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Doctor: Any past medical history? Patient: No.

Section Header: PAST MEDICAL HISTORY Summary: Nonsignificant.

Doctor: With ten being the worse pain ever, how would you rate your pain out of ten today, ma'am? Patient: Um, out of ten, I'd say it's about a two. Doctor: That's good. What helps the pain feel better? Patient: Um, it gets better with elevation, and when I just rest.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient rates the pain at 2/10 on the pain analog scale. The patient states that with elevation and rest, her pain subsides.

Doctor: Nurse, did you get the documents from the patient? Guest_clinician: I did. Here is her full history and notes from her physical examination. She also completed the patient questionnaire before arriving. You can review that. Doctor: Thank you, Nurse. What is she here for today? Guest_clinician: She came in for a consultation because she's been experiencing difficult headaches, tunnel vision, and dizziness. Doctor: Sounds good. Was there anything else? Guest_clinician: Oh, yeah. These are the results from her tests. She brought them so you could refer to them. Doctor: Thank you, Nurse. I'll go see her now. Patient: Hello Doctor. I've been waiting a long time. I'm getting impatient as I get older. Doctor: What? You don't look old at all, ma'am. Patient: Oh, wow. That's a nice compliment for a sixty year old lady. Doctor: How can I help you today? Patient: I have these super bad headaches. Help me, please. Doctor: When did they start? Patient: I had them since I was twenty five years old. Doctor: Oh, wow. That long? Did you get them every day since then? Patient: Not every day. That's crazy. I did get them more when my husband died in nineteen ninety six. I was heartbroken. Doctor: I'm sorry to hear that. How did the headaches feel? Patient: It felt like a drum in my head. Doctor: I haven't heard that description before. Would you say it was pulsating? Patient: Something like that. Yes. Doctor: Did you take any medication? Patient: Lots of it. My son wrote it on a paper so that I could give you the names. Here you go. Doctor: I see you were given papaverine. Did that help? Patient: They did. My headaches would vanish. Doctor: How long did you take it for? Patient: I think six months. My headaches stopped for a while, but they came back in two thousand and four. Doctor: How often would you say you get headaches now? Patient: I think more than before. Like one to two per week. I also get some dizziness too. It says for two hours. Doctor: Do you take the papaverine when you feel it? Patient: I do. My headaches vanish after thirty minutes of taking it. Doctor: I see. Did you ever experience any problems with your vision too? Patient: Yes. A lot. There were zig zag lines coming out of nowhere. I thought I was going to die. Doctor: Oh, wow. I will do a test right now to check your vision. Patient: Will you use a bright pen? Doctor: I will. Does it give you any discomfort? Patient: The bright light hurts my eyes. Doctor: I see. I'll only do it to the side then. Just look forward for me, please. Patient: Thank you. Doctor: Are you able to see the light? Patient: What light? Doctor: It looks like you have trouble seeing things in your peripheral vision. The discomfort you experience with bright lights is also called photophobia. Patient: That sounds scary. Will I be fine? Doctor: Yeah. You don't have to worry. Are you experiencing any dizziness or lightheadedness right now? Patient: Now that you mentioned it, I am. Doctor: Have you ever fainted before? Patient: I think one time. My son was there to help. Doctor: That's good to hear. I'll write down that you experienced a syncope. Did you take any medication for this? Patient: I took some Russian medicine. Doctor: Oh, wow. Are you from Russia? Patient: No. I'm from Ukraine. Doctor: That's wonderful. How did the medicine help? Patient: It helped me a lot.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. I obtained and documented a full history and physical examination. I reviewed the new patient questionnaire, which she completed prior to her arrival today. I also reviewed the results of tests, which she had brought with her. Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25. She recalls that in 1996 when her husband died her headaches became more frequent. They were pulsating. She was given papaverine, which was successful in reducing the severity of her symptoms. After six months of taking papaverine, she no longer had any headaches. In 2004, her headaches returned. She also noted that she had "zig-zag lines" in her vision. Sometimes she would not see things in her peripheral visions. She had photophobia and dizziness, which was mostly lightheadedness. On one occasion she almost had a syncope. Again she has started taking Russian medications, which did help her. The dizziness and headaches have become more frequent and now occur on average once to twice per week. They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.

Doctor: Do you drink? Patient: I used to drink before, but now I have stopped it completely. Doctor: How would you rate your pain? Patient: It is tolerable, like five out of ten but I do need some pain medications. Doctor: Then why do you need more pain medications? Patient: Sometimes it gets hard, I really need some more pain medications. Doctor: Do you have morphine? Do you need more? Patient: I don't like morphine. Can you change it to Dilaudid? I like that medicine. That one works for me great.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: History of alcohol use in the past. He is basically requesting for more and more pain medications. He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid. His pain is tolerable.

Guest_clinician: She has a vast history of surgeries. Doctor: Yeah, I am looking at her reports. She had surgery for spina bifida when she was a baby and they had to put a shunt. Guest_clinician: Yeah, later she had her uterus removed and also had to undergo a breast reduction surgery. Doctor: Hm.

Section Header: PAST MEDICAL HISTORY Summary: Back closure for spina bifida, hysterectomy, breast reduction, and a shunt.

Doctor: Are you married or divorced? Patient: I am married. Doctor: Okay. Patient: Hm. Doctor: Do you smoke cigarettes or drink alcohol? Patient: No, I have never.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She is married and does not smoke or drink nor did she ever.

Doctor: What is your family medical history? Patient: I am not sure. Everyone is healthy as far as I know.

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

Doctor: Good morning, ma'am. My chart says that you're forty nine years old, and White, is that correct? Patient: Yes, that's all correct. Doctor: What do you do for a living? Patient: I'm a secretary. Doctor: Great, welcome back to the Dermatology office, do you remember when your last appointment was? Patient: Um, I think it was on August tenth two thousand four. Doctor: Good, that's what I have here as well, so has your acne improved since your last visit? Patient: Well, not really, and I think I have a rash too. Doctor: How long have you been dealing with this? Patient: Um, at this point it's been about two months. Doctor: Where do you see this rash? Patient: Um, it's right here, on my chest, stomach, neck, and back, it's all over my upper body. Doctor: I see, it appears that your acne is flaring, and there are small lesions on the follicles as well. Have you been taking your Amoxicillin and using your Tazorac? Patient: Yeah, I taken five hundred M G of amoxicillin twice a day, and I use the cream as well. Doctor: Good, the acne on your face appears to be clearing. Patient: Thank you, I've been out of medicine for about three days now though. Doctor: Okay, we might refill that. Have you had any other treatments aside from what I've done? I Patient: Um, my husband drove me to Healing Waters and they did, um, photofacials. Is there anything that can be done in the office today, like, um, cosmetic procedures, or do you have any skin care products? I want to keep up my appearances since I work the front office as a secretary.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004. She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back. On examination, this is a flaring of her acne with small folliculitis lesions. The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also. She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc. The patient is married. She is a secretary.

Doctor: It looks like your Xrays show bronchitis. Patient: Is there anything I can take for it? Doctor: Yes, I'm going to prescribe you something that will help clear your lungs.

Section Header: ASSESSMENT Summary: Bronchitis/URI.

Doctor: How's it going X Y Z? I see you're in a walking boot. What happened? Patient: I hurt my foot pretty bad yesterday. Doctor: How'd it happen? Patient: Basketball. I play for the University of Houston. I went up for a three and came down and landed on this guy's foot. I was so pissed. Doctor: Dang, that sucks. Were you guys playing a home game? Patient: We were traveling to Duke. We could've won the game if I didn't get hurt. Doctor: You'll get them next time. Did you keep playing? Patient: Yeah, I did. I got taped up by the trainer, and I went back into the game. Doctor: I see. Who was the trainer that helped you? Patient: His name is John Houston. Do you know him? Doctor: Oh, John! He's a good friend of mine. Patient: Yeah, he told me to come see you. He checked my foot. Here's the notes he wrote. Doctor: It looks like you have some tenderness around your navicular, which is a bone in your ankle. Patient: Dang, that's whack. Doctor: Which way did you twist your ankle? Patient: My foot twisted inwards. Kind of like this. Doctor: I see. Your foot inverted. Did it swell up right away? Patient: Aw, man. My foot was huge right after it happened. It hurt so much too. Doctor: Continue to keep that tape on. Are you limping or anything? Patient: Yeah, I am. I can't really put weight on my foot because it'll hurt a lot. Doctor: I see. Well, I examined your foot, and it looks like the pain is around the top, back and middle of your foot.

Section Header: HISTORY of PRESENT ILLNESS Summary: XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot.

Guest_family: So apart from constipation what is his problem? What is up with his lungs? Doctor: Yeah so, we call it foreign body impaction. It is mostly affecting his right nostril and as you said there is constipation.

Section Header: ASSESSMENT Summary: 1. Infected foreign body, right naris. 2. Mild constipation.

Patient: I was working when it happened so we are going through workers comp. Doctor: Okay. Don't worry. Let's see. Oh wow! Patient: Yeah, this arm, it was a hot oil. Doctor: Yeah, too bad, looks like from elbow to wrist. The whole medial side is burnt. Patient: I am using cool packs since it happened. My friend is helping me so much, he drove me to Emergency Department. Doctor: Okay, how old are you? Patient: I am forty one. Doctor: What is your job? I mean what do you do? Patient: I am a cook at coffee shop.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a Workers' Compensation injury. This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect. He has had it cooled, and presents with his friend to the Emergency Department for care.

