! Doctor: It looks like there is a flap injury developed after puncture wound. It seems like a centimeter long and viable. How old are you sir? And what ethnicity do you identify with? Patient: White male. I am fifty years old. Is my right leg going to be okay? Doctor: The skin looks viable. We can save the tissue.

Section Header: HISTORY of PRESENT ILLNESS Summary: This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him. He sustained a bite to his right lower leg. Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that. The dog has given no prior history of any reason to believe he is not a healthy dog. The patient himself developed a puncture wound with a flap injury. The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot. It appears to be viable. The wound is open about may be roughly a centimeter in the inside of the flap. He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment.

Doctor: Are you aware of any family medical history? Patient: Nope. Both of my parents, they died of old age. They were in their eighties. I cannot remember of any other medical issue in any of my relatives. Doctor: What about memory loss or stroke or high blood pressure, diabetes, or any other kind of mental illness? Patient: Nope. Doctor: Anyone sick in your family out of these things? Patient: Nope. Doctor: Do you have kids? Patient: Yeah, I have five children and they all are doing well in their life.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father and mother died in their 80's of "old age." There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well.

Doctor: Do you have any significant medical conditions in your history that I should know about? Patient: What, like high blood pressure? Doctor: Well, it could be anything from high blood pressure, to depression, to something as serious as cancer. Patient: Oh, no, I don't have anything like that, at least not that I know if.

Section Header: PAST MEDICAL HISTORY Summary: None.

Doctor: Hi! How are you two doing today? Guest_family: We are doing good. I am tired today. Doctor: Our records show that he is up to date on all of his two month old immunizations. Guest_family: That is right! He had his shots the last time we were here. Doctor: Does he have any health conditions or difficulties during childbirth? Guest_family: Nope. He is healthy.

Section Header: PAST MEDICAL HISTORY Summary: Unremarkable. He has had his two-month immunizations.

Doctor: Hello! How are you all today? Guest_family: Not good. We are really worried about our daughter. Doctor: What happened? Guest_family: I turned my back for one second and I saw her under the counter in the cabinet. We have childproofing on that cabinet. I don't know how she got it open. I pulled her out from the cabinet, and she had the bottle of ant bait in her hands. She had spilled the entire bottle all over her. She had the liquid on her hands. I don't know if she drank any of it or put her hands in her mouth. Doctor: Do you know what the ant bait was called? Guest_family: No. I know it was the kind with Borax in it. Doctor: Do you know how big the container was? Guest_family: It was an eleven M L bottle. I am not sure if that stuff is toxic or not? Doctor: How old is she? Guest_family: She is fourteen months. Doctor: Have you noticed and strange behavior or vomiting? Guest_family: No.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it. It had 11 mL of this fluid in it. She spilled it on her, had it on her hands. Parents were not sure whether she ingested any of it. So, they brought her in for evaluation. They did not note any symptoms of any type.

Doctor: Hello. Are you ready for your surgery today? Patient: I'm ready as can be. This isn't my first rodeo. Doctor: I see. Have you had surgeries before? Patient: Yeah, I have. I think it's in my report that you have with you. Doctor: You're right. It says here you've had some stripping of veins in your legs, a tonsillectomy, and a adenoidectomy.

Section Header: PAST SURGICAL HISTORY Summary: Lower extremity vein stripping, tonsillectomy and adenoidectomy.

Doctor: Is she married? Guest_family: Um no, she's divorced. Doctor: Any history of tobacco, alcohol or drug use? Guest_family: I think she used to drink? But I'm not positive.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: divorced. unknown history of tobacco/ETOH/illicit drug use.

Doctor: And tell me, are you allergic to any medications? Patient: No. Not that I know of. Doctor: Okay.

Section Header: ALLERGY Summary: There were no known drug allergies.

Doctor: I'd like to get her in to see you sometime next week for her enlarged thyroid. Guest_clinician: Is she symptomatic? Doctor: Yes, she's experiencing increased difficulty swallowing. She's also reporting throat tightness on an off. Guest_clinician: What's her medical record number?

