Dialogue stringlengths 41 8.86k | Target stringlengths 41 6.28k |
|---|---|
Doctor: What brings you back into the clinic today, miss?
Patient: I came in for a refill of my blood pressure medicine.
Doctor: It looks like Doctor Kumar followed up with you last time regarding your hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Have you noticed a... | Section header: GENHX Section text: The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check. She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Since her last visit she has been followed... |
Doctor: How're you feeling today?
Patient: Terrible. I'm having the worst headache of my life.
Doctor: I'm so sorry. Well you are only twenty five, so let's hope this is the last of the worst. Let's see how we can best help you. When did it start?
Patient: Around eleven in the morning.
Doctor: Today?
Patient: Um ... | Section header: GENHX Section text: The patient is a 25-year-old right-handed Caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the July 31, 2008. She described the headache as worse in her life and it was also accompanied by... |
Doctor: Hello, miss. What is the reason for your visit today?
Patient: I think I have some warts on my back end where the poop comes out.
Doctor: I see. When did you start noticing them?
Patient: I think like three to four weeks ago.
Doctor: Do you feel any pain or discomfort?
Patient: It itches a little, but I ha... | Section header: GENHX Section text: This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region. She has noticed approximately three to four weeks ago. She denies any pain but does state that there is some itching. No other symptoms associated. |
Doctor: Are you taking any over the counter medicines?
Patient: No, only the ones which were prescribed.
Doctor: No alternative medicine, naturopathy or anything?
Patient: No, only whatever is here in this prescription.
Doctor: Okay let me take a look...so you were prescribed Salmeterol inhaler-
Patient: On as needed... | Section header: MEDICATIONS Section text: Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines. |
Doctor: Hi, how are you?
Patient: I burned my hand.
Doctor: Oh, I am sorry. Wow!
Patient: Yeah.
Doctor: Is it only right arm?
Patient: Yes. | Section header: CC Section text: Burn, right arm. |
Doctor: How's your asthma since you started using your inhaler again?
Patient: Much better. I don't know why I didn't take it with me everywhere I went.
Doctor: It's important to carry it with you, especially during times where you're exercising or walking more than usual.
Patient: Yeah. I think I've learned my less... | Section header: PASTMEDICALHX Section text: Asthma. |
Doctor: Do you smoke?
Patient: No, I quit before I had my daughter.
Doctor: Are you currently pregnant?
Patient: No, I'm not.
Doctor: Did you have any complications with the birth of your daughter?
Patient: I actually had a C section.
Doctor: Have you had any other surgeries in the past?
Patient: I got my appendi... | Section header: PASTMEDICALHX Section text: The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions. The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant. The patient has had a C-section and also an append... |
Doctor: Any know drug allergies?
Patient: No. | Section header: ALLERGY Section text: No known drug allergies. |
Doctor: Hi there, sir! How are you today?
Patient: Hello! I am good.
Doctor: I would like to start with your family medical history today. What do you know about their medical history?
Patient: My mother and father both had heart disease. Well, my mother had complication from her heart disease and that is how she pas... | Section header: FAM/SOCHX Section text: His mother died of complications from heart disease. His father died of heart disease in his 40s. He has two living brothers. One of them he does not speak too much with and does not know about his medical history. The other is apparently healthy. He has one healthy child.... |
Doctor: Can you tell me about any diseases that run in your family?
Patient: Sure, my brother has a prostate cancer.
Doctor: Okay, brother.
Patient: My father had brain cancer.
Doctor: Okay, dad.
Patient: Then on both sides of my family there are many heart related issues.
Doctor: Okay.
Patient: And my brother and sis... | Section header: FAM/SOCHX Section text: His brothers had prostate cancer. Father had brain cancer. Heart disease in both sides of the family. Has diabetes in his brother and sister. |
Doctor: Good afternoon, ma'am. Welcome to A B C D General Hospital. Before we begin, I just need to confirm some background information on you.
Patient: Good afternoon, doctor. Absolutely, that's no problem.
Doctor: First, how old are you?
Patient: I'm nineteen, sir.
Doctor: Good, and your chart says you identify as... | Section header: GENHX Section text: This 19-year-old Caucasian female presents to ABCD General Hospital. The patient states she has had worsening bunion deformity for as long as she could not remember. She does have a history of Charcot-Marie tooth disease and desires surgical treatment at this time. |
Doctor: I hear someone has a birthday coming up, how old are you turning, ma'am?
Patient: I'll be ninety later this month, doctor.