Doctor: Do you have any medical conditions that I should know about? Patient: Um, I have high blood pressure, and asthma. Doctor: I also see here that you have cervical cancer, can you tell me more about that? Patient: Yeah, I got diagnosed at fifteen years old. Doctor: How would you describe the progression of your cancer? Patient: Now, um, I'd say it's dormant.

Section Header: PAST MEDICAL HISTORY Summary: Significant for hypertension, asthma, and cervical cancer. The cervical cancer was diagnosed as 15 years old. The patient states that her cancer is "dormant."

Doctor: You can take Ibuprofen as needed for pain.

Section Header: MEDICATIONS Summary: Ibuprofen PRN.

Doctor: Do you take anything for acid reflux? Patient: Yeah, I take Aciphex. Doctor: Is that twenty M G once a day? Patient: It is. I also take one baby Aspirin in the mornings.

Section Header: MEDICATIONS Summary: Aciphex 20 mg q.d. and aspirin 81 mg q.d.

Doctor: Do you smoke? Patient: Yes. Doctor: How much do you smoke? Patient: I smoke about two packs of cigarettes a day. Doctor: Okay.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Smokes 2ppd cigarettes.

Doctor: Any numbness or tingling? Patient: No. Doctor: Are your experiencing any muscle weakness? Patient: No. Doctor: Any problem walking, or did you lose balance or fall? Patient: Nope. Doctor: So, your gait is fine. Any stroke in the past? Patient: No, nothing like that.

Section Header: REVIEW OF SYSTEMS Summary: NERVOUS SYSTEM: No gait problems, strokes, numbness or muscle weakness.

Doctor: Past surgeries I should know of? Patient: I had my gallbladder, appendix, and uterus removed. Doctor: Oh wow, I see. When did you get these surgeries? Patient: I had my gallbladder removed in O eight, appendix removed in twenty twelve, and uterus removed this past year. Doctor: Any other medical history? Patient: My bladder was sagging the last time I saw the urologist. Doctor: Does the diagnosis bladder prolapse sound familiar? Patient: Yeah, I believe so. They said it was grad four last time. Doctor: Have you followed up with your urologist recently? Patient: Chip Winkel? No, not as of late.

Section Header: PAST SURGICAL HISTORY Summary: Significant for cholecystectomy, appendectomy, and hysterectomy. She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.

Doctor: Do you have allergies? How old are you, young man? Patient: Yes ragweed. I am twelve. Doctor: So basically, you are just congested? Patient: Yes that's right. The last ten days. Doctor: Any headache? What comes out of your nose? Patient: Yes I had a little yesterday. Clear boogers. Doctor: You feel hot? Patient: No. Doctor: Anyone sick at home? Guest_family: No.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion. He does have significant allergies including ragweed. The drainage has been clear. He had a little bit of a headache yesterday. He has had no fever. No one else is ill at home currently.

Doctor: Are you married? Patient: I'm divorced. Doctor: Do you have any kids? Patient: Yes, I have two boys and they live with me. Doctor: Any abnormal pregnancy. Any abortions? Patient: No, none of them. Doctor: Do you smoke or consume alcohol or have ever used any illicit drug? Patient: No.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.

Doctor: I want to go over your medical history. I see here you saw the dermatologist a month ago. Patient: Yeah. She said that I um have an overactive sweat gland. Doctor: Does hidradenitis suppurativa sound familiar? Patient: It does. Doctor: I ask because it's also included in your last visit with your dermatologist. Patient: Those are the red bumps, right? Doctor: Yes. There's a note here that you could've potentially had Staph with it as well. Patient: Oh yeah. I've also had a lot of abscesses in the past. Doctor: It looks like you've had them in your upper mid thigh, vulva area, and the area between your vulva and anus. Patient: For about two years now. Doctor: Right. And a history of asthma? Patient: Correct.

Section Header: PAST MEDICAL HISTORY Summary: 1. History of recurrent abscesses in the perineum, upper medial thigh, and the vulva area for about 2 years. Per her report, a dermatologist had told her that she had an overactive sweat gland, and I believe she probably has hidradenitis suppurativa. Probably, she has had Staphylococcus infection associated with it as well. 2. Reported history of asthma.

Patient: Hello, how are you? Doctor: I am good, tell me what brings you here? Patient: I am having this chest pain. I was hospitalized last year in October and at that time they put this catheter in my heart. I also underwent a heart scan. It's here in this report. Doctor: Yeah, I see that you got nuclear and myocardial perfusion scan, which was normal. They were looking for some heart artery lesion but then it was thought to be due to spasm. Patient: Right. Doctor: It is also mentioned here that you have hyperlipidemia. Patient: Yes. Doctor: And are you still smoking? Patient: Yes, in fact I have been smoking actively from pass three to four days because I am really stressed. Doctor: Hm. And would you say, you might have had some exertion recently or did some steep hiking or some cardio exercises which might have caused some additional stress on your heart causing chest pain? Patient: No, I did not do any exertion. Just actively smoking that's all.

Section Header: PAST MEDICAL HISTORY Summary: Hyperlipidemia, smoking history, and chest pain. He has been, in October of last year, hospitalized. Subsequently underwent cardiac catheterization. The left system was normal. There was a question of a right coronary artery lesion, which was thought to be spasm. Subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal. The patient continues to smoke actively since in last 3 to 4 days especially when he is stressed. No relation to exertional activity.

Doctor: I am sorry about that. Patient: Yes, for assault, that's why I was in detention. Doctor: Okay. Doctor: When was this? Patient: Around December of two thousand nine. Patient: Not sure if I am under legal contraints right now. Doctor: Okay so we don't know.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He had an assault in December 2009, which led to his previous detention. It is unknown whether he is under legal constraints at this time.

Doctor: Do you smoke cigarettes? Patient: Yes, I do. Doctor: How many packs a day. Patient: Maybe one a day. Doctor: Okay, you should think about quitting.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is still a smoker.

Doctor: What happens when you take Sulfa drugs? Patient: Oh man, I get a really ugly looking rash. Doctor: I'll make note of that so we have it in your chart.

Section Header: ALLERGY Summary: Sulfa (rash).

Doctor: Any known drug allergies? Patient: Nope, none whatsoever.

Section Header: ALLERGY Summary: No known drug allergies.

Doctor: Do you smoke cigarettes or drink alcohol? Patient: No. Doctor: Any use of recreational substances or IV drug abuse? Patient: No.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.

Doctor: Tell me what brings you here today? Patient: I'm having some issues with my right hand. Doctor: What kind of issues? Patient: I'm having these pins and needles kind of feeling in my hand and it has been going on for several weeks. Sometimes I feel it gets numb. I think it might be carpal tunnel, but I'm not sure. I'm just worried. Doctor: Did you do anything for it? Patient: At work I recently moved my keyboard down. I just hope it will help. You know, I do a lot of the same kind of activities all the time. All of it I typing based. Doctor: What is more difficult, day or night? Patient: It gets worse at night. If I sleep on it, like in a certain way, it will just wake me up and it starts hurting. These tingling sensations are the worst. It helps if I shake it then the sensation goes away. It irritates me all the time. Doctor: Is it complete hand or is there any part of hand that is worse than others? Patient: It is mostly my middle finger, but maybe my first or second finger of the hand also, but mostly my middle finger. Doctor: Is there pain anywhere else? Patient: In my thumb as well. I'm just afraid it can be arthritis. I don't want that, too, on my plate.

Section Header: HISTORY of PRESENT ILLNESS Summary: This patient presents to the office today because of some problems with her right hand. It has been going tingling and getting numb periodically over several weeks. She just recently moved her keyboard down at work. She is hoping that will help. She is worried about carpal tunnel. She does a lot of repetitive type activities. It is worse at night. If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her. It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand. She has some pain in her thumb as well. She thinks that could be arthritis.

Doctor: Have you been in any accident? Patient: I have been a truck driver for some time but luckily have not been in any major auto accident. I had hit a moose once, where I bumped my head but do not remember getting hurt anywhere else. I had broken my ankle in the past. Doctor: Hm, I see here you mentioned to the nurse, that a car fell on your chest six years back? Patient: Oh yes, I was repairing my car and it fell off the car jack stand and fell on my chest but fortunately I was not hurt.

Section Header: HISTORY of PRESENT ILLNESS Summary: He had a broken ankle in the past. They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago. He told me that he hit a moose once, but he does not remember hitting his chest.

Doctor: Did you ever had pneumonia? Patient: No, never. Doctor: Do you have any history of lung disease? Patient: No. Doctor: Any history of tuberculosis? Patient: No. Doctor: Are you feeling any shortness of breath or difficulty breathing? Patient: No. Doctor: Okay. Do you have any wheezing? Patient: No.

Section Header: REVIEW OF SYSTEMS Summary: RESPIRATORY: No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.

Doctor: Tell me about your past medical history. Is there anything that I should be aware of? Patient: No, I don't think so. Doctor: Any known allergies? Patient: No. Doctor: Have you ever been diagnosed with diabetes or high blood pressure? Patient: Oh, last year I did have some incidents of high blood pressure, but I didn't take any medications for it. Doctor: Have you seen any variation in your weight? Patient: How do you know? It's been up. About fourteen pounds since last year.

Section Header: PAST MEDICAL HISTORY Summary: Unremarkable. There is no history of allergies. He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.

Doctor: How did your treatment for the thrombosis go? I believe we did it on February nineteen of two thousand and seven. We finished the note the next day in order to send to your other following doctor. Patient: The treatment went well. Thanks!

Section Header: PAST SURGICAL HISTORY Summary: The treatment of the thrombosis was documented on 02/19/2007 and 02/20/2007.

Doctor: Where are you having numbness? Patient: In my left hand. Doctor: And no other symptoms? Any coughing or chest pain? Patient: No. Just that weird feeling in my left hand. Doctor: Any visual changes or motor changes. Patient: Nothing. Doctor: Great. What about any phlegm or shortness of breath? Patient: Nope.

Section Header: REVIEW OF SYSTEMS Summary: No coughing, sputum production, dyspnea or chest pain. No vomiting or abdominal pain. No visual changes. No neurologic deficits other than some numbness in his left hand.

Doctor: How are you feeling? Patient: I've been having a lot more joint pain lately. Doctor: You're seventy seven, correct? Patient: Don't remind me. Doctor: When did you first start experiencing joint pain? Patient: Couple years ago. Doctor: In what ways has it worsened? Patient: It's caused me to become less active in general. My hands and wrists aren't as mobile. Doctor: Have you noticed any increased swelling? Patient: No, but it's all gotten to be a little too uncomfortable. Doctor: I see here that you take the generic of Daypro. Is that helping? Patient: No. Doctor: And no redness to the area, right? Patient: No. Doctor: Fever or chills? Patient: I had diarrhea for a few days, but it's gotten much better. I was also having trouble holding my bladder. Doctor: Are you going to the bathroom more often, experiencing excessive thirst, or other problems? Patient: No. My incontinence is a bit better and so is my ankle and foot swelling. Doctor: How has your blood sugar been? Patient: A little better. Doctor: Have you checked your blood pressure recently? Patient: Not recently. Doctor: Any new medications? Patient: I'm back on Zoloft again because I think I might be depressed. Ever since losing most of my mobility, I haven't been feeling like my usual myself. I'm also sleeping all the time.

Section Header: HISTORY of PRESENT ILLNESS Summary: A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Daypro generic does not seem to be helping at all. No fever or chills. No erythema. She actually is doing better. Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema. Blood sugars seem to be little better as well. The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things. She has had no polyuria, polydipsia, or other problems. No recent blood pressure checks.

Doctor: Anyone in your family been sick lately? Patient: Yes, my sister has sinus problems. She was seen today. Doctor: Okay that means she will be treated. Patient: Yes. Doctor: How about other family members? Patient: No, my mom and dad are healthy. Doctor: Good. Good. Patient: Hm!

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The sister is in today with clinical sinusitis. Mother and father have been healthy.

Doctor: So, tell me what's going on with you? Patient: Well, yesterday evening between seven or eight I developed nausea and suddenly it started hurting on the right side of my chest? Doctor: Where exactly did it hurt? Patient: Ah, my upper chest part and it went all around my right side till my back. Doctor: Okay, how do you feel now? Patient: I feel very weak and tired, don't feel like doing anything but resting. Doctor: Any fever? Patient: Yeah, nurse just took my temperature it was one hundred point three. Doctor: Okay. Did you have these symptoms before? Patient: No, first time. I never felt like this before. Doctor: Okay. Any chills or shivering? Patient: No. Doctor: When was your last bowel movement? Patient: It was yesterday. Doctor: Did you notice any blood in your stool or any rectum bleeding? Patient: No. Doctor: How old are you? Patient: I am twenty eight. Doctor: Okay, and you had a gastric bypass surgery, one year ago. Patient: Yes, almost one year ago. I lost about two hundred pounds after that. Doctor: And you felt well after the surgery? Patient: Absolutely! Until yesterday when my nausea and pain started. Doctor: Okay.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on it but has not done so. He has overall malaise and a low-grade temperature of 100.3. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum.

Doctor: Okay, so it looks like your blood work shows that your sodium levels are very low. This could explain some of the symptoms you've been having lately. Patient: What does that mean? Why are my sodium levels so low? Doctor: It could be due to a number of- Patient: Should I start eating more salt? Doctor: Not necessarily. But I believe it's partly due to the diuretic that you've been taking these past few weeks. Your blood work also shows anemia. I'd like to start you on some iron supplements for now and get you back in for another eval. The front desk has access to your orders and they can print you out a lab slip. Patient: Do you think the iron will help with my tiredness? I've been so exhausted and caffeine hasn't been helping one bit.

Section Header: ASSESSMENT Summary: 1. Acute tiredness. 2. Anemia of unknown etiology. 3. Acute hyponatremia.

Doctor: So, you are a cigarette smoker? Patient: Yeah. Doctor: How much do you some? Patient: Not as much as some people. Doctor: How much is that exactly? Patient: Well, I probably buy a new pack once a week. Doctor: Okay. So that is about four packs a month and fifty packs a year. Patient: Yeah, I guess so.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: 50+pack-yr cigarette use.

Doctor: Are you married, sir? Patient: Yes, to my wonderful wife. Doctor: Great, can I assume you support each other at home? Patient: Yes, doctor, that's correct. Doctor: Do you smoke or drink, sir? Patient: Well, I don't smoke, and I don't do anything harder, either. But I drink just about every day. Doctor: How much do you drink a day? Patient: I drink maybe two or three drinks a day, so maybe four or nine a week.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He is married and has support at home. He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week.

Doctor: Do you know if anyone in your family has history of heart disease, stroke anything of that sort? Patient: Let me think. You mean only blood relatives? Doctor: Yes. Patient: Yes. We have some of those diseases in our family.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Remarkable for coronary artery disease, stroke, and congestive heart failure.

Doctor: What kinds of surgeries have you had in the past? Patient: I have had a heart bypass surgery. Doctor: Is that C A B G? Patient: Maybe. And I have had my tonsils and appendix taken out. Doctor: Sure. Okay.

Section Header: PAST SURGICAL HISTORY Summary: CABG, appendectomy, tonsillectomy

Doctor: Good morning, ma'am. Can you tell me more about this low back pain? Patient: Well, I'm not as young as I used to be, I'm fifty nine. Doctor: What set this pain off? Is there any injury? Patient: Yes, I had a fall in the beginning of two thousand six. I slipped on a freshly waxed floor. Doctor: What part of your lower back did you fall onto? Patient: I fell onto my tailbone and just general lower back. Doctor: Is this the only fall you've had? Patient: No, I had another one in March of two thousand six. Doctor: What happened when you fell that time? Patient: I was trying to qualify on the gun range with a handgun, when I lost my footing. Doctor: What made you lose your footing? Patient: I think it was more weakness than a loss of balance. Doctor: What treatments have you had for this? Patient: Well, I've been to P T, and I had, um, cauterization of some of the nerves in my lower back. Doctor: How many times have you had this cauterization done? Patient: I've had it twice, once in October and the other in November. Doctor: This was in two thousand eight, right? Patient: Correct. The P T said I have low back pain and degenerative disc disease.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is a 59-year-old female, who was referred to Physical Therapy, secondary to low back pain and degenerative disk disease. The patient states she has had a cauterization of some sort to the nerves in her low back to help alleviate with painful symptoms. The patient states that this occurred in October 2008 as well as November 2008. The patient has a history of low back pain, secondary to a fall that originally occurred in 2006. The patient states that she slipped on a newly waxed floor and fell on her tailbone and low back region. The patient then had her second fall in March 2006. The patient states that she was qualifying on the range with a handgun and lost her footing and states that she fell more due to weakness in her lower extremities rather than loss of balance.

Doctor: Have you ever had surgery, ma'am? Patient: Yeah, doctor, I've had a whole lifetime worth of back surgeries. Doctor: How many surgeries have you had? Patient: I've had four. Doctor: Do you know the surgeries you've had? Patient: Actually, I have the op notes here. Doctor: I see, you've had an anterior cervical discectomy, and fusion of C three through C seven. Patient: Yes, I had all of those with Doctor L. Doctor: Do you have any children? Patient: Yes doctor, I have seven, but I had three miscarriages. Doctor: Were any of your children born through C sections? Patient: No, none of them were.

Section Header: PAST SURGICAL HISTORY Summary: She has had over her over her lifetime four back surgeries and in 2005 she had anterior cervical discectomy and fusion of C3 through C7 by Dr. L. She is G10, P7, no cesarean sections.

Doctor: Have you ever had any major surgeries? Patient: I had a skin tag removed but no. No major surgeries. Doctor: Okay.

Section Header: PAST SURGICAL HISTORY Summary: No significant past surgical history.

Doctor: With ten being the worst pain imaginable, out of ten, how would you describe your pain today? Patient: I'd say its about a six out of ten today. Doctor: What makes the pain worse? Patient: It's worse when I try to walk around on it. Doctor: Do you have any pain at night? Patient: No, thankfully I don't. Doctor: How long have you been wearing that exterior knee brace? Patient: Oh, for a little while now.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient rates his pain at 6/10 on the Pain Analog Scale, primarily with ambulation. The patient does deny pain at night. The patient does present with his knee brace on the exterior of his __________ leg and appears to be on backboard.

Doctor: I need to ask you a few questions. Patient: Sure. Doctor: Do you feel any weakness or tiredness? Patient: No. Doctor: Any uneasiness or illness? Patient: No, nothing of that sort. Doctor: Any chills or high temperature? Patient: Nope. Doctor: Any excessive sweating or night sweating? Patient: Um, no. Doctor: How about allergies, are you allergic to anything? Patient: No, no allergies. Doctor: Alright.

Section Header: REVIEW OF SYSTEMS Summary: GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

Doctor: Do you smoke or drink? Patient: No. Doctor: Any drug use? Patient: No.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: No alcohol, drugs, or tobacco.

Doctor: Do you smoke? Patient: Yes! Doctor: How about alcohol, do you drink? Patient: Yes, I do. Doctor: And how much do you drink and is it occasional or on daily basis? Patient: Well, I love my wine, I drink about four to five glasses per day. Doctor: Wow! That's a lot.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is a smoker and drinks alcohol daily in considerable amounts.

Doctor: Do you smoke cigarettes? Patient: Yes.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is a smoker.

Doctor: Any important family history, any medical issues in the family? Patient: Well, my father died of a heart attack. I don't remember how old he was, but I do remember that he had some long run heart issues. Doctor: What about your mom? Patient: My mom's death was a mystery for all of us. She died of some complications because of the dental procedures. So never got to know what killed her. Doctor: Do you have kids? Are they all doing good health wise? Patient: I have a daughter, she's healthy.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy.

Doctor: Hi there! How are you today? Patient: Hi. I am not doing so well. I have had this cough and a pain in my stomach. Right here by my belly button. Doctor: How long has this been going on? Patient: Two days. It has been very painful. Doctor: I would like to examine your abdomen. Is that okay? Patient: Yes.

Section Header: CHIEF COMPLAINT Summary: Cough and abdominal pain for two days.

Doctor: Can you please confirm the medications that you have already taken? Patient: Yeah, I just finished the course for Minocin. I also took Duraphen II D M.

Section Header: MEDICATIONS Summary: Recently finished Minocin and Duraphen II DM.

Doctor: Has anyone in your family had a history of heart disease or issues? Patient: Well, yeah. Actually, my dad passed away due heart disease. Doctor: Oh, I am sorry to hear that. Do you know what kind of heart problem he had? Patient: Yeah, it is called co- Doctor: Oh, coronary heart disease? Patient: Yes, exactly! Doctor: I see.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: His father died of coronary artery disease.

Doctor: Good morning, ma'am. Just to confirm, you're thirty two years old, correct? Patient: Yes, doctor, that's correct. Doctor: Good, so, have you been able to get a P C P yet? Patient: No, I haven't gotten one just yet. Doctor: Are you in the process of getting one? Patient: Yeah, Project Access is trying to find me one. Doctor: Good, um, what seems to be the problem today, then? Patient: Well, I was at Doctor X Y Z's office today, I had an appointment, but they cancelled me because I don't have the Project Access insurance yet. Doctor: I see, what were you going to see Doctor X Y Z for? Patient: I'm having a lot of pain in my foot. Doctor: Okay, have you seen Doctor X Y Z before? Patient: Yeah, I saw him on May fourteenth two thousand four. Doctor: But you still don't have a P C P, correct? Patient: Yes, that's correct. Doctor: Okay, we've seen you quite a few times in here. You were in here last week and saw Doctor X Y Z for some back pain, how did they treat you? Patient: Um, I got some pain medicines and muscle relaxers. Doctor: Okay, so, can you tell me more about your foot, please? Patient: Well, I have this pain in my foot, and I had surgery before so there's plates and screws in it. Doctor: Have you ever talked to anyone about removing this hardware? Patient: Well, I was supposed to see Doctor X Y Z about it, but since that appointment was cancelled, I came here. Doctor: I see, how long have you had this foot pain? Patient: Um, it started hurting a lot yesterday. Doctor: Is there any injury here? Patient: No, it's just chronically painful, honestly. Doctor: Do any activities bother it? Patient: Yeah, I can't exercise without a lot of pain. Doctor: I see, well, we've x rayed this before, and I see the hardware in there, but there's no apparent abnormality or evidence of loosening, at least from what I can see.

Section Header: HISTORY of PRESENT ILLNESS Summary: This 32-year-old female comes in again still having not got a primary care physician. She said she was at Dr. XYZ office today for her appointment, and they cancelled her appointment because she has not gotten her Project Access insurance into affect. She says that Project Access is trying to find her a doctor. She is not currently on Project Access, and so she is here to get something for the pain in her foot. I did notice that she went in to see Dr. XYZ for a primary care physician on 05/14/2004. She said she does not have a primary care physician. She was in here just last week and saw Dr. XYZ for back pain and was put on pain medicines and muscle relaxers. She has been in here multiple times for different kinds of pain. This pain she is having is in her foot. She had surgery on it, and she has plates and screws. She said she was suppose to see Dr. XYZ about getting some of the hardware out of it. The appointment was cancelled, and that is why she came here. It started hurting a lot yesterday, but she had this previous appointment with Dr. XYZ so she thought she would take care of it there, but they would not see her. She did not injure her foot in any way recently. It is chronically painful. Every time she does very much exercise it hurts more. We have x-rayed it in the past. She has some hardware there. It does not appear to be grossly abnormal or causing any loosening or problems on x-ray.

Doctor: Do you smoke or drink? Patient: No. Doctor: Any drugs? Patient: You mean like meth? Doctor: Yeah. Patient: No, never did it. Doctor: Okay.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: denied ETOH/Tobacco/illicit drug use.

Doctor: Hello, miss. How are you? What brings you to my office today? Patient: I am doing well. Just here for a refill on my medication. Doctor: Great. That should be easy. How has the stress management been going to control the acne? Patient: It is going well. My husband has been on board with my meditations and yoga. He is very supportive. Doctor: Wonderful. Are will still clean from drinking and smoking? That can interact with your medications. Patient: Yeah I know. I don't drink or smoke.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient is married. She is a nonsmoker and nondrinker.

Doctor: So I have here that you're taking three different medications. Patient: Yeah. I've been taking them every day just like they told me to. Doctor: I see. That's good. Did you refill your prescriptions with the newly revised doses? It looks like they changed the dosing of your medications at the hospital. Patient: Um I've just been taking what I have at home. Doctor: I advise that you take the doses that they prescribed. If you'd like me to put in a new order, please let me know. Patient: Okay, yeah that's fine. I can pick it up on my way home. I didn't think the dosing mattered much as long as I took the meds every day.

Section Header: MEDICATIONS Summary: I reviewed his medication list in the chart. He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.

Doctor: Any major surgeries in the past? Patient: Not too many, but a catheter was put in my heart. Doctor: Oh, so cardiac catherization, correct? Patient: Yep.

Section Header: PAST SURGICAL HISTORY Summary: No major surgery except for prior cardiac catheterization.

Doctor: Hello, sir. I see you're being seen for an evaluation for your allergy. Can you please confirm your age? Patient: Yeah, that's right. Thirty four. Doctor: Let me take a look at your medical records. I see you were treated at the A B C Medical Center for an allergic reaction, correct? Patient: Yeah. I was rushed to the hospital that day. After, they told me to get checked for a follow up. Doctor: Who told you to have a follow up? Patient: One of the E R doctors and the kidney doctor. Doctor: I see. Your records indicate you had some swelling around the eye on May third of two thousand and eight. The cause was unknown. I see you were transferred from A B C Medical Center to X Y Z Medical center that day. Patient: Yeah, that sounds about right. Were there more details about that? Doctor: Yeah, there is. It says here you have a history of renal failure, so you needed dialysis. They believe the allergic reaction was due to this medicine called, Keflex, which was used during your dialysis treatment. Does that name ring a bell? Patient: Yeah, it does. I forgot why they gave it to me. Doctor: Usually, Keflex is used to treat a skin cellulitis dialysis shunt infection. Patient: Oh, I see. Doctor: I would like to ask you more about your allergies. What would you say you're allergic to? Patient: I've had a lot of problems with grass and sometimes pollen. Doctor: I see. I'll put that down as grass allergies, and environmental and inhalant allergies. Do you have any life-threatening allergic reactions? Patient: Nope. Never had that. Doctor: Have you ever had any swelling under the skin due to something you ate or touched? Patient: Nope. Never had that either. Doctor: That's great. I'm taking a look at your medications. I see you aren't taking anything for your allergies, but you are taking Atenolol. Do you have high blood pressure? Patient: Yeah, I do. Doctor: I see. All that's left from your report are the treatments they gave you before you were discharged from the hospital. Patient: What were the treatments they gave me? Doctor: Looks like they monitored you the whole time and gave you some corticosteroid therapy and antihistamine therapy. You didn't have any additional problems as well.

Section Header: HISTORY of PRESENT ILLNESS Summary: A 34-year-old male presents today self-referred at the recommendation of Emergency Room physicians and his nephrologist to pursue further allergy evaluation and treatment. Please refer to chart for history and physical, as well as the medical records regarding his allergic reaction treatment at ABC Medical Center for further details and studies. In summary, the patient had an acute event of perioral swelling, etiology uncertain, occurring on 05/03/2008 requiring transfer from ABC Medical Center to XYZ Medical Center due to a history of renal failure requiring dialysis and he was admitted and treated and felt that his allergy reaction was to Keflex, which was being used to treat a skin cellulitis dialysis shunt infection. In summary, the patient states he has some problems with tolerating grass allergies, environmental and inhalant allergies occasionally, but has never had anaphylactic or angioedema reactions. He currently is not taking any medication for allergies. He is taking atenolol for blood pressure control. No further problems have been noted upon his discharge and treatment, which included corticosteroid therapy and antihistamine therapy and monitoring.

Guest_family: Doctor, you must tell her. She has stopped taking her medications. And her blood pressure is out of control, she is angry all the time and not looking after herself at all. Patient: That is not true! Doctor: Miss Tara, you need to take your medications on time. You are hypertensive and your readings don't look good. Patient: I don't want to take anymore medications. I want to try some natural remedies to treat my high blood pressure. I am not going to take any prescription meds that's it. Doctor: If that's the case then I will make note in your file that you are not complying.

Section Header: PAST MEDICAL HISTORY Summary: Hypertension. The patient noncompliant

Patient: I think I got some allergy, my lips are swollen and its causing me difficulty in swallowing. Doctor: Oh, let me take a look.

Section Header: CHIEF COMPLAINT Summary: Swelling of lips causing difficulty swallowing.

Doctor: Any medical history? Patient: Um I suffer from depression and high blood pressure. Doctor: Are you taking anything for either? Patient: Only for high blood pressure. Doctor: Have you had surgeries in the past? Patient: I had surgery to get a few hemorrhoids removed back in two thousand and ten.

Section Header: PAST MEDICAL HISTORY Summary: Significant only for hemorrhoidectomy. He does have a history of depression and hypertension.

Doctor: Do you have a family history of any medical conditions, such as diabetes or heart disease? Patient: No, nothing.

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

Doctor: How's your family? Patient: They're doing well, thank you. My three boys are all grown up. Hard to believe they're living their own as young professionals. One of them is actually a G I doctor in San Diego, California. Doctor: You must be so proud of your boys. Patient: My wife and I always say how lucky we are. Doctor: I'm sure. And I have a few more questions before we wrap up. Patient: Go for it. Doctor: Do you drink or smoke? Patient: I smoke about a third of a pack a day and I drink every now and again, but nothing crazy.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. The patient is married. She has three grown sons, all of which are very successful in professional positions. One son is a gastroenterologist in San Diego, California.

Doctor: How's it going, buddy? I haven't seen you in a long time Patient: Hey, Doctor. It's been a while. I've been doing well. Just here for my check up. Doctor: Nice. How's the family doing? Are they all well? Patient: Yeah, they're doing great. Nobody has been sick for a while. Doctor: That's great to hear. Nobody has new medical conditions either, right? Patient: Not that I know of. They're all doing good.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Reviewed and unchanged.

Doctor: So, you and your husband live together, correct? Patient: Yes. It's a miracle we've lasted this long. Guest_family: Can't argue that. Doctor: Are you able to walk any distance without assistance? Guest_family: She's most comfortable in her wheelchair, but she usually walks with a walker if she's at home. Patient: Yeah, he's right. Doctor: And how often do you walk with your walker? Patient: If I were to guess, I'd say half the time. Doctor: Great. Guest_family: If I'm nearby, I like to keep any eye on her incase she feels unstable and needs help sitting back down. Doctor: It's good that you're both looking out for each other. Now moving onto the last few questions. Do you smoke or drink? Patient: No and no. Doctor: Did you smoke or drink in the past? Patient: No.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows. No history of alcohol abuse or smoking.

Doctor: You do not look so well today. What seems to be the problem? Patient: Well‚ I am having a hard time. My whole body aches and I am in pain. Doctor: Do you have a history of drug use? Patient: Well yes. I am detoxing. Doctor: What kind of drugs have you been using? Patient: Heroin. Doctor: Okay. How long have you been using? Patient: I don't feel well. Maybe a year. I can't sleep or eat. Doctor: Have you had a fever, chills, vomiting or diarrhea? Patient: I think I have a fever. I feel chilled. I have had some diarrhea.

Section Header: CHIEF COMPLAINT Summary: Detox from heroin.

Doctor: How would you rate your general health? Patient: I've been in reasonably good health at least physically. I try to go on frequent walks and eat a clean diet. However, there was one instance where I was not well mentally. After my husband died in nineteen seventy five, I had what I believe was a nervous breakdown. As a result of this, I was hospitalized for several weeks and treated with E C T. Doctor: I'm so sorry to hear about the loss of your husband. I can't imagine how difficult that must've been. I'm glad that you sought the care that you needed to feel better at that time. Did this happen when you were living in the United States or Korea? Patient: This all happened when I was living in Korea. I'm grateful that I had my family and friends to support me. Doctor: Social support is very important, especially when you are processing the loss of a loved one. Patient: Absolutely. Doctor: I have a few more questions before we move on. Any past medical problems? Patient: I used to have high blood pressure. Doctor: When you say used to, do you mean it's been resolved now? Patient: Yes. Doctor: Great news. How about surgeries? Have you had any in the past? Patient: None whatsoever. Doctor: Any alcohol or tobacco? Patient: No, I stay away from things like that.

Section Header: PAST MEDICAL HISTORY Summary: The patient has generally been in reasonably good physical health. She did have a "nervous breakdown" in 1975 after the death of her husband. She was hospitalized for several weeks and was treated with ECT. This occurred while she was living in Korea. She does not smoke or drink alcoholic beverages. She has had no prior surgeries. There is a past history of hypertension, but this is no longer present.

Doctor: Are you experiencing any headaches, or do you have any history of migraine? Patient: No. Doctor: Any temporary loss of consciousness? Patient: No. Doctor: Any feeling of being off balance or fainting? Patient: No. Doctor: Any continuous sound you may hear? Patient: No. Doctor: Okay so no tinnitus. Any mouth sores or ulcers? Patient: Um, no. Doctor: Do you notice any change in your voice, any hoarseness? Patient: No, nothing like that. Doctor: Did you notice any swelling in and around your mouth? Patient: No, I did not. Doctor: Any history of goiter or swelling of your thyroid gland? Patient: Nope. Doctor: Okay.

Section Header: REVIEW OF SYSTEMS Summary: HEENT: No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.

Doctor: Hello, miss. How can I help? Patient: Well, I just turned fifty seven this year and I would like to get rid of these wrinkles on my face. I don't like them one bit. Doctor: You look beautiful and actually have a lot of fullness in the face. It is great that you do not smoke and do not have history of skin disease. We can definitely help you with these minor issues.

Section Header: HISTORY of PRESENT ILLNESS Summary: This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids. In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.

Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: Remind me, how young are you? Patient: Oh doctor, you flatter me. I'm sixty two years old. Doctor: Great, and you've had a rotator cuff repair before, correct? Patient: Yes, that's correct. Doctor: Good, well, what seems to be the problem today? Patient: I'm still having a lot of pain in this shoulder. Doctor: Oh no, have you had any recent imaging done on this shoulder? Patient: Yes, I had an M R I not too long ago, can you take a look? I have it right here. Doctor: Thank you, yes, um, this M R I shows that you've torn that rotator cuff again. Patient: Oh no, can we do another surgery to repair it again? Doctor: Yes, we'll have to. Patient: What's the risk of infection of the surgery? Doctor: Its less than one percent. We'll use antibiotics to control for infection the entire time. Patient: Will I be asleep again? Doctor: Yes, you won't feel a thing. Patient: Great, yes, I'd like to go forward with the surgery. I need to get back to playing tennis.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 62-year-old female who previously underwent a repair of rotator cuff. She continued to have pain within the shoulder. She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff. She wished to proceed with a repair. All risks and benefits of the surgery were discussed with her at length. She was in agreement with the above treatment plan.

Doctor: What brings you in today? Patient: I dropped a glass and one of the broken pieces cut my foot pretty badly. There was a lot of blood. Doctor: Is the area still bleeding? Patient: I got it to stop bleeding while I was waiting for my ride. Doctor: Is there any pain in the area? Patient: No, it doesn't hurt. Doctor: Are you able to walk normally without pain or discomfort? Patient: Yes. Doctor: Are you experiencing any numbness or loss of strength in the area? Patient: No. Doctor: Do you have any other injuries on any other part of your body? Patient: No. Doctor: Have you had any recent illnesses? Patient: No. Doctor: Do you have any other concerns while you are here today? Patient: No.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 32-year-old male who had a piece of glass fall on to his right foot today. The patient was concerned because of the amount of bleeding that occurred with it. The bleeding has been stopped and the patient does not have any pain. The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort. The patient denies any injuries to any other portion of his body. He has not had any recent illness. The patient has no other problems or complaints.

Doctor: What do you do for a living, sir? Patient: I'm actually retired, but I used to work as a dock hand. Doctor: That's great, congratulations on your retirement! Patient: Thank you so much, doctor. Doctor: I just need some background information on you, sir. Do you smoke? Patient: Sure, I smoke about a half a pack of cigarettes a day. Doctor: Do you drink, sir? Patient: Well, not anymore, but I used to be an alcoholic.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand

Doctor: Any surgical history? Patient: I had my thyroids taken out. Doctor: When did you have them taken out? Patient: Hm three years ago. Man, time flies. Doctor: Did you experience any complications post surgery? Patient: Nothing out of the ordinary. Doctor: Who was the surgeon who did your thyroidectomy? Patient: Doctor X. Doctor: What was the final diagnosis? Patient: I had a growth on my thyroids. Doctor: Was the growth cancerous? Patient: It was. I was initially reluctant to get them out, but I realized it was necessary. I didn't have much of a choice if I wanted to live ya know. Doctor: That's understandable. I'm sorry you had to go through that. Surgery is daunting, let alone surgery to remove cancer.

Section Header: PROCEDURES Summary: Total thyroidectomy.

Doctor: Welcome in. I am Doctor Welch. Guest_family: Thank you! It is nice to meet you. Doctor: How old is your daughter? Guest_family: She is three years old now. Doctor: Hi there! Patient: Hi! Doctor: Mom I would like to start off with some questions regarding pregnancy, childbirth, and prior children. Guest_family: Okay. Doctor: Do you have any other children? Guest_family: No. She is my only child. Doctor: Have you ever had any miscarriages or abortions prior to having your daughter? Guest_family: I had a very early miscarriage before getting pregnant again with her. Doctor: I am so sorry to hear that. Guest_family: Thank you. I was difficult but when I got pregnant again with her, we were so overjoyed. Doctor: Did you have any difficulties or problems during your pregnancy with her. Guest_family: I had the flu in my seventh or eighth month of pregnancy. Other than that I had no problems. Doctor: How far along were you when you gave birth? Guest_family: I was thirty six weeks. Doctor: Did you have a vaginal birth or a C section? Guest_family: I had a regular birth. Doctor: Were any tools used during the birth to help with the birthing process? Guest_family: No. Doctor: How long were you in labor for? Guest_family: I was in labor for eleven hours. Doctor: Were you given any anesthesia during the birth? Guest_family: They gave me a little bit of laughing gas but not much. Doctor: What was her birth weight? Guest_family: Seven pounds and ten ounces. Doctor: Do you recall her Apgars score? Guest_family: No. I am not sure. Doctor: How long did you stay in the hospital after the birth? Guest_family: Five days. Doctor: Let us move to questions regarding your daughter. Has she had any development problems? Guest_family: She did not walk until well after two years old. She only rolled from side to side at two. Doctor: Okay. How old was she when she spoke her first words? Guest_family: She was around one or two. Doctor: When did she start to feed herself, using her hands? Guest_family: She was two. Doctor: Has she been toilet trained yet? Guest_family: No. She is not interested but I have been trying.

Section Header: HISTORY of PRESENT ILLNESS Summary: Spontaneous Vaginal delivery at 36weeks gestation to a G2P1 mother. Birth weight 7#10oz. No instrumentation required. Labor = 11hours. "Light gas anesthesia" given. Apgars unknown. Mother reportedly had the "flu" in the 7th or 8th month of gestation. Patient discharged 5 days post-partum. Development: spoke first words between 1 and 2 years of age. Rolled side to side at age 2, but did not walk. Fed self with hands at age 2 years. Never toilet trained.

Doctor: Okay and are you working? Patient: Oh yes, I am a farmer. I have a farmland and my wife, and I do farming. Doctor: Good, so you are one happy married couple working together. Patient: Ah, yes. Doctor: And how about tobacco, do you smoke or eat? Patient: Absolutely not. Doctor: Any use of drugs or alcohol? Patient: Drugs? Doctor: Yeah, like cocaine or anything like that. Patient: Oh that, no. No drugs. Patient: And I don't drink either. Doctor: Alright.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Farmer, Married, no Tobacco/ETOH/illicit drug use.

Doctor: Well, looking at your hand x ray, the bone looks in alignment, and I don't see any effusion. Doctor: Any tenderness or pain? Patient: Ah, not really! Doctor: There is no asymmetry. Can you move your hand up and down? Now rotate it. Can you move your fingers? Patient: Yes, I can do all of that, no problem at all. Doctor: Can you bend your hand? Patient: Yes. Doctor: Perfect.

Section Header: EXAM Summary: BONE: No misalignment, asymmetry, defect, tenderness or effusion. Capable of from of joint above and below bone.

Doctor: How about any surgeries in the past? Patient: Well, I had colon surgery in nineteen eighty nine or was it ninety, oh yeah in nineteen ninety. Doctor: Okay and anything else? Patient: Ah yes, I had three surgeries for my sinus one was the same year as my colon surgery, one was before that. So, the first one was in nineteen eighty seven I believe then nineteen ninety and the last one was in two thousand five. Doctor: Wow, you remember the years also. Patient: Yeah, surprisingly.

Section Header: PAST SURGICAL HISTORY Summary: Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.

Doctor: So, do you drink or smoke, sir? Patient: I'd say I have the occasional drink, but I don't smoke. Doctor: What do you do for a living? Patient: I'm a nursing aid in a nursing home right now. Doctor: Do you work the normal day shift? Patient: No, I work the second shift, so I work some late nights and early mornings. Doctor: Are you back at Wichita State this semester? Patient: No, I decided to take some time off. Doctor: Is everything okay? Patient: Yeah, I'm just really tired, so I decided to step away for a little. Doctor: That's understandable. Are you dating right now? Patient: Yes, I've been dating my boyfriend for a while now. Doctor: Is there any significant stress in your relationship? Patient: No, everything is going really well.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Only occasionally drinks alcohol and he is a nonsmoker. He currently is working as a nurse aid, second shift, at a nursing home. He states that he did not enroll in Wichita State this semester. Stating he just was tired and wanted to take some time off. He states he is in a relationship with one partner and denies any specific stress in the relationship.

Doctor: What brings you in today, miss? Patient: I haven't been feeling well since I went to the dentist. Doctor: When did you go to the dentist? Patient: It was in May last year. Doctor: What happened at the dentist? Also, sorry, but how old are you. Patient: It was after I left the dentist. I was driving home, and I got lightheaded. I was so lightheaded that I had to pull over. Doctor: How long did the episode last? Patient: About two to three minutes. Doctor: Is this the only time that this has happened? Patient: No. In November last year, I was in the middle of eating breakfast when I got dizzy. I was so dizzy that I was nauseous, and I threw up several times. I was so exhausted from the dizziness and throwing up that I went to my room and took a two hour nap. I felt better and back to normal after I woke up from my nap. Doctor: How long did the vertigo last? Patient: It lasted about two to three minutes. So, about the same amount of time. Doctor: Have you had any other dizzy episodes? Patient: No I didn't but in January on the thirteenth my right arm went numb. It lasted for about four to five hours. Doctor: Are you left handed, or right? Patient: I am right handed. Doctor: Have you experienced any slurred speech or trouble swallowing? Patient: No. Doctor: Have you had any continuing weakness other than the time in January? Patient: No. Doctor: Have you experienced any headaches or visual changes? Patient: No. Doctor: Any continuing vertigo or lightheadedness? Patient: No.

Section Header: HISTORY of PRESENT ILLNESS Summary: This 61y/o RHF experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in 5/92. In 11/92, while eating breakfast, she suddenly experienced vertigo. This was immediately followed by nausea and several episodes of vomiting. The vertigo lasted 2-3minutes. She retired to her room for a 2 hour nap after vomiting. When she awoke, the symptoms had resolved. On 1/13/93 she had an episode of right arm numbness lasting 4-5hours. There was no associated weakness, HA, dysarthria, dysphagia, visual change, vertigo or lightheadedness.

Doctor: Oh wow, you got stung quite a few times. Patient: Yeah, you're right about that. In my seventy six years this i have never gotten stung. This is new. Guest_family: He got stung around noon while I was inside preparing lunch. Patient: Yeah, they got both my hands and right knee. Those little monsters. Doctor: Did you notice redness and swelling right away? Patient: Um not right away. Doctor: How long did it take for your body to react? Patient: Bout thirty minutes or so. Doctor: Did you experience any shortness of breath, itching, or hives? Patient: No, surprisingly. Doctor: And no tongue swelling or trouble swallowing? Patient: No. Doctor: Have you gotten stung in the past? Or is this your first time? Patient: I got stung about a month ago. No redness or swelling like I do now. I guess it could've been due to the Benadryl I took as soon as it happened. Doctor: Did you take Benadryl again today? Patient: No, I figured I'd be okay. Guest_family: He takes Metoprolol and Hydrochlorothiazide for his blood pressure. Patient: And a baby Aspirin in the mornings. Doctor: Did you take your daily medications today? Patient: Yeah."

Section Header: HISTORY of PRESENT ILLNESS Summary: Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today. He did not note any immediate reaction. Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath. He denies any sensation of tongue swelling or difficulty swallowing. The patient states he was stung approximately one month ago without any serious reaction. He did windup taking Benadryl at that time. He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.

Doctor: What is your family medical history? Patient: I was adopted. I don't know my family medical history.

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

Doctor: Were you ever diagnosed with any blood or heart disease? Patient: Uh no. Doctor: Any other past medical issues? Patient: No.

Section Header: PAST MEDICAL HISTORY Summary: None.

Doctor: Any major or minor surgeries done in the past? Guest_family: Sorry, I have no idea about it. Guest_family: I just started working for him.

Section Header: PAST SURGICAL HISTORY Summary: Unknown.

Doctor: I can see your medication list here. Doctor: Do you take Accutane and Ovcon? Patient: Yes, I do. Doctor: Okay. Patient: Okay.

Section Header: MEDICATIONS Summary: Accutane and Ovcon.

Doctor: What are you taking? Patient: I take Tylenol. Doctor: Is that only for pain? Patient: Yes it is.

Section Header: MEDICATIONS Summary: Tylenol.

Guest_clinician: Hello, doctor. Let me give you a run down as to what we are dealing with today. This patient was last seen in January two thousand and four. She is coming for a follow up on interstitial disease secondary to lupus pneumonitis. I will let her tell you more about what happened yesterday. Doctor: Thanks, nurse. How are you feeling today, miss? Welcome back to the Pulmonary Medicine Clinic. What happened yesterday? Patient: Well, I was doing fine since last time. My respiratory issues have been great and I have had no major difficulties breathing. Doctor: That's good to hear. What happened yesterday that caused you to want to come in so urgently? Patient: Yesterday I noticed that I have some back and joint pain. When I breathe deep my back hurts. Doctor: Are you experiencing any coughing? Patient: No, coughing at this moment. Doctor: Have you been producing any mucus the times that you do cough? Patient: No, I already said I didn't cough. Doctor: Okay. Any fevers or chills? Patient: Nothing so far. Doctor: Do you have any other symptoms currently? Patient: I do notice that I am more tired than usual. Doctor: During physical activity do you seem out of breath or more tired than usual? I want to see if your pulmonary system is inhibited. Patient: No. I don't have issues with breathing when I do daily activities.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. She was last seen in the Pulmonary Medicine Clinic in January 2004. Since that time, her respiratory status has been quite good. She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort. She denies any problems with cough or sputum production. No fevers or chills. Recently, she has had a bit more problems with fatigue. For the most part, she has had no pulmonary limitations to her activity.

Doctor: Hello sir, it's been a while since your last visit. How have you been? Patient: Hello doctor, yes, I have come a long way. I guess last time I was here was in two thousand and two if I am not wrong. Was does your system say? Doctor: You are right! It was August second of two thousand and two to be very precise. Doctor: Please confirm for the records, you are a white married man and must be forty nine years old now. Am I right? Patient: You got it all right doctor! Doctor: Are you still working in that airplane company? Patient: Yes sir, still with Alaska Airlines but I have been promoted and work as a plane mechanic. Doctor: That is so nice! Good for you man! So, tell me how can I help you today? What brought you to our dermatology department today? Patient: I'm having pain in my stomach on the right side and down here. Doctor: Is it only on the right side or anywhere else? Patient: It is on both sides and now I can feel it on the middle part of my left thigh as well. Doctor: Tell me more about it. How did it start? When did you first notice it? Patient: It's been going on and off. It was not there for a while, but now it is like back again mainly on my tummy, down here. It is painful when I touch it. At first, I thought maybe I'm having shingles. Doctor: When did you notice it? Patient: It all started before the holidays, I think one and a half months before the holidays. It is still going on for the past eight days in my tummy and the hips mainly on the right side. Doctor: Did you get any treatment for this? Any over the counter medicines? Patient: No, as I told you I thought it was shingles, but then there was no change in the skin, no rashes, nothing. I was not sure what to take. Doctor: Okay, do you bathe every day? Patient: Yes, I do but I try to use as little soap as possible. Doctor: Okay, here is what I think, all your symptoms are pointing towards hyperesthesia. I would like to run some tests to find the underlying cause and then we will start the treatment. A nurse will come and take you to the lab. Does this sound good to you? Patient: Yes.

Section Header: HISTORY of PRESENT ILLNESS Summary: This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh. It cleared for awhile. This has been an intermittent problem. Now it is back again on his right lower abdomen. At first, it was thought that he may have early zoster. This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area. He has had no treatment on this; there are no skin changes at all. The patient bathes everyday but tries to use little soap. The patient is married. He works as an airplane mechanic.

Doctor: Are you finished with your cancer treatments? Patient: Yes. I am in remission now. Doctor: That is great! When was your last radiation treatment? Patient: It has been over two years since my last treatment.

Section Header: IMAGING Summary: She has had no recent radiological procedures.

Doctor: Do you smoke? Patient: Yeah. I smoke about a pack a day. Doctor: Do you have any plans of quitting? Patient: Eh not really. Doctor: As your doctor, I'd advise that you consider nicotine patches and find ways to break your smoking habit. Patient: Okay. I'll see what I can do. Doctor: Do you drink? Patient: Socially. Doctor: Are you married? Patient: No, but I have two littles ones. Doctor: Aw, how old are they? Patient: I have a four year old and a six year old. Doctor: That's great. I'm sure they keep you busy. Any hobbies? Patient: They really do, especially the four year old. As for hobbies, I like fixing up computers. I also like fishing, hiking, and camping with the family.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: He smokes one pack of cigarettes per day. He is a social drinker. He is not married, but has two children. Hobbies: Computers, hiking, camping, fishing.

Doctor: Good morning, ma'am. Before we begin today, can you confirm your age for me? Patient: Good morning, doctor. Sure, I'm seventy nine years old. Doctor: Great, thank you. What seems to be the problem today, ma'am? Patient: Well, I have this arthritis, as you know. Doctor: Yes, how would you describe your arthritis? Patient: Well, at this point I'd say it's debilitating. Doctor: I see, so the antiinflammatories and rest haven't helped at all? Patient: No, I haven't had any improvement, doctor. It's still so bad. Doctor: I see, I believe you'd be a good candidate for a knee replacement. Patient: Yes, I thought so. What are the risks of infection for the surgery? Doctor: Um, it's less than one percent, we use prophylactic antibiotics to control for infection the entire time. Patient: That's great, what about anesthesia, will I be asleep for this? Doctor: Yes, you won't feel a thing. Patient: Great, yes, I'd like to do the surgery, doctor.

Section Header: HISTORY of PRESENT ILLNESS Summary: This is a 79-year-old female who has disabling bilateral knee degenerative arthritis. She has been unresponsive to conservative measures. All risks, complications, anticipated benefits, and postoperative course were discussed. The patient has agreed to proceed with surgery as described below.

Doctor: Welcome to the clinic. Patient: Thank you. Doctor: Are you from the area? Patient: I was born and raised in Iowa. My husband and I moved here twenty years ago, and we have been here ever since. Doctor: It is a wonderful city. Do you have kids? Patient: Yes! We have two kids. Doctor: Do you have any history or present use of tobacco, alcohol and recreational drugs or substances? Patient: I have a glass of wine every once and a while but no to the rest.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.

Doctor: Any of your family members have issues like seizures? Patient: None on my father's side, but, yeah, on my mom's side some of the family members had seizures. Like, my mom had them during her childhood. I know that my great grandmother had it and so does my great aunt.

Section Header: FAMILY HISTORY/SOCIAL HISTORY Summary: There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt. There is no other significant neurological history on the paternal side of the family.

Doctor: Do you have a sore throat, cough or earache? Patient: No.

Section Header: REVIEW OF SYSTEMS Summary: Negative as far as sore throat, earache, or cough.

Doctor: Can you tell me what are the diseases you have been diagnosed with in the past? Patient: Sure, I have had hypertension, diabetes, asthma and cholesterol problem. Doctor: Ok, is there anything else? Patient: Nope. Doctor: And it is type two diabetes, right? Patient: Yes. Doctor: Thank you!

Section Header: PAST MEDICAL HISTORY Summary: Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.

Doctor: Good afternoon, sir. Do you remember the details of your surgery? Patient: No, can you remind me? Doctor: Well, um, we did a right orchiectomy due to your testicular cancer, when did you have that? Patient: Um, it was about eighteen years ago now, so that was about nineteen eighty nine. Doctor: Good, while you're here, do you have any other conditions that I should be aware of? Patient: Sure, I have G E R D, and um, I B S. Doctor: Thank you, what about allergies, do those bother you? Patient: Yeah, unfortunately I have those. Doctor: Do you have them in the spring, or in the fall? Patient: Actually, I have them in both. It's really annoying. Doctor: What allergy symptoms do you have usually? Patient: Um, another doctor called it a postnasal drip. Doctor: Okay, yes, I'm familiar with that. Have you ever had any other surgeries? Patient: Yeah, um, I had a hernia removed and repaired some time ago. Doctor: I see, what about any other major medical conditions? Patient: I've had carpal tunnel before. Doctor: Which hands did you have it in? Patient: I've had it in both.

Section Header: PAST MEDICAL HISTORY Summary: Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.

Doctor: Good morning, Miss X Y Z, correct? Patient: Yes, that's me, good morning doctor. Doctor: Before we begin, I just need a few pieces of information. How old are you? Patient: I'm forty four years young, doctor. Doctor: Good, thank you. Next, which hand do you write with? Patient: I write with my right hand. Doctor: Finally, what do you do for a living? Patient: I'm an aircraft mechanic. Doctor: Very nice, so, how did you get hurt? Patient: Um, I was working on repairing an airplane at work when I fell between the plane and one of the stands. Doctor: How big was the gap that you stepped in? Patient: Um, it was about a foot and a half. Doctor: Which knee did you hurt? Patient: It was my left knee. Doctor: Did you have surgery after the accident? Patient: Yes I did, I had two arthroscopies, and an, um, patellar replacement after those. Doctor: Okay, yes, I see. Patient: Then, I had a left knee replacement on Month D D, Y Y Y Y. Doctor: Do you have any imaging of this knee? Patient: I didn't have any x rays done, but I have an MRI report and notes from Doctor A B C D. Doctor: Can I see that report? Patient: Yes absolutely, here. Doctor: Okay, so this M R I from September two thousand six shows some nonspecific edema anterior to the patellar tendon, but thankfully there's no evidence of fracture of ligamentous avulsion or abnormality. Patient: What does that mean? Doctor: There's some bleeding in the bone there, but nothing is broken or out of alignment. Patient: Oh, thank you, that's good. Doctor: Oh certainly, yes, it is. What treatments have you had for this knee, aside from surgery? Patient: I've done a full course of PT for this. Doctor: Where is your knee pain? Patient: Mostly, it's here in the front of the knee, and then on both sides, like the inside and outside. Doctor: Does the pain go down your leg at all? Patient: Yes, it goes down my, is this the femur? Doctor: Yes, that's the femur. Patient: Then this must be my tibia, it goes down the front of that too. Doctor: Does it go into your thigh at all? Patient: Yes, it goes into the back of my thigh. I feel numbness and tingling back there. Doctor: Do you feel anything in the feet? Patient: Nope, my feet are completely normal, thankfully. Doctor: Are you having any back pain? Patient: A little, I feel something in my lower back, I'm not sure if it's related. Doctor: Does anything make your knee pain worse? Patient: Yeah, I can hardly walk anymore, it hurts so bad. Doctor: What kind of symptoms do you see when you walk on this? Patient: I feel popping and grinding, and my knee swells up. Doctor: That numbness and tingling you feel in the thigh, do you feel that in the knee at all? Patient: Actually yes, it feels like pins and needles there. Doctor: What about this, when I touch the knee do you feel any abnormal discomfort or pain over the rest of the knee? Patient: No, nothing out of the ordinary there. Doctor: What about this, this is the fibular head, which is where you feel the pins and needles. I'm applying pretty heavy pressure here, how would you describe what you're feeling? Patient: Um, numbness, tingling, and then that same pins and needles feeling. Doctor: Is there any instability? Patient: Yes, and there's pain with it too. Doctor: Are you working right now? Patient: No, I'm not right now. Doctor: Any allergies I should know about? Patient: Yes, actually, I'm allergic to a lot of pain medications. Doctor: Okay, have there been any changes in how you're walking? Patient: Yes, I had to change my walking pattern to take weight off my knee, and I think that has to do with my back pain. Doctor: That's certainly a possibility. How would you describe your pain? Patient: I'd say its constant, shooting, cramping, aching, throbbing, feels like it's being pulled, sharp, and , um, stabbing. All of those words seem fitting. Doctor: Okay, does the pain wake you up at night? Patient: Yeah, it does occasionally. Doctor: Does anything make this feel better? Patient: Yeah, it gets a little better if I lay down or if I keep my leg elevated. Doctor: Out of ten, with ten being the worst pain ever, how would you describe your pain on average? Patient: Um, I'd say six out of ten. That's how it is right now, too. Doctor: What about at its worst? Patient: Easily, its ten out of ten. Doctor: Finally, what about when the pain is at its least? Patient: Um, when it's not too bad, I'd say it's a three out of ten. I also have this other M R I report from September of O six, here. Doctor: Thanks. I see. They said that there is nonspecific edema anterior to the patellar tendon, but there is no acute fracture or any ligament abnormalities. That's good.

Section Header: HISTORY of PRESENT ILLNESS Summary: Ms. XYZ is an otherwise fairly healthy 44-year-old right-handed aircraft mechanic. On her date of injury, she reports that she was working on an aircraft when she fell between the airplane and a stand with about an 18-inch gap in between. She injured her left knee and underwent two arthroscopic procedures followed by patellar replacement and subsequently a left total knee arthroplasty in Month DD, YYYY. The patient is seen with no outside images, but an MRI report of the left knee and office notes from Dr. ABCD. The patient reports that she has undergone a full course of physical therapy and complains primarily of pain in the anterior aspect of the left knee and primarily over the medial and lateral tibial components with pain extending proximally to the distal femur and distally down into the anterior tibial plateau area. She has intermittent numbness and tingling in the posterolateral thigh and no symptoms at all into her feet. She has axial low back pain as an ancillary symptom. Her pain is worse with walking and is associated with swelling, popping and grinding. She complains of pins and needles sensation over the area of the common peroneal nerve overlying the fibular head. She has no dysesthetic or allodynic symptoms with light touch over the remainder of the knee and the femoral nerve area. Heavy pressure and light percussion of the fibular head produce painful numbness, tingling, and pins and needles sensation. The patient underwent a left knee MRI in September of 2006 revealing nonspecific edema anterior to the patellar tendon, but no evidence of an acute fracture or a femoropatellar ligament avulsion or abnormality. She has continued to complain of persistent instability and pain. She is not working. She has a number of allergies to different pain medications and feels that her back has been bothersome mostly due to her gait disturbances relating to her knee. Her pain is described as constant, shooting, cramping, aching, throbbing, pulling, sharp, and stabbing in nature. It occasionally awakens her at night. It is better in recumbency with her leg elevated. Exacerbating factors include standing, walking, pushing, puling. VAS pain scale is rated as 6/10 for her average and current pain, 10/10 for worst pain, and 3/10 for her least pain.

Doctor: How old are you? Patient: I'm eighty six years old. Doctor: What gender do you identify with? Patient: I identify as a female. Doctor: How long have you had this back and buttock pain? Patient: Its been a while, now. I know I have a fracture in my lower back. Doctor: How have you been managing this? Patient: Another doctor called this conservative treatment. I've been resting a lot, and using antiinflammatories. Doctor: Has there been any improvement? Patient: Its been several months at this point, and honestly no, there's been no improvement. I'm still in a lot of pain. Doctor: This C T Scan you had recently shows sclerosis, with some healing of a L five compression fracture, but if you look here, the healing is not complete. Patient: What can we do about this? I'm in so much pain. Doctor: I believe you'd be a candidate for a bilateral L five kyphoplasty. Patient: What's that? Doctor: It's a small procedure on that L five vertebra. Its minimally invasive, and we can actually do it as an outpatient procedure. Patient: Oh, wow, that's good to hear. What are the risks of infection? Doctor: Very low, historically, they're less than one percent. Patient: How is this possible? Doctor: We'll use antibiotics in order to control for infection. Patient: That's great, will I be under anesthesia? Doctor: Yes, you'll be asleep for the whole thing. Patient: Great, yes, I'd like to have this done, I can't keep living in this pain. Doctor: Awesome, I agree. Do you have control over your bladder and bowel movements? Patient: Yes, thankfully, I have complete control over everything like that still. Doctor: Do you wear a brace or corset normally? Patient: Yes, I usually wear both. Doctor: Okay, last question, can you notice any weakness in your body? Patient: No, I'm still very strong, even at my age.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is to come to the hospital for bilateral L5 kyphoplasty. The patient is an 86-year-old female with an L5 compression fracture. The patient has a history of back and buttock pain for some time. She was found to have an L5 compression fracture. She was treated conservatively over several months, but did not improve. Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing. The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty. She denies bowel or bladder incontinence. She does complain of back pain. She has been wearing a back brace and corset. She does not have weakness.

Doctor: Good afternoon, sir, and who's the patient today? You, or your daughter? Guest_family: Not me today, its my daughter. Doctor: And how old are you, dear? Patient: I'm eighteen. Doctor: What seems to be the problem today? Patient: I hurt my right knee while playing tennis, um, it was about three days ago now. It really hurts. Doctor: I see, tennis, huh? Was there any contact involved? Patient: No, I took a step wrong when I went for an awkward shot. Doctor: Are you able to stand on this knee? Patient: Not well, it feels unstable, like I'm going to fall over. Doctor: Have you ever hurt this knee before? Patient: Yeah, tore my ACL in two thousand eight. Doctor: I assume you had surgery for that? Patient: Yeah I did, um, with Doctor X. He called it an, um, A C L reconstruction. Doctor: How did you recover from this? Guest_family: She didn't do well, she didn't do what we or the others doctors suggested, and the knee never really got the same tightness back. Doctor: What did they do about that? Guest_family: I have it in my notes here, they did an, um, A C L revision. That was done by Doctor Y. Doctor: When was that done? Guest_family: Looks like it was at the end of two thousand eight. Doctor: Following the revision, how did you cover? Patient: I did everything they said, I did it exactly as they wanted, and I did fine until this last injury. Doctor: Good, was there any instability following the revision? Patient: Nope, I was really stable.

Section Header: HISTORY of PRESENT ILLNESS Summary: The patient is an 18-year-old girl brought in by her father today for evaluation of a right knee injury. She states that approximately 3 days ago while playing tennis she had a non-contact injury in which she injured the right knee. She had immediate pain and swelling. At this time, she complains of pain and instability in the knee. The patient's past medical history is significant for having had an ACL injury to the knee in 2008. She underwent anterior cruciate ligament reconstruction by Dr. X at that time, subsequently in the same year she developed laxity of the graft due in part to noncompliance and subsequently, she sought attention from Dr. Y who performed a revision ACL reconstruction at the end of 2008. The patient states she rehabbed the knee well after that and did fine with good stability of the knee until this recent injury.

Doctor: How're you feeling today? Patient: Much better. The antibiotics seemed to really help. Doctor: Are you still experiencing any symptoms? Patient: Um no, thankfully. I had some wheezing when I first started the antibiotics, but it's improved a ton. I don't think the wheeze is even there anymore. Doctor: Good, good.

Section Header: PAST MEDICAL HISTORY Summary: He has had some wheezing in the past but nothing recently.