Section Header: DIAGNOSIS Summary: Symptomatic thyroid goiter.

Doctor: Hi! How are you today? Patient: I am doing well. I start a new job on Monday. I have been unemployed for about a year now. It is going to be nice to get back to work. Doctor: Congratulations. Do you use tobacco products, drink alcohol or recreational drugs? Patient: I used to smoke a little bit, but I quit ten years ago. Doctor: Great! Patient: I don't drink or do drugs.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He was unemployed and denied any alcohol or drug use. He was a prior 'mild' smoker, but quit 10 years previous.

Doctor: So, tell me about your family's medical history. Patient: Hm, my mother passed away due to cancer. Doctor: Oh, what type? Patient: Actually, I don't know that. Doctor: Okay. Patient: And my dad died due to heart attack. Doctor: Oh. Patient: Yeah. Doctor: Okay, I don't see your vaccination record here, do you have it? Patient: No, I don't have it. I moved here from a different country a long time ago with barely anything. I don't have any medical records from my past. Doctor: I see.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Mother died of cancer, unknown type. Dad died of an MI. VACCINATION STATUS: Unknown.

Doctor: Welcome back to the clinic, Miss A B C. Patient: Thank you. Doctor: It looks like we last saw you June twenty first, this year. Doctor X and Y referred you for the evaluation of your pinched nerve in the C six regain on the left side. I also see that we are following up on the significant rotator cuff tear on the left side. Did you get scheduled for the surgery with Doctor Yen yet? Patient: Yes. I believe the surgery is scheduled for July twentieth. Doctor: How is your shoulder feeling? Patient: My shoulder is the same. I am still in a significant amount of pain. Doctor: I am sorry to hear that. Your surgery is coming up soon and that should help. Patient: I hope so. Doctor: We are also following up the pinched nerve in your upper left extremity C six. How are you feeling? Patient: I have had some pain starting in that same spot, and it goes down the left arm into my wrist. Doctor: Have you had any weakness associated with your upper extremities on the left side? Patient: It is mild and it is about the same as the last time. Doctor: Is it about the same as the last time you were here? We have it noted in the last note that it was mild as well. Patient: Yes. It has been the same. Doctor: Any weakness or symptoms on the right side? Patient: No, not really. Doctor: Any difficulty with mobility or moving around on either side? Patient: No. Doctor: Have you been experiencing any bowel or, bladder dysfunction. Patient: No. Doctor: I see in the chart for our last visit, I only had a report of a prior cervical spine M R I. I don't have any recent images. I going to refer you for a cervical spine M R I. Are you able to get the imaging done today and I will have you return to the clinic at the end of today? Patient: Yes. I can do that. I took the whole day off of work today. Doctor: Great! I will put the order in right now.

Section Header: HISTORY of PRESENT ILLNESS Summary: Ms. ABC returns today for followup regarding her left shoulder pain and left upper extremity C6 radiculopathy. I had last seen her on 06/21/07. At that time, she had been referred to me Dr. X and Dr. Y for evaluation of her left-sided C6 radiculopathy. She also had a significant rotator cuff tear and is currently being evaluated for left-sided rotator cuff repair surgery, I believe on, approximately 07/20/07. At our last visit, I only had a report of her prior cervical spine MRI. I did not have any recent images. I referred her for cervical spine MRI and she returns today. She states that her symptoms are unchanged. She continues to have significant left-sided shoulder pain for which she is being evaluated and is scheduled for surgery with Dr. Y. She also has a second component of pain, which radiates down the left arm in a C6 distribution to the level of the wrist. She has some associated minimal weakness described in detail in our prior office note. No significant right upper extremity symptoms. No bowel, bladder dysfunction. No difficulty with ambulation.

Doctor: Are you on any medications at this time? Patient: None whatsoever. Doctor: Got it.

Section Header: MEDICATIONS Summary: None.

Doctor: Hey, how is the patient doing? Guest_clinician: I actually don't know, I was not able to examine him. He is having special procedures done for the past two hours for some medical management. Doctor: Oh, I see.

