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file mode 100644 index 0000000..4494f57 --- /dev/null +++ b/use-cases/medical-summary/README.md @@ -0,0 +1,90 @@ +# Medical Summary Database + +A PostgreSQL database containing synthetic medical data from Synthea, organized for medical summary generation and analysis. + +## Project Structure + +``` +medical-summary/ +├── database/ # Database files +│ ├── 01-create-tables.sql # Table creation script +│ ├── 02-load-initial-data.sql # Data loading script +│ └── validate-data.sql # Data validation queries +├── docs/ # Documentation +│ └── database-schema-reference.md # Database schema documentation +├── source-data/ # Compressed CSV data files (18 .csv.gz files) +├── docker-compose.yml # Docker Compose configuration +└── README.md # This file +``` + +## Quick Start + +1. **Start the database:** + + ```bash + docker compose up -d + ``` + + This automatically: + - Creates the PostgreSQL database + - Initializes all tables + - Decompresses and loads all CSV data (1.9+ million records) + +2. **Verify the data:** + + ```bash + docker exec medical_summary_db psql -U medical_user -d medical_summary -f /tmp/validate-data.sql + ``` + +3. **Connect to the database:** + ```bash + docker exec -it medical_summary_db psql -U medical_user -d medical_summary + ``` + +## Database Details + +- **Database:** medical_summary +- **User:** medical_user +- **Password:** medical_pass +- **Port:** 5434 (mapped from container's 5432) + +## Data Overview + +The database contains 18 tables with synthetic medical data: + +- **Core Tables:** patients (1,163), providers (5,056), organizations (1,127) +- **Clinical Data:** encounters (61,459), conditions (38,094), medications (56,430) +- **Administrative:** claims (117,889), payers (10), observations (531,144) +- **Additional:** allergies, careplans, immunizations, procedures, and more + +### Data Storage + +All CSV data files are stored in compressed format (gzip) to reduce repository size: + +- **Original size:** ~539MB +- **Compressed size:** ~56MB (89% reduction) +- **Automatic decompression:** Files are decompressed on-the-fly during database initialization +- **No manual steps required:** Docker setup handles everything automatically + +See [docs/database-schema-reference.md](docs/database-schema-reference.md) for detailed schema information. + +## Development + +### Data Validation + +Run validation queries: + +```bash +docker exec medical_summary_db psql -U medical_user -d medical_summary -f /tmp/validate-data.sql +``` + +### Stop the Database + +```bash +docker compose down # Stop containers +docker compose down -v # Stop and remove volumes (data will be lost) +``` + +## Configuration + +Database credentials are configured in `docker-compose.yml`. The default configuration is suitable for local development. diff --git a/use-cases/medical-summary/database/01-create-tables.sql b/use-cases/medical-summary/database/01-create-tables.sql new file mode 100644 index 0000000..c4248bb --- /dev/null +++ b/use-cases/medical-summary/database/01-create-tables.sql @@ -0,0 +1,334 @@ +-- Medical Summary Database Schema + +-- Organizations table +CREATE TABLE organizations ( + id UUID PRIMARY KEY, + name VARCHAR(255), + address TEXT, + city VARCHAR(100), + state VARCHAR(25), + zip VARCHAR(10), + lat DECIMAL(10, 8), + lon DECIMAL(11, 8), + phone VARCHAR(30), + revenue DECIMAL(15, 2), + utilization INTEGER +); + +-- Providers table +CREATE TABLE providers ( + id UUID PRIMARY KEY, + organization UUID REFERENCES organizations (id), + name VARCHAR(255), + gender VARCHAR(10), + speciality VARCHAR(100), + address TEXT, + city VARCHAR(100), + state VARCHAR(25), + zip VARCHAR(10), + lat DECIMAL(10, 8), + lon DECIMAL(11, 8), + utilization INTEGER +); + +-- Payers table +CREATE TABLE payers ( + id UUID PRIMARY KEY, + name VARCHAR(255), + address TEXT, + city VARCHAR(100), + state_headquartered VARCHAR(50), + zip VARCHAR(10), + phone VARCHAR(30), + amount_covered DECIMAL(15, 2), + amount_uncovered DECIMAL(15, 2), + revenue DECIMAL(15, 2), + covered_encounters INTEGER, + uncovered_encounters INTEGER, + covered_medications INTEGER, + uncovered_medications INTEGER, + covered_procedures INTEGER, + uncovered_procedures