Doctor: You're here for a follow up not very long after your first visit. What seems to be the problem today?
Patient: Well, actually, my high blood pressure and right arm symptoms are ba... | Section header: GENHX Section text: The patient is an 89-year-old lady. She actually turns 90 later this month, seen today for a short-term followup. Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved. Blood pressure is bett... |
Doctor: Are you talking any medications?
Patient: No, I don't believe in meds.
Doctor: Oh really, let me check your list.
Patient: Yeah never.
Doctor: Wow amazing. | Section header: MEDICATIONS Section text: None. |
Doctor: Any past medical history?
Guest_family: She has a history of peptic ulcer disease and we think she may have had a possible stroke three or four years ago. I would have to double check.
Doctor: Let me see if I can find it in her records.
Doctor: Does she see a neurologist?
Guest_family: Um I'm not sure. I c... | Section header: PASTMEDICALHX Section text: PUD, ?stroke and memory difficulty in the past 1-2 years. |
Doctor: How old are you?
Patient: I am forty four.
Doctor: Are you right handed or left handed?
Patient: I'm right handed.
Doctor: Tell me what happened.
Patient: I don't know. I woke up over this numbness on my left side of the body. I remember it was on July twenty nineth.
Doctor: Was there any sensation like h... | Section header: GENHX Section text: This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right wh... |
Doctor: You had a heart surgery, right?
Patient: Yes, that is right.
Doctor: Pacemaker?
Patient: Yes, they did that.
Doctor: What else? What other surgeries?
Patient: I have had a hysterectomy.
Doctor: Okay.
Patient: Yeah. | Section header: PASTSURGICAL Section text: Placement of pacemaker and hysterectomy. |
Doctor: How old are you, young boy?
Patient: I am twenty nine.
Doctor: And you got right side shoulder pain? Is this something new?
Patient: Yes. That is right.
Doctor: What were you doing when this happened?
Patient: I think I was picking up a stack of cardboard, then putting it down on the ground and twisting to the... | Section header: GENHX Section text: This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain. He states that this began approximately one week ago when he was lifting stacks of cardboard. The motion that he describes is essentially picking up a stack of cardboard at hi... |
Doctor: When did the nausea and vomiting start?
Patient: About a few hours ago. I can't seem to stomach anything.
Doctor: How many episodes of vomiting have you had?
Patient: At least four.
Doctor: Any abdominal pain, fever, chill, or other symptoms?
Patient: Just nausea and vomiting. It's been so terrible.
Docto... | Section header: CC Section text: Intractable nausea and vomiting. |
Doctor: Good afternoon, ma'am.
Patient: Good afternoon, doctor.
Doctor: Is this your assistant, ma'am?
Patient: Yes, she helps me out all day.
Doctor: Great, do you have your food diary sheets?
Patient: Yes, can you give them to her, please?
Doctor: Thank you. What are you doing for exercise?
Patient: Um, right... | Section header: GENHX Section text: The patient's assistant brings in her food diary sheets. The patient says she stays active by walking at the mall. |
Doctor: Is he currently taking any medication?
Guest_family: No. | Section header: MEDICATIONS Section text: None. |
Doctor: Hello, sir. I see your last visit was on July two thousand and seven. What was the reason for that visit?
Patient: My asthma was acting up, and it felt like I couldn't breathe.
Doctor: Do you have a history of asthma?
Patient: Not that I know of, but I know I always get this really bad cough where I cough u... | Section header: PASTMEDICALHX Section text: Asthma with his last admission in 07/2007. Also inclusive of frequent pneumonia by report. |
Doctor: Do you know about any medical traits in your family?
Patient: No, everyone in my family is quite healthy. I'm not aware of any medical problems.
Doctor: Are you sexually active?
Patient: Yes, I am with my boyfriend.
Doctor: Do you take any drugs or alcohol or smoke?
Patient: No, none of them. | Section header: OTHER_HISTORY Section text: completely unremarkable FHx. Has boyfriend and is sexually active. Denied drug/ETOH/Tobacco use. |
Doctor: Any past medical history?
Patient: Um there were a couple times where I noticed my blood pressure was high but that's improved as of late.
Doctor: When did these episodes occur?
Patient: About a year ago.
Doctor: Did you follow up with your previous doctor?
Patient: Yeah, my old doctor knows.
Doctor: Okay... | Section header: PASTMEDICALHX Section text: Unremarkable. There is no history of allergies. He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year. |
Doctor: Are you allergic to anything?
Patient: Yes, I am allergic to Penicillin.
Doctor: Any other drugs that you could be allergic to?