Section Header: CHIEF COMPLAINT Summary: Medical management. The patient has been in special procedures now for over 2 hours and I am unable to examine.

Guest_family: So, you mean it is something simple? Doctor: Yes, it is probably sinus infection and then cough secondary to that infection. Guest_family: Will that be treatable? Doctor: Yes, it is. Guest_family: Okay nice.

Section Header: ASSESSMENT Summary: Clinical sinusitis and secondary cough.

Doctor: You have an infection that has become septic. We are going to have to start you on intravenous antibiotics. Patient: Okay. Doctor: We also need to address the blood clotting. I am going to give you an anticoagulant to prevent any further clotting issues. Do you have any questions? Patient: No.

Section Header: DIAGNOSIS Summary: 1. Disseminated intravascular coagulation. 2. Streptococcal pneumonia with sepsis.

Doctor: So, what do you do for a living, sir? Patient: Right now, I'm a truck driver, sir. Doctor: Wow, that's hard work. Are you working right now? Patient: No, I can't right now, I'm on sick leave. Doctor: Are you married? Patient: Yes, to my wonderful wife. She's helping to take care of me. Doctor: Do you two have any children? Patient: Yes, we have three. We all live together, and for that I'm very thankful. Doctor: Do you smoke, sir? Patient: Yeah, I smoke about two packs a day. Doctor: How about alcohol? Do you drink? Patient: No, just smoking for me. Doctor: How about more illicit substances, have you used illegal or prescription drugs inappropriately? Patient: Oh, absolutely not. Doctor: That's good. Do you have any other medical conditions that run in your family that I should know about? Patient: No, not that I know of.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Occupation: truck driver. Work status: on sick leave. Marital status: married. Children: three. The patient lives at home with family. Tobacco history: smokes two packs of cigarettes per day. The patient denies the use of any alcoholic beverages. The patient denies any current or past history of illegal / recreational drug or prescription drug abuse or addiction. Family History: There are no known significant medical illnesses in the immediate and past family history.

Doctor: Hello there, how are you? Patient: I am good, thank you for asking. Doctor: So, what brings you in today? Patient: Well, I think I am suffering from memory loss, like short term memory loss. Doctor: Okay, and why do you say so? Patient: I have been under tremendous stress for the last five to ten years. I am currently working for T mobile customer service and my work is really hectic. It requires a lot of technical knowledge with project deadlines which is adding to my stress. Patient: Sometimes I have trouble absorbing all the technical knowledge and computer skills or customer issues. Doctor: Hm. Patient: I did my M B A in business for a reason, I wanted to make a good career, but this job is very demanding and stressful. I previously worked at a bank in Conway Springs, Norwich. I have worked many jobs around accounting and management services, but my current job is a high stress one. Doctor: I see, are you married? Patient: I have been widowed for past eleven years. My husband died in a car accident, he was hit by drunk driver. It was not the time for my husband to go! After he left, I had to take care of everything and that's another reason for my stress from the past several years. Doctor: I am so sorry to hear that. Patient: Yeah. Doctor: Okay, so tell me any weakness or dizziness or lethargy in the past or now? Patient: No. Doctor: Any history of stroke? Patient: No.

Section Header: CHIEF COMPLAINT Summary: Here with a concern of possibly issues of short-term memory loss. She is under exceeding amount of stress over the last 5 to 10 years. She has been a widow over the last 11 years. Her husband died in an MVA from a drunk driver accident. She had previously worked at the bank in Conway Springs in Norwich and had several other jobs related to accounting or management services. She does have an MBA in business. Currently, she works at T-Mobile Customer Service, and there is quite a bit of technical knowledge, deadlines, and stress related to that job as well. She feels she has trouble at times absorbing all that she needs to learn as far as the computer skills, protocols, customer service issues, etc. She describes the job is very demanding and high stress. She denies any history of weakness, lethargy, or dizziness. No history of stroke.

