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Doctor: Good morning, can you tell me more about your son, ma'am. Guest_family: Sure, he's forty six, White, and he has Down syndrome. Doctor: Great, thank you. Is he still having problems with his hypothyroidism and onychomycosis? Guest_family: Yes, that's correct doctor. Doctor: Has he remained complaint with his Lamisil? Guest_family: Yes, he's taken six weeks of it with no problems. Doctor: Good, so we'll do an A L T blood test today. Guest_family: Why is that doctor? Doctor: Well, at his last appointment in April, he had an elevated T S H level. So, we should recheck that today. Guest_family: Yes, I remember that. Doctor: Has he been taking his Levothroid daily as well? Guest_family: Yes, he has, he doesn't like it, but I help him with it, and he eventually takes it. Doctor: Good, thanks for taking care of him, Mom. Guest_family: Oh, it's my job. Doctor: Does he take any other medications? Guest_family: He has some medicated eye drops for his cornea.

Section header: GENHX Section text: This 46-year-old white male with Down's syndrome presents with his mother for followup of hypothyroidism, as well as onychomycosis. He has finished six weeks of Lamisil without any problems. He is due to have an ALT check today. At his appointment in April, I also found that he was hypothyroid with elevated TSH. He was started on Levothroid 0.1 mg and has been taking that daily. We will recheck a TSH today as well. His mother notes that although he does not like to take the medications, he is taking it with encouragement. His only other medications are some eyedrops for his cornea.

Doctor: Do you have any questions regarding your surgery? Patient: Yes, I do, multiple. Doctor: Go ahead shoot. Patient: I have them all written down on this.

Section header: CC Section text: Surgery.

Doctor: How about any drugs, alcohol, or tobacco? Patient: No, no, and no.

Section header: FAM/SOCHX Section text: Negative for illicit drugs, alcohol, and tobacco.

Doctor: Hey, how are you? Patient: I think I am better. Doctor: So you do not have any more nausea or vomiting? Patient: No I don't. Doctor: How about any acidity? Patient: I think it's all better. Doctor: Great.

Section header: ASSESSMENT Section text: Severe nausea and vomiting likely secondary gastroenteritis, resolved.

Doctor: How are you? Patient: I am good. Doctor: That's great. You are stable. Patient: Can I go home now? Doctor: Yes, you can. Patient: Thank you!

Section header: DISPOSITION Section text: Stable.

Doctor: Good afternoon, young man, are these your parents? Patient: Yes, doctor. Doctor: Can you tell me more about your son, please? Guest_family: Well, he is seven years old, and he has had diarrhea for four days, and he's been throwing up for three days. Patient: Yeah, my brother has been doing this too. Guest_family: We had some chicken one day, and then we had more of it the next day. After they ate it they started to feel bad and still feel bad. Doctor: How many times has he had diarrhea per day since this began? Guest_family: Well, it's been about five or six times a day for the last four days. Doctor: How many times has he thrown up per day? Guest_family: Um, it has been frequent. Doctor: Has he been throwing up today? Patient: No, I haven't today. Doctor: Has he gone to the bathroom today? Patient: Yes, I peed this morning. Doctor: Has he had any fever symptoms? Guest_family: Yes, he had a fever of one hundred three last night. Doctor: Has he eaten any solid food? Patient: Yeah, I had half a hamburger and some milk last night. Doctor: Was he able to keep the food down? Guest_family: No, he threw it up. Doctor: What has he drank? Guest_family: Um, Pedialyte, Gatorade, white grape juice, and seven up, the soda.

Section header: GENHX Section text: The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea. Apparently, his brother had similar symptoms. They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened. But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad. The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days. He has not had any emesis today. He has urinated this morning. His parents are both concerned because he had a fever of 103 last night. Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis. He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything.

Doctor: Welcome into the clinic! I would like to start with your past medical history. Patient: I have high blood pressure and macular deterioration. Last year I caught pneumonia but that has cleared up. Doctor: Okay. What brings you in today? Patient: I have had this cough and pain on the right side of my abdomen. Doctor: How long has this been going on? Patient: Two days. I have had body aches and have been feeling nauseous too. Doctor: Have you had a fever? Patient: I think so. I was chilled and my forehead was warm. The cough is a dry sounding cough. Doctor: Does the abdominal pain come during one of these coughing episodes? Patient: Yes.

Section header: GENHX Section text: This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient stated that the abdominal pain was only associated with coughing. The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home.

Doctor: Good afternoon, dear, how old are you? Patient: I'm fourteen years old. Doctor: Good, and what brings you in for a visit today? Patient: My left knee hurts really bad. Doctor: Oh no, how long has this knee been hurting you? Patient: Well, since the fall of two thousand seven. Doctor: Have you seen another doctor for this? Patient: Mom, can you tell the doctor? Guest_family: Yes, actually, we went to another orthopedist in November of two thousand seven. Doctor: I see, and what did this doctor recommend? Guest_family: We got an MRI, I have a disc with the images, and the report as well right here, if you want to take a look at it. Doctor: Thank you, yes, so this shows left patellar chondromalacia. Has she been to P T? Guest_family: We got a referral for P T, but they only wanted to do, um, let me look at my notes, patellar tracking exercises. Doctor: I see, has she been wearing her brace? Guest_family: Yes, she has been. I've been making sure of it. Doctor: That's good, and how is your pain today, dear? Patient: P T only made the pain much worse, it hurts so much. Guest_family: Yes, she's in a lot of pain, is there anything else we can do, besides P T? Doctor: Well, we're in a pretty difficult spot here. The majority of my patients get significantly better by just going to P T. Guest_family: Is there any surgery to fix this? Doctor: Usually, we manage this for six months without surgery, and she hasn't reached that milestone yet. But, because her pain is getting so severe, I can do a lateral capsular release on this knee. Guest_family: What is that? Doctor: It's a small procedure, minimally invasive, and we can do it outpatient. Her kneecap is partially dislocating, so this surgery will get everything back into alignment. Guest_family: Okay, what is the risk of infection? Doctor: The risk of infection is actually less than one percent. We use antibiotics to control for infection. Patient: Will I be asleep for this? Doctor: Yes, you won't feel a thing. Patient: Will I need to go back to P T? Doctor: Yes, you'll need to go some after the surgery to make sure everything heals up okay. The other risks include bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling. Guest_family: I think we'd like to do the surgery. What do you think, honey? Patient: Yeah, I think so too, I want to get back to playing soccer. Sp 3

Section header: GENHX Section text: The patient is a 14-year-old girl who started having left knee pain in the fall of 2007. She was not seen in Orthopedic Clinic until November 2007. The patient had an outside MRI performed that demonstrated left patellar chondromalacia only. The patient was referred to physical therapy for patellar tracking exercises. She was also given a brace. The patient reported increasing pain with physical therapy and mother strongly desired other treatment. It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy. Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered. Risk and benefits of surgery were discussed. Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling. All questions were answered, and mother and daughter agreed to the above plans.

Doctor: What brings you here today? Patient: I have pain in my tummy. Doctor: When did you first notice it? Patient: It started suddenly around noon.

Section header: CC Section text: Abdominal pain.

Doctor: Welcome to the clinic., ma'am Patient: Thank you. Doctor: What brings you into see me? Patient: I have been struggling with pain and stiffness in my right neck and shoulder. Doctor: How long has this been going on for? Patient: Maybe for about four months. Doctor: In these past four months have your symptoms becomes worse or has it improved at all? Patient: It has been getting worse. The pain is worse at night. It wakes me up at night. I haven't had a good night sleep in four months. Doctor: Have you experienced any pain or numbness in your arm, wrist, or hand? Patient: Yes! About two weeks after the pain started, I was having some numbness and painful cramping in these two fingers here. Doctor: The right hand and the first and second finger? Patient: Yes. Doctor: How old are you? Patient: I am forty six. Doctor: Are you left or right handed? Patient: Right. It was a throbbing pain in my hand. Doctor: Have you had any other pain anywhere else in your body? Patient: I few times I had some numbness in both of my legs. It started with a pinching from my tailbone area. Doctor: Did you experience any trauma neck, head or back? Patient: No. I don't know where this pain came from. Oh, every once and a while I have this electric shock like sensation shooting down my spine when move my neck certain way. Doctor: Any pain or symptoms in your left arm or shoulder? Patient: No. Doctor: Have you had any visual changes or disturbances? Patient: No. Doctor: Any difficulties with your bowels or your bladder? Patient: No. Doctor: Have you been taking any thing for the pain? Patient: I have been taking Naprosyn. Doctor: Has the Naprosyn help relieve your pain? Patient: Only a little bit. Doctor: Okay.

Section header: GENHX Section text: This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma. She had been taking Naprosyn with little relief.

Doctor: Is this baby number two? Patient: Yes, this is baby number two. Doctor: How many times have you been pregnant, including miscarriages or abortions if any? Patient: I've been pregnant two times in total. No miscarriages or abortions. Doctor: When was your last period? Patient: About a month ago. Doctor: And how would you describe your periods? Light, normal, heavy? Patient: Pretty normal. Doctor: Any abnormal pap smears? Patient: No, fortunately they've all been normal. Doctor: That's wonderful to hear. And my last question for you is if you've ever gotten a mammogram? Patient: I haven't gotten one before. Do I need to get one? I just turned thirty nine. What's the recommended age again? Doctor: It depends. For example, the recommended age would be younger for someone who has a family history of breast cancer. Given that you don't have a positive family history of breast cancer, I'd advise getting one in a few years at the age of forty five.