Patient: Nope that is all.
Doctor: Okay. | Section header: ALLERGY Section text: Penicillin. |
Guest_clinician: What brought them in today?
Doctor: Poor renal sufficiency, possibly due to dehydration or diabetic nephropathy. She also has high blood pressure and low blood sugar as a result of missing meals regularly. | Section header: ASSESSMENT Section text: 1. Hypoglycemia due to not eating her meals on a regular basis. 2. Hypertension. 3. Renal insufficiency, may be dehydration, or diabetic nephropathy. |
Patient: Doc what are you going to diagnose me as?
Doctor: We are looking at blood born pathogen exposure secondary to needlestick.
Patient: Yes, I was also thinking around contamination. | Section header: ASSESSMENT Section text: Blood-borne pathogen exposure secondary to contaminated needlestick. |
Guest_clinician: She was in a car crash, correct?
Doctor: Correct. About two days ago. I believe it was a head on collision. | Section header: CC Section text: Motor vehicle accident. |
Doctor: Any allergies I should know about?
Patient: Nope, no allergies for me. | Section header: ALLERGY Section text: No allergies. |
Doctor: Hello sir. Let me first start by asking your age. How old are you?
Patient: I'm twenty four.
Doctor: So, what brought you here? How can I help you?
Patient: I was out for fishing this weekend, I think I got into some poison ivy and I have these rashes all over my chest, legs, arms and also some are on my ba... | Section header: GENHX Section text: He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing. He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid ... |
Doctor: You had mentioned that cancer runs in your family. What type of cancer?
Patient: Skin cancer.
Doctor: Any other health problems in the family?
Patient: High blood pressure. | Section header: FAM/SOCHX Section text: Cancer, hypertension. |
Doctor: Hi, what brings you here today?
Patient: I feel this lump on the upper side of my breast.
Doctor: Both sides?
Patient: No, only on the left side.
Doctor: Do you feel it deep inside or on the outer side?
Patient: Only on the outer side. | Section header: CC Section text: Suspicious calcifications upper outer quadrant, left breast. |
Doctor: I understand that you are new to the clinic. Welcome.
Patient: Yes, I am new here. I have lived in Arizona for the last four years. I am from Maine. That is where I grow up and most of my family still lives there.
Doctor: What line of work are you in?
Patient: I am a homemaker. I used to clean house, a whil... | Section header: FAM/SOCHX Section text: The patient is originally from Maine. She has lived in Arizona for 4 years. She has had 2 children; however, only one is living. She had one child died from complications of ulcerative colitis. She has been predominantly a homemaker during her life, but has done some domest... |
Doctor: You okay there?
Patient: Uh yeah, sorry. I'm just trying to adjust the stretcher.
Doctor: Want some help?
Patient: No, thank you. I think I got it.
Doctor: So how're you doing?
Patient: Fine, but I have this weird lump in my chest.
Doctor: When did you first notice it?
Patient: It's been there for a whil... | Section header: CC Section text: Lump in the chest wall. |
Doctor: Hello, so you are here for follow up today.
Patient: Yes, very much.
Doctor: I will ask you some regular questions, okay?
Patient: Sure.
Doctor: Any pain in urination?
Patient: Nope.
Doctor: Any fever or chills?
Patient: Neither of them.
Doctor: Have you noticed any blood while urinating? Any blood in y... | Section header: GENHX Section text: The patient presents today for followup. No dysuria, gross hematuria, fever, chills. She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence. She is voiding daytime every 1 hour in the morning especial... |
Doctor: Have you lost weight?
Patient: No, I haven't, you can ask my daughter.
Doctor: How about anything like fever, nausea, vomiting, pain?
Patient: No.
Doctor: And as we discussed you have problem talking and comprehending.
Patient: Yes.
Doctor: And you get urine infections too?
Patient: Yes.
Doctor: And as discus... | Section header: ROS Section text: As in HPI. Patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. She has had some difficulty expressing herself, but seems to comprehend speech as above. The patient has had a history of chronic urinary tract infections and her drainage... |
Doctor: Do you use tobacco products? Cigarettes, chewing tobacco or vaping?
Patient: I used to smoke a pack a day. I quit that awful habit in nineteen eighty five.
Doctor: Do you work?
Patient: I am retired.
Doctor: Wonderful. Is your husband retired with you?
Patient: Yes. We both are. I cannot imagine working a f... | Section header: FAM/SOCHX Section text: She is married. A 76-year-old who used to smoke a pack a day and quit in 1985. She is retired. |
Doctor: Hi there, how are you?