Doctor: Hi there! Welcome to the clinic. Patient: Thank you. Doctor: Doctor Murphy sent your records over. I reviewed the ultrasound, and we did find a kidney stone that has become stuck in the ureter on the left side. The stone is large enough to block the flow of urine from the kidney to the bladder. How much pain are you having and where is the pain located? Patient: I am in a great deal of pain. It is coming from my left side right here. Doctor: Okay. Let use discuss your treatment options. Patient: Okay.

Section Header: CHIEF COMPLAINT Summary: Left flank pain, ureteral stone.

Doctor: Any allergies? Patient: What do you mean? Doctor: Are you allergic to anything? Patient: No no, oh no.

Section Header: ALLERGY Summary: He has no known medicine allergies.

Doctor: You have type two Diabetes? Patient: Yes. Doctor: And High Cholesterol? Patient: Yes. Doctor: Your diabetes is poorly controlled. Patient: I will keep an eye on it.

Section Header: PAST MEDICAL HISTORY Summary: Diabetes type II, poorly controlled, high cholesterol.

Doctor: Can you tell me more about your daughter's injury? Guest_family: Well, we came in in November, and she was diagnosed with an acute on chronic right slipped capital femoral epiphysis. Doctor: Did she have surgery on this? Guest_family: Yes, let me look at my notes, I have it written down here, um, a situ pinning. Doctor: Remind me, how old are you, dear? Patient: I'm thirteen now. Doctor: Okay, thank you. So, um, if you look her at the x rays, it appears that the screw is now going into the hip joint. Guest_family: They didn't see that before. What can we do about this? Doctor: We'll need to do another operation in order to remove this screw and put a shorter one in. We need to do the surgery because this can cause further joint damage. Guest_family: Are there any risks of infection from this surgery? Doctor: Overall, the risk of infection is very low, honestly its less than one percent. Guest_family: That's good to hear, will she go to sleep during surgery? Doctor: Yes, we'll use anesthesia the entire time. She won't feel a thing. Guest_family: What does recovery look like for this surgery? Doctor: I expect her to heal up very well, but there's always a risk of some changes in sensation and motion, and she may be stiff for some time following everything. Other risks include bleeding, but I would not worry about these things. Guest_family: Okay, how does that sound, honey? Would you like to do this? Patient: Yeah, I want to get back to playing sports with my friends. Guest_family: I agree, Doctor, we'll do the surgery.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis. She underwent in situ pinning. The patient on followup; however, noted to have intraarticular protrusion of her screw. This was not noted intraoperatively on previous fluoroscopic views. Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one. Risks and benefits of surgery were discussed. Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage. All questions were answered and parents agreed to above plan.

Doctor: What brings you in today? Patient: Um a number of different things. I don't even know where to start to be honest. Doctor: I understand. What's bothering you the most? Patient: Lemme think. I'm uh having really bad pain. Doctor: Where's the pain located? Patient: Hm. It's in a tricky spot. Guest_family: Hi. Husband here. Let me help explain. She's been having severe lower back pain. It started off mild and got worse over the course of a few days. She's also a lot more sluggish as a result. Doctor: Any recent injuries or falls? Guest_family: None. She spends most of her time in bed.

Section Header: CHIEF COMPLAINT Summary: Severe back pain and sleepiness. The patient is not a good historian and history was obtained from the patient's husband at bedside.

Doctor: Hello, I want you to meet my assistant. She will be helping me out with your case today. Doctor: Please represent the patient's case. Guest_clinician: Patient is a seventy six year old male. He complains of generalized weakness and malaise for several months. He has a two week history of worsening orthostatic dizziness. He denies any recent symptoms of fever or shortness of breath, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes. Doctor: You said you are feeling dizziness, so what makes it worse? Patient: It's bad whenever I try to stand straight. I also have these intermittent headaches where it feels like somebody is hammering inside. Doctor: Do these headaches change with changing the positions or standing straight? Patient: No. Doctor: Does the patient have any known medical history? Guest_clinician: Yes, he has a history of sinusitis. Doctor: So, your headaches-- how long has this been going on? Patient: Many weeks now. Doctor: Do you smoke? Patient: I used to smoke a hundred and even more packs per year. Now it's just one to two packs each day. Doctor: Has there been any weight loss? Patient: I lost forty pounds.