Section header: GYNHX Section text: Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal.

Doctor: Okay, I want you to follow up with our hand therapist Doctor X at her A B C D office in one to two weeks. Patient: Okay, I will make an appointment today.

Section header: DISPOSITION Section text: Follow up with Dr. X in ABC Office in 1 to 2 weeks.

Doctor: So we're here to follow up on a few things. I'd like to know how you're keeping up with your blood sugar checks. Patient: I've been checking my blood sugar one to two times a day. Doctor: Have you been keeping a log? Patient: Uh yeah, but I need to be better at it. Doctor: Do you have the log with you today? Patient: Yep, in fact it's right here. Let me grab it for you. Doctor: Great. Patient: Here ya go. Doctor: Thank you. And have you been watching your cholesterol intake since getting blood work done? Your labs show your cholesterol levels are a bit elevated. I'd like for you to monitor your cholesterol and go in for another set of labs before our next visit. Patient: Do I need to fast for it again? Doctor: Yes, you'll need to fast. I'd recommend going in early in the morning before eating any breakfast. Patient: That sounds like a good plan. Doctor: And as for your sinusitis, how have you been feeling since finishing your course of antibiotics? Patient: Much better. No more headaches and a stuffy nose.

Section header: CC Section text: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis.

Doctor: What brings you in today? Patient: My back started hurting last night. I have a stomachache. I have had pain with urination for the last two days. Doctor: Do you have any other symptoms? Patient: I just started coughing and now I have a fever. Doctor: Do you have any history of kidney stones? Patient: Yes. I had kidney stones less than a year ago. I had a urinary tract infection at the same time. It was awful.

Section header: GENHX Section text: The patient complains of backache, stomachache, and dysuria for the last two days. Fever just started today and cough. She has history of kidney stones less than a year ago and had a urinary tract infection at that time. Her back started hurting last night.

Guest_clinician: When did she have lumbar discitis? Doctor: A little over a year ago. She received antibiotic therapy and ended up having debridement and instrumentation with Doctor XYZ. Guest_clinician: How's she doing today? Doctor: Really quite well. Guest_clinician: She also had a P E with that prior hospitalization, correct? Doctor: Yes.

Section header: PASTMEDICALHX Section text: Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well. She had a pulmonary embolus with that hospitalization.

Doctor: Do you have sugar or blood pressure problems? Patient: Oh, I have high blood pressure but it's well under control. I make sure to keep it under normal range. Doctor: Good. Any other health issues? Patient: Yeah, I have history of high triglycerides. But otherwise, I am pretty healthy. Doctor: Okay. Do you smoke? Patient: No.

Section header: GENHX Section text: She has had hypertension very well controlled and history of elevated triglycerides. She has otherwise been generally healthy. Nonsmoker.

Doctor: Hello, miss. The nurse who seated you tells me you are here for a second opinion on surgery. Patient: Hello, doctor. Yes, I have been told that both eyes need cataract extraction. I came for a second opinion because I will only have surgery if necessary. I am nervous. Doctor: What is the reason for the extraction? Patient: I am not exactly sure because the other doctors said a bunch of medical terms. I have had laser in my eyes though. That was for macular degeneration. Doctor X said I had neurovascular age-related macular degeneration. Doctor: Do you know what laser you had on your eyes? Patient: No. I just know laser was done by Doctor X four times to the macula on the right and two times on the left.

Section header: GENHX Section text: The patient seeks evaluation for a second opinion concerning cataract extraction. She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery. Past ocular surgery history is significant for neurovascular age-related macular degeneration. She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.

Doctor: Any allergies? Patient: Um yeah. I'm trying to remember the name. It's a pain killer that starts with an L. Oh Lortab. Doctor: What happens when you take Lortab? Patient: Really bad hives. I've only ever taken it once. Doctor: I'll make note of that in your chart so we have it in your records.

Section header: ALLERGY Section text: She is allergic to Lortab.

Doctor: Do you have any known drug allergies? Patient: No, none that I know of.

Section header: ALLERGY Section text: None.

Doctor: Welcome in. Patient: Thank you. Doctor: What do you do for work? Patient: I work in Human Resources for the State of Maryland. Doctor: Do you live alone or with others? Patient: I live alone. Doctor: Do you smoke cigarettes? Patient: I used to smoke like a chimney. I quit smoking a while back. I had been smoking for about sixteen years. Doctor: That's great! When did you quit? Patient: I quit in nineteen eighty four. That is also the year I quit drinking. Doctor: What was the reason behind quitting drinking? Patient: I had a drinking problem. I am in A A. I have been in A A since I quit. Doctor: That's great. Keep up the hard work. Patient: Thank you. Doctor: Do you have any history of recreational or I V drug use? Patient: Yes. I used to take pills, but I never got into needle drugs. Thank God. I went through treatment, all those years back. I started going to A A and got my life together. Doctor: Do you have any other risk factors for H I V? Like multiple sex partners? Patient: No. I had my last H I V test over two years ago. I have been with the same guy for over two years. Doctor: Okay.

Section header: FAM/SOCHX Section text: He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use. He denies any HIV risk factors and states that his last HIV test was over two years ago.

Doctor: Hi, tell me about your family? Did anyone have any medical diseases? Patient: Both of my parents were healthy, but my maternal grandfather had a stroke. Doctor: Did anyone in your family ever have migraines? Patient: No, not that I know.

Section header: FAM/SOCHX Section text: MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family.

Doctor: Do you have any chronic medical conditions that I should know about? Patient: What do you mean by that, doctor? Doctor: Well, it could be anything from high blood pressure, to depression, to cancer. Do any of those sound familiar? Patient: Oh, yeah, I have a few things like that. I have anemia, high cholesterol, and, um, hypothyroidism.

Section header: PASTMEDICALHX Section text: Anemia, high cholesterol, and hypothyroidism. PAST

Doctor: How old are you? Patient: Oh, I am fifty eight now. Doctor: So, you are here today because you are having some vision difficulties? Tell me about what has been going on, ma'am. Patient: Yeah. Okay. It all started a year ago. It started with losing the color in my vision. Doctor: Was the loss sudden or gradual? Patient: Gradual. And now I am starting to have blurry vision. Doctor: When did that start happening? Patient: I noticed it two months ago. Doctor: Is the blurred vision an all blur or is there a blind spot of blurred vision. Patient: It is an all over vision blur and then I have on blind spot in my right eye. Doctor: Have you had any fluctuations in your symptoms in the last year? Have you gained any vision back? Patient: Some days I feel like things are a little better but not much. I have basically been the same. Doctor: Have you experienced any weakness, dizziness, vertigo, nausea or vomiting? Patient: No. Doctor: Any double vision or headaches? Patient: No. Doctor: Any pain in or behind the eye at all? Patient: No. Doctor: Any other health concerns or complains? Patient: No. Just the vision problems. Doctor: Alright! Let me take a look here.

Section header: GENHX Section text: 58 y/o female presents with a one year history of progressive loss of color vision. In the past two months she has developed blurred vision and a central scotoma OD. There are no symptoms of photopsias, diplopia, headache, or eye pain. There are no other complaints. There have been mild fluctuations of her symptoms, but her vision has never returned to its baseline prior to symptom onset one year ago.

Doctor: How are you feeling today? Patient: I have been having some trouble breathing. I had tightness in my chest after walking up stairs. Doctor: Let me listen to your lungs.

Section header: CC Section text: "Trouble breathing."

Doctor: Good afternoon, ma'am. Before we begin, can you confirm your age for me, please? Patient: Sure, I'm fifty six years old. Doctor: Great, thank you. What seems to be the problem today? Patient: Well, I have a history of systemic lupus erythematosus. Doctor: How have you been treated for this in the past? Patient: Um, I went to a rheumatologist about four months ago, I had discomfort in both of my hands. Doctor: Which hand was worse? Patient: My left was worse than my right at that time. Doctor: Have you seen anyone else for this? Patient: Um, I came in on October thirtieth two thousand seven. I was having the same problem. Doctor: What did they do for you at that time? Patient: They have me a trial of Elavil because they thought it was, um, ulnar or radial neuropathy. Doctor: Did they give you any topical creams? Patient: Yeah, they gave me a prescription for Zostrix but I couldn't fill it because of my insurance. Doctor: I see, have your symptoms gotten worse since they began? Patient: Yeah, especially here, at the base of my left hand, like around my wrist. Doctor: Which fingers do you feel it in? If any? Patient: Right here, doctor. Doctor: Okay, these are your second, third, and fourth fingers. Do you have any other symptoms of note? Patient: Um, actually yeah, I've been having some respiratory problems for the last three days or so. Doctor: What symptoms have you been experiencing? Patient: Um, I've had a dry cough and I feel like I've had a fever but I haven't taken my temperature. Doctor: Have you had any night sweats or chills? Patient: No, not that I can remember. Doctor: Have you had any chest pain or discomfort? Patient: No. Doctor: What about shortness of breath, or G I problems? Patient: Thankfully, no.