INTEGER, + covered_immunizations INTEGER, + uncovered_immunizations INTEGER, + unique_customers INTEGER, + qols_avg DECIMAL(5, 2), + member_months INTEGER +); + +-- Patients table +CREATE TABLE patients ( + id UUID PRIMARY KEY, + birthdate DATE, + deathdate DATE, + ssn VARCHAR(15), + drivers VARCHAR(20), + passport VARCHAR(20), + prefix VARCHAR(10), + first VARCHAR(100), + last VARCHAR(100), + suffix VARCHAR(10), + maiden VARCHAR(100), + marital VARCHAR(20), + race VARCHAR(50), + ethnicity VARCHAR(50), + gender VARCHAR(10), + birthplace TEXT, + address TEXT, + city VARCHAR(100), + state VARCHAR(25), + county VARCHAR(100), + zip VARCHAR(10), + lat DECIMAL(10, 8), + lon DECIMAL(11, 8), + healthcare_expenses DECIMAL(15, 2), + healthcare_coverage DECIMAL(15, 2) +); + +-- Encounters table +CREATE TABLE encounters ( + id UUID PRIMARY KEY, + start TIMESTAMPTZ, + stop TIMESTAMPTZ, + patient UUID REFERENCES patients (id), + organization UUID REFERENCES organizations (id), + provider UUID REFERENCES providers (id), + payer UUID REFERENCES payers (id), + encounterclass VARCHAR(50), + code VARCHAR(50), + description TEXT, + base_encounter_cost DECIMAL(10, 2), + total_claim_cost DECIMAL(10, 2), + payer_coverage DECIMAL(10, 2), + reasoncode VARCHAR(50), + reasondescription TEXT +); + +-- Conditions table +CREATE TABLE conditions ( + start DATE, + stop DATE, + patient UUID REFERENCES patients (id), + encounter UUID REFERENCES encounters (id), + code VARCHAR(50), + description TEXT +); + +-- Allergies table +CREATE TABLE allergies ( + start DATE, + stop DATE, + patient UUID REFERENCES patients (id), + encounter UUID REFERENCES encounters (id), + code VARCHAR(50), + system VARCHAR(100), + description TEXT, + type VARCHAR(50), + category VARCHAR(50), + reaction1 VARCHAR(50), + description1 TEXT, + severity1 VARCHAR(20), + reaction2 VARCHAR(50), + description2 TEXT, + severity2 VARCHAR(20) +); + +-- Medications table +CREATE TABLE medications ( + start DATE, + stop DATE, + patient UUID REFERENCES patients (id), + payer UUID REFERENCES payers (id), + encounter UUID REFERENCES encounters (id), + code VARCHAR(50), + description TEXT, + base_cost DECIMAL(10, 2), + payer_coverage DECIMAL(10, 2), + dispenses INTEGER, + totalcost DECIMAL(10, 2), + reasoncode VARCHAR(50), + reasondescription TEXT +); + +-- Careplans table +CREATE TABLE careplans ( + id UUID PRIMARY KEY, + start DATE, + stop DATE, + patient UUID REFERENCES patients (id), + encounter UUID REFERENCES encounters (id), + code VARCHAR(50), + description TEXT, + reasoncode VARCHAR(50), + reasondescription TEXT +); + +-- Procedures table +CREATE TABLE procedures ( + start DATE, + stop DATE, + patient UUID REFERENCES patients (id), + encounter UUID REFERENCES encounters (id), + code VARCHAR(50), + description TEXT, + base_cost DECIMAL(10, 2), + reasoncode VARCHAR(50), + reasondescription TEXT +); + +-- Immunizations table +CREATE TABLE immunizations ( + date DATE, + patient UUID REFERENCES patients (id), + encounter UUID REFERENCES encounters (id), + code VARCHAR(50), + description TEXT, + base_cost DECIMAL(10, 2) +); + +-- Devices table +CREATE TABLE devices ( + start DATE, + stop DATE, + patient UUID REFERENCES patients (id), + encounter UUID REFERENCES encounters (id), + code VARCHAR(50), + description TEXT, + udi TEXT +); + +-- Observations table +CREATE TABLE observations ( + date DATE, + patient UUID REFERENCES patients (id), + encounter UUID REFERENCES encounters (id), + category VARCHAR(50), + code VARCHAR(50), + description TEXT, + value TEXT, + units VARCHAR(50), + type VARCHAR(50) +); + +-- Imaging studies table +CREATE TABLE imaging_studies ( + id UUID, + date DATE, + patient UUID REFERENCES patients (id), + encounter UUID REFERENCES encounters (id), + series_uid VARCHAR(100), + bodysite_code VARCHAR(50), + bodysite_description TEXT, + modality_code VARCHAR(50), + modality_description TEXT, + instance_uid VARCHAR(100), + sop_code VARCHAR(50), + sop_description TEXT, + procedure_code VARCHAR(50), + PRIMARY KEY (id, instance_uid) +); + +-- Supplies table +CREATE TABLE supplies ( + date DATE, + patient UUID REFERENCES patients (id), + encounter UUID REFERENCES encounters (id), + code VARCHAR(50), + description TEXT, + quantity INTEGER +); + +-- Payer