Section Header: HISTORY of PRESENT ILLNESS Summary: This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes. He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.

Doctor: Have you ever had jaundice? Patient: Um, no. Doctor: Any rash or anything? Patient: Nope.

Section Header: REVIEW OF SYSTEMS Summary: INTEGUMENTARY: Negative rash, negative jaundice.

Doctor: Good morning, ma'am, before we begin, how old are you? Patient: Good morning, doctor, I'm twenty five. Doctor: Good, thank you. So, how are you feeling today? Patient: I'm okay, but I have this rash and itching over my right arm. It's so itchy and I scratch all the time. Doctor: Is this your dominant hand? Patient: Yes, so this had especially been bothering me. Doctor: When did you first notice these symptoms? Patient: Um, I think it was in October of nineteen ninety two. I think it was the twenty third. Doctor: Have you had any symptoms in any other parts of your body? Patient: Um, yeah, I've had tingling in both my legs, like in the front, and then it goes into my toes too. Doctor: Did this tingling sensation go away? Patient: Yes, it went away the next day without me doing anything. Doctor: Have these symptoms returned at any point? Patient: Well, two days later, so that'd be the twenty fifth, I noticed that my legs felt like they were asleep. I really couldn't feel anything. Doctor: Have these symptoms spread to any other part of the body? Patient: Yeah, I couldn't really feel anything in the middle of my chest. I also have started having pain in my right shoulder blade. Doctor: Do these symptoms interfere with your ability to move? Patient: Yes, I don't really feel comfortable standing on my own, and I can't walk very well. Doctor: Do you have any cold or flu like symptoms? Patient: No, heat and cold don't bother me Doctor: Do you feel any significant fatigue? Patient: No, not really. Doctor: Have you had any significant weight loss? Patient: No.

Section Header: HISTORY of PRESENT ILLNESS Summary: 25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt "asleep" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.

Doctor: How's it going? Patient: Good, can't complain. Doctor: Glad to hear. So today we're going to do a comprehensive eval. It'll be a bit different than our usual visits together. Would you like your mom to step in the room, too? Patient: Yeah, that's not a problem. Doctor: Alright. I'll grab her from the waiting room. I'll be right back.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient comes in today for a comprehensive evaluation. She is well-known to me. I have seen her in the past multiple times.

Guest_clinician: I was not able to get her complete history and review of systems. But she is scheduled for a bladder distension surgery. Doctor: Okay. Guest_clinician: Also, I am not sure if she is off Coumadin because of the surgery. Doctor: Oh yeah, she has chronic AFib and she is on Coumadin. Not sure if she has stopped the medicine due to upcoming surgery. Guest_clinician: The only thing she could tell was that she was having tremors for the past three to four years and was diagnosed with early Parkinson's disease. Doctor: Alright.

Section Header: REVIEW OF SYSTEMS Summary: Complete review of systems is unobtainable at present. From what I can tell, is that she is scheduled for an upcoming bladder distension surgery and I do not know if this is why she is off Coumadin for chronic AFib or what, at this point. Tremor for 3-4 years, diagnosed as early Parkinson's.

Doctor: Hello. What is the reason for your visit today? Patient: I keep having this dry cough and it gets hard to breathe at times. Doctor: Were you exposed to anything recently? Patient: Here's a note from a contractor that worked on my house recently. I wasn't sure what it meant. Doctor: I see. It looks like you may have been exposed to asbestos. Patient: Oh, no! Am I going to be fine? Doctor: I'll take a look, but I want to ask you a quick question. Did you have any family living with you at the time? Patient: Nope. I live alone, so my family wasn't there to be exposed.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No noted exposures.