Section header: GENHX Section text: The patient is a 56-year-old female with a history of systemic lupus erythematosus, who was last seen in rheumatology clinic approximately 4 months ago for bilateral hand discomfort, left greater than right. The patient was seen on 10/30/07. She had the same complaint. She was given a trial of Elavil at bedtime because the thought was to see that represented ulnar or radial neuropathy. She was also given a prescription for Zostrix cream but was unable to get it filled because of insurance coverage. The patient reports some worsening of the symptoms especially involving at the dorsum of the left hand, and she points to the area that actually involves the dorsal aspect of the second, third, and fourth digits. The patient recently has developed what sounds like an upper respiratory problem with a nonproductive cough for 3 days, although she reports that she has had subjective fevers for the past 3 or 4 days, but has not actually taken the temperature. She has not had any night sweats or chills. She has had no recent problems with chest pain, chest discomfort, shortness of breath or problems with GU or GI complaints. She is returning today for routine followup evaluation.

Doctor: Do you remember the name of the medication you are taking? Patient: I have two, but I do not remember their name or why I am taking it. Doctor: That is fine, we will figure it out.

Section header: MEDICATIONS Section text: She is on two different medications, neither of which she can remember the name and why she is taking it.

Doctor: I wanted to talk to you about your family medical history. Patient: Okay, how this will be helpful? Doctor: Family history plays an invaluable role in your health. It provides us with important clues and insight to predict and detect diseases before obvious symptoms appear. Patient: My mom dealt a long time with anxiety and stress disorder.

Section header: FAM/SOCHX Section text: Patient admits a family history of anxiety, stress disorder associated with mother.

Doctor: Okay, let's review your family history. Patient: Ready when you are. Doctor: Does anyone in your family have high blood pressure or high cholesterol? Patient: Both my parents have high blood pressure. Doctor: Are they being treated for it? Patient: Um yes. Oh they also have E T. Doctor: Do any of your siblings have it as well? Patient: No. Doctor: Does anyone in your family have an autoimmune disorder. Patient: Hm. Give me a second to think. Does lupus count? Doctor: Yes. Who do you know that has lupus? Patient: My cousin. Doctor: On your mom or dad's side? Patient: Uh mom.

Section header: FAM/SOCHX Section text: Both parents have ET and hypertension. Maternal cousin with lupus.

Doctor: What are you taking as a maintenance treatment? Patient: Oh, I take Flonase. Doctor: And do you have a lot of issues after taking that? Patient: No I do not. Doctor: That is good.

Section header: MEDICATIONS Section text: He is maintained on Flonase and denies much in the way of nasal symptoms.

Doctor: Hello. Looks like we are here for a six months follow up. How are we doing? Patient: I have stayed relatively the same. My main complaint is that I feel tired throughout the day. The C P A P is doing fine and I wake up refreshed, but I don't like how I crash. Doctor: Alright. How are the thyroid issues? Patient: I seem to be fine. My thyroid gland does not seem enlarged and I can breathe like normal. No fever or anything. Doctor: Have you experienced any of the following: temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, or diarrhea? Patient: Nothing of the kind. Doctor: How has you weight been? Patient: It has been stable. Doctor: Any muscle weakness closest to the body's center? Patient: No, nothing like that. Not bad for forty five.

Section header: GENHX Section text: This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 years old. Her last visit was about 6 months ago. Since that time, the patient states her health has remained unchanged. Currently, primary complaint is one of fatigue that she feels throughout the day. She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day. In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism. She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea. Her weight has been stable. She is not reporting proximal muscle weakness.

Doctor: So I understand you had a fainting episode yesterday? Patient: Yes, I did. Doctor: Has this happened to you before? Patient: Yes. It happens whenever needles are involved. Doctor: You had a Vasovagal Syncope. How are you feeling today? Patient: I feel normal today.

Section header: CC Section text: Syncope.

Doctor: Hello, how are you? Patient: I am not so good. Doctor: Oh, what is going on with you? Patient: Well, I have lot of swelling in my legs. Doctor: Hm, okay.

Section header: CC Section text: I have a lot of swelling in my legs.

Doctor: Hi there, sir! I am Doctor Frankland. Patient: Hi! It's nice to meet you. Doctor: What brings you into see me today? Patient: I have had this pain in my finger and wrist for about a month. I have had some numbness too. The numbness started in the finger and is now in the wrist too. Doctor: Which wrist and finger is it that is hurting? Patient: The left one and the middle finger, here. Doctor: What was to time frame of the procreation of the numbness from the finger to the wrist? Patient: It started when I woke up and then by the end of the day my wrist was numb too. Doctor: When did you start experiencing pain in the wrist area? Patient: A few days after the numbness started. Doctor: Which hand is your dominate hand? Patient: I am left handed. Doctor: What do you do for work? Patient: I am a cook. I also cut the fish for the whole restaurant. I cut fish for hours in the mornings and it has been a struggle and it is aggravating my finger and wrist. Doctor: How old are you? Patient: I am forty four. Doctor: Do you have any history of injuring a neck injury? Patient: No. Doctor: Any neck pain or weakness? Patient: No. Doctor: Any difficulties with bowel movements or urination? Patient: No.

Section header: GENHX Section text: This 44 y/o LHM presented with a one month history of numbness and pain of the left middle finger and wrist. The numbness began in the left middle finger and gradually progressed over the course of a day to involve his wrist as well. Within a few days he developed pain in his wrist. He had been working as a cook and cut fish for prolonged periods of time. This activity exacerbated his symptoms. He denied any bowel/bladder difficulties, neck pain, or weakness. He had no history of neck injury.

Doctor: Good morning. How are you feeling today? Patient: I feel good, considering. I slept well last night. Doctor: Are you expensing any pain or discomfort? Patient: No. I feel fine.

Section header: EXAM Section text: GENERAL: The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative. No dysarthria is noted. No discomfort on presentation is noted.

Doctor: How are you doing with everything? Patient: I'm good. It's hard when you are in quarantine. I hope things will get back to normal soon. Doctor: So, you are here for your breast examination. Patient: Yes, it was due for so long. Doctor: I'm going to touch both of your breasts one by one to check for any lump or kind of mass. Okay? Patient: Yeah. Doctor: Okay, so both looks good. Are you feeling any pain while I'm touching? Patient: No, I don't feel any pain. Doctor: That's good, no masses, no pain and I do not feel anything in your armpit area.

Section header: EXAM Section text: BREASTS: The breasts show no masses or tenderness. No axillary adenopathy.

Doctor: How's your wife doing? I think the last time I saw her was two weeks ago. She was telling me about the remodeling you've been doing around the house. Patient: She's doing well, thanks for asking. Oh yeah, the remodeling has been a lot. I didn't think it'd take as long as it has. Doctor: Yeah, it can take some time. We remodeled our kitchen three years ago and it turned our lives upside down. So tell me, how's training going for you? I believe you were telling me that you have a five k coming up. Patient: Yeah, it's two weeks away. I've been jogging and doing cross country track about five times a week. I also lift twice a week on my better days. Doctor: That's great! And no smoking or drinking, correct? Patient: Nope. Doctor: How's work been treating ya? Patient: Pretty darn well actually. I go into the allergy and immunology clinic four days outta the week. I like that my hours are flexible. My patients also haven't run away from me yet, which is always a good sign.

Section header: FAM/SOCHX Section text: The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician in allergy/immunology.

Doctor: My nurse tells me you're thirty four years old, is that correct? Patient: Yes, I just had my birthday, doctor. Doctor: You identify as African American, correct? Patient: Yes, that's right, sir. Doctor: You're here for a follow up? What brings you back in today? Patient: Well, I don't really have a single acute complaint, but I have a muscle sprain in my upper back. Doctor: Is there an injury associated with this pain, ma'am? Patient: I think it has to do with me lifting weights. Doctor: Yes, that's common. Is this messing with your ability to work? Patient: No, it's not really. Doctor: What do you do for a living? Patient: I'm a housekeeper, it's my profession. Doctor: Are you having trouble sleeping at night? Patient: Yes, it's not severe, but I'm having some trouble. Doctor: With ten being the worst pain imaginable, how would you rate your pain today? Patient: I'd say it's usually a two out of ten. Doctor: When it's the worst, how would you rate it? Patient: When that happens, I'd say it's a three or a four. Doctor: Do you take any medicines for this pain? Patient: Over the counter medications usually help the pain go away. Doctor: Do you have any other complaints? Patient: No, just this muscle pain. Doctor: Do you have any loss of balance when you hold something with this arm? Patient: No, my strength and everything is normal there. Doctor: Do you have any signs of infection? That'd be anything like fever or chills, anything like that? Patient: No, I don't have anything like that.

Section header: GENHX Section text: This is a 34-year-old African American female who comes today for routine followup. She has no acute complaints. She reports that she has a muscle sprain on her upper back from lifting. The patient is a housekeeper by profession. It does not impede her work in anyway. She just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication. No other associated complaints. No neurological deficits or other specific problems. The patient denies any symptoms associated with opportunistic infection.