transitions table +CREATE TABLE payer_transitions ( + patient UUID REFERENCES patients (id), + memberid VARCHAR(50), + start_year TIMESTAMPTZ, + end_year TIMESTAMPTZ, + payer UUID REFERENCES payers (id), + secondary_payer UUID REFERENCES payers (id), + ownership VARCHAR(50), + ownername VARCHAR(255) +); + +-- Claims table +CREATE TABLE claims ( + id UUID PRIMARY KEY, + patientid UUID REFERENCES patients (id), + providerid UUID REFERENCES providers (id), + primarypatientinsuranceid VARCHAR(100), + secondarypatientinsuranceid VARCHAR(100), + departmentid INTEGER, + patientdepartmentid INTEGER, + diagnosis1 VARCHAR(50), + diagnosis2 VARCHAR(50), + diagnosis3 VARCHAR(50), + diagnosis4 VARCHAR(50), + diagnosis5 VARCHAR(50), + diagnosis6 VARCHAR(50), + diagnosis7 VARCHAR(50), + diagnosis8 VARCHAR(50), + referringproviderid UUID REFERENCES providers (id), + appointmentid VARCHAR(100), + currentillnessdate DATE, + servicedate DATE, + supervisingproviderid UUID REFERENCES providers (id), + status1 VARCHAR(50), + status2 VARCHAR(50), + statusp VARCHAR(50), + outstanding1 DECIMAL(10, 2), + outstanding2 DECIMAL(10, 2), + outstandingp DECIMAL(10, 2), + lastbilleddate1 DATE, + lastbilleddate2 DATE, + lastbilleddatep DATE, + healthcareclaimtypeid1 VARCHAR(50), + healthcareclaimtypeid2 VARCHAR(50) +); + +-- Claims transactions table +CREATE TABLE claims_transactions ( + id UUID PRIMARY KEY, + claimid UUID REFERENCES claims (id), + chargeid INTEGER, + patientid UUID REFERENCES patients (id), + type VARCHAR(50), + amount DECIMAL(10, 2), + method VARCHAR(50), + fromdate DATE, + todate DATE, + placeofservice VARCHAR(100), + procedurecode VARCHAR(50), + modifier1 VARCHAR(10), + modifier2 VARCHAR(10), + diagnosisref1 INTEGER, + diagnosisref2 INTEGER, + diagnosisref3 INTEGER, + diagnosisref4 INTEGER, + units DECIMAL(10, 2), + departmentid INTEGER, + notes TEXT, + unitamount DECIMAL(10, 2), + transferoutid VARCHAR(100), + transfertype VARCHAR(50), + payments DECIMAL(10, 2), + adjustments DECIMAL(10, 2), + transfers DECIMAL(10, 2), + outstanding DECIMAL(10, 2), + appointmentid VARCHAR(100), + linenote TEXT, + patientinsuranceid VARCHAR(100), + feescheduleid VARCHAR(100), + providerid UUID REFERENCES providers (id), + supervisingproviderid UUID REFERENCES providers (id) +); + +-- Create indexes for better query performance +CREATE INDEX idx_patients_name ON patients (last, first); +CREATE INDEX idx_encounters_patient ON encounters (patient); +CREATE INDEX idx_encounters_dates ON encounters (start, stop); +CREATE INDEX idx_conditions_patient ON conditions (patient); +CREATE INDEX idx_medications_patient ON medications (patient); +CREATE INDEX idx_observations_patient ON observations (patient); +CREATE INDEX idx_procedures_patient ON procedures (patient); +CREATE INDEX idx_claims_patient ON claims (patientid); +CREATE INDEX idx_claims_transactions_claim ON claims_transactions (claimid); diff --git a/use-cases/medical-summary/database/02-load-initial-data.sql b/use-cases/medical-summary/database/02-load-initial-data.sql new file mode 100644 index 0000000..d31f0ab --- /dev/null +++ b/use-cases/medical-summary/database/02-load-initial-data.sql @@ -0,0 +1,323 @@ +-- Load CSV data into PostgreSQL tables +-- This script runs automatically when the PostgreSQL container is first created + +-- Note: PostgreSQL COPY expects lowercase column names to match table schema +-- The CSV headers are uppercase, so we specify the column mappings explicitly + +-- Load organizations first (referenced by other tables) +COPY organizations ( + id, name, address, city, state, zip, lat, lon, phone, revenue, utilization +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/organizations.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load payers (referenced by other tables) +COPY payers ( + id, + name, + address, + city, + state_headquartered, + zip, + phone, + amount_covered, + amount_uncovered, + revenue, + covered_encounters, + uncovered_encounters, + covered_medications, + uncovered_medications, + covered_procedures, + uncovered_procedures, + covered_immunizations, + uncovered_immunizations, + unique_customers, + qols_avg, + member_months +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/payers.