Doctor: How are you feeling today, ma'am? Patient: Honestly, overall, I'm feeling a lot better. Doctor: Are you still having the diarrhea and decreased appetite? Patient: Yes, but I'm still feeling better though. Doctor: Have you been peeing a normal amount? Patient: Yeah, no problems there. I measured it like you told me to—six hundred M L. Doctor: When was the last time you peed? Patient: Um, it was about seven this morning. Doctor: Are you having any fever symptoms? Patient: No, I feel pretty well.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient seen and examined feels better today. Still having diarrhea, decreased appetite. Good urine output 600 mL since 7 o'clock in the morning. Afebrile.

Doctor: Do you smoke, sir? Patient: No. Doctor: Do you drink? Patient: No. I was a boxer before so that's why I was always stayed away from these things. Doctor: How is your living condition? Are you living alone or with family? Patient: Mostly I'm by myself during the daytime. Family comes to help with me on and off. I just love it that way. I wasn't to be in an independent home setting soon.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He is a nonsmoker and nondrinker. Prior boxer. He lives in a home where he would need to be independent during the day. Family relatives intermittently available. Goal is to return home to an independent fashion to that home setting.

Doctor: Do you smoke cigarettes? Patient: Yes. Doctor: Do you drink alcohol or use recreational drugs? Patient: Yes, I have been in and out of treatment. I am not doing so well with staying clean. Doctor: What substances do you use? Patient: I drink, and I did some coke today. I have been in treatment for heroin and alcohol.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Noncontributory.

Doctor: Hello how are you? Doctor Mina is an intern working with me. She will be taking notes and discussing your case today. Patient: That's okay. Doctor: So, tell me Doctor Mina, what brings this young man today here? Guest_clinician: This is a sixteen year old right handed boy. He is studying in eleventh grade. He is having some difficulties with vision like blurring and focusing. He was diagnosed with a suprasellar tumor. Later on, January fourth, he underwent a surgery for his tumor. Biopsy reports said that it was craniopharyngioma. Even after the surgery, there was some residual disease left and his visual apparatus was decompressed. Doctor: Thank you Doctor. Tell me how are you doing young man? Are there any difficulties going back to school? Patient: I am doing fine. I do get some headaches and it feels like somebody is ringing bells in my ears. My eyesight has improved a lot.

Section Header: HISTORY of PRESENT ILLNESS Summary: Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor. He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor. Histology returned as craniopharyngioma. There is some residual disease; however, the visual apparatus was decompressed. According to him, he is doing well, back at school without any difficulties. He has some occasional headaches and tinnitus, but his vision is much improved.

Doctor: Remind me, please, when was your surgery? Patient: Well, it's been about two and a half months now. Doctor: Great, we repaired that slipped capital femoral epiphysis on both sides, we call it S C F E. Patient: Thank you for reminding me, I forgot the names of everything.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a patient post-surgery, 2-1/2 months. The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.

Doctor: Any medications I should know about? Patient: Nah, no daily meds.

Section Header: MEDICATIONS Summary: None.

Doctor: Is your husband still around, ma'am? Patient: No, he passed away a few years ago. Doctor: I'm so sorry to hear that. Patient: Oh, it's quite all right. Doctor: Do you drink or smoke? Patient: No, I don't do either of those. Doctor: Good, so where are you living now? Patient: I'm living at Kansas Christian Home. Doctor: Do you live independently there? Patient: Yes, thankfully. But, I can't do a lot of things. I have to be sure to take my medicines. Doctor: Did you drive yourself today? Patient: No, I had a driver today. Can we speed this up, I need to get to the noon meal.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is widow. She is a nonsmoker, nondrinker. She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal.

Doctor: Welcome in, Miss A! Patient: Thank you. Doctor: How have you been doing? Patient: I am good today! Doctor: Have you not been feeling good other days? Patient: I have been feeling nervous and having some anxiety lately. Doctor: Is your feelings of nervousness or anxiousness triggered by anything specific? Patient: It varies. I feel anxious when I think about retuning to work or this upcoming trip that I have planned. Doctor: How often do you feel this way? Patient: It comes and goes. Doctor: Have you ever had any treatment or history of depression, anxiety, or mood disorders? Patient: No.