Doctor: How can I help you today. Patient: I have been having irregular periods. Doctor: When was your last menstrual period? Patient: My last period was on June first two thousand and four. Doctor: Are you currently sexually active? Is there a possibility of pregnancy? Patient: No! There is no possibility that I am pregnant. I have not had sex in two years. Doctor: How old where you when you had your first menstrual period? Patient: I was ten years old when I got my first period. My cycle has never been regular. It runs in my mom's side of the family. Doctor: What is your family history of reproductive health conditions on your mom's side of the family? Patient: My mom and my aunt have both had total hysterectomies. Doctor: Is there any other personal medical history I should know about? Patient: I see Doctor X Y Z Allen for my abnormal heart valve condition. I am on S B E prophylaxis. I have to limit my activity because of my heart condition. Doctor: Do you avoid decongestants? Patient: Yes.

Section header: PASTMEDICALHX Section text: She denies sexual activities since two years ago. Her last menstrual period was 06/01/2004. Her periods have been irregular. She started menarche at 10 years of age and she is still irregular and it runs in Mom's side of the family. Mom and maternal aunt have had total hysterectomies. She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen. She avoids decongestants. She is limited on her activity secondary to her heart condition.

Doctor: How have you been feeling? How is your leg feeling? Patient: My right leg is in a lot of pain. The nurse just changed the bandage. I only have a rash where the bandage is. Doctor: It looks like we have you taking Vicodin for the pain. Is the medication not helping? Patient: The pain medication is horrible. I have been throwing up, off and on. I have been constipated since I have been here. Doctor: I'll note that. Vomiting since February nineteen of two thousand seven. I am sorry to hear that. I will make a change to the medication and get you something for the constipation issue. Patient: Thank you. Doctor: Have you had any shortness of breath, chest pain or coughing up blood? Patient: No. Doctor: Any joint pain, headaches or rashes? Patient: No. Just a rash where the bandages are like I said earlier. I also want to discuss this acne while I am here. I have had it for about two years. It's nothing big, just mild to moderate in severity.

Section header: ROS Section text: He has had emesis off and on related to Vicodin and constipation since 02/19/2007, also related to pain medication. He has had acne for about two years, which he describes as mild to moderate. He denied shortness of breath, chest pain, hemoptysis, dyspnea, headaches, joint pains, rashes, except where he has had dressings applied, and extremity pain except for the right leg pain.

Doctor: Does anyone in your family have a neurological disorder? Patient: No, not to my knowledge.

Section header: FAM/SOCHX Section text: unremarkable.

Doctor: Do you smoke, sir? Patient: Well, I used to a long time ago, but I don't anymore. Doctor: Good, what about alcohol, do you drink? Patient: Well, my wife and I have a drink or two a day.

Section header: FAM/SOCHX Section text: He has a very remote history of tobacco use. He has one to two alcoholic drinks per day. He is married.

Doctor: Did you had any medical issues in the past? Patient: No, nothing major. Doctor: You said nothing major, so, what was there? Patient: I had a little curve in the spine. It was not major. Doctor said that it can be corrected by exercises.

Section header: PASTMEDICALHX Section text: Also positive for some mild scoliosis.

Doctor: Do you have any medical conditions that I should know about? Patient: Yeah, I have chronic diarrhea, and C O P D. Doctor: Are you a smoker? Patient: Yes, I have been for a long time. Doctor: How would you characterize your smoking level? Patient: Um, I'd say it's pretty heavy.

Section header: PASTMEDICALHX Section text: Includes chronic diarrhea as I mentioned before and chronic obstructive pulmonary disease secondary to heavy smoking.

Doctor: You have atrial fibrillation from the past? Patient: Yes, rhythm problem is bad. Doctor: And no dizziness? Patient: Yes. I do. Doctor: Okay well...

Section header: ASSESSMENT Section text: 1. Atrial fibrillation. 2. Dizziness.

Doctor: Do you have any allergies? Patient: No allergies. Doctor: Nothing? Cat dander, pollen? Patient: Nope.

Section header: ALLERGY Section text: None.

Doctor: Do you live with your husband? Patient: Yes, we live on a ranch about twenty miles away. Doctor: Do you have children? Patient: We had six children all together, but two of them passed away suddenly. Doctor: I'm so sorry to hear that. How old were they? Patient: One was forty years old and the other was forty five. Doctor: Wow, they were quite young. I offer you my sincerest condolences. Patient: Thank you. It's been really hard on my family, but we're trying our best to get by. Doctor: That's all you can do. It's important to spend time with each other every chance you get. Patient: Exactly. Doctor: I have a few more questions to ask before we end today. Patient: Go ahead. Doctor: Do you have family history of any medical problems? Patient: No. Doctor: Do you smoke or drink? Patient: Never.

Section header: FAM/SOCHX Section text: She is married, lives with her husband, has 2 children that passed away and 4 surviving children. No history of tobacco use. No history of alcohol use. Family history is noncontributory.

Doctor: So let's see here. Any history of high blood pressure or diabetes? Patient: No, sir. Doctor: How about heart disease? Patient: No, no heart disease. Doctor: And no cancers? Patient: No and for that I'm thankful.

Section header: PASTMEDICALHX Section text: None. No history of hypertension, diabetes, heart disease, liver disease or cancer.

Doctor: What is your family medical history? Patient: My dad had Alzheimer's disease. He is in a facility that cares for him now. Doctor: I am sorry that must be hard. Patient: It is. My aunt, his sister helped me get everything set up for him. She had a stroke last month. Doctor: Oh no. How is she doing now? Patient: She is home now but her husband is having to help take care of her. The doctors said it looks good for her to have a full or almost full recovery. Doctor: That is a relief. Patient: Yes, it is! Doctor: Any other family health problems that you know of? Patient: No not that I know of.

Section header: FAM/SOCHX Section text: Alzheimer's disease and stroke on paternal side of family.

Doctor: So, how much longer are you in juvie, young man? Patient: I've got about three weeks left, sir. Twenty five days, if you want to be exact. Doctor: Good, time to make the best of getting out, right? Patient: Absolutely, I don't want to go back. Doctor: Good. Do you smoke, young man? Patient: No sir, absolutely not.

Section header: FAM/SOCHX Section text: He is in Juvenile Hall for about 25 more days. He is a nonsmoker.

Doctor: Hello, I am Doctor Rez. I will ask you a few questions about your personal and family history, okay? Patient: Yes, that's okay. Doctor: Did any one in your family get diagnosed with any medical conditions? Patient: My mom has lumps in her breast but it is benign, however my granny on my father side had cancer. Doctor: What kind of cancer, do you know? Patient: Well, it was breast cancer don't know if there are types for it. Doctor: No, that's fine. Did you ever have palpitations? Patient: What do you mean by that? Doctor: Um, Palpitations means the sensation when you feel that your heart is racing or pounding really fast even without doing any strenuous exercise or anything. Patient: Oh, got it. No, I never had that. Doctor: What about any uncontrolled urine leakage? Any accidents? Patient: No. Doctor: What about any recent sudden hair loss or any other concerns? Patient: No, nothing like that. Doctor: Any other treatments in the past? Patient: Yeah, I recently got treatment for my sinus.

Section header: FAM/SOCHX Section text: Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis.

Doctor: Any history of smoking? Patient: Uh yeah, but I quit in two thousand seven. Doctor: On average, how many packs per day did you smoke? Patient: Uh if I were to guess, I'd say one pack per day. Doctor: Any other drugs? Patient: I used to do coke, but I quit that in two thousand five. Doctor: And any history of drinking? Patient: Um I used to drink one pint per day, but I quit drinking more than ten years ago.

Section header: FAM/SOCHX Section text: The patient is a former smoker, reportedly quit in 2007. He used cocaine in the past, reportedly quit in 2005. He also has a history of alcohol abuse, but apparently quit more than 10 years ago.

Doctor: Can you tell me more about your family's medical history? Are there any conditions of note? Patient: Well, my dad died from prostate cancer, and my mom died as well, she was an alcoholic. Doctor: I'm so sorry to hear that, ma'am, how old were they? Patient: Well, my father was eighty, and my mother was sixty seven. Doctor: I'm so sorry, do you have any siblings? Patient: Yeah, I had a brother, he passed away too, from bone and throat cancer. Doctor: I'm sorry, how old was he? Patient: He was seventy, doctor. Doctor: Do you have any children? Patient: I have four, two of each. Doctor: That's wonderful, how are your sons doing? Patient: They're thirty seven and thirty eight, and they're both doing really well. Doctor: That's great, what about your daughters? Patient: Well, they're sixty and fifty eight, and they both have cancer. They're real fighters. Doctor: I'm sorry, that must be so hard to deal with. Are there any other conditions you're aware of? Patient: Oh yeah, we have it all, nervous condition, high blood pressure, kidney and lung disease, depression, it's all there.

Section header: FAM/SOCHX Section text: Her father died at the age of 80 from prostate cancer. Her mother died at the age of 67. She did abuse alcohol. She had a brother died at the age of 70 from bone and throat cancer. She has two sons, ages 37 and 38 years old who are healthy. She has two daughters, ages 60 and 58 years old, both with cancer. She describes cancer hypertension, nervous condition, kidney disease, lung disease, and depression in her family.

Doctor: Are you married? Patient: Yes. Doctor: Where do you work? Patient: I work as a secretary in a law firm. Doctor: Do you smoke or drink? Have you ever tried any illegal drug? Patient: No, none of these.

