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GENHX

The patient is a 26-year-old female, referred to Physical Therapy for low back pain. The patient has a history of traumatic injury to low back. The patient stated initial injury occurred eight years ago, when she fell at a ABC Store. The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection. The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall. The patient gave birth in August 2008 and since the childbirth, has experienced low back pain. The patient also states that she fell four to five days ago, while mopping her floor. The patient stated that she landed on her tailbone and symptoms have increased since that fall. The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.

Doctor: When did your pain begin? Patient: I've had low back pain for about eight years now. Doctor: Is there any injury? Patient: Yeah, it started when I fell in an A B C store. Doctor: How old are you now? Patient: I'm twenty six. Doctor: What kind of treatments have you had for this low back pain? Patient: Yeah, I got referred to P T, and I went, but only once or twice, um, and if I remember right, they only did the electrical stimulation, and heat. Doctor: I see, how has your pain progressed over the last eight years? Patient: It's been pretty continuous, but it's been at varying degrees, sometimes are better than others. Doctor: Do you have any children? Patient: Yes, I had my son in August of two thousand eight, and I've had back pain since giving birth. Doctor: Have you had any falls since the initial one? Patient: Yes, I fell four or five days ago while I was mopping the floor. Doctor: Did you land on your lower back again? Patient: Yes, right onto my tailbone. Doctor: Did that make the low back pain worse? Patient: Yes. Doctor: Have you seen any other doctors for this issue? Patient: Yes, I saw Doctor X on January tenth two thousand nine, and I have a follow up appointment scheduled for February tenth two thousand nine.

ROS

As mentioned denies any oropharyngeal swelling. No lip or tongue swelling. No wheezing or shortness of breath. No headache. No nausea. Notes itchy rash, especially on his torso and upper arms.

Doctor: Hey, bud. What brings you in today? Patient: A rash on my upper arms and torso. Doctor: When did it start? Patient: Bout a day or two ago. Doctor: Any itchiness to the area? Patient: Yes, a lot actually. Doctor: Have you had episodes of shortness of breath or wheezing? Patient: No. Doctor: How about swelling to your lips, tongue, or throat? Patient: No. Doctor: And no nausea or headaches? Patient: No. Doctor: Have you applied anything to the rash? Patient: No, I thought it'd go away on its own.

PASTMEDICALHX

Essentially unchanged from her visit of 04/15/2005.

Doctor: Has anything changed in your medical history since you last visit on April fifteenth two thousand five? Patient: What do you mean by that? Doctor: Have you been diagnosed with any new medical conditions, or are you experiencing any new symptoms? Patient: Oh, no, nothing like that.

MEDICATIONS

Accutane.

Doctor: How've you been treating your acne? Patient: The dermatologist started me on Accutane. Doctor: How long have you been on Accutane? Patient: About three months now. Doctor: Have you noticed any improvements since starting it? Patient: Yeah, kinda.

CC

Confusion and hallucinations.

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

GENHX

32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.

Doctor: How is his birth history? Was he born normal? Or was there any abnormality? Guest_family: He was born at thirty two weeks. He was my fourth pregnancy, and he was around four pounds and eleven ounces. Doctor: Was he placed in an incubator? Guest_family: Yes, he was there for three weeks. He had jaundice but they didn't give any treatment for it.

PASTSURGICAL

He has not had any previous surgery.

Doctor: Have you had any surgeries in the past? Patient: Nope I have not. Doctor: Anything? Patient: No.

GENHX

Back pain after a fall.

Doctor: Hello. How are you doing today? Patient: Not great. My back is killing me. Doctor: What happened? Patient: I fell down on it. Doctor: I see. Let's do some tests to see if you damaged anything.

FAM/SOCHX

The patient has a history of inhalation on intravenous drug abuse. She is currently on methadone maintenance. She is being followed in Psychiatry for depression and substance abuse issues. She lives with a room-mate.

Doctor: When are you planning to quit your I V and inhalation drugs Mister X Y Z? Patient: I am on treatment now. They are following me up for depression issues too. Doctor: Okay yes, you are on methadone maintenance. Patient: Yes. Doctor: Who lives with you? Patient: I have a roommate.

GENHX

The patient is a 57-year-old female being seen today for evaluation of pain and symptoms related to a recurrent bunion deformity in bilateral feet, right greater than left. The patient states she is having increasing symptoms of pain and discomfort associated with recurrence of bunion deformity on the right foot and pain localized to the second toe and MTP joint of the right foot as well. The patient had prior surgery performed approximately 13 years ago. She states that since the time of the original surgery the deformity has slowly recurred, and she has noticed progressive deformity in the lesser toes at the second and third toes of the left foot and involving the second toe of the right foot. The patient is employed on her feet as a hospital employee and states that she does wear a functional orthotic which does provide some relief of forefoot pain although not complete.

Doctor: Good afternoon, ma'am. Patient: Good afternoon, doctor. Doctor: Before we begin, how old are you? Patient: I'm fifty seven years old. Doctor: Very well, and what seems to be the problem today? Patient: So, I had surgery on these feet, um, like thirteen years ago to remove bunions, but they're back now. Doctor: I see, are these bunions present on both feet? Patient: Yeah, they are. Doctor: Is one foot worse than the other? Patient: Yeah, my right foot is worse than the left. Doctor: Is the pain getting worse? Patient: Yes, and I'm so uncomfortable. Doctor: On the right foot, do you have any other pain? Or is it just because of the bunion? Patient: Well, I have some pain here, and here. Doctor: Okay, just so you know, these are the second toe, and M T P joint. This is where you're feeling the pain, right? Patient: Yes, it hurts so bad there. Doctor: There's some deformity here at the second toe as well. Patient: Yes, I see what you're talking about. Doctor: Going back to that surgery thirteen years ago, did you heal up well? Patient: Since that surgery this bunion has slowly been coming back. Doctor: I see. Patient: Please, look at my left foot, do those toes look strange to you? Doctor: Yes, you have that deformity in the second and third toes of the left foot as well. Patient: What does that mean? Doctor: It means you have some arthritis in these toes. What do you do for a living? Patient: I see. I work in the hospital. Doctor: Can I assume you're on your feet all day for work? Patient: Yes, I have to stand all day every day. Doctor: Do you wear supports, or any kind of orthotics? Patient: Yes, I wear orthotics. Doctor: Do those provide any relief? Patient: They definitely give me some relief, but I'm still in so much pain.

GENHX

She was born, normal spontaneous vaginal delivery at Woman's weighing 7 pounds 3 ounces. No complications. Prevented, she passed her hearing screen at birth.

Doctor: Hi, I will ask about some birth related questions about your baby, okay? Guest_family: Yeah, sure. Doctor: Was she born normal or cesarian? Guest_family: No cesarian, there was normal delivery. It was spontaneous too. Doctor: Where was she born? Guest_family: At the Women's. Doctor: What was her weight at birth? Guest_family: She weighed seven pounds three ounces. Doctor: Any complications? Guest_family: No. Doctor: Was there any hearing test? Guest_family: Yeah, she cleared her all her screening tests.

FAM/SOCHX

He denies tobacco or alcohol. He has what sounds like a data entry computer job.

Doctor: So, where do you work? Patient: Oh, I am a data operator for an I T company. Doctor: Okay. Doctor: Do you smoke or drink? Patient: No, I don't!

DISPOSITION

To home with his son.

Doctor: Who are going to stay with? Patient: I am going home with my son. I will stay with him.