Patient: I am okay.
Doctor: So, I see you turned eighty-eight yesterday, happy birthday!
Patient: Thank you!
Doctor: And you are referred by Doctor X, he is your primary physician, right?
Patient: Correct! I am also seeing Doctor Y for my leukemia.
Doctor: Hm he mentioned that it's chro... | Section header: GENHX Section text: The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues. He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of ... |
Doctor: Ready to go home?
Patient: I just can't wait.
Doctor: Sure. I can understand.
Patient: Bye Doctor.
Doctor: Yes. See you soon. | Section header: DISPOSITION Section text: The patient will be going home. |
Doctor: Hello, sir. How are you today? Can you confirm your age?
Patient: Fifty eight. I feel like my balance is off, and I've been feeling tired and weak.
Doctor: How long have you been experiencing this?
Patient: It's been going on for six to eight weeks.
Doctor: I see. Did you feel any other symptoms?
Patient: I... | Section header: GENHX Section text: This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of in... |
Doctor: Have you had any illnesses in the past?
Patient: Nope.
Doctor: Anything that is worth mentioning?
Patient: Nope.
Doctor: Sure?
Patient: Yes. | Section header: PASTMEDICALHX Section text: Noncontributory. |
Doctor: Good afternoon, sir. My nurse tells me you're twenty eight years old, is that correct?
Patient: Good morning, doctor. Yes, that's correct.
Doctor: So, what happened?
Patient: Well, I punched a wall about three days ago.
Doctor: Which hand is it?
Patient: It's my right hand.
Doctor: Is this your dominant han... | Section header: GENHX Section text: The patient is a 28-year-old right-hand dominant gentleman, who punched the wall 3 days prior to presentation. He complained of ulnar-sided right hand pain and was seen in the emergency room. Reportedly, he had some joints in his hand pushed back and placed by somebody in emergen... |
Doctor: Hello there, how are you?
Patient: I am good, thank you.
Doctor: He is my colleague Doctor Mason, and he will be assisting me today and taking down notes.
Guest_clinician: Hi there.
Patient: Hello.
Doctor: Is it okay with you if he can join us?
Patient: Sure, no problem.
Doctor: Great, thank you
Doctor: Docto... | Section header: EXAM Section text: GENERAL: Well developed, well nourished, alert, in no acute distress. GCS 50, nontoxic. |
Doctor: Anyone sick in your family?
Patient: No.
Doctor: How about anyone with the same disorders?
Patient: No, I don't know.
Doctor: Okay don't you worry. | Section header: FAM/SOCHX Section text: Noncontributory. |
Doctor: How did the patient do on the activity test?
Guest_clinician: Patient was good. I have advised him to continue with his normal activities as long as he is feeling fine. | Section header: PLAN Section text: As tolerated. |
Doctor: How old was he when he were first evaluated in the other hospital?
Guest_family: He was seven.
Doctor: Which hospital was that again?
Guest_family: It was at U I H C.
Doctor: So what exactly happened?
Guest_family: He was doing all good like seven months before his evaluation, then he started having some dizzy... | Section header: GENHX Section text: The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he wa... |
Doctor: Do you have major illnesses in the family like diabetes or high B P?
Patient: No nothing. No major illnesses.
Doctor: Okay.
Patient: Yes. | Section header: FAM/SOCHX Section text: Noncontributory. |
Doctor: Good morning, sir.
Patient: Good morning, doctor.
Doctor: I just need some background information before we begin today.
Patient: Sure.
Doctor: Good, have you ever had surgery, sir?
Patient: Yeah, actually I've had it on my knee, a nose job, and, um, carotid sinus surgery. | Section header: PASTSURGICAL Section text: Right knee surgery, cosmetic surgery, and carotid sinus surgery. |
Doctor: Are you still working?
Patient: No, I am retired now. I used to work for the U S postal service as an electronic technician but took retirement one year earlier due to my disability.
Doctor: Ah okay. And who is in your family?
Patient: Well, I stay with my wife and daughter in our apartment.
Doctor: Okay. Do yo... | Section header: FAM/SOCHX Section text: The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entir... |
Doctor: Good afternoon, how are you today?
Patient: I am good Doctor, thanks for asking.
Doctor: This is my colleague Doctor White, and she will be taking the notes. Is it okay if she joins us?
Patient: Oh sure, no problem.
Doctor: Thank you.
Guest_clinician: Hello, I am Doctor White, nice to meet you.