Section header: FAM/SOCHX Section text: Married, Secretary, No h/o tobacco/ETOH/illicit drug use.

Doctor: It looks like E M S found you in bad shape? Patient: What? Guest_family: My mother is hard of hearing. She is eighty five. They found her on the toilet. Doctor: Did your mother tell you anything about her condition before E M S arrived? Guest_family: She said she threw up right before they came and she had diarrhea. Doctor: Ma'am. How are you feeling now? Patient: I have been sick to my stomach. My belly has been hurting. I threw up. Doctor: How many times did you vomit ma'am? Patient: I don't know. Doctor: Do you recall the color of the vomit? Did you see any blood or notice the color of the vomit? Patient: I don't know.

Section header: GENHX Section text: The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing.

Doctor: Do you have kids, ma'am? Patient: Yes, I do. I have two sons and we adopted a girl. Doctor: Where did you adopt? Patient: Just here. Doctor: and you are married right? Are you working? Patient: Yes, I have been married a long time. I retired from Avon. Doctor: Do you smoke cigarettes or drink? Patient: I do not smoke or drink alcohol.

Section header: FAM/SOCHX Section text: She has two sons and an adopted daughter. She is married long term, retired from Avon. She is a nonsmoker, nondrinker.

Doctor: How's the little dude? Guest_family: He has fever and bad congestion for the last two days. He has had a fever for one. I try to suck the discharge out through nose. Doctor: I am guessing he has some mild problems with breathing while feeding. Guest_family: Yes, that is correct. He is drinking milk every couple hours, only for ten minutes instead of twenty minutes. Guest_family: He has fever too, so she gave him Tylenol. Guest_family2: He is very fussy. Doctor: Is he sleeping well? Guest_family: Yes, he sleeps. But he is not able to breath well even with albuterol. Doctor: How about wet and dirty diapers? Guest_family: He is peeing less I think because he used to have eight to ten wet diapers but now it's down to four in a day. And five dirty diapers. Doctor: How about any diarrhea? Guest_family: No, he doesn't have any diarrhea, they are soft and yellow. Doctor: Any rashes or acne? Guest_family: No. Doctor: How about vomiting? Guest_family: No, he did not vomit. Doctor: How old is he? And, sorry this is odd, but what ethnicity do you identify as? I need it foe the paperwork. Guest_family: Twenty one days old Caucasian male. Doctor: Do you notice him getting blue at all? Or does this area sink in when he tried to breathe? Guest_family: No, neither. Doctor: Is he having any trouble breathing in general? Guest_family: No.

Section header: GENHX Section text: The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions). One day ago, mom also noticed a tactile temperature and gave the patient Tylenol. Baby also has had some decreased p.o. intake. His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion. He sleeps well, but has been more tired and has been fussy over the past 2 days. The parents noticed no improvement with albuterol treatments given in the ER. His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours. Mom denies any diarrhea. His bowel movements are yellow colored and soft in nature. The parents also noticed no rashes, just his normal neonatal acne. The parents also deny any vomiting, apnea.

Doctor: Are you taking Benicar? Patient: Yes, twenty daily. Doctor: And what else? Patient: I take some multivitamin, glucosamine, Vitamin B complex, Vitamin E and a low dose Aspirin. Doctor: Okay that's good information.

Section header: MEDICATIONS Section text: Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin.

Doctor: Do you smoke? Patient: Nope. Doctor: How about alcohol intake? Patient: Nope. Doctor: What about any kind of drug usage? Patient: Nope.

Section header: FAM/SOCHX Section text: Denies ETOH/illicit drug/Tobacco use.

Doctor: Hi, how are you? Patient: I am okay. Doctor: Do you have any bone pain or issues around that? Patient: No, I do not. Doctor: So, they gave you a dose of Tylenol here in the emergency department to treat your pain. Is your pain under control? Patient: Yes, with medication I feel it is better, but I want to be removed from the backboard. Doctor: Okay, let's get you off. Yeah, your C T scans of the abdomen appeared normal. And there was no sign of bleeding. I believe, you just have a contusion and abrasion to abdomen from the seatbelt and likely from the airbag as well. Patient: Oh okay. Doctor: It's good that you can stand and walk through the emergency department without difficulty. I do not see any abrasions or lacerations. Patient: Yeah, nothing like that and I can walk.

Section header: EDCOURSE Section text: The patient was removed from the backboard within the first half hour of her emergency department stay. The patient has no significant bony deformities or abnormalities. The patient is given a dose of Tylenol here in the emergency department for treatment of her pain. Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard. The patient's CT scans of the abdomen appeared normal. She has no signs of bleeding. I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well. The patient is able to stand and walk through the emergency department without difficulty. She has no abrasions or lacerations.

Doctor: Lets talk about your family history, does cancer run in your family ma'am? Patient: Oh yes! My family has a history of lung, liver and prostate cancer. Doctor: Oh wow! Patient: Yeah. Doctor: And you mentioned that your mother had Alzheimer's? Patient: Well, I am not sure about Alzheimer, but she had some dementing disease. It started when she was in her eighties. It was kind of mild case. Patient: And she actually passed away in her eighties due to old age. Doctor: Okay, how about your siblings, do they have any signs of Alzheimer? Patient: No, they are fine. Doctor: Okay.

Section header: FAM/SOCHX Section text: Significant for lung, liver, and prostate cancer. Her mother died in her 80s of "old age," but it appears that she may have had a mild dementing illness at that time. Whatever that dementing illness was, appears to have started mostly in her 80s per the patient. No one else appears to have Alzheimer disease including her brother and sister.

Guest_clinician: What's their medical history? Doctor: I have here hypertension, diabetes, diabetic retinopathy, and elevated lipids. They're in post C V A. Guest_clinician: Do you know their neurologist? Doctor: I can have the nurse or scribe go in and ask again. Guest_clinician: Great.

Section header: PASTMEDICALHX Section text: Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.

Guest_clinician: Were you able to get a history from her? Doctor: I tried but was unsuccessful. She's very out of it. Guest_clinician: Does she have a history of alcohol abuse? Doctor: According to her records, she has a long history of alcohol abuse.

Section header: PASTMEDICALHX Section text: Significant for alcohol abuse. Unable to really gather any other information because she is so obtunded.

Doctor: The patient has a history of C A D. Guest_clinician: Are they being followed by a cardiologist? Doctor: Not to my knowledge. I can check their electronic medical records. One sec.

Section header: FAM/SOCHX Section text: Positive for coronary artery disease.

Doctor: Hi sir, how old are you? Patient: I am thirty. Doctor: We are following up today for your moderate to severe apnea, right? Patient: Yes, that is correct, I still can't sleep. Doctor: Okay and you did the CPAP? Patient: Yes. Doctor: Okay, let's review it today. Patient: Sure.

Section header: GENHX Section text: Mr. ABC is a 30-year-old man who returns in followup of his still moderate-to-severe sleep apnea. He returns today to review his response to CPAP.

Doctor: Any smoking or alcohol? Patient: No, I don't smoke but I drink wine. Doctor: Are you married? Patient: Yes, I am. Patient: I have three stepchildren and one of my own and I work for A B C D.

Section header: FAM/SOCHX Section text: He is a non-cigarette smoker. He has occasional glass of wine. He is married. He has one biological child and three stepchildren. He works for ABCD.

Doctor: Congratulations on your new baby! How are you doing today? Patient: I'm doing well, no headaches, and I'm breastfeeding well. Doctor: Have you had any bleeding? Patient: Nope, none. Doctor: Are you using a mini pad? Patient: Yeah, I use it twice a day. Doctor: Do you have any cramping or clotting? Patient: No, thankfully I don't. Doctor: What color is your discharge, ma'am? Patient: Well, its turned from red to brown, and now its kind of yellowish. Doctor: Okay, have you had sex again yet? Patient: No, we're waiting a little longer. Doctor: Are you going to the bathroom regularly? Patient: Regularly? Yes, but I'm having some pain with it, and then every once in a while I have some bright red bleeding. Doctor: Are you constipated? Patient: No, I'm not. Guest_family: She hasn't been eating her vegetables like she should. Doctor: That'll also do it. Patient: Okay, well, my seasonal allergies are back too. Doctor: What symptoms do you have with your allergies? Patient: I get itchy watery eyes, a runny nose, I can't stop sneezing, and I have a lot of pressure in my ears.

Section header: GENHX Section text: She is doing well postpartum. She has had no headache. She is breastfeeding and feels like her milk is adequate. She has not had much bleeding. She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish. She has not yet had sexual intercourse. She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding. She has not been particularly constipated but her husband says she is not eating her vegetables like she should. Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.

Doctor: Do you have any major medical conditions that run in your family that I should know about? Patient: What do you mean by that? Doctor: Well, it could be anything from diabetes to high blood pressure to cancer. Patient: Oh, yeah. My brother had prostate cancer.

Section header: FAM/SOCHX Section text: His brother had prostate cancer.

Doctor: Hi, how are you? Patient: Hi! I am okay other then this back pain. Doctor: I am so sorry. Tell me about your back. Patient: Three nights ago, I fell on my steps bringing in the groceries from the car. Doctor: How did you land when you fell? Patient: I fell and landed on my right hip. I hit my low back on the railing. Doctor: I would like to get some imaging done today. Patient: Okay.