FAM/SOCHX

He immigrated to this country in 1984, although he lists himself as having a green card still at this time. He states he lives on his own. He is a single male with no history of marriage or children and that he had high school education. His recreational drug use in the chart indicates that he has had a history of methamphetamines. The patient denies this at this time. He also denies current alcohol use. He does smoke. He is unable to tell me of any PCP. He is in counseling service with his case manager being XYZ.

Doctor: When did you move here from Philippines, sir? Patient: I think somewhere around nineteen eighty four. Doctor: Oh wow, it's been a while, do you have a green card? Patient: Yes I do have G C. My apartment is not too far from there. Doctor: Do you live by yourself? Or you married? Patient: No, I live by myself. Never been married or widowed or kids. Doctor: Okay what have you studied? Patient: I finished high school. But I do work. Doctor: Okay. Do you drink alcohol or smoke? Patient: I do smoke but no alcohol. Doctor: How about drugs? Patient: I used to but not anymore. Doctor: Which one? Patient: Meth. Doctor: Okay. Do you have a P C P? Patient: No. But I have a case manager, Mister X Y Z. He is making me go to counselling Doctor: Okay. Can I get the notes? Patient: Yes, I can ask them to send you. Doctor: Okay that will be good. Patient: Awesome!

GENHX

The patient is a 62-year-old African-American male with a significant past medical history of diabetes, hypertension, previous stroke in 2002 with minimal residual right-sided weakness as well as two MIs, status post pacemaker insertion who first presented with numbness in his lower extremities in 2001. He states that since that time these symptoms have been progressive and now involving his legs above his knees as well as his hands. More recently, he describes a burning sensation along with numbness. This has become a particular problem and of all the problems he has he feels that pain is his primary concern. Over the last six months, he has noticed that he cannot feel hot objects in his hands and that objects slip out of his hands. He denies any weakness per se, just clumsiness and decreased sensation. He has also been complaining of brief muscle jerks, which occur in both hands and his shoulders. This has been a fairly longstanding problem, and again has become more prevalent recently. He does not have any tremor. He denies any neck pain. He walks with the aid of a walker because of unsteadiness with gait. Recently, he has tried gabapentin, but this was not effective for pain control. Oxycodone helps somewhat and gives him at least three hours pain relief. Because of the pain, he has significant problems with fractured sleep. He states he has not had a good night's sleep in many years. About six months ago, after an MI and pacemaker insertion, he was transferred to a nursing facility. At that facility, his insulin was stopped. Since then he has only been on oral medication for his diabetes. He denies any back pain, neck pain, change in bowel or bladder function, or specific injury pre-dating these symptoms.

Doctor: How old are you, sir? Patient: I am sixty two year old African American. Doctor: Do you have any relevant past medical history? Patient: I do have diabetes, high blood pressure and I had a stroke in the year two thousand and two. I do have weakness on my right side after that. I also had two heart attacks. Ah. Doctor: Any history of surgery? Patient: I have a pacemaker. Doctor: It shows here that you came to us in two thousand and one for weakness and numbness in your legs. How is that now? Patient: Oh, it was never gone. Instead, it has also moved to my hands and areas above my knees. Doctor: What are your symptoms now? Patient: It's mostly like something is burning and numbness is still there. Doctor: Is that your main concern? Patient: Yeah, it is. That is my main problem. I do have pain, but it is not that much of a concern. Patient: For the last six months, I cannot feel anything hot in my hands. Things slip out of my hand. I don't have any weakness as such, but it's just like that feeling of clumsiness and it's just lots of sensation. Patient: Sometimes I feel, like, these jerks in my body, mainly my shoulders and both hands. Doctor: Has it been for some time? Patient: It has been like forever but now I am noticing it more than before. Doctor: Do you get any kind of tremors? Patient: No. Doctor: Any neck pain? Patient: No, but as you might have noticed I am using this walker because I do not feel safe walking. Doctor: Have you used anything for your pain? Patient: Yeah, they tried different medicines but only oxycodone helped a little. It does give me sometimes around three hours of relief. Gabapentin did not work at all. Doctor: How is your sleep? Patient: I cannot sleep properly because of the pain. It has been for many years. I haven't had a proper sleep. Doctor: When did you get your pacemaker? Patient: It was around six months ago after the heart attack and pacemaker I was transferred to a nursing home. There they stopped my insulin and since then, I'm taking tablets for that. Doctor: Do you have any back pain? Patient: Nope. Doctor: Any change in bathroom routine? Patient: No. Doctor: Did you ever have any accidents or any injury before all this started? Patient: No, nothing like that.

CC

The patient does not have any chief complaint.

Doctor: Hi, how can I help? Patient: No, I just came in for follow up. Doctor: Okay so just a follow up today. No complaints? Patient: Nope. Nothing. Doctor: That's great.

ROS

Patient is hard of hearing. She also has vision problems. Denies headache syndrome. Presently, denies chest pain or shortness of breath. She denies abdominal pain. Presently, she has left hip pain and left shoulder pain. No urinary frequency or dysuria. No skin lesions. She does have swelling to both lower extremities for the last several weeks. She denies endocrinopathies. Psychiatric issues include chronic depression.

Doctor: Just to go over few things let me ask, any aches and pains? Patient: Currently I just have left hip pain and shoulder pain. Doctor: Oh, how bad is it? Patient: Pretty bad. Doctor: What else is going on? Patient: I have this leg swelling from last couple weeks. Doctor: Any new skin lesions on your legs from the swelling? Patient: No. Doctor: How about problems with urination and abdominal pain? Patient: No problems with urination. Doctor: How about chest pain or shortness of breath or hormonal imbalances? Patient: No I don't have any such problems, except I have vision and hearing problems. Doctor: You have chronic depression right? Patient: Yes that is correct. Doctor: Any sort of headaches? Patient: No. Doctor: What about thyroid dysfunction?

FAM/SOCHX

lives with parents and attends mainstream 5th grade classes.

Doctor: Hi there! I am Doctor Frankland. Patient: Hi. It is nice to meet you. Doctor: How are you today? Patient: I'm good. Doctor: Do you live at home with both of your parents? Patient: Yes. Doctor: What grade are you in? Patient: Firth grade. Doctor: Mom, is he in public school? Guest_family: Yes. Doctor: Is he enrolled in any special education classes? Guest_family: No. He is in all the regular mainstream classes. Doctor: Great!

GENHX

The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position. It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over. Lorazepam did not help this sensation. His blood pressure has been up lately and his dose of metoprolol was increased. They feel these symptoms have gotten worse since metoprolol was increased.

Doctor: What brings you here today, sir? Patient: I'm feeling a lot of lightheadedness and I just cannot keep stable. I'm losing my balance all the time. Doctor: Do you have any spinning sensation? Patient: No, but I had it before when I had vertigo. I'm just feeling lightheaded. Doctor: Is it happening after anything special you are doing? What symptoms are you witnessing? Patient: Whenever I'm trying to change my positions like standing from sitting or getting up from the bed it is happening. Normally sitting back down helps. But it is not completely gone for like fifteen to thirty minutes. I feel very shaky and weak. Doctor: Are you taking any medications for that? Patient: Ah yes, I was taking lorazepam, but it did not help with the sensation. Doctor: Anything else going on? Patient: Um, my blood pressure was up so they increased my dose of metoprolol for it. They think all these symptoms are because of the increased dose. I just wanted to check in with you as well.

MEDICATIONS

No medications other than recent amoxicillin.

Doctor: Are you taking any medication? Guest_family: Yes, I am taking that antibiotic. Doctor: Oh yes! Guest_family: Yeah. Doctor: Yes, you are taking amoxicillin. Guest_family: That's right.