Patient: Nice ... | Section header: EXAM Section text: RESPIRATORY: Good respiratory effort. Clear to auscultation. Clear to percussion. Chest: Symmetrical rise and fall. Symmetrical expansion. No egophony or tactile fremitus. |
Doctor: Where do you live?
Patient: I live in a board and care. It is a nice small care home with some very nice and supportive people. It is just next to the Safeway on Village Drive.
Doctor: Nice. It looks like you love living there.
Patient: Oh yes. I feel very relaxed there.
Doctor: Did you consume alcohol in an... | Section header: FAM/SOCHX Section text: The patient lives in a board and care. No tobacco, alcohol or IV drug use. |
Doctor: Have you had any surgeries in the past?
Patient: Actually, yes, I had my gallbladder removed in nineteen ninety two.
Doctor: Great, any other surgeries? Think back a little further?
Patient: Oh yeah, I had my appendix out in nineteen eighty eight. | Section header: PASTSURGICAL Section text: Appendectomy 1988. Cholecystectomy. 1992 |
Doctor: How are feeling now after the treatment?
Patient: I am feeling pretty fair, improving slowly.
Doctor: Okay?
Patient: Okay. | Section header: DISPOSITION Section text: Fair, but improved. |
Doctor: Sir? Can you hear me? Are you Mister Smith's wife?
Guest_family: Yes. I am his wife.
Doctor: How old is he? Can you tell me a little bit of how your husband's condition has come to this point? His level of consciousness is concerning.
Guest_family: He is eighty five. He took the entire M G of Xanax. He is on... | Section header: GENHX Section text: The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness. The patient apparently lives with his wife and was found to have a decreased status since the last one day. The patient actually was seen in the emergency room the... |
Doctor: How have you been feeling? Is the Wellbutrin keeping your mood stabilized?
Patient: I have been feeling good. The Wellbutrin is working well for me.
Doctor: It is important to not consume any alcohol or recreational drugs while taking Wellbutrin.
Patient: I don't drink or do drugs. | Section header: FAM/SOCHX Section text: The patient has a history of depression. No history of substance abuse. |
Doctor: Tell me a little bit about your family history.
Patient: My dad and grandpa both had type two diabetes. My son is struggling with type one diabetes at the moment.
Doctor: I'm sorry to hear that. Does anyone in your family have heart problems?
Patient: No.
Doctor: How about cancer?
Patient: Two of my cousi... | Section header: FAM/SOCHX Section text: As far as heart disease there is none in the family. As far as cancer two cousins had breast cancer. As far as diabetes father and grandfather had type II diabetes. Son has type I diabetes and is struggling with that at the moment. |
Doctor: Where do you work, miss?
Patient: Well, you see, I am a civil engineer. Right now, due to pandemic like everyone else I am working from home.
Doctor: Are you working full time or is your disability affecting that?
Patient: No, I can only work on half time. This disability does not let me work full time. I nee... | Section header: FAM/SOCHX Section text: The patient is a civil engineer, who currently works from home. She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby. She does not smoke and does ... |
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. | Section header: FAM/SOCHX Section text: Noncontributory. |
Doctor: Have you had any anxiety attacks lately?
Patient: No.
Doctor: Have you felt depressed or had any mood swing problems?
Patient: No.
Doctor: Any phobias?
Patient: No, not really.
Doctor: Okay. | Section header: ROS Section text: PSYCHIATRIC: Normal; Negative for anxiety, depression, or phobias. |
Doctor: Do you have a history of mental illness or psychological disease?
Patient: No. | Section header: PASTSURGICAL Section text: None Past Psychological History: None |
Doctor: Hello sir. How are you doing today? You still look a little uncomfortable. Is there still pain?
Patient: Yeah. Still a good amount of pain. I did not take my pain medication this morning though. Not sure if that will make a huge difference.
Doctor: That is possibly why you are still in pain. How is movement? C... | Section header: GENHX Section text: The patient states pain still significant, primarily 1st seen in the morning. The patient was evaluated 1st thing in the morning and did not take his pain medications, so objective findings may reflect that. The patient states overall functionally he is improving where he is able... |
Doctor: Have you had any surgeries in the past?
Patient: Yes, I had knee surgery.
Doctor: Which knee?
Patient: Right. | Section header: PASTSURGICAL Section text: Right knee surgery. |
Doctor: Are you sexually active?
Patient: Yes.
Doctor: How many partners do you have?
Patient: Just one.
Doctor: Is this a monogamous relationship?
Patient: Yes.
Doctor: What gender is you partner?
Patient: He is a male. We have been together for three years. He is H I V positive. | Section header: FAM/SOCHX Section text: Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years. |
Doctor: I remember you mentioned that you had one operation done in the past.
Patient: I had a lymph node biopsy back in September of O three.
Doctor: Did it come back negative?
Patient: Fortunately, yes. | Section header: PASTSURGICAL Section text: Excisional lymph node biopsy (9/03). |
Doctor: It looks like you have an extensive medical history.
Patient: I blame my heart. It's caused me the most trouble. I had coronary artery bypass surgery in twenty ten along with an angioplasty.
Doctor: I'm sorry that your heart has been giving you so much trouble. I'm happy that you're here with us today and tak... | Section header: PASTSURGICAL Section text: Coronary artery bypass surgery and a prior angioplasty and prostate biopsies. |
Doctor: Do you have any medical problems?
Patient: Let's see. I have diabetes, high blood pressure, high cholesterol, and osteoporosis.
Doctor: And any surgeries?
Patient: Several.
Doctor: Which ones?
Patient: I had my tonsils taken out when I was a kid. I also had my uterus removed along with my ovaries and fall... | Section header: PASTSURGICAL Section text: She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases. She also has had a parathyroidectomy but still has had some borderline elevated calcium. Also, hypertension, hyperlipidemia, as well as diabetes. She also has os... |
Doctor: What is your family medical history?
Patient: My mother passed away from complications with Huntington Disease. She was diagnosed and had been having treatments at U I H C. My grandmother and two of my aunts also passed away from Huntington as well.
Doctor: I am so sorry. Do you have siblings?
Patient: Yes! I... | Section header: FAM/SOCHX Section text: Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice. He and his wife have 2 adopted children. |
Doctor: Any medical problems on your mom or dad's side?
Patient: My dad has lupus and his brother has Addison's disease. High blood pressure also runs in the family.
Doctor: Is your dad being treated for lupus?
Patient: Yes, he follows up with his rheumatologist pretty regularly. | Section header: FAM/SOCHX Section text: HTN, father with SLE, uncle with Addison's Disease. |
Doctor: I will do a quick exam on you.
Patient: What kind of exam?
Doctor: I'm just checking for lymph nodes. Whenever there is an infection those guys are the first ones to be noticed with swelling.
Doctor: Okay, so let's first check your neck area. It looks good. I don't feel any inflamed lymph node. Your armpits lo... | Section header: EXAM Section text: LYMPH: No neck, axillary or groin adenopathy was noted. |
Doctor: What are some medications you are on?
Patient: I am on pain pills.
Doctor: Do you know their names?
Patient: Yes. Oxycontin and Vicodin.
Doctor: Okay that helps. | Section header: MEDICATIONS Section text: OxyContin and Vicodin. |
Doctor: I am looking at the list of your medication.
Patient: Okay.
Doctor: All I can see is Risperdal and Invega.
Patient: I think that is correct.
Doctor: Are you not taking anything else?
Patient: Yes, I take some multivitamins, but do I need to mention it?
Doctor: Yes, you should. We need to know everything.
Patien... | Section header: MEDICATIONS Section text: Listed as Invega and Risperdal. |
Doctor: Good morning, ma'am.
Patient: Oh, good morning, doctor.
Doctor: Please, tell me about your living situation.
Patient: Well, right now, I live at home with my kids and my dad.
Doctor: I see here that you're not able to go up the stairs well, can you tell me more about that?
Patient: Yeah, I can't use the sta... | Section header: FAM/SOCHX Section text: The patient lives in a private home with children and her father. The patient states that she does have stairs to negotiate without the use of a railing. She states that she is able to manage the stairs, however, is very slow with her movement. The patient smokes 1-1/2 packs... |
Patient: My physician did a blood test. My potassium is high. He recommended me to meet you.
Doctor: Okay. I did not get the blood report yet. I am waiting for your doctor's office to send it to me. Is it only your potassium that is elevated?
Patient: Yes, that's what they told me. | Section header: CC Section text: "My potassium is high" |
Guest_family: He was going to buy me a surprise but met with this car accident.
Doctor: I am sorry! He does have multiple trauma due to the accident, and he will require aftercare.
Guest_family: Yeah. | Section header: DIAGNOSIS Section text: Aftercare of multiple trauma from an motor vehicle accident. |
Doctor: So, what is your family's living situation at home?
Guest_family: Um, he lives at home with me, and his father.
Doctor: May I assume that you are his biological parents?
Guest_family: Yes, that's correct.
Doctor: Great, does he have any siblings?
Guest_family: No, right now, he's an only child.
Doctor: Wha... | Section header: FAM/SOCHX Section text: lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools. |
Doctor: Good afternoon, what gender do you identify with?
Patient: Thank you for asking, I identify as a female.
Doctor: Thank you. Do you know of any chronic illnesses?
Patient: No, but can you give me some examples of what you mean?
Doctor: Well, high blood pressure, osteoarthritis, diabetes, depression, anything lik... | Section header: PASTMEDICALHX Section text: She claims no chronic illnesses. |
Doctor: Do you have any major medical conditions that I should know about?
Patient: What, like cancer?
Doctor: It doesn't have to be that serious, but is there anything you take medicine for?
Patient: Oh, I have allergies and asthma. | Section header: PASTMEDICALHX Section text: Asthma and allergies. |
Doctor: Can you tell me something about your mom and dad? Like any diseases they have had?
Patient: Sure, my dad died of heart attack when he was sixty five and my mom died of stroke when she was seventy.
Doctor: How's about siblings, miss? Any health issues?
Patient: No, my brother is healthy. | Section header: FAM/SOCHX Section text: Basically unchanged. Her father died of an MI at 65, mother died of a stroke at 70. She has a brother, healthy. |
Doctor: Does anyone in your family suffer from any health problems?
Patient: No one comes to mind.
Doctor: Great. | Section header: FAM/SOCHX Section text: Negative. |
Doctor: Tell me, what's going on?
Guest_family: She is complaining of weakness on the right side of her face.
Patient: And I feel the right side is drooping.
Doctor: Okay, let me look at it. | Section header: CC Section text: Right-sided facial droop and right-sided weakness. |
Doctor: My chart here says that you're eighty three years old, is that correct, ma'am?
Patient: Yes doctor, that's correct, I just had my birthday.
Doctor: Happy belated birthday! How have you been doing since your last visit?
Patient: Well, my cancer hasn't needed phlebotomies for several months now, which is good. ... | Section header: GENHX Section text: The patient is an 83-year-old female with a history of polycythemia vera. She comes in to clinic today for followup. She has not required phlebotomies for several months. The patient comes to clinic unaccompanied. |
Doctor: So, do you have any family history of cancer?
Patient: Well, yes, but I can't remember who had what kind.
Doctor: Still, that's helpful, thank you. What about heart disease?
Patient: That too, there's some history of heart disease, but I can't remember who. | Section header: FAM/SOCHX Section text: 1. Cancer. 2. Coronary artery disease. |
Doctor: As far as you know, are there any major health conditions that you know about?
Patient: What do you mean by that?
Doctor: Anything like cancer, or arthritis, do those sound familiar?
Patient: Oh, um, no nothing like that. | Section header: PASTMEDICALHX Section text: Otherwise, negative. |
Doctor: Do you have any medical history that we should be aware of?
Patient: I have type two diabetes. My numbers always come high.
Doctor: Okay, anything else?
Patient: I also have high cholesterol.
Doctor: Okay. | Section header: PASTMEDICALHX Section text: Diabetes type II, poorly controlled, high cholesterol. |
Doctor: Hello. How are you feeling today?
Patient: Great. I'm just here for my yearly physical.
Doctor: Oh, good. I see your past medical history is missing. Do you, by chance, know if you've had any health related problems before?
Patient: Uhm. Let me check my notes on my phone. I knew this question would pop up, b... | Section header: PASTMEDICALHX Section text: Significant for asthma, allergic rhinitis and cervical dysplasia. |
Doctor: How's the little one doing?
Guest_family: She is doing okay.
Doctor: How long was your pregnancy?
Guest_family: Thirty six weeks.
Doctor: Was your delivery normal or C section?
Guest_family: It was a C section.
Doctor: How much did she weigh?
Guest_family: She was eight pounds and three ounces.
Doctor: Tell ... | Section header: PASTMEDICALHX Section text: Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces. She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue. |
Doctor: What medications are you taking right now?
Patient: I am taking Advair and Allegra.
Doctor: Okay is it helping you?
Patient: I don't know, I am not sure the Allegra is helping. But I do take them regularly.
Doctor: But is it like better than Claritin?
Patient: Yes, I think so.
Doctor: Okay that's good.
Patient:... | Section header: MEDICATIONS Section text: Advair and Allegra. He has been taking these regularly. He is not sure the Allegra is working for him anymore. He does think though better than Claritin. |
Doctor: Anybody sick in family?
Patient: No one.
Doctor: How about any illnesses that run in your family?
Patient: No, everyone is healthy. | Section header: FAM/SOCHX Section text: Noncontributory. |
Doctor: Hi again! How has your acne been since you started the spironolactone?
Patient: It has been improving.
Doctor: Have you experienced any increased thirst, mood changes or unusual fatigue?
Patient: No. | Section header: CC Section text: The patient comes for a routine followup appointment. |
Doctor: Well, I don't think you need any restraints as you are doing fine. I do want to make sure you have a chair and bed monitor since you have a history of multiple falls. They can help detect fall.
Patient: I don't want that, I will manage.
Doctor: Are you sure?
Patient: Yes! | Section header: EDCOURSE Section text: RESTRAINTS: None. The patient has declined use of chair check and bed check. |
Doctor: Do you know when was the last time you got a tetanus shot?
Patient: No I don't remember.
Doctor: Okay. | Section header: IMMUNIZATIONS Section text: Not sure. |
Doctor: Hi there! How are you today?
Patient: Hi! I am good.
Doctor: Welcome in!
Patient: Thank you.
Doctor: Lets start with a little social history. Are you a tobacco or alcohol user?
Patient: No.
Doctor: Are you married? Do you have children?
Patient: I am not married but I do have a two year old son.
Doctor:... | Section header: FAM/SOCHX Section text: She is followed by a gynecologist in Bartow. She is not an alcohol or tobacco user. She is not married. She has a 2-year-old child. |
Doctor: Tell me about your family medical history.
Patient: My family is pretty healthy. I don't know of any health problems. | Section header: FAM/SOCHX Section text: Noncontributory. |
Doctor: Welcome in.
Patient: Thank you.
Doctor: Do you smoke?
Patient: No, I don't. Smoking is gross.
Doctor: I agree. Do you drink alcohol?
Patient: Yes.
Doctor: How much do you drink per day or week?
Patient: When I get off work usually have a glass of wine. I don't ever have more then one glass.
Doctor: Okay. | Section header: FAM/SOCHX Section text: She does not smoke. She takes one glass of wine per day. |
Doctor: The nurse applied antibiotic ointment and a bandage to your foot. Did she go over how to change the bandage at home?
Patient: Yes. | Section header: EDCOURSE Section text: The patient had antibiotic ointment and a bandage applied to his foot. |
Doctor: Hello. Before we begin, I need you to confirm some information for me.
Patient: What kind of information?
Doctor: About your family. Do you know if you have certain medical conditions that run in your family?
Patient: Nope. My family is very healthy. | Section header: FAM/SOCHX Section text: Negative. |
Doctor: How about any breathing issues or asthma?
Patient: Actually, I have a history of asthma.
Doctor: Oh okay, and was it severe or mild?
Patient: Well, it was not severe but still remarkable.
Doctor: Hm, alright. Anything else?
Patient: Yes, I also struggled with a serious acne problem.
Doctor: Got it. | Section header: MEDICATIONS Section text: Significant for asthma and acne. |
Doctor: How's she doing?
Guest_family: She's had better days.
Doctor: Aw and why's that?
Guest_family: She's been really congested recently. Snorting a lot more, too. She's onlt eleven and I think it is odd she snores so much. I took her to see the allergist and he said it's not her allergies so we stopped giving he... | Section header: GENHX Section text: This is an 11-year-old female who comes in for two different things. 1. She was seen by the allergist. No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting. They do not notice a lot of snoring at night though, but she seem... |
Doctor: Why are you holding your face?
Patient: Ah! Have pain in my tooth.
Doctor: Oh, how bad is it?
Patient: Oh, awfully bad.
Doctor: I am so sorry. | Section header: CC Section text: Toothache. |
Doctor: Have you had similar symptoms before?
Patient: No never like this.
Doctor: Any other complaints you have had in the past?
Patient: Just some knee pain issues.
Doctor: Okay, so chronic knee pain.
Patient: Yes. | Section header: PASTMEDICALHX Section text: Chronic knee pain. |
Doctor: Can you tell me about any cancers in your family?
Patient: Yes, my sister has ovarian cancer, and my father has liver cancer.
Doctor: Oh I am so sorry.
Patient: That is okay.
Doctor: Any heart conditions?
Patient: My mom and dad both have heart disease. My dad has diabetes too. | Section header: FAM/SOCHX Section text: Consistent with a sister of his has ovarian cancer and his father had liver cancer. Heart disease in the patient's mother and father, and father also has diabetes. |
End of preview. Expand in Data Studio
No dataset card yet
- Downloads last month
- 15