Section header: GENHX Section text: Back pain after a fall.

Doctor: Have you seen your lab results? Patient: No, do you have those in today? Doctor: Yes, I have them right here. They're essentially negative, except it appears that you had C difficile in the past. Do you remember that? Patient: Yes, I got it when I worked at a hospital after graduating. Doctor: Yeah, its unfortunately more common there.

Section header: PASTMEDICALHX Section text: Essentially negative other than he has had C. difficile in the recent past.

Doctor: Breath in breath out, let me tap it and see. Well, your lungs sound clear. Patient: Okay.

Section header: EXAM Section text: CHEST: Lungs bilaterally clear to auscultation and percussion.

Doctor: Are you still taking the Trizivir? Patient: Yes. Doctor: How much are you taking? Patient: I take one pill two times a day. Doctor: Are you taking any other medications? Patient: I take Ibuprofen for body aches from time to time but that's it.

Section header: MEDICATIONS Section text: 1. She is on Trizivir 1 tablet p.o. b.i.d. 2. Ibuprofen over-the-counter p.r.n.

Doctor: I just need to confirm some information before we begin sir, you're forty one, correct? Patient: Yes sir, that's correct. Doctor: Good, so what happened? Patient: Well, I work at A B C, and about two days ago I slipped on some oil that had spilled. Doctor: How did you fall? Patient: I fell with both my arms outstretched, but I fell mostly on my left shoulder. Doctor: Where is your left shoulder pain? Patient: Mostly, it's in the back of my shoulder. Doctor: Going backwards a little, how about the right shoulder? Patient: It hurt really bad yesterday, but that's gone away now. Doctor: Good, do you have any pain in the front of the shoulder? Patient: No sir, I don't have anything there. Doctor: Good, how about weakness? Is there any shoulder weakness? Patient: No, it's not really weak at all. Doctor: How have your symptoms progressed over the last two days? Have they gotten better, or worse? Patient: Um, overall, I'd say it's gotten better. I have a little better range of motion. Doctor: Have you been able to do any activities? Patient: I was able to get in the swimming pool with my kids, and I didn't really have any trouble. Doctor: Good, what medicines have you taken for this? Patient: I've just taken some Advil so far.

Section header: GENHX Section text: The patient is a 41-year-old male presenting for initial evaluation of his left shoulder. He works at ABC and two days ago was walking though an area, where there was some oil spilled on the floor. He fell and landed on bilateral outstretched arms and then further fell landing primarily on his left shoulder. He presents today reporting primarily posterior shoulder pain. The right shoulder was bothersome yesterday, but is now asymptomatic. He has no anterior shoulder pain. He denies any feelings of weakness. He reports some improvement over the last two days especially in his range of motion. He was able to get into the swimming pool last night with his children without difficulty. He has had no additional treatment other than over-the-counter Advil.

Doctor: Hi there! It is good to see you both. How has everything been going for the both of you? Patient: Hi Doctor. Guest_family: Things have been pretty good. She has been having some new emotional outbursts. I made an appointment with the down syndrome behavioral specialist that you recommended from the last time we were here. Doctor: That is great. Keep me updated on her progress. Her bloodwork came back showing an underactive thyroid. This explains the recent weight gain and fatigue. I would like to start her on a medication called levothyroxine. We will need to check her bloodwork again in one month to see how her thyroid respond to the medication. Guest_family: Okay. Doctor: Is there any other concerns you have today? Guest_family: Yes. She has this toenail that looks strange and discolored. Doctor: Let me look. Can you remove your socks for me? Patient: Yes. Doctor: Is it this nail? Guest_family: Yes. Doctor: This is very common. It is called Onychomycosis. It is nail fungus. Since only one nail is affected, I would recommend starting off with a topical treatment. I will send the drops to your pharmacy. You will put on drop on the affected nail, daily.

Section header: ASSESSMENT Section text: 1. Down's syndrome. 2. Onychomycosis. 3. Hypothyroidism.

Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: Have you ever had surgery, ma'am? Patient: Actually, yes I have. I had pinning surgery done on both of my ears. Doctor: Do you remember how old you were when you had surgery? Patient: Um, I was five or six years old. It was when I was a kid, I know that for sure.

Section header: PASTSURGICAL Section text: Bilateral pinning of her ears.

Doctor: Do you have any allergies? Patient: Not that I know of. Doctor: Okay.

Section header: ALLERGY Section text: None known.

Doctor: What is your family medical history? Patient: My dad has high blood pressure. My mom has had a ton of skin cancer removed. Doctor: Do you know what type of skin cancer she has removed? Patient: I have no idea.

Section header: FAM/SOCHX Section text: HTN and multiple malignancies of unknown type.

Doctor: Hello, miss. Today we're going to do a recheck for your hypertension. Sound good? Patient: Yes, of course. Doctor: I just want to check to see if you have any symptoms that can possibly raise alarm. Patient: I have been coming to you for the last fifteen of my seventy eight years on Earth. I know how a follow up works. Doctor: You are a seasoned veteran. Alright. So how is your chest? Any pains or tightness? Patient: No, luckily I do not have that. Doctor: Is your heart beating alright? Do you feel like it is beating too fast or hard? Patient: No. I can't really feel my heart beat normally, but I guess that is better than feeling it beat constantly. Doctor: You are correct. You shouldn't notice it. How is sleeping? Patient: Sleeping has been fine. I sleep through the night. Doctor: Great. Any shortness of breath that causes you to wake up? Patient: None. I don't have shortness of breath at any other time of the day. Doctor: Are your legs doing well? Any swelling? Patient: No. No swelling.

Section header: GENHX Section text: The patient is a 78-year-old female who returns for recheck. She has hypertension. She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.

Doctor: Hello, it's nice to meet you. Patient: It's nice to meet you as well. Doctor: My name is Doctor X and I will be taking care of you today. Patient: Thank you. Doctor: I've been told that you'd like a refill on your Xanax prescription and something to help you break your smoking habit. Patient: Yes, I feel like I've tried everything in the book and I still can't break the habit. One of my buddies was telling me about this medicine called Clantix or something like that. Doctor: Yes, I've heard of Chantix. We can look into it and see what's best fit. Patient: Okay, great. Since moving back home, I've ran out of Xanax. Doctor: How long have you been taking it? Patient: Almost a year now. I usually take it on days where my anxiety is really bad. Doctor: I see here that you also have mesothelioma in the lining of your stomach, is that correct? Patient: Yes, I need to find a new cancer specialist that's closer to where I live. Doctor: Are you currently experiencing any pain? Patient: Not at the moment, but I do get pain when I eat sometimes. Other times it's when I'm not even doing anything. It's been chronic so nothing new. Doctor: Do you take anything for the pain? Patient: I haven't in a while. Doctor: When were you diagnosed with mesothelioma? Patient: About six or so months ago.

Section header: GENHX Section text: The patient presents today stating that she needs refills on her Xanax, and she would also like to get something to help her quit smoking. She is a new patient today. She states that she has mesothelioma in the lining of her stomach and that it does cause her some problems with eating and it causes some chronic pain. She states that she is under the care of a cancer specialist; however, she just recently moved back to this area and is trying to find a doctor a little closer than his office. She states that she has tried several different things to help her quit smoking and she has failed everything and had heard good results about Chantix and wanted to give it a try.

Doctor: Are you allergic to anything? Doctor: Like any medications? Patient: No, I am not allergic to anything. Doctor: Perfect! Patient: Hm.

Section header: ALLERGY Section text: None.

Doctor: Welcome to the clinic. Patient: Thank you. It is nice to meet you. Doctor: It is nice to meet you to. I hear an accent. Where are you from? Patient: I am from Denmark. I speak Danish as my first language. Me and my husband have been in the States for many many years. When we first got here, we did not speak a word of English. Doctor: Wow! Your English is excellent now. Patient: Thank you. Doctor: How old are you? Patient: I just turned seventy four last month. Doctor: Happy birthday! Patient: Thank you. Doctor: So, your primary care physician sent you here for possible hydrocephalus. Patient: Is that the water on brain thing? Doctor: Yes. Patient: Then, yes. Doctor: Can you tell me about the symptoms that you have been having. Patient: I think I have been walking funny lately. I have also been losing my balance. Doctor: How do you know that you have been walking funny? Patient: My husband noticed that I have been walking funny. He noticed it about over six months ago or so. Doctor: What do you notice about the way your wife's walk that has changed? Guest_family: She walks wider then she used to, and I noticed that she stooped over. She walks much slower than she did before. She is often losing her balance. I have noticed her touching the walls and furniture to stabilize herself. Doctor: Okay. Have you noticed her stabilizing herself all of a sudden? Guest_family: No. It has been happening more and more over the last six months or so. Doctor: What else have you noticed about the way she walks? Guest_family: I noticed that she is having trouble stepping up onto things like a scale. She seems very unbalanced. She also seems to take her time as she walks. She can't be hurried. Doctor: That is good that you are taking your time. Do you use any devices to assist you to get around? Like a cane or a walker? Patient: No. Guest_family: I must help her get in and out of the car. Not every time but sometimes. I am very concerned because she has been falling more and more recently. Patient: I have had one emergency room visit. Doctor: What happened that you had to go to the emergency room? Patient: I fell. I was walking to the bedroom. I lost my balance so I put my hand out to brace myself against the wall and my hand slipped. I fell on my wrist. Guest_family: She broke her wrist. Doctor: When did this fall happen? Patient: March two thousand and seven. Guest_family: She has fallen a few times since she broke her wrist. It makes me so nervous. Doctor: I can see why that would make you nervous. Have you had any headaches? Patient: No. I never get headaches. Doctor: Aren't you lucky. Patient: Yes, I guess so. Doctor: Have you had any problems with your memory or cognitive abilities? Patient: I am still able to pay the bills on time. I don't feel as smart as I used to be. I do feel like my thinking has slowed down over the last few months. Doctor: What is your perspective on her memory and her cognitive abilities? Guest_family: I have noticed some changes. She will occasionally start a sentence and then not know what words to use to finish the sentence. Doctor: Has she ever had trouble finishing a sentence the in the past? Guest_family: No, she has always been very well spoken never has lost thoughts. Doctor: Have you had any fainting or vertigo episodes? Patient: I have not fainted. I have had some dizzy spells in the past but not recently. Doctor: Have you had and problems with your bowel movements? Patient: No. Doctor: Any bladder issues or frequent urination? Patient: No. Doctor: Okey. Let us do some an exam. Patient: Okey.