DIAGNOSIS

1. Bipolar disorder. 2. Iron deficiency anemia. 3. Anxiety disorder. 4. History of tubal ligation.

Guest_clinician: I see that the patient was in yesterday. Doctor: Yes, she's a frequent flyer. Guest_clinician: What's her medical history? Doctor: She suffers from bipolar disorder and anxiety. She's also anemic and not on any iron supplements. As for surgeries, she's had her tubes ligated.

FAM/SOCHX

He is a non-cigarette smoker and non-ETOH user. He is single and he has no children. He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.

Doctor: Do you smoke? Patient: No, I do not. Doctor: How about alcohol. Patient: No, I don't drink alcohol as well. Doctor: Okay let me ask you, do you have any children or are you married? Patient: No, I am single, thus no kids. Doctor: Okay, where do you work? Patient: I work as a payroll representative. I used to do a lot of work in jewelry business, with chemical. Doctor: interesting. Patient: Yeah.

EDCOURSE

The patient was seen in the urgent care and examined. At this time, her photophobia and nausea make migraine highly likely. She is well appearing and we'll try Tylenol with codeine for her pain. One day off school and follow up with her primary doctor.

Doctor: I looked over your report from urgent care. Patient: They didn't do much other than tell me to follow up with you. Doctor: Given that you're sensitive to light and feel nauseated, I believe a migraine is highly likely. Patient: Can I take anything for it? Doctor: I'm going to prescribe you Tylenol with codeine to help your pain. Patient: Can I get a doctor's note, too? Doctor: Yes. In fact, I'd like you to take a day off from school and rest until you start to feel better. Patient: Okay. Thank you.

MEDICATIONS

Include Cipro and Flagyl.

Doctor: Let me write you a prescription for Cipro and Flagyl. Patient: Okay.

GENHX

This is a 51-year-old right hand dominant female with a longstanding history of pain as well as locking sensation to her right thumb. She was actually able to spontaneously trigger the thumb. She was diagnosed with stenosing tendinosis and wishes to proceed with release of A1 pulley. All risks and benefits of the surgery was discussed with her at length. She was in agreement with the above treatment plan.

Doctor: Hello, ma'am. How are you doing today? Patient: My right hand hurts. Doctor: Is that your dominant hand? Patient: It is. Doctor: I see. What seems to be the problem? Patient: I feel like my right thumb just locks up, and I can't move it anymore. Doctor: Does it stay locked? Patient: No, it doesn't. It just moves out of nowhere. Like right now! Doctor: I can see that. Have you seen someone about your thumb before? Patient: I have. These are the notes from that visit. Here you go. Doctor: Thank you. It looks liked you were diagnoses with stenosing tendinosis, which is trigger finger. Patient: Is that common for a fifty one year old woman like me? Doctor: Yeah, it is. We can proceed by releasing the A one pulley? Patient: Could you describe what that means? Could you also go over the risks and benefits of the surgery? Doctor: Of course. I'll explain it and give it to you in writing. Patient: Thank you. I'll most likely agree to it. I need to fix this thumb.

GENHX

The patient is keeping a food journal that she brought in. She is counting calorie points, which ranged 26 to 30 per day. She is exercising pretty regularly. She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia. The patient requests information on diabetic exchanges. She said she is feeling better since she has lost weight.

Doctor: Are you keeping up with your food journal? Patient: Yes, and I have it with me today. Doctor: Good, and you're using calorie points, correct? Patient: Yes, I range from twenty six to thirty. Doctor: Good, are you exercising regularly? Patient: Yes, I am. I'm also going to Overeaters Anonymous. Doctor: How is that going? Patient: Good, my sponsor is helping me, and told me to think about snacks that can help with my high blood sugar. That was what we talked about last. Doctor: Good, all of that is good to hear. Patient: I'm feeling a lot better, and I've lost weight, but do you have any information on diabetic exchanges, doctor?

FAM/SOCHX

Noncontributory.

Guest_clinician: Any significant family history of disease? Doctor: None according to my records.

PASTSURGICAL

Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.

Doctor: Have you ever had surgery? Patient: One too many times. Doctor: Which ones? Patient: I had my appendix taken out and glaucoma surgery fairly recently. I also had my gallbladder taken out ten years ago and a partial colon resection due to colon cancer in nineteen sixty one. Doctor: Any recurring episodes of colon cancer? Patient: No, thankfully.

PASTSURGICAL

The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative.

Doctor: What is your surgical history? Patient: I had cataract surgery on both eyes. I also had knee replacement surgery on my left knee.

FAM/SOCHX

Family history is remarkable for heart disease, cerebrovascular disease, diabetes, and hypertension.

Doctor: Hi, there. How are you doing? Patient: I think I have some sort of condition. Doctor: Why do you say that? Patient: My body has been feeling weird lately. Doctor: I see. Is there anything that runs in your family? Patient: I know a lot of my family has some sort of heart problem. We have high blood pressure and blood sugar. There's one more thing. It starts with a C. Something to do with the brain. Do you know? Doctor: Is it cerebrovascular disease? Patient: There you go. How'd you get that so fast? Doctor: I guess I know my stuff.

GENHX

This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine. The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.

Doctor: Hi mister Jones. Do you remember me from the last time you were here? How old are you now? Patient: I am fifty two. Yes doc. I remember you. Doctor: What have you been using most recently? I need to know what kind of drugs we are dealing with. Patient: I gotta kick the heroin. It's going to kill me this time. Please help me. My whole body hurts. I am so cold. Doctor: Okay. Is there anything else that you been using recently? Alcohol? Pills? Patient: I did some coke. It's this heroin that is going to get me. I used to abuse alcohol, but now I have switched to drugs.

FAM/SOCHX

Noncontributory.

Doctor: Anyone sick in your family? Patient: No one. Doctor: Okay. Patient: Everyone is healthy.

FAM/SOCHX

His father died of colon and thyroid cancers at age 52. One brother died of stomach cancer at age 53 and one brother committed suicide. Five other siblings are all healthy. Negative for coronary heart disease, hypertension, diabetes, or kidney disease.

Doctor: Tell me a little more about your family. Are there any significant conditions that your parents or siblings had that you know of? Patient: Um, my dad died a few years back. He had color cancer and thyroid cancer. Doctor: I'm so sorry to hear that, sir. How old was he? Patient: Thank you, he was only fifty two. Doctor: That's tragic, I'm sorry. What about your siblings? Patient: I have seven total. One of my brothers died from stomach cancer when he was fifty three and another brother committed suicide. Doctor: I'm so sorry to hear that. Can I assume your other siblings are healthy? Patient: Yes sir, they're all doing very well. Doctor: That's good. Do you have any other conditions, like heart disease, high blood pressure, diabetes, or kidney disease? Patient: Nope, I keep pretty healthy.

PLAN

1. Take medications regularly. 2. PT, OT, speech therapist to evaluate and treat at Siskin Rehab Hospital. 3. Continue Cipro for an additional two days for his UTI.

Doctor: I have sent over your referral for physical therapy, occupational therapy and speech therapy. The patient coordinator at Siskin Rehab Hospital will give you a call within two days to see up your appointments. It is important to take your medications regularly. You need to continue the Cipro for an additional two days only. That will take care of the U T I. Do you have any questions? Patient: No.

FAM/SOCHX

Mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old.

Doctor: Can you tell me about cancer in your family? Patient: Yes, my mom had stomach cancer and she died at fifty nine. Doctor: And father? Patient: My dad died at ninety one years of age. Doctor: Okay.

PASTMEDICALHX

Negative. Generally very healthy.

Doctor: Does she have any past medical history or health problems? Guest_family: No. She is a healthy child.

LABS

All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122. Urine pregnancy test was negative.