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load patients +COPY patients ( + id, + birthdate, + deathdate, + ssn, + drivers, + passport, + prefix, + first, + last, + suffix, + maiden, + marital, + race, + ethnicity, + gender, + birthplace, + address, + city, + state, + county, + zip, + lat, + lon, + healthcare_expenses, + healthcare_coverage +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/patients.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load providers +COPY providers ( + id, + organization, + name, + gender, + speciality, + address, + city, + state, + zip, + lat, + lon, + utilization +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/providers.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load encounters +COPY encounters ( + id, + start, + stop, + patient, + organization, + provider, + payer, + encounterclass, + code, + description, + base_encounter_cost, + total_claim_cost, + payer_coverage, + reasoncode, + reasondescription +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/encounters.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load conditions +COPY conditions (start, stop, patient, encounter, code, description) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/conditions.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load medications +COPY medications ( + start, + stop, + patient, + payer, + encounter, + code, + description, + base_cost, + payer_coverage, + dispenses, + totalcost, + reasoncode, + reasondescription +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/medications.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load procedures +COPY procedures ( + start, + stop, + patient, + encounter, + code, + description, + base_cost, + reasoncode, + reasondescription +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/procedures.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load allergies +COPY allergies ( + start, + stop, + patient, + encounter, + code, + system, + description, + type, + category, + reaction1, + description1, + severity1, + reaction2, + description2, + severity2 +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/allergies.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load careplans +COPY careplans ( + id, + start, + stop, + patient, + encounter, + code, + description, + reasoncode, + reasondescription +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/careplans.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load immunizations +COPY immunizations (date, patient, encounter, code, description, base_cost) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/immunizations.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load devices +COPY devices (start, stop, patient, encounter, code, description, udi) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/devices.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load observations +COPY observations ( + date, patient, encounter, category, code, description, value, units, type +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/observations.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load imaging_studies +COPY imaging_studies ( + id, + date, + patient, + encounter, + series_uid, + bodysite_code, + bodysite_description, + modality_code, + modality_description, + instance_uid, + sop_code, + sop_description, + procedure_code +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/imaging_studies.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load supplies +COPY supplies (date, patient, encounter, code, description, quantity) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/supplies.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load payer_transitions +COPY payer_transitions ( + patient, + memberid, + start_year, + end_year, + payer, + secondary_payer, + ownership, + ownername +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/payer_transitions.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load claims +COPY claims ( + id, + patientid, + providerid, + primarypatientinsuranceid, + secondarypatientinsuranceid, + departmentid, + patientdepartmentid, + diagnosis1, + diagnosis2, + diagnosis3, + diagnosis4, + diagnosis5, + diagnosis6, + diagnosis7, + diagnosis8, + referringproviderid, + appointmentid, + currentillnessdate, + servicedate, + supervisingproviderid, + status1, + status2, + statusp, + outstanding1, + outstanding2, + outstandingp, + lastbilleddate1, + lastbilleddate2, + lastbilleddatep, + healthcareclaimtypeid1, + healthcareclaimtypeid2 +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/claims.