Section header: GENHX Section text: The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus. Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband. With respect to her walking and balance, she states "I think I walk funny." Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture. Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself. She has difficulty stepping up on to things like a scale because of this imbalance. She does not festinate. Her husband has noticed some slowing of her speed. She does not need to use an assistive device. She has occasional difficulty getting in and out of a car. Recently she has had more frequent falls. In March of 2007, she fell when she was walking to the bedroom and broke her wrist. Since that time, she has not had any emergency room trips, but she has had other falls. With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency. The patient does not have headaches. With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, "I do not feel as smart as I used to be." She feels that her thinking has slowed down. Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing. The patient has not had trouble with syncope. She has had past episodes of vertigo, but not recently.

Doctor: I mean, I am so happy to see your report today, your blood pressure looks much better. That's amazing given your past few visits your B P was out of control and even with changing your medications we were having tough time bringing it down. Patient: Yeah, I feel much better, I read about my condition and it is called something as um refraction or-- Doctor: Refractory hypertension. Patient: Oh yeah that! Doctor: But the good news is that it is getting better. Patient: Yes. Doctor: Last time we talked about seeing the internal medicine doctor there at your senior center, right? Patient: Yes, I made an appointment last week, um, no week before that, but I completely forgot about it. Doctor: Hm, okay we need to reschedule that. Patient: Yes, I will do it today. Doctor: Okay, your reports look fine. G F R is below sixty percent, that's a good sign. Overall, Miss K, you look better, but we need to reschedule your appointment with the Internist. That's kind of important. Patient: Okay, I will do that. Thank you! Doctor: You are welcome.

Section header: ASSESSMENT Section text: This is a return visit for this patient who has refractory hypertension. This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously. We had discussed with her in the past beginning to see an internist at the senior center. She apparently had an appointment scheduled and it was missed. We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.

Doctor: Did you ever visit any hospital for any kind of surgery? Patient: No.

Section header: PASTSURGICAL Section text: No previous surgeries.

Doctor: Hi there! How are doing today? Patient: I am doing well. Doctor: How have you been doing with keeping your hemoglobin levels between four and five point six prercent? Patient: I have been doing well. I have been able to keep it within that range.

Section header: CC Section text: Followup diabetes mellitus, type 1.

Doctor: So, are you married, ma'am? Patient: Well, no I'm not. My husband and I got a divorce. Doctor: I'm sorry to hear that, do you have any children? Patient: It's okay, it was for the best. Yes, I have two. Doctor: Do you live with either of them? Patient: Yeah, um, I live with my son right now. Doctor: Do you smoke or drink? Patient: No I do not.

Section header: FAM/SOCHX Section text: Denies any tobacco or alcohol use. She is divorced with 2 children. She lives with her son.

Doctor: Good afternoon, so, who is the patient today? Guest_family: Good afternoon, doctor. My granddaughter is your patient today. Doctor: What seems to be the problem today, young lady? Patient: Well, I'm having a lot of headaches, I feel it in my face. Doctor: Does it feel like pressure? Patient: That, and I have the sniffles. Doctor: What other symptoms have you had? Patient: Um, well, last night I had a sore throat, and I was coughing up phlegm. Doctor: Interesting, anything else? Patient: Um, I've had a rash on my face, back, and arms for the last three days or so. Doctor: Is it itchy? Patient: Yes, so we've been taking a lot of Benadryl. Doctor: I see, are you going to school? Patient: I have been, there's been a lot of fifth disease this year. Doctor: Okay, and have you been wheezing lately? Patient: No, I haven't been. Doctor: I see you have asthma, have you had any medication for this? Patient: No, I haven't had anything.

Section header: GENHX Section text: Grandfather brings the patient in today because of headaches, mostly in her face. She is feeling pressure there with a lot of sniffles. Last night, she complained of sore throat and a loose cough. Over the last three days, she has had a rash on her face, back and arms. A lot of fifth disease at school. She says it itches and they have been doing some Benadryl for this. She has not had any wheezing lately and is not taking any ongoing medications for her asthma.

Doctor: Did you have any surgeries in the past? Patient: Yes, I had a partial removal of my ovaries and then I also had my appendix removed. Doctor: Okay anything else? Patient: Yeah, I also got my tummy tucked. Doctor: Okay.

Section header: PASTSURGICAL Section text: Significant for partial oophorectomy, appendectomy, and abdominoplasty.

Doctor: Good afternoon, young man. Patient: Hello, doctor. Doctor: How old are you, young man? Patient: I'm thirteen, sir. Doctor: Thank you, so, what happened? Patient: I sliced my right ring finger with a piece of glass while I was playing around with my friends. Doctor: You need to be more careful, young man. What kind of symptoms do you feel in that finger? Patient: You're right. I have a lot of, um, numbness and tingling in it.

Section header: GENHX Section text: This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.

Doctor: Hello. How are you feeling today? Patient: Not so well. I went to a party last night and my chest and body have been hurting a lot. Doctor: I see. Did you smoke at the party? Patient: Nope. I never smoked in my life. Doctor: Great. Where on your body does it hurt? Patient: Like my upper right side of my stomach area. Doctor: I see. Did you drink alcohol last night? Patient: I had to drive some people home, so I was sober. I also don't like the taste of alcohol, so I stay away from it.

Section header: FAM/SOCHX Section text: Denies tobacco or alcohol use.

Patient: And do I have to restrict my movement or activities? Doctor: Um, I have taken the plaster off and your foot looks good. I don't want you to restrict your activities, but you are the best judge of the situation. So, I will advise you to take it slow and do as much as you can tolerate. Patient: Got it. Thank you, Doctor. Do I need a follow-up? Doctor: As long as you are doing fine, having no pain, I think we are okay. Patient: Alright then bye. Doctor: Bye.

Section header: PLAN Section text: As tolerated.

Doctor: What is your family medical history? Patient: My dad had stomach cancer. Doctor: How old was he when he was diagnosed? Patient: I think he was seventy something. My sister has breast cancer. She is in her fifty's. Doctor: Any family history of uterine, ovarian or colon cancer? Patient: No. Not that I am aware of.

Section header: FAM/SOCHX Section text: 1. A sister with breast carcinoma who was diagnosed in her 50s. 2. A father with gastric carcinoma diagnosed in his 70s. 3. The patient denies any history of ovarian, uterine, or colon cancer in her family.

Doctor: Do you drink or smoke? Patient: No I don't. I have to care for my daughter. She is a widow. Doctor: So you live with her? Patient: Yes, she lives at home.

Section header: FAM/SOCHX Section text: She denies alcohol or tobacco use. She is the caretaker for her daughter, who is widowed and lives at home.