Doctor: I looked at your labs. Everything looks normal for the most part. You do have abnormal levels for Sodium and Creatinine which are related to your kidneys. Then your thyroid levels are not normal as well. Patient: How about my E K G? I had a negative pregnancy test. Doctor: Oh yes that. Your E K G showed a higher heart rate of one twenty two per minute. We will evaluate everything further.

GENHX

The patient returns today for a followup. She was recently in the hospital and was found to be septic from nephrolithiasis. This was all treated. She did require a stent in the left ureter. Dr. XYZ took care of this. She had a stone, which was treated with lithotripsy. She is now back here for followup. I had written out all of her medications with their dose and schedule on a progress sheet. I had given her instructions regarding follow up here and follow with Dr. F. Unfortunately, that piece of paper was lost. Somehow between the hospital and home she lost it and has not been able to find it. She has no followup appointment with Dr. F. The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc. Later she apparently found the prescriptions and they were filled. She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take. She had no clue as to seeing Dr. XYZ again. She says she is still not feeling very well and feels somewhat sick like. She has no clue as to still having a ureteral stent. I explained this to she and her husband again today.

Doctor: Good morning. So, you are here for your follow up today. Patient: Yes, sir. Doctor: Update me what happened, why were you in the hospital? Patient: I had a lot of back pain and less of urine output. I always had burning sensation whenever I used to go to the bathroom. So, I went to the doctor, and they said it is kidney stones. I knew something was wrong, but then I started having fever. So, I went to the hospital and they said that it was infection. It all began with my kidney stones. Doctor: I see. So how are you feeling now? Patient: I'm feeling better. The burning sensation is gone. Pain has subsided. Doctor: It says that they put a stent in your ureter. Are you feeling any discomfort with it? Who was your doctor there? Patient: No discomfort, I'm just here for my follow up. Doctor X Y Z did operate on me to remove all those stones, the kidney stones. She is a good doctor. She did take care of me. I feel all new now. Doctor: That's nice to hear. I'm glad you are feeling okay. You remember I wrote down all the medications with their doses on your progress note, a sheet that we gave to you. Your nephew called me and he said that the prescription was lost and instructions were lost. What happened there? Patient: I don't know. I remember you gave me a paper saying it has all the medicines. It's everything related to them and all the things that I have to do. But I don't know what happened between the hospital and the home. I completely lost it. And I don't know where did it go. Doctor: It had instructions to follow up here and also to follow up with Doctor F. Do you have an appointment with Doctor F? You never did call me after the day you were dismissed from the hospital saying that you might have lost the paper that we gave to you. Patient: No, unfortunately I don't have any appointment with Doctor F. I was not even aware about that, that I have to take an appointment because maybe it was only there in the paper. It completely got out of my mind. Somehow, I did find the prescription paper where all the medicines were and I was able to get them filled and I was taking all my antibiotics and everything else which was there. Doctor: I think it was Levaquin. Do you have any more to take? Patient: I do have one more to take. Doctor: So, when are you seeing Doctor X Y Z? Patient: Do I have to see her? I haven't set up anything. Doctor: You do. Any other issues? Patient: Yeah, I'm not still feeling very well. I still feel that I'm sick or something like that. It's just that I didn't get my whole self back. You said I got a stent. I have no idea. I don't feel like having one. Doctor: Are you the husband? Guest_family: Yes, I am. I just wanted to be here with her today. Doctor: That's good. Okay, let me explain it to both of you once again. See, she got a ureteral stent. It means that the doctors there, they have made a pathway for the urine to flow around the kidney stone without blocking anything. So, it is to help her overall. She needs to take her medicines and make her appointment with Doctor F. Also, she does need to see if Doctor X Y Z needs a follow up. You can call them and ask. Other than that, everything seems fine. Patient: Yep. I will make those appointments. Thank you for your guidance. Doctor: Take care.

FAM/SOCHX

Father died at age 85 of "old age," mother died at age 89 of "old age." Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease. Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.

Doctor: I'd like to know more about your family's medical history. Patient: Buckle up. This is a long one. My son is fifty eight and he suffers from glaucoma, high cholesterol, high blood pressure, and R A. My eldest brother passed away at ninety two due to old age and my two younger brothers followed in their seventies after a long battle with Parkinson disease. Doctor: I'm incredibly sorry to hear that. Patient: It's alright. Both my mom and dad died in their mid eighties from old age. I think my dad was eighty five and my mom eighty nine.

GENHX

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

Doctor: How are you related to the patient? Guest_family: I am his friend; I work with him in a coffee shop. He works as a cook there. Doctor: Can you tell me your age? Patient: I'm forty one. Doctor: Can you tell me what exactly happened? Guest_family: He was cooking, and the hot oil splashed onto his arm. Doctor: Did this happen in the coffee shop kitchen? Patient: Yes. I don't know how the oil splashed but burned my hand. I tried to let it cool down, but the pain was unbearable. I asked my friend to take me to the emergency department here. Doctor: So, this will be the workers' compensation for injury. Patient: I guess, yeah. Doctor: OK, let me see your hand. Patient: OK. Doctor: The burn is from the elbow to the wrist. It is mainly on the medial aspect. Doctor: OK, don't worry. We will take care of you.

DISPOSITION

To home.

Doctor: Are you ready for home? Patient: Yes. Doctor: Who will help at home? Patient: Just my family. Doctor: That is great. Patient: Thanks.

ASSESSMENT

1. Multiple problems including left leg swelling. 2. History of leukocytosis. 3. Joint pain involving the left shoulder, probably impingement syndrome. 4. Low back pain, chronic with obesity. 5. Obesity. 6. Frequency with urination. 7. Tobacco abuse.

Doctor: It looks like your white blood cell count is normal according to your most recent labs. But, I do want to keep an eye on it given your history of high white blood cells. Patient: That's good to hear. I'm glad that it's back to normal. Patient: However, I must say that I've been having a lot of pain over the past several days. Doctor: Where's the pain located? Patient: It's mainly my left shoulder and lower back. Doctor: Oh, I see. Have you been taking anything for the pain? I remember you were having problems with your lower back the last time you were here. Did you get a chance to see the orthopedist? I believe the left shoulder pain could be due to impingement syndrome. Patient: No, I haven't taken anything for it yet and I forgot to make an appointment with the doc you recommended. I've been smoking cigs to help with the pain. Doctor: I'd advise that you try to wean off smoking for now and consider looking into nicotine patches. Let me see what I can do for the pain and if we can schedule you to see an orthopedist. Patient: Thanks, doc. I've had a lot of trouble weaning off cigs for a while now. I've also been eating pretty bad, too. I got to do better. Doctor: It'll take time, but with the right diet and regimen, you'll be on better track towards attaining a healthy weight and lifestyle. Patient: Oh, and before I forget- Doctor: Yes? Patient: I seem to be peeing a lot more these days. Doctor: Are you experiencing any other urinary symptoms? Patient: No, nothing else. Doctor: I'll order a urine sample for today's visit to see if you have an infection. Patient: Thank you, doc. And before you write the order, do you know why my one leg is more swollen than the other? Doctor: Let me take a look.

PLAN

Activity is as tolerated. Diet is as tolerated.

Doctor: How are you feeling? Patient: I feel good. I feel like I am getting stronger every day. Doctor: Great! I would like you to continue your exercises at home but please take it slow. Try to stick to the diet we discussed for the next month. Do you have any questions? Patient: No.

GENHX

He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm. He says that he has been stung by wasps before and had similar reactions. He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past. He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.

Doctor: Hello, sir. What brought you in today? Patient: Do you not see the swelling on my right hand and arm? I'm white. The swelling should be noticeable! Doctor: Oh, wow! How did this happen? Patient: I got stung by this huge Yellow Jacket Wasp yesterday. I usually see Doctor X Y Z, but he wasn't available. Doctor: I see. Have you ever been stung by a wasp before? Patient: Oh, yeah. Plenty of times. I'm twenty nine right now. I've been getting stung since I was in my early twenties. I usually just swell up like I am right now. Doctor: That's good. You never had any severe reactions before? Patient: I did one time before, which is why I came here early to get it checked out. Doctor: I see. Just a lot of swelling, correct? What about any anaphylaxis type reactions? Patient: What type of reaction? I don't know what that means, but you're right about the swelling. Doctor: It's a reaction that occurs that makes your body go into shock and lowers your blood pressure. Patient: Oh, I get you. No, I've never experienced that before. Doctor: Great. Have you ever felt a shortness of breath or your throat closing up before? Patient: Nope. That would be really scary though. Doctor: Sounds good. Have you ever felt anxious or a fast heart beat after you've been stung? Patient: No, I haven't. I've only had swelling in the areas I've been stung.

EDCOURSE

The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.

Doctor: Are you in pain? Patient: Yes, I want something strong for this. Doctor: We can give you a shot. Patient: Yes please. Doctor: Okay nurse, give her Dilaudid of 4 M G I M. Patient: Thank you. Doctor: How are you now? Any bad side effects? Patient: No I feel much better.

FAM/SOCHX

The patient denies smoking cigarettes. The patient does drink alcohol and also uses illicit drugs.

Doctor: Do you smoke cigarettes? Patient: No. No cigarettes. Doctor: Do you drink alcohol or use recreational drugs? Patient: I drink alcohol and I smoke weed from time to time.

FAM/SOCHX

The patient has been a smoker since the age of 10. So, he was smoking 2-3 packs per day. Since being started on Chantix, he says he has cut it down to half a pack per day. He does not abuse alcohol.

Doctor: Are you a smoker? Patient: Yes. I do not drink if that is any constellation. Doctor: How much do you smoke per day? Patient: I just started taking Chantix and now I am down to a half a pack a day. Doctor: How much did you smoke per day prior to starting Chantix? Patient: I was smoking about two to three packs a day. I have been smoker since I was ten years old.

MEDICATIONS

Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily.

Doctor: Let me add Flagyl intra venously. It will be five hundred M G every eight hours and I would also like to add Levaquin five hundred M G daily. Patient: Okay.

ROS

No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits.

Doctor: Any difficulty in hearing? Patient: No. Doctor: Difficulty swallowing? Patient: Um no. Doctor: Any double vision or blurred vision or difficulty seeing things properly? Patient: No, no problem at all. Doctor: Okay. Doctor: How about headaches or migraine? Patient: No headache. Doctor: Did you notice any change in your bowel moment? Patient: No, it is the same. Doctor: Any pain while urinating or change in frequency? Patient: No. Doctor: Okay.

ROS

The remaining ROS is unremarkable.

Guest_clinician: I did a review of her systems, and everything looks normal other than what was mentioned earlier. Doctor: Okay, thanks for your help. Guest_clinician: No problem.

PLAN

Daily applications of Acticoat, pressure relief, at least getting out of the chair for half of the time, at least eight hours out of the chair, and we will see her in one week.

Doctor: Okay, so let's go over the plan again. I'd like you to apply Acticoat dressing daily and make sure you're spending at least eight hours out of the chair for pressure relief. Any questions? Patient: That sounds doable. I'll try my best. No questions about the plan. Doctor: I'd also like you to come back in a week for a reevaluation. Patient: Can I make that appointment today? Doctor: Yes, the receptionist will be able to get you on the schedule for next week. Patient: Great.

ASSESSMENT

Substance abuse.

Doctor: When are you planning to quit? Patient: I always plan to do it. Doctor: Okay let me refer you to a substance abuse clinic because you need it. Patient: Okay, I will look at it. Doctor: Sure. But please try to stop your substance abuse. It is a bad habit. Patient: Yes.

FAM/SOCHX

Denies history of Tobacco/ETOH/illicit drug use.

Doctor: Do you have a history of tobacco, alcohol or recreational drug use? Patient: No.

GENHX

A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache. Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved. She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay. She continues to have some left-sided jaw pain. Denies any headache, fever, cough, or sore throat. She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that. She has also had problems with sinusitis in the past and chronic left-sided headache.

Doctor: How are you Miss G? Patient: I am good doctor, thank you for asking. Doctor: So, tell me what is going on? Patient: I have this ear pain and headache for some time. It's better than before but I still want to get it checked. Doctor: Okay, when exactly did it start? Patient: Um, almost three weeks ago. I am having difficulty hearing. I also feel this pressure on the left side of my sinus causing tooth pain. I went to my dentist yesterday, but my teeth are fine. Doctor: Okay, do you have headache now? Patient: No, just ear pain and this jaw pain on the left side. Doctor: Any fever, cough, sore throat, or any cold like symptoms? Patient: No, but I have a sinus problem and I suffer from chronic left sided headache. Doctor: How old are you? Patient: Oh, I am forty nine. Doctor: Hm, so are you taking any medications for your pain? Patient: No, currently I am just using Cutivate for my eczema. It has helped me a lot, I do need a refill for it. Doctor: Okay I will send a prescription for it to your pharmacy.

ROS

PSYCHIATRIC: See psychiatric evaluation.

Doctor: So, I have the evaluation report from your psychiatrist. Patient: Ah, okay and what does it says? Doctor: Well, he thinks you are doing really good. Patient: Nice!

GENHX

Daily headaches for 6 months in a 57-year-old.

Doctor: How are you today? Patient: I am doing okay. Doctor: Just to confirm, you are fifty seven years old? Patient: Yes. Doctor: What brings you to see me today? Patient: I have been having these headaches every day for the last six months. Doctor: That is a long time. I am sorry that you have been experiencing that. Patient: Well, I am hoping you can make them stop. Doctor: I will do my very best to help.

FAM/SOCHX

Ms. A had difficulty providing information on familial medical history. She reported that her mother died three to four years ago from lung cancer. Her father has gout and blood clots. Siblings have reportedly been treated for asthma and GI tumors. She was unsure of familial history of other conditions such as hypertension, high cholesterol, stroke, etc.

Doctor: Welcome to the office, Miss A. I am Doctor Luna. Patient: Thank you. It is nice to meet you. Doctor: What is your family medical history? Patient: My mother died about three or maybe it is four years ago? Doctor: I am so sorry to hear that. How did she pass? Patient: She had lung cancer. My mom didn't talk much about her own health problems. Doctor: What about your father? Does he have any health conditions? Patient: My dad has gout. I think he also had blood clots. That is all that I can remember my dad talking about. Doctor: Do you have siblings? Patient: Yes. My brother has asthma and uses an inhaler. My sister had some sort of tumors removed from her stomach or something. Oh, I think I remember my mom talking about some of her family having issues with high blood pressure, high cholesterol and someone had a stroke. I am not sure though. Doctor: Okay.

MEDICATIONS

None.

Doctor: Are you taking any medications? Patient: No. Doctor: Any over the counter drugs or anything? Patient: None. Doctor: Okay.

FAM/SOCHX

Non-contributory

Doctor: Do you know any familiar diseases in your family? Patient: Do you mean like B P, high sugar? Doctor: Yes. Patient: No, no one in my family has anything like that. Doctor: Great.

GENHX

This is a 53-year-old man, who presented to emergency room with multiple complaints including pain from his hernia, some question of blood in his stool, nausea, and vomiting, and also left lower extremity pain. At the time of my exam, he states that his left lower extremity pain has improved considerably. He apparently had more significant paresthesias in the past and now he feels that the paresthesias have improved considerably. He does have a history of multiple medical problems including atrial fibrillation, he is on Coumadin, which is currently subtherapeutic, multiple CVAs in the past, peripheral vascular disease, and congestive heart failure. He has multiple chronic history of previous ischemia of his large bowel in the past.

Doctor: Hi sir, let me start by getting your age. Guest_family: He is fifty three! Doctor: So, tell me what's going on? Guest_family: He is complaining of so many things but- Patient: But I have a lot of pain from my hernia. That's the number one complaint, but I am also having pain in my lower legs. Guest_family: He has so many issues going on with him, that is why I got him to emergency. Patient: My wife freaks out easily. Doctor: Don't worry, let me take a look. So, any nausea and or vomiting? Patient: Yes both. And I am not sure, but I think I noticed some blood in my stool. Doctor: Oh, but you are not sure? Patient: It is questionable! Doctor: I see. And on the scale of one to ten, ten being severe, how will you rate your lower extremity pain? Patient: Actually, my leg pain has improved considerably. I did have more significant tingling and numbness in the past but now it has improved a great deal. Doctor: Hm. Guest_family: He has so many medical issues. Here, I have gotten his reports. You can look at them Doctor. Doctor: Oh, that's great, thank you for getting these, let me go through them quickly. So, I see you have a history of multiple- Guest_family: Strokes? Doctor: Yeah, also called as C V A. Peripheral vascular disease. Oh, and heart failure too. Guest_family: Yes. Patient: Yeah. Doctor: And you also have a history of multiple bowel ischemia. Patient: Well, yeah. Doctor: There is a reason why your wife is worried. So, are you taking any medicines currently? Guest_family: He is taking Coumadin for his atrial fibrillation. Also, they mentioned it's not optimal for his condition but- Doctor: Oh, I see its subtherapeutic. Patient: Yeah, but I am still taking it.

PASTSURGICAL

Back surgery, shoulder surgery, and appendicectomy.

Doctor: Do you have any prior history of surgeries? Patient: I had surgery on my back and shoulder after a bad skiing accident. Doctor: How long ago did you have those surgeries? Patient: About three to four years ago. Oh, I had my appendix removed when I was a teenager.

ALLERGY

She has hay fever, eczema, sinus, and hives. She has no melanoma or skin cancers or psoriasis. Her mother had oral cancer. The patient is a nonsmoker. No blood tests. Had some sunburn in the past. She is on benzoyl peroxide and Daypro.

Doctor: So, ma'am, what brings you in for a visit today? Patient: Well, a few things, I have hay fever, um, eczema, sinus problems, and hives. Doctor: Wow, that's quite a lot. Do you have any history of melanoma, or skin cancer? Patient: No, just the eczema. Doctor: How about psoriasis? Patient: No, that doesn't ring any bells. Doctor: Do you have any family history of cancer? Patient: Um, yes, my mother had mouth cancer. Doctor: I see, do you smoke tobacco? Patient: Um, no, that never appealed to me, especially with the history of cancer. Doctor: Can I safely assume that you've been sunburned before? Patient: Sure, it happens when I go to the beach all the time. Doctor: What medicines are you taking right now? Patient: Um, I'm taking benzoyl peroxide and Daypro. Sorry I forgot to bring the blood test today.

GENHX

Ms. ABC returns today for followup regarding her cervical spinal stenosis. I have last seen her on 06/19/07. Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects. I referred her to obtain a cervical spine MRI. She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck. She had some physical therapy, which has been helping with the neck pain. The right hand weakness continues. She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity. She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her. She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms. She denies any bowel and bladder dysfunction. No lower back pain, no lower extremity pain, and no instability with ambulation.

Doctor: Hello, this is my assistant, and she will be working with me today for your care. Can you please represent the patients case? Guest_clinician: This is Miss A B C. She's here for her follow up regarding her cervical spinal stenosis. She was seen by you on nineteenth June. She had an incident on fourth of June, when she lifted many objects and experienced exacerbated symptoms. She is experiencing paresthesia, weakness, and pain in her upper extremities on the right side more than the left since then. She was referred for a cervical spine M R I. Doctor: So, how are you feeling today? Patient: I'm still having all those things like pain and weakness, and I believe that everything is coming down from my neck. Doctor: Did you get some physical therapy? Did it help? Patient: I did some. It was helping me with my neck pain. But this right hand is still feeling weak. I feel it is difficult at times to open jars and open doors. Many times, I drop items. Doctor: Is it happening with both hands or one is more than the other? Patient: Right side is giving me more problems than the left. Doctor: Anything else that you noticed? Patient: Yeah, one more thing I noticed is that sometimes when I am sleeping in the night, I feel this sharp shooting pain and weakness. It goes down my left side of upper, I mean, whole hand and I feel scared after that. Doctor: Are you seeing anyone for that? Patient: Yeah, Doctor X is trying to help me, uh, with that without surgery. His methods are good it and it is helping me with my neck pain, but not hand. Doctor: Are you having any issues with your bowel movements? Patient: Nope. Doctor: Any pain in the lower side of your back or in your legs? Patient: Nope. Doctor: Any problem with walking or stability? Patient: Nope.

ROS

Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies. He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities.

Doctor: How is everything else? Patient: Fine. Doctor: Anything from head to toe? Patient: I have a shoulder issue. Can you check? Doctor: Okay, just to check back you do not have any heart, lung, stomach, hormonal issues? Patient: Nope. Doctor: Any other muscles or bone problems? Patient: None. Doctor: Okay. So, I think you have lateral side and back side cervical nerve problem going on. We call it radiculopathy, which is focal. Patient: Okay.

PASTSURGICAL

Significant for his trauma surgery.

Doctor: Did you had any surgery in the past? Patient: Yes, I had this major trauma surgery some time back.

GENHX

The patient is a 19-year-old male who was involved in a fight approximately an hour prior to his ED presentation. He punched a guy few times on the face, might be the mouth and then punched a drinking glass, breaking it and lacerating his right hand. He has three lacerations on his right hand. His wound was cleaned out thoroughly with tap water, and one of the navy corpsman tried to use Superglue and gauze to repair it. However, it continues to bleed and he is here for evaluation.

Doctor: How old are you young man? Patient: I am nineteen. Doctor: What happened? How did you get hurt? Patient: I was in a fight. Some people are just rude. Doctor: Oh, that's bad! How did you hurt your right hand? Patient: Ah, I punched that other guy in face or maybe his mouth, I don't remember exactly but he got a good one. Later, in anger I punched in a glass. It broke the glass and spilled all the drink. I think I got a cut as it was bleeding badly. Doctor: I see three cuts in your right hand. Doctor: When you came here in Emergency your wound was clean and looked like somebody tried to fix your cut. Do you remember any details about it? Patient: Yeah, I remember there was a navy corpsman. He was very helpful; he cleaned my cut with the tap water. He also tried to close it up with gauze and superglue. He said it will stop bleeding, but nothing helped. They called for help and here I am in emergency.

ALLERGY

She has hay fever, eczema, sinus, and hives. She has no melanoma or skin cancers or psoriasis. Her mother had oral cancer. The patient is a nonsmoker. No blood tests. Had some sunburn in the past. She is on benzoyl peroxide and Daypro.

Doctor: Hello, miss. How are you doing today? Patient: My skin has been going crazy. Doctor: Could you describe to me what's happening? Patient: I can't really describe it, but I can show you. Here's a report from my local doctor. Doctor: I see. It says you have hay fever, eczema, sinus problems, and hives, correct? Patient: Yeah, I guess so. Doctor: Does this run in your family? Patient: Uhm. I don't think so. I know my mom has some type of cancer in her mouth. Doctor: I see. Have you been screened for cancer before? Patient: Oh, yeah. Here's the report with all that information. Doctor: This looks good. It says you don't have melanoma or skin cancers or psoriasis. Patient: Sounds good to me. So, what's all this stuff on my skin? Doctor: Hm. Let me take a look. Have you been sunburned before? Patient: Oh, yeah. I had some and it burned a lot. Doctor: I see. Are you currently taking any medications? Patient: It's on the report from my local doctor. Doctor: Looks like you're taking benzoyl peroxide and Daypro. You're not smoking with these medications, right? Patient: Do I look like I smoke? I've never smoked in my life.

PASTSURGICAL

Unknown.

Doctor: Has she had any surgeries in the past? Guest_family: I couldn't tell ya even if I wanted to. I have no clue, sorry. Doctor: Is there someone we could call who might know? Guest_family: I can't think of anyone off the top of my head. Maybe her daughter? But she's outta town right now.

PASTSURGICAL

Cholecystectomy without complication

Doctor: Do you have a history of any surgical procedures? Patient: I had my gallbladder removed. Doctor: Did you have any complications with the surgery? Patient: No.

ROS

The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.

Doctor: Any fever, chills? Patient: No. Doctor: How about cough cold symptoms? Patient: Nope no problems like that. Doctor: Okay. Any chest pain or breathlessness? Patient: No, I don't have chest issues. Doctor: Any problems with bowel or bladder? Patient: No. Doctor: Pain in neck or head or hand, feet or anywhere? Patient: No everything is fine.

ALLERGY

None.

Doctor: Are you allergic to anything, food or medicines? Patient: No allergies that I know of.

ROS

HEENT: See has had headaches, and some dizziness. She denies any vision changes. CARDIAC: She denies any chest pain or palpitations. RESPIRATORY: She denies any shortness of breath. GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis. NEUROLOGICAL: She denies any neurological deficits. All other systems were reviewed and were negative unless otherwise mentioned in HPI.

Doctor: How many days has it been since your headaches started? Patient: About two days now. Doctor: How long do they normally last? Patient: A couple hours. Doctor: Any nausea or vomiting with the headaches? Any vision changes? Patient: Yeah, it's been pretty consistent. No vision changes. Doctor: Have you tried to take anything for it? Patient: No, nothing. Oh and I have some dizziness with the headaches, too. Doctor: How would you describe the dizziness? Room spinning? Patient: Um kind of. Doctor: Is this new for you? Patient: Yeah. I've never had headaches like this before. Doctor: Do you have any chest pains or an irregular heart beat? Patient: No. Doctor: Any numbness or tingling on any part of your body? Patient: No. Doctor: Okay. How is your urine and feces? Any blood? Any diarrhea? Patient: None, thankfully.

PASTMEDICALHX

Hypertension, depression, and osteoporosis.

Doctor: Do you have any medical conditions that I should know about? Patient: Actually yes, I have high blood pressure and, um, depression. Doctor: That's good to know, thank you. What about your bones? Patient: Um, yes, I have osteoporosis too.

FAM/SOCHX

She lives with her husband. She is a nonsmoker and no history of drug or alcohol abuse. She does drink two to three drinks daily. She completed 12th grade.

Doctor: Hello, I will ask you a few basic questions, okay? Patient: Okay. Doctor: What is your living status? Do you live alone or with family? Patient: I am with my husband. Doctor: What is your education level? Patient: I cleared my twelfth grade but never joined college after that. Doctor: Um, did you ever take any kind of illicit drugs? Patient: Nope. Doctor: Any chronic drinking habit or smoking? Patient: No, I never smoked, and I do take two or three drinks daily but nothing like being alcoholic.

GYNHX

She does not bleed. She has both ovaries, as well as her uterus and cervix. She is on no hormonal therapy.

Doctor: Hello, miss. What brings you into the practice today? Patient: I have been missing a lot of periods and I am not sexually active. I do not bleed. Is something wrong with me? Doctor: What is your history with your reproductive parts? Have you had any surgeries? Patient: I have everything still. I have both ovaries, I have a uterus, and I have a cervix still. Doctor: Are you on any type of hormonal therapies? Patient: I am not taking anything. This is the first time I have brought this up to the doctor.

ASSESSMENT

1. Serous otitis. 2. Atopic dermatitis.

Doctor: How long have you been having this pain in your ear? Patient: It's been three or four days. Doctor: Okay, let me check your ears, which side is in pain? Patient: The left one. Doctor: Okay let me check both ears. Well, you have lot of fluid accumulated in your left ear, which has caused infection in your middle part of the ear. It is called as Serous Otitis. Patient: Nothing to worry about? Doctor: I will prescribe you some antibiotics, it should take care of it. Patient: Thank you! Doctor: Anything else? Patient: Ah yes, my eczema is also acting up. Doctor: Hm, you have a history of atopic dermatitis in other words eczema. Patient: Yeah, I have had it since childhood.

FAM/SOCHX

There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.

Doctor: When were you diagnosed with type two diabetes? Patient: Two years ago. Doctor: Does diabetes run in the family? Patient: Nope. I believe I'm the only one who has it. Doctor: How about heart disease, stroke, cancer, or high blood pressure? Patient: Nope. My family is pretty healthy for the most part.

FAM/SOCHX

Not obtainable.

Doctor: Can you tell me some illness that might run in your family? Patient: No I don't know. Doctor: Are you sure? Patient: Yes.

FAM/SOCHX

ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92)

Doctor: Do you drink or smoke? Or take any other kind of drugs? Patient: I used to smoke and drink, but I quit years ago. Maybe it was like in ninety two. Doctor: How many cigarettes were you smoking then? Patient: You see that is a tough one to remember. It was anywhere around thirty packs per year.

MEDICATIONS

loratadine beclomethasone nasal fluticasone/salmeterol inhaled Montelukast cephalexin hydrocodone

Guest_clinician: Has she taken anything for her symptoms? Doctor: She's tried Loratadine Beclomethasone Nasal Fluticasone and Salmeterol Inhaled Montelukast Cephalexin Hydrocode. Guest_clinician: Has she noticed any relief with these medications? Doctor: Um some relief.

PASTSURGICAL

None.

Doctor: Any past surgeries? Patient: Nah.

GENHX

This is a 58-year-old white female suffering increasing right knee pain for number of years prior to surgical intervention. She was completely refractory to conservative outpatient therapy. She had undergone two knee arthroscopies in the years preceding this. They were performed by myself. She ultimately failed this treatment and developed a collapsing-type valgus degenerative osteoarthritis with complete collapse and ware of the lateral compartment and degenerative changes noted to the femoral sulcus that were proved live. Medial compartment had minor changes present. There was no contracture of the lateral collateral ligament, but instead mild laxity on both sides. There was no significant flexion contracture preoperatively.

Doctor: I hear someone just had a birthday! How young are you now, ma'am? Patient: Hello, doctor. I just turned fifty eight. Doctor: That's wonderful. You identify as white as well, correct? Patient: Yes, that's correct. Doctor: Is this right knee still bothering you? Patient: Yes, and it's been going on for years now. Doctor: I've done two arthroscopies on this knee, right? Patient: Yeah, that's right. Doctor: How have you handled conservative treatment? Patient: What does that mean? Doctor: Well, that's the antiinflammatories, rest, and changes in activity you've been advised to do. Patient: Honestly, there's been no improvement. Doctor: Okay, and I'm looking at your images, and they show collapsing type valgus degenerative osteoarthritis, and there's complete collapse and wear of the lateral compartment and degenerative changes noted to the femoral sulcus. Patient: Okay, I need you to explain that for me, doctor. Doctor: In summary, you have a pretty significant amount of arthritis in this knee. Patient: Lateral compartment, that's the outside of the knee, right? Doctor: Yes, that's correct. Your medial, or inside part of the knee, looks much better comparatively, but there's still some arthritis. Patient: Okay, thank you. Doctor: Are you able to flex and extend the knee all the way? Patient: Yes, look. Doctor: Can I test your stability? Okay, yes, there's some laxity here on both sides of the knee.

ROS

Otherwise negative.

Doctor: I reviewed all your systems, everything looks fine. Patient: Nice.

EDCOURSE

The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort.

Doctor: Let me give you some medication in your I V. Patient: Please make this all go away. I am feeling really sick like I am going to throw up. Doctor: Sure, sure. Nurse, please give him Norflex sixty M G, Zofran four M G, morphine sulfate four M G. Patient: Will I feel better after that? Doctor: Yes. Patient: I am feeling better after couple hours.

CC

Diarrhea, vomiting, and abdominal pain.

Doctor: It seems like you are not feeling very well today? Patient: Yeah. I have had diarrhea and pain in my stomach. Doctor: Have you experienced any vomiting? Patient: Yes. I threw up this morning.

FAM/SOCHX

unknown.

Doctor: Do you know about any medical problems running in your family? Patient: No, I don't know anything. I was never close to my family.

ROS

Please see history of present illness. Psychiatric: She has had some suicidal thoughts, but no plans. She denies being suicidal at the current time. Cardiopulmonary: She has not had any chest pain or shortness of breath. GI: Denies any nausea or vomiting. Neurological: No numbness, weakness or tingling.

Doctor: Have you had any thoughts of harming yourself or others? Patient: I've had thoughts of not wanting to be alive anymore but no plans of actually hurting myself. And absolutely no desire to hurt others. Doctor: Are you feeling suicidal right now? Patient: No, not right now. Doctor: Do you see a therapist or psychiatrist for this? Patient: No. Doctor: Are you having any other symptoms, such as chest pain or shortness of breath? Patient: Nah. Doctor: Any nausea or vomiting? Patient: No. Doctor: How about numbness, weakness, or any tingling? Patient: No. Doctor: Okay, let me see how we can help you today. Have you spoken to anyone else about these thoughts? And what do you think triggers these emotions for you?

CC

Non-healing surgical wound to the left posterior thigh.

Doctor: So, tell me what is going on? Patient: Well, I have this wound on my thigh from my surgery and its not healing and honestly, I am a little worried. Doctor: Okay, let me have a look, which side? Patient: It's on the back of my left thigh.

ALLERGY

There is no known drug intolerance in the past.

Doctor: Any medication intolerances? Patient: No.

GENHX

This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain. He also has pain in his left ankle, but he is able to walk normally. He has had previous pain in his left knee. He denies any passing out, any neck pain at this time even though he did get hit in the head. He has no chest or abdominal pain. Apparently, no knives or guns were involved.

Doctor: Good morning, young man. Patient: Hello, doctor. Doctor: So, before we get started here, how old are you? Patient: I'm seventeen, sir. Doctor: Thank you, um, what happened? Patient: Um, so I got into a fight at juvie, and I hurt my left elbow during it. Doctor: I see, do you have any other pain? Patient: Well, I have some in my left ankle too. Doctor: Is this pain messing with your walking, or no? Patient: No, I can walk and everything just fine. I used to have some knee pain too, but that was in the past. Doctor: Did you get knocked out during the fight? Patient: No, I held my own, but I did get hit in the head. Doctor: So, your neck doesn't hurt from the fight? Patient: Nope, just my elbow and ankle. Doctor: Were any weapons used in the fight, like guns or knives? Patient: No sir, just fists. Doctor: Do you have any chest or abdominal pain? Patient: No, sir.

FAM/SOCHX

Denies the use of alcohol or tobacco.

Doctor: Do you drink alcohol or smoke cigarettes? Patient: No, I do not. Doctor: Are you sure? Patient: Yes.

EXAM

CHEST: The chest examination is unremarkable.

Doctor: I will do some examinations on you. I will check your chest and then I will talk to you as I move forward, okay? Patient: I'm okay with that. Doctor: So, let's see what we have here. Hm, Yeah, just looks good. I do not find anything abnormal.

PASTMEDICALHX

History of migraine.

Doctor: And you mentioned that you have a history of migraine? Patient: Yes, that's correct.

MEDICATIONS

His only medications are Ziac and Remeron.

Doctor: What medications are you taking currently? Patient: Well, I'm taking Remeron for depression and Ziac for high blood pressure.

OTHER_HISTORY

Reviewed. There are no changes, otherwise.

Guest_clinician: Did you get a chance to review patient's chart? Doctor: Yes, I reviewed his past medical history and family and social history. Doctor: There are no changes, right Mister Jay? Patient: Yes, nothing changed. Guest_clinician: Okay, sounds good.

PROCEDURES

Permanent pacemaker placement after temporary internal pacemaker.

Doctor: How are you feeling? Patient: I am well. Doctor: So, we have placed a permanent pacemaker and removed your temporary internal pacemaker. Patient: Yes.

ROS

The patient prior to today has been very well without any signs or symptoms of viral illness, but yesterday he began to experience symptoms of nausea, had an episode of vomiting last night. Has low appetite. There were no fevers, chills, or malaise. No headache. No congestion or cold. No coughing. He had no sore throat. There was no chest pain or troubled breathing. He did have abdominal symptoms as described above but no abdominal pain. There were no urinary symptoms. No darkening of the skin or eyes. He had no yellowing or darkening of the urine. He had no rash to the skin. There was no local infection at the side of the fingerstick. All other systems were negative.

Doctor: How has our little man being doing? Guest_family: Before today he has been doing well, but yesterday he threw up at night and has been very nauseous. He did not complain of stomach issues prior. He is not eating either. Doctor: How is his appetite? Guest_family: Low. He has no fever, chills, or weakness. Doctor: What about coughing, sore throat? Guest_family: No. Doctor: Any chest pain or trouble breathing? Guest_family: No. Doctor: Any changes in his urination, maybe in color? Guest_family: No. Doctor: Any changes in skin color? Guest_family: No. No rash or anything either.

IMAGING

EKG shows sinus tachycardia, no acute ST changes.

Doctor: Well, I have your E K G report, shows you have sinus tachycardia. In other words, your heart is beating faster than normal due to rapid firing of sinus node. Patient: Okay. Doctor: Well, there are no S T changes. Patient: Hm.

IMMUNIZATIONS

Up-to-date.

Doctor: Good news! No need for any shots today. He is up to date on his immunizations. Guest_family: Good! He hates shots.

ASSESSMENT

Chronic atrial fibrillation, the patient has been restarted back on aspirin 81 mg at the time of discharge. Aspirin should be continued with Nexium 40 mg once daily in order to prevent any future occurrence of upper GI bleed. If the patient has any occurrence of upper GI bleed such as coffee-ground emesis or melena then aspirin should be discontinued.

Doctor: I'm glad to hear that your Afib is under control. I'd like for you to start taking baby aspirin again. Patient: Should I continue taking Nexium? Doctor: Yes, I'd like you to also take Nexium forty M G once a day in order to reduce the risk of an upper G I bleed. Patient: Sounds good. Doctor: And I ask that you call me immediately if you notice coffee like grounds in your vomit or bloody stool. Patient: Okay. Doctor: If you have either of these symptoms, then we'll need to put a stop to aspirin.