Section Header: HISTORY of PRESENT ILLNESS Summary: Ms. A did not report a history of psychological or psychiatric treatment. She reported that her current mood was good, but did describe some anxiety and nervousness about various issues such as her return to work, her upcoming trip, and other events. She reported that this only "comes and goes."

Doctor: Who lives with you, miss? Patient: I live with my boyfriend. Doctor: Do you smoke cigarettes? Patient: Yes, I do. Doctor: How about drugs? Patient: Sometimes, but I don't want to talk about it. Doctor: Okay. Anything else you want to talk about? Patient: Pardon?

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She lives with her boyfriend. The patient has history of tobacco abuse as well as multiple illicit drug abuse.

Doctor: Good afternoon, sir. Patient: Good afternoon, doctor. Doctor: Refresh my memory, please, how old are you, sir? Patient: I'm forty nine. Doctor: Also, I need you to remind me, when was your lower back surgery? Patient: It was in January of two thousand five. What was the name of the surgery, again? Doctor: It was a lumbar disc replacement. So, how are you feeling today? Patient: Truthfully doctor, the surgery did nothing. I'm still in a lot of pain. Doctor: Besides the surgery, what other interventions have you tried? Patient: I have them written down, let me look. Um, I did acupuncture, T E N S unit at P T, and I've been to the chiropractor too. Doctor: Have you taken any medicines? Patient: Yeah, I have those written down here. I've taken Elavil, Topamax, Cymbalta, Neurontin, and Lexapro. Doctor: Are you still taking any of these? Patient: No, I had bad side effects to some, and the others just didn't do anything. Doctor: Have you had any injections for this pain? Patient: I've had a few into the, um, piriformis. Doctor: Did that do anything? Patient: Um, it provided some brief relief, I guess. I had a Botox procedure done on March eighth two thousand six. Doctor: How did this work? Patient: Honestly, it did nothing. Doctor: Where is your pain, exactly? Patient: I'd say its seventy five percent in my butt and leg, and twenty five percent in my lower back. Doctor: Are you able to workout, or exercise, anything like that? Patient: I've tried to increase how much I walk, but when I do I get spasms in my lower back. Doctor: I see, with ten being the worst pain of all time, how would you rate your pain today? Patient: I'd say it's a six out of ten today. Doctor: What adjectives would you use to describe the pain? Patient: Um, I'd say its shooting, sharp, and, um, aching. Doctor: Specifically, what activities make the pain worse? Patient: Well, lifting, standing for a long time, or, um, squatting. I can't do that anymore. Doctor: Does anything make the pain better? Patient: Um, sitting back, ice, and I guess there's some improvement with the pain medication. Doctor: Is the pain constant, or does it come and go? Patient: It's constant now, but, um, the intensity of it comes and goes. Doctor: Are you able to sleep at night? Patient: Not really, it is affecting my sleep, which in turn affects my mood. Doctor: So, overall, I can summarize and say you're not happy with your pain relief so far? Patient: Yes, doctor, that's correct.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a pleasant 49-year-old gentleman post lumbar disc replacement from January 2005. Unfortunately, the surgery and interventional procedures have not been helpful in alleviating his pain. He has also tried acupuncture, TENS unit, physical therapy, chiropractic treatment and multiple neuropathic medications including Elavil, Topamax, Cymbalta, Neurontin, and Lexapro, which he discontinued either due to side effects or lack of effectiveness in decreasing his pain. Most recently, he has had piriformis injections, which did give him a brief period of relief; however, he reports that the Botox procedure that was done on March 8, 2006 has not given him any relief from his buttock pain. He states that approximately 75% of his pain is in his buttock and leg and 25% in his back. He has tried to increase in his activity with walking and does note increased spasm with greater activity in the low back. He rated his pain today as 6/10, describing it is shooting, sharp and aching. It is increased with lifting, prolonged standing or walking and squatting, decreased with ice, reclining and pain medication. It is constant but variable in degree. It continues to affect activities and sleep at night as well as mood at times. He is currently not satisfied completely with his level of pain relief.