Patient: I think I need help. Doctor: I am here to help. Tell me what's going on. Patient: I am having mood swings, sometimes I feel super happy and sometimes I am just super sad and angry with myself. I find myself in tears thinking about things or situations which are not even real. Doctor: How old are you ma'am? Patient: I have just completed five decades of my life. Doctor: Did you ever try to hurt yourself? Patient: No, that thought never came to my mind. I just feel sad, like nobody cares if I exist. Sometimes I feel I can conquer the world and do anything I put my heart and mind into. It's just that I am not sure how will I feel after an hour. Doctor: How long have you had these symptoms? Patient: It has been going on for many months. At first, I ignored everything but now It feels like I am not myself any more with all these mood swings. Doctor: Do you work? Patient: Yes, I am a hygienist and work in a Bright Dentals. Doctor: How are you doing at work with your mood swings? Patient: Huh, my symptoms have sure started affecting my work. You know what the worst part is, my boss came to me last week and asked if I was on some kinds of drugs. I literally shouted at her saying no and left the clinic in tears. I think I need some drugs; I mean some medications to deal with my issues. Doctor: Have you ever been on any kind of medicine or treatment before? Patient: Yeah, I was on Wellbutrin before. It was prescribed by Doctor Jonah. I was eating a lot and even gained like twenty pounds in just a few months. My insurance didn't even cover it, I had to pay from my pocket. Doctor: Do you know what you were diagnosed with? Patient: It is all in these papers, I got my file with me, I just want to be normal me again. Doctor: Let me check and enter it in the medical record for future references. According to this, they prescribed Wellbutrin for obsessive compulsive type disorder and yes it was related to your overeating. Did it help you? Patient: Yes, I was doing better once I started taking that medicine regularly. I continued it even though I had to pay out of my pocket. Doctor: Have you ever been on antidepressants? Patient: No. Doctor: Any hot flashes or night sweat? Did you ever find yourself waking up to wet bed due to sweating? Patient: No. Doctor: Just putting together all that you have told me here. You have mood swings; you find yourself in tears without any specific reason, you are not suicidal, never been on any kind of antidepressants. Am I missing something here? Patient: Sometimes I really find it hard to concentrate. As a hygienist I really need to focus on the gums of the patients and cleaning but sometimes it gets hard to focus. Normally, at work I just stop when it gets hard to focus and take a walk around the clinic. It has started affecting my work. I need help! Doctor: Okay, I understand. Anything else that I should be aware of? Patient: Oh yeah, the insomnia, I am hardly sleeping. At times I feel like a zombie. Doctor: Any surgeries in the past? Patient: Yeah, I had some complications and they had to remove my complete uterus along with tubes and ovaries. Doctor: Oh! When was this? Patient: In the December of two thousand and three.

Section header: GENHX Section text: A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stated may be she needed to be, meaning taking some medications. The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication. She has not been on any other antidepressants in the past. She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia. She denies any hot flashes or night sweats. She underwent TAH with BSO in December of 2003.

Doctor: Any known past medical history? Patient: I have high blood pressure. Doctor: Anything else? Patient: Yeah, I remember I also had higher number of fat in my blood.

Section header: PASTMEDICALHX Section text: Include dyslipidemia and hypertension.

Doctor: Good morning, ma'am, welcome in. I believe this is our first time meeting. Patient: Good morning, doctor. Yes, this is my first time in. Doctor: Great, how old are you? Patient: I'm fifty five, doctor. Doctor: Thank you, what seems to be the problem today? Patient: Well, I'm having a laundry list of symptoms coinciding with my allergies. Doctor: Like what, ma'am? Patient: Well, my sense of taste is diminished, dry mouth, um, acid reflux, and G I issues, and then I have asthma, and reactions to things like aerosols. Doctor: I see, do you have any food allergies? Patient: Um, I think.

Section header: GENHX Section text: A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies. Please refer to chart for history and physical and review of systems and detailed medical history.

Doctor: What's your family history? Patient: Both my parents are deceased. Doctor: I'm so sorry to hear that. I offer you my sincerest condolences. Patient: Thank you. My dad passed away at seventy five from leukemia and my mom fell victim to heart problems and alcoholism at thirty eight. Doctor: Does anyone else in your family suffer from leukemia, cardiac problems, or alcohol abuse? Patient: One of my uncles on my dad's side was recently diagnosed with leukemia. Doctor: Oh, wow. I see.

Section header: FAM/SOCHX Section text: Positive for mother passing away at the age of 38 from heart problems and alcoholism, dad passed away at the age of 75 from leukemia. One of her uncles was diagnosed with leukemia.

Doctor: Any fever or chills? Patient: No. Doctor: Any headache or body pains? Patient: No. Doctor: Any nausea vomiting? Patient: I had vomiting a few times. Doctor: Did you observe any blood? Patient: No. Doctor: Okay, any diarrhea? Patient: No, on the contrary I am having constipation every now and then, it's really bothering me now. I feel bloated all the time and don't feel fresh in the morning or throughout the day. Doctor: Oh, how long have you had this problem? Patient: Couple of months now. Doctor: Hm, I see, does it hurt you to pass stool? Did you notice any blood? Patient: No. I use suppositories. Doctor: Oh, that's great. You are doing the right thing. In addition to that I will prescribe you some strong laxative you can drink that in morning it should help. Patient: Okay! Doctor: Any complains of heart burn or acidity or stomach pain? Patient: No, not really. I do get this twisty pain in my stomach sometimes which I think is mainly due to my constipation. Doctor: Yeah, you can get that kind of pain with constipation. Any cough or cold like symptoms? Any cough with sputum? Patient: No, I feel fine. Doctor: Okay, basically I don't think you have any stomach ulcer or anything, but we need to treat your constipation because I know it can be really uncomfortable.

Section header: ROS Section text: General review of system is significant for difficulty with intermittent constipation, which has been problematic recently. He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough.

Doctor: Do you take Diovan, estradiol, Norvasc, Wellbutrin? Patient: Yes, and the Wellbutrin is an inhaler. Doctor: Okay so inhaler SR? Patient: Yes. Doctor: Do you take oxygen therapy at home? Patient: Yes. Doctor: Okay.

Section header: MEDICATIONS Section text: Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.

Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: How long have you and your husband been married? Patient: Oh, at this point I don't even know how long its been. Doctor: I assume you live together? Patient: Yes, we do. Doctor: What do you do for a living? Patient: I'm a school nurse for the School Department. I love working with the children. Doctor: That's wonderful. Do you drink or smoke? Patient: No, I don't drink, and I quit smoking cigarettes about twenty five years ago. Doctor: Good for you.

Section header: FAM/SOCHX Section text: The patient is married. She lives with her husband and is employed as a school nurse for the School Department. She had quit smoking cigarettes some 25 years ago and is a nondrinker.

Guest_clinician: Any past surgeries? Doctor: It looks like she had an appendectomy along with a total abdominal hysterectomy and bilateral salpingo oophorectomy sometime ago. Guest_clinician: Okay, noted. Doctor: Oh and it looks like she had a right hip fracture back in O five after a fall.

Section header: PASTSURGICAL Section text: Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.

Doctor: Before we begin today, sir, I just need a few pieces of background information. I see here on my chart that you're thirty years old, is that correct? Patient: Yes doctor, that's correct. Doctor: Okay, and which hand is your dominant hand? Patient: I use my right hand for everything. Doctor: Now, take me through the timeline of your symptoms, please. When did everything start? Patient: I was doing well until July of nineteen ninety three. Doctor: What were your initial symptoms? Patient: I began having weakness in my right arm, and there was some neck pain too. Doctor: Okay, when these symptoms began, how did you manage them? Patient: At first, I went to a chiropractor, but after a while my arm started atrophying, and my right hand felt tight. I couldn't extend all my fingers out. Doctor: Once you noticed the atrophy and contractures, that's the tightness you were experiencing, how were you treated? Patient: After that, I went to a neurosurgeon close to my house, and he ordered an, um, C T scan of my neck. Doctor: Okay, do you have the report of that C T Scan with you today? Patient: Yes, doctor, I have it right here. They were one on the twenty fifth of September in ninety two. Doctor: Thank you, okay, this shows an intramedullary lesion at C two three, and an extramedullary lesion at C six seven. Patient: That means tumor, right? Doctor: Yes sir. Did you have neck surgery? Patient: Yeah, I have the op notes right here. Doctor: Okay, just so you know, you had a C six T one laminectomy, and they decompressed the spinal cord. How did you respond to this surgery? Patient: Well, honestly, I improved for about three months following the operation, but after that I just got worse and worse. Doctor: Once your symptoms worsened, what happened? Patient: Um, I started having this burning sensation on my left side. Doctor: Did you have any weakness, sir? Patient: Yeah, I had weakness in both my arms. Doctor: Was one side worse than the other? Patient: Yes, my right side was worse than my left. Doctor: In addition to the burning and weakness, did you have any other symptoms? Patient: Um, I had really bad balance, I felt nauseous, like I was going to throw up at all times, which I did do some, and, um, my heart was beating really fast, and my blood pressure went up really high. Doctor: After all these symptoms began, how were you treated? Patient: On, um, August thirty first nineteen ninety three I had an M R I of my neck, and I have that report right here, too. Doctor: Thank you, this shows diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. Patient: Sorry to interrupt, what does all that mean? Doctor: Well, that's more tumors in the spine. Did you have another surgery for this? Patient: Yeah, I had brain surgery. I have those notes right here, too. Doctor: Okay, so you had a suboccipital craniotomy with tumor excision, decompression, and biopsy. The biopsy showed hemangioblastoma. Patient: That's cancer, right? This was all done on September first of nineteen ninety three. Doctor: Well no, not exactly, it's a benign tumor. After this surgery how were your symptoms? Patient: I felt good, the doctors said I stabilized out. I went through some radiation procedures from September of ninety three to January nineteenth of ninety four. Doctor: How have your symptoms progressed since? Patient: I went to the NeuroOncology clinic on October twenty sixth nineteen ninety five because I was having weakness in both arms and both legs, as well as trouble swallowing food. Doctor: How much weakness was there? Patient: It was so bad I couldn't even put on a shirt, or raise my arms, or even feed myself. Doctor: Can you go up and down stairs? Patient: No, not really, but I can climb them. Doctor: How about going to the bathroom, is everything normal there? Patient: Yeah, no problems there. Doctor: Good, and what did the doctor at that clinic recommend? Patient: They were considering doing chemo.

Section header: GENHX Section text: This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94. He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention.