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Doctor: Do you have a family history of neurological conditions that I should know about? Patient: What exactly do you mean by that, doctor? Doctor: Well, it could be anything from A D H D, to epilepsy, to Alzheimer's. Patient: Oh, no.

Section header: FAM/SOCHX Section text: non-contributory.

Doctor: Are you on any medications? Patient: Yeah. I take Abilify to help with my mood. Doctor: Do you find that it's helping? Patient: A little, yeah.

Section header: MEDICATIONS Section text: Abilify.

Doctor: Your culture results came back positive for Streptococcus pneumoniae. This is a bacterial infection. I would like to take a course of antibiotics. This should start to improve your symptoms with in three to four days. Patient: Okay. Doctor: Please let me know if your symptoms have not improved or becomes worse. Patient: I will. Thank you.

Section header: ASSESSMENT Section text: Upper respiratory infection.

Patient: I had a lung transplant in two thousand and four because of Pulmonary Fibrosis. Doctor: Okay, how are you now? It was, was that for both lungs? Patient: Yes, both sides. Doctor: You do have irregular heart rhythm, right? Patient: Yes, I do.

Section header: PASTMEDICALHX Section text: Significant for history of pulmonary fibrosis and atrial fibrillation. He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis.

Doctor: How are you? Patient: Look at this fifth fingernail on my left hand, doctor. Doctor: Oh what is stuck here? Patient: I think it's wood splinter. Doctor: Oh, must be painful! Patient: Yes a lot.

Section header: ASSESSMENT Section text: Foreign body of the left fifth fingernail (wooden splinter).

Doctor: Can you move your arms? I would like to see how your range of motion is. Patient: Sure, see. Like that? Doctor: Yes, yes, looks good for both arms and legs. Patient: Great. Doctor: I do not see any obvious deformities in head neck or in extremities. Patient: Yes, no problems. Doctor: Okay? Patient: Okay.

Section header: EXAM Section text: MSK: The head and neck by inspection showed no obvious deformity. Again, the extremities showed no obvious deformity. Range of motion appeared to be normal for the upper and lower extremities.

Doctor: Are you allergic to anything? Patient: Yes, I am allergic to eggs and peanuts. Doctor: Oh, okay. Doctor: Anything else? Any medication? Patient: No, nothing else. Doctor: Alright.

Section header: ALLERGY Section text: Eggs and peanuts.

Doctor: Do you smoke, sir? Patient: No. Doctor: Do you drink? Patient: Sometimes I take a beer or two. Doctor: Are you married? Patient: For last ten years. Doctor: What do you do for living? Patient: I install floor. I am associated with a construction company and my main work is flooring installation.

Section header: FAM/SOCHX Section text: He is a nonsmoker. He occasionally has a beer. He is married. He works as a flooring installer.

Doctor: Good morning, young lady. Is this your mother? Patient: Yes, this is my mommy. Doctor: Good morning, mom. Can you tell me more about your daughter, please? Guest_family: Good morning, doctor. Well, she's thirteen now, but she's had feet problems all her life. Doctor: What's been the problem with her feet? Guest_family: Well, she had bilateral feet corrections when she was a year old. Doctor: Okay, how has she been since that procedure? Guest_family: Well, just look at her heel, doctor. Doctor: Yes, I see. She has pretty significant calcaneal valgus deformity. Patient: What does that mean, doctor? Doctor: Your heel is out of alignment, sweetie. Do you have pain? Patient: Yes, I have a lot of pain, doctor. Guest_family: What can we do about this, doctor? Doctor: Well, given all of her symptoms, I think we should do a calcaneal osteotomy and Achilles lengthening procedure. Guest_family: What does that procedure entail? Doctor: Well, in short, we'll go in there and straighten everything out, and get everything lined back up. Guest_family: What's the risk of infection with the surgery, sir? Doctor: Actually, it's less than one percent, so it's extremely low. Guest_family: How is this possible, doctor? Doctor: We use antibiotics to control for infection the entire time. Guest_family: That's great. Will she be asleep for this procedure? Doctor: Yes, we'll use anesthesia the entire time. She won't feel a thing. Guest_family: Okay, that's good too. What about after the procedure? What's the protocol? Doctor: Well, I'll need your help. We have to be strict about her being nonweightbearing for six weeks at minimum. Guest_family: Will she need a brace too? Doctor: Yes, at least for six months, but if she does everything I ask of her, it will be only six months. Guest_family: Okay, yes, I think we should do the procedure. What do you think, honey? Patient: Yes, I want to get back to playing sports with my friends. Doctor: The other risks include bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures. I would not worry about these issues, though. It is quite rare. So, looking at her radiographs, the spinal arch is definitely collapsed. I think you guys are making the right decision.

Section header: GENHX Section text: The patient is a 13-year-old female who had previous bilateral feet correction at 1 year of age. Since that time, the patient has developed significant calcaneal valgus deformity with significant pain. Radiographs confirmed collapse of the spinal arch, as well as valgus position of the foot. Given the patient's symptoms, surgery is recommended for calcaneal osteotomy and Achilles lengthening. Risks and benefits of surgery were discussed with the mother. Risks of surgery include risk of anesthesia; infection; bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures. The patient will need to be strict nonweightbearing for at least 6 weeks and wear a brace for up to 6 months. All questions were answered and parents agreed to the above surgical plan.

Doctor: Good morning, young man. Are these your parents? Patient: Yes. Doctor: Good, can you tell me more about your son, please? Guest_family_1: Well, he's five now, and he fell onto his right arm on December fifth two thousand seven. Doctor: After he fell, how was he treated? Guest_family_1: We went to the E D right after he fell, and they said he had complete fractures of both bones in the arm. Doctor: Yes, I see that here, he also has shortening bayonet apposition. Guest_family_1: What can we do for this? Doctor: There's actually a few options here. First we can cast it and see how he heals, generally, children heal up very well from fractures. Guest_family_1: That's good, we like that option more than any kind of surgery. Doctor: However, surgery is also an option here as well. Guest_family_1: Yeah, to be completely sure we fix this, I think we should opt for the surgery, what do you think, honey? Guest_family_2: Yes, I agree. What are the risks of infection for this surgery? Doctor: The risk of infection is very low, generally less than one percent. We use antibiotics to control for infection. Guest_family_1: Will he be asleep for the surgery? Doctor: Absolutely, he won't feel a thing. Other risks include bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, and cast tightness. I would not worry about these risks. We have great results with these surgeries. Guest_family_1: Then yes, we'd like to do the surgery.

Section header: GENHX Section text: The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007. The patient was seen in the emergency room. The patient had a complete fracture of both bones with shortening bayonet apposition. Treatment options were offered to the family including casting versus closed reduction and pinning. The parents opted for the latter. Risks and benefits of surgery were discussed. Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness. All questions were answered, and the parents agreed to the above plan.

Doctor: Hello. Are you a new patient? Patient: I am. I've been traveling a lot, so I don't have a local doctor I usually see. Doctor: That's fine. What is the reason for your visit? Patient: I've had this dark spot on my leg for a long time. Doctor: I see. Do you know if your family has any chronic medical problems? Patient: Not that I know of. Doctor: That's good. I think I'll be able to remove it surgically. Before I go over the procedures, have you had a surgery before? Patient: Yeah, I have. I had surgery on my back and to remove my appendix. Doctor: Sounds good. Other than that dark spot, you seem to be very healthy.

Section header: PASTMEDICALHX Section text: Negative for chronic medical problems. No local physician. Has had previous back surgery and appendectomy, otherwise generally healthy.

Doctor: It's surgery day! How are you feeling? Patient: Not as excited as you. Doctor: Have you had a surgery before? Patient: Yeah. It was something with my chest. Guest_family: Hi Doctor. I'm the mother. He had a chest port placement. Doctor: I see. Thank you for letting me know.

Section header: PASTSURGICAL Section text: Significant for a chest port placement.

Doctor: What is your living status? Do you live alone or with family? Patient: I live with my boyfriend. Doctor: Do you smoke? Patient: Yes. Doctor: For how long you are smoking? Patient: Around ten years. Doctor: How many cigarettes do you take? Patient: Well, one pack of cigarettes lasts for around three days. Doctor: Do you drink? Patient: I do take beer. Doctor: How many do you drink a day? Patient: I take around six bottles once a week. Doctor: Are you working somewhere? Patient: I was working in a herbicide plant. There were so many layoffs because of this pandemic. I lost my job too.

Section header: FAM/SOCHX Section text: Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.

Doctor: I want to talk to you about your reproductive history, okay? Patient: Okay. Doctor: Do you take birth control pills? Patient: Yes, I do. Doctor: Do you have any kind of medical history that I should be aware of? Patient: I had both chickenpox and measles when I was a kid.

Section header: PASTMEDICALHX Section text: Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.

Doctor: Just want to ask you few questions. Patient: Okay shoot. Doctor: Do you have any nausea, vomiting? Patient: Yes to both. Doctor: How about fever? Patient: Yes, I do. Doctor: Any blood in sputum or chest pain? Patient: Yes, I do.

Section header: ROS Section text: Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.

Doctor: Well, this is a case of hypothermia. Guest_family: Will he survive? Doctor: Don't worry, we will take care of him.

Section header: DIAGNOSIS Section text: Hypothermia.

Doctor: Do you take any tobacco related products? Patient: I used to chew tobacco, but I quit when I was thirty seven. Doctor: What about alcohol consumption? Do you drink? Patient: I take one glass of wine every day. Doctor: Are you married? Patient: Yes, sir. I'm married to a wonderful woman for last thirty five years. Doctor: Are you still working? Patient: I used to. Now I'm retired, I was a lab manager before.

Section header: FAM/SOCHX Section text: He has a history of tobacco use, which he quit at the age of 37. He has one alcoholic drink per day. He is married. He is a retired lab manager.

Doctor: Hello! What brings you back into the clinic today? Patient: I came back because I increased my methothrexate as we discussed the last time I was here. A few days later I started getting multiple canker sores in my mouth. They hurt. Doctor: I am sorry. It is likely that the increased dosage of your methothrexate is the cause of the mouth sores. Have you experienced a decreased appetite, nausea, abdominal discomfort or diarrhea? Patient: No. It is painful to eat with the sores, but I still have an appetite. Doctor: Have you had any new rashes, or hair loss? Patient: No. Doctor: I would like to get some bloodwork done. I would also recommend we decrease your dosage back to your previous amount. I would also like to see you back in two weeks to see how you are doing. Patient: Okay.

Section header: CC Section text: Please evaluate stomatitis, possibly methotrexate related.

Doctor: Are you aware of any medical issues in your family? Patient: No. Doctor: How about any known heart disorder or diabetes in the family. Patient: No, I'm not aware of anything like that.

Section header: FAM/SOCHX Section text: Otherwise noncontributory.

Doctor: So, I am looking at his x ray and it does not show any open fracture or any kind of bone abnormality. Guest_family: Okay, I was really worried about my son. Doctor: I understand, but like I said, I didn't see any open fracture in his x ray report nor any abnormality. Guest_family: Okay.

Section header: IMAGING Section text: X-rays shows no open fracture or bony abnormality.

Doctor: Do you drink? Patient: Yes, I do take two or four beers in a day. Doctor: Do you smoke? Patient: Oh yeah, I'm a smoker. I take around one to two packs of cigarettes each day.

Section header: FAM/SOCHX Section text: 2-4 Beers/day. 1-2 packs of cigarettes per day.

Doctor: Do you live alone? Patient: I wouldn't say I live alone. I have three cats and they always keep me company. Doctor: Aw, what kind of cats? Patient: Two Persian cats and one Chartreux. Doctor: Are you currently working? Patient: I retired a few months ago. I used to work as a psych aide for the State of Pennsylvania. Doctor: Congratulations on your retirement. Patient: Thank you. Doctor: How long did you work as a psych aide? Patient: Thirty two years. Doctor: Incredible. One more question. Do you smoke, drink, or use drugs recreationally? Patient: I drink wine every now and then. I used to smoke back in the day, but I'm five years smoke free. I do not do drugs. Doctor: Always great to hear.

Section header: FAM/SOCHX Section text: The patient lives by herself and has three pet cats. She is an ex-smoker, quit smoking about five years ago. She occasionally drinks a glass of wine. She denies any other recreational drugs use. She recently retired from State of Pennsylvania as a psychiatric aide after 32 years of service.

Doctor: Hi there! What brings you in today? Guest_family: I think my baby got into the ant bait. I am not sure if he consumed any of it but he was under the counter and it was in his hands. Doctor: What kind ant bait did he get into? Guest_family: It was the one with Borax in it. Doctor: Do you have a picture of it? Guest_family: Yes. It is in my phone.

Section header: CC Section text: Possible exposure to ant bait.

Doctor: Good morning, ma'am. I just need to confirm some information about you before we begin today. Patient: Good morning, doctor. Sure, that's no problem. Doctor: Great, so you're sixty seven years old, and White, correct? Patient: Yes, that's right doctor. Doctor: Thank you. Do you remember how many cycles of carboplatin and Taxol you've had for your cancer, ma'am? Patient: Um, I've had six, I'm here for a follow up today. Doctor: Yes, I see here that your last chemo treatment on January eighteenth two thousand eight. Patient: Yes, I remember that. Can you remind me the full name of my cancer? Doctor: It's a uterine papillary serous carcinoma. Patient: Thank you, doctor. Doctor: Sure, do you have any problems today? Patient: Well, I just have some numbness in my right upper arm today. Doctor: Has this gotten worse recently? Patient: Well, no, not really. Doctor: That's good. Do you feel this in your toes at all? Patient: No, there's no numbness there. Doctor: Good, do you have any tingling or burning to speak of? Patient: No, thankfully no.

Section header: GENHX Section text: The patient is a 67-year-old white female with a history of uterine papillary serous carcinoma who is status post 6 cycles of carboplatin and Taxol, is here today for followup. Her last cycle of chemotherapy was finished on 01/18/08, and she complains about some numbness in her right upper extremity. This has not gotten worse recently and there is no numbness in her toes. She denies any tingling or burning.

Doctor: How long has she had difficulty swallowing? Guest_family: A while now. We scheduled her to see an endocrinologist, but she's not able to get in until Monday. I wanted to see if we could get to the bottom of it now. Doctor: It does appear that her thyroids are fairly enlarged. I believe that's where most of her symptoms, if not all, are stemming from. Guest_family: Does that mean she'll need surgery? Doctor: We'll have to see, but chances are higher since she's experiencing symptoms due to her thyroid. Guest_family: When will we find out? Doctor: I'd like to get some imaging done and see if we can get a consult in first.

Section header: DIAGNOSIS Section text: Symptomatic thyroid goiter.

Doctor: Do you have any significant medical conditions that run in your family that I should be aware of? Patient: Yes, um, I know some of my relatives have had coronary artery disease, and, um, high blood pressure. Doctor: What about cancer? Does anyone in your family have a history of cancer? Patient: No, that doesn't ring any bells.

Section header: FAM/SOCHX Section text: Includes coronary artery disease, hypertension. Nobody in the family was diagnosed with any type of colon cancer or any type of other cancer.

Doctor: When was your injury, sir? Patient: Um, if I recall, it was on November twentieth two thousand eight. Doctor: What do you do for a living, sir? Patient: I work at the Purdy Correctional Facility, doctor. Doctor: How did you get hurt? Patient: Well, an inmate broke some of the overhead sprinklers, and I slipped on all the water and I landed on the back of my head, and then onto my back. Doctor: Which side took most of the hit? Patient: It was mostly on my left side. Doctor: How were you after the fall? Patient: Well, I was pretty stunned, mostly. I didn't want to come in, but my employers asked me to just to be sure. Doctor: Who has evaluated you to date? Patient: Um, I went to Gig Harbor Urgent Care, and then they sent me to Tacoma General Hospital. At Tacoma they said I have a whiplash and concussion. Doctor: What did they do at the hospital? Patient: Um, they did a C T scan, and they found a dark spot on my brain. Doctor: What did they recommend about the spot? Patient: They said I should have another M R I and they diagnosed an, um, recurrent acoustic neuroma. Doctor: So, you've had this before? How did they know you had it? Patient: I used to see a chiropractor, and they suggested that I get a scan and that's how they found it before. Doctor: When was this? Patient: Um, it was in October of two thousand five. Doctor: Did you have surgery on this? Patient: Yes, I'm recovering now. Doctor: Are they still considering radiation? Patient: Yes, it's under consideration but there's no final decision yet. Doctor: Okay, what does the chiropractor do for you? Patient: You know, the usual, adjustments and massages, stuff like that. Doctor: Has there been any improvement? Patient: Overall, my spine pain has improved a lot. Doctor: That's good. Okay, so after your fall, what other treatments did you have? Patient: I went to Prompt Care in Bremerton, and saw Doctor X Y Z. She's an osteopathic doctor. Doctor: How did she treat you? Patient: She ordered an M R I of my neck, I have the report right here. Doctor: Okay, this shows some mild disc bulge at C four C five. Did she let you go back to work? Patient: Yes, she released me back to full duty. I was doing fine after the neurosurgical treatment. Doctor: Do you have any other treatment planned? Patient: Some radiation. Doctor: What else has she treated you for? Patient: Oh, you know, just general aches and pains on my back and neck. I have been seeing her since two thousand and two.

Section header: GENHX Section text: This patient was injured on November 20, 2008. He works at the Purdy Correctional Facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back. The patient said he primarily landed on the left side. After the accident he states that he was generally stun and someone at the institute advised him to be evaluated. He went to a Gig Harbor urgent care facility and they sent him on to Tacoma General Hospital. At the Tacoma General, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a CT scan. The patient describes that he had a brain CT and a dark spot was found. It was recommended that he have a followup MRI and this was done locally and showed a recurrent acoustic neuroma. Before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in October 2005. The patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments. Overall his spine complaints have improved substantially. After the fall, he also saw at Prompt Care in the general Bremerton area, XYZ, an Osteopathic Physician and she examined him and released him full duty and also got an orthopedic consult from XYZ. She ordered an MRI of his neck. Cervically this showed that he had a mild disc bulge at C4-C5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned. Since 2002 the patient has been seeing the chiropractor, XYZ for general aches and pain and this has included some treatments on his back and neck.

Doctor: Any past medical problems or surgeries that I should know of? Patient: Nope, none that I can think of.

Section header: PASTMEDICALHX Section text: There is no significant past medical history noted today.

Doctor: So, I see here in your reports you have arthritis in you both knees. Patient: Yes. Doctor: And you got a tear in your eye in the past, right? Patient: Ah yes, I got a tear in my retina. Doctor: Right. Also, it's mentioned here that you have atrial fibrillation. Patient: That's correct. Doctor: Are you taking any medications? Patient: Yes, I am on anticoagulants. Doctor: Okay.

Section header: PASTMEDICALHX Section text: Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear.

Doctor: Have you had any procedures in the past? Patient: No.

Section header: PROCEDURES Section text: None.

Doctor: Do you have any medical conditions that run in your family that I should know about, ma'am? Patient: Um, yeah, my dad had prostate cancer. Doctor: What about your mother, or the rest of your family? Patient: Um, my mom's brother had Hodgkin's disease, melanoma, and prostate cancer.

Section header: FAM/SOCHX Section text: Her father had prostate cancer. Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer.

Doctor: Do you drink? Patient: Not really, no. Doctor: Any drugs? Patient: No. Doctor: Do you get a chance to exercise during the week? Patient: I like to go on walks with my dog every day. I'm also eating a lot healthier these days. Doctor: That's wonderful. How's work going for you? Patient: I actually got promoted last month so it's been going well. I've had a lot more time to spend with my family as a result. Doctor: That's great to hear. Congratulations! Patient: Thank you so much.

Section header: FAM/SOCHX Section text: No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.

Doctor: Are you allergic to anything? Patient: No, I do not have any allergies. Doctor: Great.

Section header: ALLERGY Section text: No known drug allergies.

Doctor: What do you do in the hospital? Patient: I work as a phlebotomist and respiratory therapist. Doctor: Ok, how old are you? Patient: I am fifty four. Doctor: You are very young. Patient: Thank you! Patient: So, as you remember I was trying to measure blood gas as I was working with a patient and I accidently jammed that needle inside my right hand index finger. Patient: I am coming for regular screening. Doctor: Were you wearing gloves? Patient: Yes, I had gloves and protective clothing. Doctor: Yes, thank you for that. Did they screen patient? Patient: Yes, he got negative HIV but positive Hep C. Doctor: Ok. Patient: I am scared.

Section header: GENHX Section text: The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserting a needle using the right hand. He did have a protective clothing including use of gloves at the time of the incident. As he advanced the needle, the patient jerked away, this caused him to pull out of the arm and inadvertently pricked the tip of his index finger. The patient was seen and evaluated at the emergency department at the time of incident and had baseline studies drawn, and has been followed by employee health for his injury. The source patient was tested for signs of disease and was found to be negative for HIV, but was found to be a carrier for hepatitis C. The patient has had periodic screening including a blood tests and returns now for his final exam.

Doctor: They took some fluid out of your back remember? Patient: Yes actually. Doctor: We got the results back for that and it looks like it was clear then it turned bloody. Patient: They checked my urine and blood too. Doctor: Yes, they did. I see the orders for urine culture, B M P, C B C, C R P, and blood culture as well. Patient: I got albuterol nebulizer treatment too. Doctor: That is good. but did that help you? Patient: No, it did not. Doctor: Oh I am sorry. Patient: It is okay. Doctor: I see that they gave you some antibiotics in E R? Patient: Yes, Ampicillin and Cefotaxime.

Section header: EDCOURSE Section text: In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.

Doctor: Tell me about your medical history. Did you have any surgeries? Any medical issues in the past? Patient: I had my tonsils removed when I was a kid, maybe around eight. I was hospitalized for the heart attack in ninety six. They did some surgery to check how my heart is functioning and then they did a bypass I guess. Doctor: Do you have some record of those surgeries? Patient: Oh yes, I got it with me. Here it is. Doctor: That is awesome. Let me have a look. So, according to this you had L I M A to L A D coronary bypass graft. You also had had three saphenous vein grafts performed. Patient: Yes I had so many surgeries, it's hard to keep a track of all those complex names. That's why I keep those papers with me all the time if I go to any new doctor. Doctor: I will add all these surgeries into my record. Thank you.

Section header: GENHX Section text: He had tonsillectomy at the age of 8. He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure. He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.

Doctor: How's everyone in your family? Patient: My mom, dad and siblings are good. Doctor: They are well, that is good. That's what we want. Patient: Yes.

Section header: FAM/SOCHX Section text: Mother, father and siblings were alive and well.

Doctor: So, what do you do for a living, sir? Patient: I work at A B C store, doctor. Doctor: That's great, do you smoke? Patient: No, I don't smoke at all. Doctor: How about alcohol? Do you drink? Patient: I'd say I drink socially, like if I'm at a party, or something.

Section header: FAM/SOCHX Section text: Works at ABC. Social alcohol and he does smoke.

Doctor: Do you take any daily medications or supplements? Patient: Nope.

Section header: MEDICATIONS Section text: None.

Doctor: Good afternoon, sir, how are you today? Patient: Good afternoon, Doctor, my knees are in a lot of pain today. Doctor: Is the pain equal? Or is one knee worse than the other? Patient: Um, the left knee hurts more than the right, but there's pretty significant pain with both. Doctor: Is it interfering with your ability to walk? Patient: Yes, I can walk like, maybe a half a mile a day, then the pain gets too bad. Doctor: Are you able to go up and down stairs? Patient: I have to take them one at a time. Doctor: I see you have degenerative joint disease of both knees, does that ring any bells? Patient: Yes, but what does that mean? Doctor: You have arthritis in both of your knees, sir. Patient: Ah, yes. Doctor: Have you had surgery on these knees? Patient: Um, I had surgery on both of these knees, let me check my notes. It was an, um, arthroscopy. Doctor: When were these surgeries? Patient: They were in the nineteen ninety one nineteen ninety two time frame, somewhere in there. Doctor: How have you managed this since the surgeries? Patient: I've taken antiinflammatories, had injections, and I've even used narcotics. Doctor: I see. If those haven't helped, I think you'd be a good candidate for knee replacements. Patient: Can we do both at the same time? Doctor: No, let's do the left since that one hurts more. Do you have any other conditions I should know about? Patient: I've had a lot of back surgeries, I have spinal stenosis. Doctor: Do you know what surgeries you've had? Patient: Let me check my notes, um, I've had a spinal decompression and epidural steroids injection. Doctor: Who has prescribed you narcotics for this pain? Patient: The pain is so bad, but Doctor X has handled those.

Section header: GENHX Section text: The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both. He is able to walk approximately a 1/2-mile a day but is limited because of his knees. Stairs are negotiated 1 at a time. His problems with bilateral knee DJD have been well documented. He had arthroscopy in the 1991/199two time frame for both of these. He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections. At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side. He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids. Significant pain is handled by narcotic medication. His attending physician is Dr. X.

Doctor: Do you smoke? Patient: Yes. Doctor: How much? Patient: Two cigarettes per day. Doctor: Okay that is not bad, but try quitting. Patient: Okay. Doctor: Alcohol? Patient: No, I don't drink.

Section header: FAM/SOCHX Section text: Tobacco use, averages two cigarettes per day. Alcohol use, denies.

Doctor: Hi Ryan, what brings you here today? Patient: Well, you told me to follow up if my cough doesn't get better. Also, I started having several other issues. Doctor: Oh really! Patient: Yeah. Doctor: Okay, so tell me about your cough, is it getting worse than before? Patient: It's about the same but not getting better. Doctor: Hm. And what about your diarrhea and stomach pain? Patient: No more diarrhea and no pian. Doctor: Bowel movement? Patient: Normal. Doctor: Any pain while peeing? Are you able to empty your bladder completely? Patient: No pain and no problem emptying my bladder. Doctor: Okay good. Any nausea or vomiting? Patient: Nope, but I have developed this weird sore taste in my mouth. Doctor: Oh okay. How long? Patient: Since last week. Doctor: I see. Any loss of appetite? Patient: No, not really. Doctor: Okay and what other issues were you talking about? Patient: Yeah, I am also having some trouble with my eyes, I am able see fine, but it feels kind of funny. Doctor: Okay. Patient: And then my back is hurting so much, and last week my right shoulder and neck started to hurt. Doctor: Did you injure it or had a fall or anything? Patient: No. Doctor: Okay.

Section header: GENHX Section text: The patient is in with several medical problems. He complains his mouth being sore since last week and also some "trouble with my eyes." He states that they feel "funny" but he is seeing okay. He denies any more diarrhea or abdominal pain. Bowels are working okay. He denies nausea or diarrhea. Eating is okay. He is emptying his bladder okay. He denies dysuria. His back is hurting worse. He complains of right shoulder pain and neck pain over the last week but denies any injury. He reports that his cough is about the same.

Doctor: So, sir, what do you do for a living? Patient: Right now, I'm working with Chevron as a petroleum engineer. Doctor: That's fantastic. So, do you drink? Patient: Um, I'd say I drink socially, like if I'm at a party or something. Doctor: Sure, me too. Do you smoke? Patient: No sir, I don't do that.

Section header: FAM/SOCHX Section text: He is a petroleum engineer for Chevron. Drinks socially. Does not use tobacco.

Doctor: Is anyone else at home sick? Patient: No. My husband and daughter seem to be doing okay. They haven't complained of anything yet.

Section header: FAM/SOCHX Section text: Noncontributory. No one else at home is sick.

Doctor: Hi, how are you doing, ma'am? What brings you here today? Patient: I'm good, thank you. I'm having this weakness on my left side after the brain, I mean, after they removed my tumor from the brain. Doctor: Remind me when did you have your surgery for brain tumor? Patient: It was on October twenty fourth last year. Doctor: How old are you now? Patient: I'm sixty four. Patient: He is my husband, Al. Doctor: Hi, nice to meet you. Doctor: Tell me what happened. Patient: They asked me to go to the physical therapy for all the problems I was having after my brain surgery. I went from November fifth to the fourteenth of last year. I did therapy for around two weeks starting on November fifth. My problems were not solved so I went to the hospital and then they did some tests and they found out something was wrong. They said there is swelling in my brain so they admitted me there and then I had my second surgery. Doctor: When was the second surgery? When did you get admitted? Patient: It was on December fifth. I was there in the rehab the whole time and then I was discharged for home one month after my second surgery. Doctor: Was there any other issue? Guest_family: Yeah. When she was in the rehab she developed something which they called D V T in her left calf. She did not have any such problem again after that.

Section header: GENHX Section text: The patient is a 64-year-old female referred to physical therapy following complications related to brain tumor removal. The patient reports that on 10/24/08 she had a brain tumor removed and had left-sided weakness. The patient was being seen in physical therapy from 11/05/08 to 11/14/08 then she began having complications. The patient reports that she was admitted to Hospital on 12/05/08. At that time, they found massive swelling on the brain and a second surgery was performed. The patient then remained in acute rehab until she was discharged to home on 01/05/09. The patient's husband, Al, is also present and he reports that during rehabilitation the patient did have a DVT in the left calf that has since been resolved.

Doctor: What medication have you tried? Patient: I took Nexium. Doctor: Pain? Patient: Yes.

Section header: MEDICATIONS Section text: Nexium.

Doctor: Well, I am looking at your test reports and your blood sugars have been running up and down but nothing to be worried about but yeah, we need to keep monitoring. This morning it was perhaps a bit high at one hundred eighty-eight. Last time it was one hundred fifty and in one report it's around one hundred twenty and in lower teens too which is good. So, tell me how are you feeling? Patient: Well, I am doing okay. I am getting treated for hemorrhoids. I am also having some constipation from the past few weeks and I have recently developed this cough which is okay as I kind of get it often. Doctor: Oh boy, that's a lot going on! Patient: Yeah. Doctor: So, tell me are your hemorrhoids painful? Patient: No, it's fine. Doctor: And are you taking anything for constipation? Patient: Well, just prune juice. Doctor: Okay, let me write you an order for a laxative that should help. How bout cough? Any pain in the ribs while coughing? Patient: Nah, I am not bothered by it. Doctor: Any headache or nerve pain or body pain? Patient: Um, no I am fine. Doctor: Any fall or imbalance problem? Patient: No. Doctor: Any agitation or any other issues? Patient: Well, I am doing okay! Sometimes if I have pain, I take Tylenol and usually it works for me. Doctor: That's good! Patient: Yeah. Doctor: So, you have been seeking psychiatric help from Doctor Hudyncia right? Patient: Yes. Doctor: She mentioned in her report that you are responding well to her treatment and that your depression is under control and the medicine is working for you. That's good news. Oh, what medicine has she prescribed? Um let me see here in the report, oh okay, got it! It's Cymbalta. Patient: Right. Doctor: And no side effects, right? Patient: No. Doctor: And looks like the plan is to treat you for a minimum one year. Patient: Yeah. Doctor: Lastly, any breathing issues? Patient: No.

Section header: GENHX Section text: Overall, the patient has been doing reasonably well. She is being treated for some hemorrhoids, which are not painful for her. There has been a note that she is constipated. Her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188. I see a couple in the 150s. However, I also see one that is in the one teens and a couple in the 120s range. She is not bothered by cough or rib pain. These are complaints, which I often hear about. Today, I reviewed Dr. Hudyncia's note from psychiatry. Depression responded very well to Cymbalta, and the plan is to continue it probably for a minimum of 1 year. She is not having problems with breathing. No neurologic complaints or troubles. Pain is generally well managed just with Tylenol.

Doctor: The next patient we have is Miss Dey, we have been regularly following up with her for her hydrocephalus since two thousand and two. Guest_clinician: Oh, okay. Doctor: She also had anterior cervical corpectomy, we removed her front part of the vertebra followed by fusion from C three to C five in March two thousand and seven. Guest_clinician: Oh wow! Doctor: Yeah. We last saw her in March two thousand and eight at that time she was experiencing some head fullness and ringing in the ears, however we decided to leave her shunt setting at one point zero. Guest_clinician: Okay, then you asked her to follow up doctor X Y Z regarding her cervical spine M R I. Doctor: Yes exactly! Let's go see her. Hello Miss Dey, how are you? This is my colleague doctor Jen, and she will be accompanying me today if that is okay with you? Patient: Of course, Hello doctors. Guest_clinician: Hi Miss Dey. Doctor: So, tell me what is going on? Patient: Well, last week I had some urine issue, like had to pee frequently. I had few episodes of urgency. Doctor: Okay and how do you feel this week? Patient: This week it's much better I am not feeling like how I was feeling last week. Doctor: Okay good. Patient: I feel no urgency or inconsistency and I am able to empty my bladder completely. Doctor: That's good. Patient: However, I do leak some pee when I cough. I wear pads daily. Doctor: And did you notice any changes regarding your bladder, do you think it is better than before or worse since the last time I saw you? Patient: I don't think it changed much, it feels almost the same. Doctor: Okay. Let's talk about your memory, any problem there, are you able to remember stuff and think about stuff? Patient: Yes, all good there, no issues. Doctor: Any headache? Patient: Nope! Doctor: Any changes in your walk or balance? Patient: Yes, I feel both have worsened. I am able to walk on uneven surface most of the time. But I feel I have become very slow. Doctor: And are you able to climb up and down the stairs? Patient: Yes. Doctor: Are you able to climb in and out of the car normally without any fuss? Patient: Yes. Doctor: Are you using cane at this point of time? Patient: No, no cane. Doctor: Okay good. Anything else you want to tell me? Patient: Ah yes, in the beginning of May, I got a spell of severe cough and because of continuous coughing I think I developed pain in my hip which travels down to my legs. Doctor: Oh okay, do you feel any tingling or numbness. Patient: Yes! I feel constant tingling sensation and a feeling that something is pinching my never. Sometimes it's just so painful. Doctor: Okay. Patient: Often I feel like my legs have become like elastic. I feel this tingling sensation is the reason my walking has become slower. Doctor: Doctor Jen did you take the notes of what she said? Guest_clinician: I did. Doctor: Okay great, anything else Miss Dey? Patient: No, I think I told you everything. Doctor: Alright you take care. I will see you next time. Patient: Bye! Doctor: Bye. Guest_clinician: Take care Miss Dey, Bye!

Section header: GENHX Section text: She has been followed for her hydrocephalus since 2002. She also had an anterior cervical corpectomy and fusion from C3 though C5 in March 2007. She was last seen by us in clinic in March 2008 and she was experiencing little bit of head fullness and ringing in the ears at that time; however, we decided to leave her shunt setting at 1.0. We wanted her to followup with Dr. XYZ regarding the MRI of the cervical spine. Today, she tells me that with respect to her bladder last week she had some episodes of urinary frequency, however, this week she is not experiencing the same type of episodes. She reports no urgency, incontinence, and feels that she completely empties her bladder when she goes. She does experience some leakage with coughing. She wears the pad on a daily basis. She does not think that her bladder has changed much since we saw her last. With respect to her thinking and memory, she reports no problems at this time. She reports no headaches at this time. With respect to her walking and balance, she says that it feels worse. In the beginning of May, she had a coughing spell and at that time she developed buttock pain, which travels down the legs. She states that her leg often feel like elastic and she experiences a tingling radiculopathy. She says that this tingling is constant and at times painful. She feels that she is walking slower for this reason. She does not use the cane at this time. Most of the time, she is able to walk over uneven surfaces. She is able to walk up and down stairs and has no trouble getting in and out of a car.

Doctor: So, you saw Doctor X? Patient: Yes, seven days back. I went to get my blood work done and then I followed up with Doctor Y. Doctor: Yes, I will look at C B C diff and C M P profile. Patient: I will follow up with my oncologist, Doctor Z, for my swellings. Doctor: Yeah, I couldn't get hold of Doctor Z but here is the phone number. You should book the appointment. Patient: Okay I will do that. Doctor: Also, I would like to follow up with your endocrinologist that is Doctor A for adjustments that is needed in your insulin pump. Patient: And you want me to see my gastro doc too? Doctor: Yes, please follow up with Doctor B for issues with your J tube. Patient: Sure thing. Doctor: Lastly, I want you to see Doctor Y if your condition changes regarding colon cancer.

Section header: PLAN Section text: The patient was instructed to see Dr. X in approximately five to seven days. She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X. She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer. She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes. We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment. She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.

Doctor: I see here that you were in for afib last month. Patient: Yep. Doctor: How're you doing? Patient: It's all under control for now. Doctor: That's good to hear. Are you still taking Metoprolol and Premarin? Patient: Yeah.

Section header: PASTMEDICALHX Section text: Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.

Doctor: Any health problems I should note? Patient: Diabetes. Doctor: Type one or two? Patient: Type two. Doctor: Are you on insulin? Patient: Yeah. I'm also trying to manage it with exercise.

Section header: PASTMEDICALHX Section text: Diabetes.

Doctor: Let me examine your leg. Well your x ray looks fine. No defect there, I don't see any mass or swelling. Are you able to walk or use that leg at all? Patient: Oh yes, I am using it. I have also started going back on my regular walk. Doctor: Good, so your muscle strength is good, no loss of muscle tone there. Patient: Yeah.

Section header: EXAM Section text: MSK: No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength.

Doctor: Hello, how are you? Patient: Hi Doctor, I am good. Doctor: So, what is going on with you? Patient: Well, I am having nausea and I just want to get it checked. Doctor: Okay.

Section header: CC Section text: Nausea.

Doctor: How long have you had this cough? Patient: Past three weeks, doc. Doctor: Are you bringing anything up when you cough? Patient: Nah. Doctor: Any shortness of breath or chest pain? Patient: Nah. Doctor: How about fevers or chills? Patient: None of that.

Section header: ROS Section text: Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.

Doctor: Let's go over your history. Patient: Okay. Doctor: I see that you had an appendectomy. Patient: Back in the nineteen forties. I also had an ankle resection in nineteen seventy five. Doctor: Any complications with either surgery? Patient: Uh nope. Doctor: I also see that you have a recurring history of pneumonia. Patient: Yeah. Started around age twenty and stuck with me ever since. Doctor: How often have you had pneumonia? Patient: Once every five years or so. Doctor: Have you ever been hospitalized due to pneumonia? Patient: Uh I'm usually given antibiotics and then discharged. Doctor: I see. Patient: Unfortunately, I've had more episodes in the past year than ever before. Doctor: Any history of inherited lung disease, bronchiectasis, or other chronic pulmonary cause for repeated pneumonia? Patient: Not to my knowledge. Doctor: And you recently saw the urologist, correct? Patient: Yes. I had a catheter placed for urinary retention. He told me he thinks it's due to an enlarged prostate. Doctor: Do you have a history of diabetes or other medical problems? Patient: Uh no. I've lost about eighteen pounds in the last month but other than that everything else seems to be fine.

Section header: PASTMEDICALHX Section text: 1. Pneumonia. He has had recurrent episodes of pneumonia, which started at approximately age 20. These have been treated repeatedly over the years, and on average he has tended to have an episode of pneumonia once every five years, although this has been far more frequent in the past year. He is usually treated with antibiotics and then discharged. There is no known history of bronchiectasis, inherited lung disease or another chronic pulmonary cause for the repeated pneumonia. 2. He has had a catheter placed for urinary retention, his urologist has told him that he thinks that this may be due to prostate enlargement. The patient does not have any history of diabetes and does not report any other medical problems. He has lost approximately 18 pounds in the past month. 3. He had an appendectomy in the 1940s. 4. He had an ankle resection in 1975.

Doctor: Hi again! How are you feeling today? Patient: I am feeling okay. Doctor: Are you still experiencing any nausea or vomiting? Patient: No. I feel better now. Doctor: Have you had any shortness of breath or chest pain? Patient: No. Doctor: Any painful or burning urination? Patient: No. Doctor: Do you have a history of any seizure disorder? Patient: No.

Section header: ROS Section text: Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time. The patient does have a history of nausea and vomiting, but is doing better.

Doctor: Tell me about your family medical history. Patient: No one in my family has any health problems.

Section header: FAM/SOCHX Section text: Noncontributory.

Doctor: Your son had his circumcision performed here at Children's Hospital, correct? Guest_family: Yes, doctor. Doctor: Do you remember the date of that procedure? Guest_family: Um, it was on September sixteenth two thousand seven. Doctor: Good, the procedure went well. He had some phimosis, but the operation was quite smooth otherwise. Guest_family: What's phimosis? Doctor: That's tightness of the foreskin. It sometimes makes the procedure more difficult, but everything went smoothly. Guest_family: Oh, that's good to hear. Doctor: He also had a little bit of bleeding when he woke up in the recovery room, so we had to put in some additional sutures. Guest_family: Okay, thank you for taking care of him. Doctor: It's my pleasure. Has he been taking his pain medicine? Guest_family: He took them for a couple days, but he really seems back to normal now. He doesn't seem to be in any pain. Doctor: Great, does he have any difficulty urinating? Guest_family: No, that's normal. Doctor: Bowel movements? How are they? Guest_family: That's normal too, doctor.

Section header: GENHX Section text: The patient had his circumcision performed on 09/16/2007 here at Children's Hospital. The patient had a pretty significant phimosis and his operative course was smooth. He did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete. His mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now. He is having no difficulty urinating, and his bowel function remains normal.

Doctor: Is this something new? Or have you had it before? Patient: No doctor, this is new. Doctor: What exactly are you feeling? Patient: I feel like my tongue is swollen. Doctor: Okay. How old are you? Patient: I am fifty four years old. Doctor: Okay let me see how we can evaluate that.

Section header: CC Section text: A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.

Doctor: So, I think we need to start you on antibiotics for that ulcer on your right foot and possible osteomyelitis. I will send a prescription to your pharmacy. Patient: Sure.

Section header: CC Section text: Antibiotic management for a right foot ulcer and possible osteomyelitis.

Doctor: Your condition is improved, and you look pretty stable. Patient: Yeah, I feel much better.

Section header: DISPOSITION Section text: Improved and stable.

Doctor: Do you have any allergies to medications? Patient: Yes. Penicillin.

Section header: ALLERGY Section text: To penicillin.

Doctor: Looks like you have a U T I and I need to give you some antibiotics to treat it. Patient: Okay. Doctor: I will write you a prescription for Macrobid. Are you still using the Walgreens pharmacy at Thrashers Corner? Patient: Yes. Doctor: Are you taking any other medications? Patient: Yes, I am taking quite a few. I always carry the list of my medications, let me tell you the names. Yeah, so I take Dilantin for my seizures, Toprol for my high blood pressure and Pravachol for my cholesterol. Doctor: Pravachol for my cholesterol. Wow, thank you for that, it helps a lot. Let me make a note of it. Patient: Sure.

Section header: MEDICATIONS Section text: Pravachol, Dilantin, Toprol, and Macrobid.

Doctor: Have you had any operations in the- Patient: Nope. No surgeries. Doctor: How about any past injuries or illnesses? Patient: Nope.

Section header: PASTMEDICALHX Section text: Otherwise noncontributory. There is no operation, serious illness or injury.

Doctor: What is going on? Patient: I have pain in my jaw since the morning. Doctor: How bad is it? Patient: Not that bad.

Section header: CC Section text: Jaw pain this morning.

Doctor: Have you taken any medications in the past? Patient: Do you mean prescription, or over the counter? Doctor: Either of those. Patient: Oh, I haven't taken anything in the past.

Section header: MEDICATIONS Section text: None.

Doctor: Any changes to your diet? Patient: I've been following the A D A diet online and maxing out at around eighteen hundred calories per day. Doctor: How're you feeling since starting this diet? Patient: A lot better actually. My blood sugar isn't as high as it used to be.

Section header: PLAN Section text: ADA 1800-calorie diet.

Doctor: Hello! How are you doing? Patient: I am doing okay. Doctor: Tell me about your past medical history. Patient: I was diagnosed with stage three ovarian cancer two years ago. They found a tumor in my upper abdomen. I had surgery and they removed everything. Doctor King is my oncologist. Doctor: Are you still undergoing treatment? Patient: Yes. Doctor: Do you have any other medical conditions? Patient: Have a heart murmur. It has not been an issue. I also have acid reflux. Doctor: Do you take medication for the G E R D? Patient: Yes. I take omeprazole.

Section header: PASTMEDICALHX Section text: 1. Gastroesophageal reflux disease. 2. Mitral valve prolapse. 3. Stage IIIC papillary serous adenocarcinoma of the ovaries.

Doctor: Hello, miss. Before we begin your physical, could you verify your age and ethnicity for me, please? Patient: I'm forty two years old and identify as white. Doctor: Thank you. I also see that you're here for a follow up for your asthma, correct? How is your asthma? Patient: That's right. Oh, man. My asthma has been getting worse over the last three months. My allergies are also acting up again. Doctor: Oh, no. Has anything changed that may have made your allergies worse? Patient: Well, my husband has been hauling more corn in since it's busy season. I think that might have made it worse. Doctor: Are you taking any medications to alleviate your asthma and allergies? Patient: I'm using my inhaler every day for my asthma. Here are the other medications and treatments I've been using. I know I wouldn't have remembered, so I put them on a paper for you to see. Doctor: Let me take a look. I see you have been taking Allegra for your allergies. Has that been helping? Patient: Eh. It kind of helps when I do take it. Doctor: You don't take it every day then? Patient: Nope. Only when I feel like I need to. Doctor: I see. What about the Flonase? Has that been helping? Patient: I'm not taking that right now, but it helped me in the past. Doctor: I also see you took Advair in the past, correct? Do you still take it? Patient: I did, but I stopped taking it because it started to annoy my private area. Doctor: I understand. Speaking more on this. Let's begin your physical. Do you have anything you'd like to add that you're starting to notice more? Patient: Oh, yeah. I feel like I'm easily annoyed right before my period. It could also be my husband, but he likes to say it's because I'm about to start my period. Doctor: I see. Do you see any other increased symptoms right before your menstrual cycle? Patient: Yeah. I feel like I've seen an increase in all the signs before my period. I'm also getting more impatient around that time, but when I'm not on my period, I feel like my mood is better. Doctor: When do you see your mood change? Patient: My husband says it's bad the week before I start my period, but I think it gets better a day after I start. Doctor: Have you seen any bleeding during your cycle? Patient: Not as much anymore. Just some spots here and there. Doctor: I see. What about hot flashes or night sweats? Patient: Nope. I feel fine most of the time. Doctor: That's good. I'm looking at your chart right now and it says you showed a U T I present, correct? Your test showed blood in your urine. Patient: Yeah, that's correct. Doctor: Has your urine been checked since then? Patient: Nope. Doctor: I see. I'll order another urine test along with additional lab tests so that we can complete your physical. Patient: I actually just had some lab work done because it was required for a life insurance application. Crazy, right? Here's the form with all the details for the lab work. Doctor: Oh, perfect. I see they looked at your cholesterol and other areas. Could you send that to me when you get the results? Patient: Of course. I'll get that sent to you A S A P.

Section header: GENHX Section text: This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma. She says her asthma has been worse over the last three months. She has been using her inhaler daily. Her allergies seem to be a little bit worse as well. Her husband has been hauling corn and this seems to aggravate things. She has not been taking Allegra daily but when she does take it, it seems to help somewhat. She has not been taking her Flonase which has helped her in the past. She also notes that in the past she was on Advair but she got some vaginal irritation with that. She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle. She has been more impatient around that time. Says otherwise her mood is normal during the rest of the month. It usually is worse the week before her cycle and improves the day her menstrual cycle starts. Menses have been regular but somewhat shorter than in the past. Occasionally she will get some spotting after her cycles. She denies any hot flashes or night sweats with this. In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously. Her urine has not been rechecked. She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.

Doctor: How are your parents doing, sir? Patient: Well, doctor, I've lost both of them now. Doctor: I'm so sorry to hear that, sir. How about your brothers? Patient: Thank you, doctor. Both of my brothers are doing very well. Doctor: Remind me, please, how old are they? Patient: One of them is sixty eight, and the other is seventy seven. I'm in the middle. Doctor: That's great. Do you have any medical conditions that run in your family? Patient: Well, I'm not sure if it counts, but I had a brother and sister, they were twins, they died at birth. Doctor: Oh no, thank you for telling me. Patient: Yes, I thought it would be important. Doctor: Do you have any children, sir? Patient: Yes, I have two sons, they're both doing very well. Doctor: How old are your sons? Patient: One of them is fifty four, and the other is fifty seven. Doctor: In addition to the neonatal deaths, do you have any other conditions that I should know about? Patient: Yeah, um, a lot of my family has diabetes, and a lot of them have had heart attacks as well.

Section header: FAM/SOCHX Section text: His parents are deceased. He has two brothers ages 68 and 77 years old, who are healthy. He has siblings, a brother and a sister who were twins who died at birth. He has two sons 54 and 57 years old who are healthy. He describes history of diabetes and heart attack in his family.

Doctor: Hello, ma'am. What is the reason for your visit today? Patient: I was referred by a doctor to come see you so that you could check up on my nasal problems. Here is my report from my previous doctor who referred me to you. Doctor: Thank you. Let me take a look. I see here it says you had severe sinusitis two to three months ago, correct? Patient: Is that what they're calling my nasal problems? Doctor: Yeah, it is. Sinusitis is the inflammation of your nasal airways. Patient: I see. Thank you for describing it to me. Doctor: No problem. Would you be able to describe to me what you had been feeling two to three months ago? Patient: Yeah, I can. My face would feel uncomfortable, my nose was stuffy, my eyes hurt, and I felt something dropping in the back of my throat. Doctor: Have you ever been prescribed any medication? Patient: Here's the list of medicine I was taking. Doctor: I see you were given antibiotics, correct? Patient: I was, but I don't know what those are. Could you explain them to me? Doctor: Antibiotics are usually used to fight infections. Patient: I had an infection? I thought I just had some nasal problems. Doctor: Your report states you had a severe infection. Do you remember if the antibiotics helped? Patient: Not really. I felt like my symptoms were the same. Doctor: I see. Did your doctor order any advanced imaging's? Patient: Yeah. They did a C T scan of my nose. Here is the report from my C T scan. Doctor: Let me take a look. It looks like you had some thickening of the mucosal layer in your right paranasal sinus. You also had some obstruction in your right ostiomeatal complex and excess growing of some of the bones in your nose. Uhm. Oh, one more thing. I see your nasal septum was shifted to the left. Patient: Oh, wow. Thank you for explaining everything to me. Doctor: No problem. Going back to your list of medications, I know you took antibiotics for your infection, but did you take any medication for your sinuses? Patient: No, I haven't. I did try this cream for my nose, but that didn't work either. Nothing worked! Doctor: I see. Looks like the cream you used was a topical nasal corticosteroid. Are there any other symptoms that you have been experiencing? Patient: I've had some trouble with my balance, and I feel like I've lost some of my hearing. I thought this was odd since I'm only fifty years old. I think my ears felt plugged or full of air, so they just needed to pop. Doctor: I see. Let's perform an audiogram test to check your ears. Patient: Sounds good. Doctor: I'm seeing that you have some mild high frequency sensorineural hearing loss. Your tympanometry seems to be normal. Your speech discrimination was also normal. Patient: That's reassuring. Doctor: I want to ask a few more questions about your ears. Do you feel any fullness or pressure? Patient: No, I don't feel anything like that right now. Doctor: Do you hear any humming, buzzing, or roaring sounds? Patient: Nope. I don't hear anything like that. Doctor: We checked your ears and now understand more about the problem, but I wonder why your balance is affected. When did you start noticing your balance was affected? Patient: I think it could have been to this one medicine that starts with an A. I forgot the name, but it didn't really help my nasal problems. It just made my balance worse. Doctor: Was the medicine called Allegra? Patient: Oh, yeah. That's what it was called. I thought I had some sort of allergy, so I thought it would help. Doctor: I see. Did you ever feel any dizziness too? Patient: Yeah, I did. Doctor: I will have you do some movements to see if your dizziness occurs. Patient: Sounds good. Doctor: Could you look to the left and then look to the right. Patient: Oh, wow. That made me very dizzy. Doctor: Looks like sudden movements and head turning make your dizziness worse.

Section header: GENHX Section text: I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis. As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms. She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics. She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left. She currently is not taking any medication for her sinuses. She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness. Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination. She has tried topical nasal corticosteroid therapy without much improvement. She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen. She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears. She denies any previous history of sinus surgery or nasal injury. She believes she has some degree of allergy symptoms.

Doctor: Is there anyone that lives with you at home? You are going to need someone to help you care for your wound. Patient: My wife lives at home with me. She can help me change my bandages.

Section header: FAM/SOCHX Section text: The patient lives with his wife.

Doctor: Hello. Looks like you're having surgery today. Patient: Yeah, I am. I forgot what the surgery was, but it says it in my report. Doctor: I'm looking at it right now. Looks like you had a PermCath inserted three times and received peritoneal dialysis

Section header: PASTSURGICAL Section text: PermCath insertion times 3 and peritoneal dialysis.

Doctor: So, what is happening with you? Patient: I had knee replacement for both my knees three years ago and now I am having some pain. Doctor: Okay and in one or both knees? Patient: Both. Doctor: Okay.

Section header: PASTMEDICALHX Section text: He has had bilateral knee replacement three years ago and experiences some pain in his knees with this.

Doctor: Hi! Patient: Hello! Doctor: How are you feeling now? Patient: I am feeling okay. Doctor: Yeah, looks like your condition is improving. Patient: Yes, I think so too.

Section header: EDCOURSE Section text: PROGNOSIS: Improved.

Doctor: And who are we seeing today? Guest_family: Hi Doctor, this my son J and that's my wife. Guest_family_2: Hi there Doctor: Well, hello young man how are you feeling today? Guest_family_2: He has been complaining of severe tummy pain and was crying the whole time. We are worried as he is a special child. He has autism. Doctor: For how long now? Guest_family_2: Autism? Doctor: No, I mean when did he start complaining of stomach pain? Guest_family_2: It started last night. Doctor: Oh okay, let me check him. Did he have any nausea or vomiting? Guest_family: Yes, he threw up a lot and is refusing to eat or drink anything. Doctor: And then he is complaining of tummy pain? Guest_family_2: Yes. Doctor: Well, the good part is he is not dehydrated. Doctor: Any diarrhea? Guest_family_2: Yes, he went three to four times. Doctor: Hm, but no blood or anything in the stools or vomit? Guest_family: No, nothing like that, we did not notice anything. Doctor: Okay good. Doctor: Well, let me run some tests but the signs and symptoms sound like he might have a stomach flu, also called as gastroenteritis in medical terms. I will start him on some medicines and hopefully that should help.

Section header: DIAGNOSIS Section text: 1. Gastroenteritis. 2. Autism.

Doctor: Hello, nice to meet you, miss. I will be taking care of you today. Before we start, can I get to know you a bit? I like to know who I am treating. Patient: Hello, nice to meet you. Of course. Um, what can I say? I am a recent widow. My husband passed when we were married for only eight years. I am also retired and loving every minute of it. Doctor: I am sorry to hear that, but I am glad you are happy after retirement. Do you celebrate your infinite days off with a drink or a cigarette? Patient: No, I do not smoke. I drink occasionally, but it is very rare. Doctor: Do you have any children that you spend your time with? Patient: I have three wonderful children.

Section header: FAM/SOCHX Section text: She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired.

Doctor: What do you use to treat your asthma? Patient: I use my Albuterol inhaler.

Section header: MEDICATIONS Section text: Albuterol.

Doctor: Do you eat three meals a day? Patient: Yes. Doctor: Do you think those meals add up to about two thousand calories a day? Patient: I would say yes.

Section header: GENHX Section text: The patient eats regular diet and eats 3 meals a day.

Doctor: Are you still taking Micronase every morning? Patient: Yes, I take um two point five M G once a day. Doctor: Great. Continue taking Micronase by mouth every day. As for your infection, I want you to start taking Bactrim twice daily. I'll be prescribing you thirty pills. It'll be Bactrim four hundred M G and eighty M G tablets.

Section header: MEDICATIONS Section text: Micronase 2.5 mg Tab PO QAM #30. Bactrim 400/80 Tab PO BID #30.

Doctor: Do you consume any kind of tobacco? Patient: No. Doctor: What about smoking? Patient: No, I've never done it. Doctor: Any kind of alcohol consumption? Patient: Nope.

Section header: FAM/SOCHX Section text: She does not smoke or drink alcohol.

Doctor: What seems to be the problem today? Patient: I've been having headaches for a while now. Doctor: How long have you been having these headaches? Patient: Um, I had my first one about two months ago. Doctor: Did you suddenly start having them, or was it more gradual? Patient: Um, I'd say it was more gradual. Doctor: Where do you feel your headaches? Patient: Right here, between my eyes. Doctor: How would you describe your symptoms? Patient: I'd say it feels like a pressure sensation. Doctor: What's the intensity of these headaches? Patient: Um, they're about moderately severe, I guess. Doctor: Do these headaches interfere with your ability to do your activities? Patient: Yes, they do. My regular activities are significantly more difficult now. Doctor: Do you have any sinus congestion? Patient: Yeah, I do. I also have some light sensitivity. Doctor: Are you stressed out at work? Patient: Yes, I have a very stressful job, doctor. Doctor: Are you sleeping well? Patient: Well, no not at all. I even try to have a little drink before bed, and it doesn't help. Doctor: Do you have any oral symptoms, like vomiting or pain in your jaw? Patient: No, nothing like that.

Section header: GENHX Section text: The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.

Doctor: Do you have any medical conditions that I should know about? Patient: No, not that I know of. Doctor: So, there's no history of depression, or cancer, or high blood pressure? Patient: No, it's not ringing any bells.

Section header: PASTMEDICALHX Section text: Negative.

Patient: I am having stomach pain. Doctor: Hm, any nausea or vomiting? Patient: Yes, both.

Section header: CC Section text: Abdominal pain, nausea and vomiting.

Doctor: Have you been experiencing any mental difficulties or confusion? Patient: No. Doctor: Any hallucinations? Are you seeing hearing thing that is not real? Patient: No.

Section header: ROS Section text: No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.

Doctor: Good afternoon, which gender do you identify with? Patient: Good afternoon, doctor, thank you for asking, I identify as a female. Doctor: Great, thank you. Have you ever had surgery on this knee? Patient: Yes, I actually had an A C L reconstruction done in March of two thousand eight. Um, it didn't go well, so they did a revision at the end of that year, in December. Doctor: I see, thank you. What about your upper body? Is there any history of surgery there? Patient: Actually, yes, I had surgery on my arm when I was six.

Section header: PASTSURGICAL Section text: She had an anterior cruciate ligament reconstruction in 03/2008, and subsequently had a revision ACL reconstruction in 12/2008. She has also had arm surgery when she was 6 years old.

Doctor: Welcome in, sir. Patient: Thank you. Doctor: What do you do for work? Patient: I am professor at the college up on the hill. Doctor: What do you teach? Patient: I teach history and the bible. Doctor: Do you drink alcohol or use tobacco products? Patient: No. I do not partake in either of those activities. Doctor: Okay.

Section header: GENHX Section text: Negative for use of alcohol or tobacco. He is a professor at College and teaches history and bible.

Doctor: Do you have any major medical conditions that I should know about? Patient: Yeah, I have a history of thyroid problems, actually. Doctor: I'm seeing here that you have a history of allergies too, is that correct? Patient: Oh yes, that's right too.

Section header: PASTMEDICALHX Section text: Past medical history is significant for allergies and thyroid problems.

Guest_clinician: How's the patient? Doctor: He's stable. Heart rate sixty five. Normal rhythm. Oxygen ninety seven percent on room air.

Section header: DISPOSITION Section text: Stable.

Doctor: Tell me about your past problems. Patient: Sure. I just came into the hospital I think about three weeks back for recurrent urine infections. Doctor: Yes it says here that you have bladder problems from a long time, mostly related to tone and capacity. Patient: Yes that is why they put catheter in me. Doctor: Okay and you have recently had right side C V A? Patient: Yes, because of my heart problems they had to put pacemaker in. Doctor: Okay. Good. Patient: I have hereditary diabetes. Doctor: Okay and your neural problem is associated to that as well. Patient: That's right. Doctor: You have pain on the right side now? Patient: Yes, because of my stroke. Doctor: And you take thyroid medications too? Patient: Yes, for my hypothyroidism. Doctor: Okay. Patient: Yeah. Doctor: What surgeries have you had in the past? Patient: I have had many surgeries. They took out my gall bladder, then colon cancer surgery was in nineteen ninety eight. Doctor: And now pacemaker placement, right? Patient: Yes, that is correct.

Section header: PASTMEDICALHX Section text: Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection. She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place. She has had right-sided CVA. She has had atrial fibrillation status post pacemaker. She is a type 2 diabetic with significant neuropathy. She has also had significant pain on the right side from her stroke. She has a history of hypothyroidism. Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998. She has had a pacemaker placement.

Doctor: Do you have any major medical conditions running in your family history that you know about? Patient: No, there's nothing of note. Doctor: So, there's no history of arthritis, or cancer that you're aware of? Patient: No, not that I know of.

Section header: FAM/SOCHX Section text: Noncontributory.

Doctor: So, does high blood pressure run in your family? Patient: Um, no it's just me. Doctor: Okay and this was your first time? Patient: Yes. Doctor: Because I am looking at your previous charts and I don't see it mentioned before. Patient: Oh yeah first time it shot up this high. I never had a high blood pressure problem before.

Section header: FAM/SOCHX Section text: Noncontributory to the present condition and review of his previous charts.

Doctor: Now, let's talk about your family history. Have any of them had cancer? Patient: Actually, yes, I know a few family members have, but I can't remember who had what kind. Doctor: That's okay. What about heart disease? Can you remember anyone having that? Patient: Yes, that rings some bells. Doctor: Thank you, has anyone in your family had a joint replacement? Patient: I know that a lot of my family has had arthritis in the past, but I can't remember whether or not they had joint replacements, honestly.

Section header: FAM/SOCHX Section text: Family history is remarkable for a remote history of cancer. Family history of heart disease and osteoarthritis.

Doctor: Hi, how are you? Patient: I am good, how about you? Doctor: Well, I am good too, thank you for asking. So, what brings you here? Patient: Um, I have developed this painful ulcer on my hip. Doctor: Oh, let me take a look. Which side? Patient: On my right hip. Doctor: Okay, I see it. Looks like you have developed pressure ulcer.

Section header: CC Section text: Pressure decubitus, right hip.

Doctor: Okay, tell me what's going on and what's brought you here. Guest_family: I am her mother. She has this blister on the side of her head right above her ear, here. I was just worried and concerned about my baby. Doctor: How old is the baby? When did you first notice it? Guest_family: She is just fourteen days old. Let me tell you from the beginning. On Friday, when I was taking her for a bath, I noticed a blister near her umbilicus area. We went to our doctor on Saturday, and they did a test. Doctor: Did you get the test result? Guest_family: I got it today. Here is the report. Doctor: Okay, let me have a look. It says she is having a growing M R S A. Guest_family: Yeah, I've been diagnosed with that too. And I am on medications. I had it on my buttock area. Doctor: Okay, so you know about it, and I don't have to explain it more. Guest_family: Yeah. Doctor: So how is the blister on the umbilicus now? Guest_family: She has been doing good. We put on some bacitracin ointment, and it almost healed up. But today I noticed that another small blister on her head. It really scared me, and I did not want to take any chance. That's why I reached out to the Infectious Disease center. I know it is private. But still, I don't want to take any chance with my baby's health. I called the center directly and they asked me to come to the hospital. Doctor: You did good. I will start the treatment. How are her eating and sleeping habits? Guest_family: She hasn't missed any of her meals. She is taking around two ounces of milk in every feed. I don't think I have any issues with her eating or sleeping. Doctor: Did she have any fever? Guest_family: Not that I noticed. Doctor: Has she been lethargic or crying more than normal? Guest_family: No. Doctor: Any other changes in her daily routine that you might have noticed? Guest_family: No, I didn't notice any changes.

Section header: GENHX Section text: A 14-day-old was seen by private doctor because of blister. On Friday, she was noted to have a small blister near her umbilicus. They went to their doctor on Saturday, culture was drawn. It came back today, growing MRSA. She has been doing well. They put her on bacitracin ointment near the umbilicus. That has about healed up. However today, they noticed a small blister on her left temporal area. They called the private doctor. They direct called the Infectious Disease doctor here and was asked that they come into the hospital. Mom states she has been diagnosed with MRSA on her buttocks as well and is on some medications. The child has not had any fever. She has not been lethargic or irritable. She has been eating well up to 2 ounces every feed. Eating well and sleeping well. No other changes have been noted.

Patient: I am in pain. I get these frequent episodes of pain and discomfort in my head. Doctor: Is it in any side of head or is it overall? Patient: Sometimes it is overall and other times just on any one side. Doctor: This sounds like it is a migraine headache.

Section header: DIAGNOSIS Section text: Migraine headache.

Doctor: Good afternoon, young man. Is this your mother? Patient: Hi, doctor. Yes, this is my mom. Doctor: Good, can you tell me more about your son, ma'am? Guest_family: Sure, well, he's six years old now, and we're here to follow up his A D H D medicines. Doctor: He's been taking Adderall, correct? How long has he been taking this? Guest_family: It's been about a month now. Doctor: How has he responded to the Adderall? Guest_family: The first day he took it, truthfully, he was wonderful. There's been a lot of improvement in his behavior, and he's really been doing well, so far. Doctor: That's great! Guest_family: Yes, but I have two concerns. When he takes the medicine first thing in the morning it seems to take a while to kick in, and then it wears off at about two P M and he has problems in the evening. Doctor: Has he had problems with his appetite? Guest_family: Um, he did at first, but it's been coming back. It's more of a problem in the morning when he first takes the medicine in the morning, not so much in the afternoon after it wears off. Doctor: Have you gotten any reports from his teachers? Guest_family: They have seen a dramatic improvement with it. Doctor: Has he taken every dose? Guest_family: Well, I missed one last weekend, and he was just horrible. Patient: Yeah, mommy, I thought I needed it, but you didn't give it to me.

Section header: GENHX Section text: This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication.

Doctor: Good afternoon, sir. Welcome in. Let's get started, how old are you? Patient: Good afternoon, doctor. I'm fifty two years old. Doctor: My nurse says that you're here for an independent evaluation, is that correct? Patient: Yes sir, that is. Doctor: Good, what do you do for a living? Patient: Right now, I'm a temporary employee for A B C A B C, I've worked for A B C D, too. Doctor: What do you do there? Patient: Mainly, I handle the loading and unloading of furniture and appliances for people's houses. Doctor: That's hard work. When did you get hurt? Patient: It was about two and a half weeks ago now, back in October. Doctor: Do you have a history of back problems, like before this injury? Patient: Yeah, I've had back pain for a long time. Doctor: What happened when you got hurt this time? Patient: I was unloading one of the A B C eighteen wheelers, when I bent down to pick up some boxes, and I felt the pain. Doctor: What kind of pain did you feel? Patient: I felt a sharp pain in my lower back right away when I tried to lift those boxes. Doctor: Does your pain go down your legs? Patient: Yes, it goes into the right side of my butt, and then all the way down the outside of my right leg, like into the knee. Doctor: How have your symptoms progressed since they began? Patient: Doctor, they've only gotten worse. Doctor: Do you have any pain in your left leg? Patient: A little, not as bad as the right. Doctor: What other symptoms are you having besides the pain down your leg? Patient: The muscles in my butt are spazzing, and it's happening more and more. Doctor: Have you seen another doctor for this? Patient: Yes, I saw Doctor Z at first. Doctor: What did they do for you? Patient: He gave me some muscle relaxers, and some, um, Lidocaine patches. Doctor: Did this help at all? Patient: No, not at all. Doctor: Who else have you seen? Patient: I saw doctor X Y Z too, through worker's comp. Doctor: When did you see them? Patient: That was back in April. Doctor: What did they recommend? Patient: Um, he sent me for an M R I, and I have the report for that right here. Doctor: Okay, this M R I report is basically negative, which is good. Did he give you any medications? Patient: Yes, he gave me some opioids. Doctor: Wow, that's strong stuff. What is your work status right now? Patient: Doctor X Y Z put me on restricted duty status, doctor. Doctor: I'm reading your notes from doctor X Y Z, he says he released you in June, and that you have reached maximum medical improvement. Patient: He told me that, but I still have pain, so I went back to see him. Doctor: When you went for follow up, did you still have that pain down your legs? Patient: Yes, I did. Doctor: What did doctor X Y Z recommend at that time? Patient: He referred me to a Pain Clinic, and he recommended I have, um, epidural injections with doctor A B C. Doctor: Did you have this done? Patient: Yes, I did. Doctor: Did this help at all? Patient: No, it did absolutely nothing. Doctor: Okay, so after that, what treatment did you have? Patient: I had an M R I, um, E M G, and nerve conduction study with doctor A B C D. Doctor: Do you have the results of that as well? Patient: Yes, doctor, they're right here. Doctor: Okay, sir, these tests are essentially normal, which is more good news. What aggravates your pain? Patient: Well, anything like sitting for a long time. When I do that, I feel it in my legs. Doctor: When you sit for a long time, is it in both legs? Patient: It's really on my right. Doctor: Are you able to sleep at night? Patient: No, sir, I'm not able to sleep at all. Doctor: Have you been able to return to work? Patient: Well, I went back to work in June, after doctor X said I'd reached the maximum medical improvement we talked about. Doctor: Finally, have you seen a chiropractor for this pain? Patient: Yeah, I saw doctor X about eight or nine times. Doctor: Did they do anything to help you feel better? Patient: Really, no, it did not. I still have the pain down my legs today.

Section header: GENHX Section text: The patient is a 52-year-old male who is here for independent medical evaluation. The patient states that he works for ABC ABC as a temporary worker. He worked for ABCD too. The patient's main job was loading and unloading furniture and appliances for the home. The patient was approximately there for about two and a half weeks. Date of injury occurred back in October. The patient stating that he had history of previous back problems ongoing; however, he states that on this particular day back in October, he was unloading an 18-wheeler at ABC and he was bending down picking up boxes to unload and load. Unfortunately at this particular event, the patient had sharp pain in his lower back. Soon afterwards, he had radiating symptoms down his right buttock all the way down to the lateral part of his leg crossing his knee. This became progressively worse. He also states that some of his radiating pain went down to his left leg as well. He noticed increase in buttock spasm and also noticed spasm in his buttocks. He initially saw Dr. Z and was provided with some muscle relaxer and was given some pain patches or Lidoderm patch, I believe. The patient states that after this treatment, his symptoms still persisted. At this point, the patient later on was referred to Dr. XYZ through the workmen's comp and he was initially evaluated back in April. After the evaluation, the patient was sent for MRI, was provided with pain medications such as short-acting opioids. He was put on restricted duty. The MRI essentially came back negative, but the patient continued to have radiating symptoms down to his lower extremity and subsequently the patient was essentially released by Dr. XYZ in June with maximum medical improvement. Unfortunately, the patient continued to have persistence of back pain and radiating symptoms down to his leg and went back to see Dr. XYZ again, and at this point, the patient was provided with further medication management and sent for Pain Clinic referral. The patient also was recommended for nerve block at this point and the patient received epidural steroid injection by Dr. ABC without any significant relief. The patient also was sent for EMG and nerve conduction study, which was performed by Dr. ABCD and the MRI, EMG, and nerve conduction study came back essentially negative for radiculopathy, which was performed by Dr. ABCD. The patient states that he continues to have pain with extended sitting, he has radiating symptoms down to his lower extremity on the right side of his leg, increase in pain with stooping. He has difficulty sleeping at nighttime because of increase in pain. Ultimately, the patient was returned back to work in June, and deemed with maximum medical improvement back in June. The patient unfortunately still has significant degree of back pain with activities such as stooping and radicular symptoms down his right leg, worse than the left side. The patient also went to see Dr. X who is a chiropractic specialist and received eight or nine visits of chiropractic care without long-term relief in his overall radicular symptoms.

Doctor: Is there any family medical history? Patient: I have a whole list. See, my grand aunt had a stroke. My M G had heart issues same as my mom, who died of a heart attack at sixty three. My father had some sort of cancer. I don't know what exactly. And my sisters have blood pressure issues. Doctor: Wow, that sure is a list. Anyone with diabetes? Patient: No. Well, that is one thing that skipped my family.

Section header: FAM/SOCHX Section text: Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.

Doctor: Does he have any known drug allergies? Guest_family: No.

Section header: ALLERGY Section text: He has no known drug allergies.