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Load claims_transactions +COPY claims_transactions ( + id, + claimid, + chargeid, + patientid, + type, + amount, + method, + fromdate, + todate, + placeofservice, + procedurecode, + modifier1, + modifier2, + diagnosisref1, + diagnosisref2, + diagnosisref3, + diagnosisref4, + units, + departmentid, + notes, + unitamount, + transferoutid, + transfertype, + payments, + adjustments, + transfers, + outstanding, + appointmentid, + linenote, + patientinsuranceid, + feescheduleid, + providerid, + supervisingproviderid +) +FROM PROGRAM 'gunzip -c /docker-entrypoint-initdb.d/data/claims_transactions.csv.gz' +WITH (FORMAT csv, HEADER true, DELIMITER ','); + +-- Verify data was loaded +SELECT 'Patients loaded: ' || COUNT(*) FROM patients; +SELECT 'Providers loaded: ' || COUNT(*) FROM providers; +SELECT 'Encounters loaded: ' || COUNT(*) FROM encounters; +SELECT 'Conditions loaded: ' || COUNT(*) FROM conditions; +SELECT 'Medications loaded: ' || COUNT(*) FROM medications; +SELECT 'Procedures loaded: ' || COUNT(*) FROM procedures; diff --git a/use-cases/medical-summary/database/validate-data.sql b/use-cases/medical-summary/database/validate-data.sql new file mode 100644 index 0000000..3cde8ee --- /dev/null +++ b/use-cases/medical-summary/database/validate-data.sql @@ -0,0 +1,182 @@ +-- Data Validation Queries for Medical Summary Database + +-- 1. Check record counts for all tables +SELECT + 'organizations' AS table_name, + COUNT(*) AS record_count +FROM organizations +UNION ALL +SELECT + 'payers', + COUNT(*) +FROM payers +UNION ALL +SELECT + 'patients', + COUNT(*) +FROM patients +UNION ALL +SELECT + 'providers', + COUNT(*) +FROM providers +UNION ALL +SELECT + 'encounters', + COUNT(*) +FROM encounters +UNION ALL +SELECT + 'conditions', + COUNT(*) +FROM conditions +UNION ALL +SELECT + 'allergies', + COUNT(*) +FROM allergies +UNION ALL +SELECT + 'medications', + COUNT(*) +FROM medications +UNION ALL +SELECT + 'careplans', + COUNT(*) +FROM careplans +UNION ALL +SELECT + 'procedures', + COUNT(*) +FROM procedures +UNION ALL +SELECT + 'immunizations', + COUNT(*) +FROM immunizations +UNION ALL +SELECT + 'devices', + COUNT(*) +FROM devices +UNION ALL +SELECT + 'observations', + COUNT(*) +FROM observations +UNION ALL +SELECT + 'imaging_studies', + COUNT(*) +FROM imaging_studies +UNION ALL +SELECT + 'supplies', + COUNT(*) +FROM supplies +UNION ALL +SELECT + 'payer_transitions', + COUNT(*) +FROM payer_transitions +UNION ALL +SELECT + 'claims', + COUNT(*) +FROM claims +UNION ALL +SELECT + 'claims_transactions', + COUNT(*) +FROM claims_transactions +ORDER BY table_name; + +-- 2. Check for orphaned records (foreign key integrity) +-- Encounters without valid patients +SELECT COUNT(*) AS orphaned_encounters +FROM encounters AS e +LEFT JOIN patients AS p ON e.patient = p.id +WHERE p.id IS NULL; + +-- Encounters without valid organizations +SELECT COUNT(*) AS encounters_without_org +FROM encounters AS e +LEFT JOIN organizations AS o ON e.organization = o.id +WHERE o.id IS NULL; + +-- Encounters without valid providers +SELECT COUNT(*) AS encounters_without_provider +FROM encounters AS e +LEFT JOIN providers AS pr ON e.provider = pr.id +WHERE pr.id IS NULL; + +-- 3. Data quality checks +-- Check for patients with invalid dates +SELECT COUNT(*) AS patients_with_invalid_dates +FROM patients +WHERE deathdate IS NOT NULL AND deathdate < birthdate; + +-- Check for encounters with invalid time ranges +SELECT COUNT(*) AS invalid_encounters +FROM encounters +WHERE stop < start; + +-- 4. Sample data verification +-- Top 5 organizations by utilization +SELECT + name, + utilization, + revenue +FROM organizations +ORDER BY utilization DESC NULLS LAST +LIMIT 5; + +-- Patient demographics summary +SELECT + gender, + COUNT(*) AS count, + AVG(EXTRACT(YEAR FROM AGE(COALESCE(deathdate, CURRENT_DATE), birthdate))) + AS avg_age +FROM patients +GROUP BY gender; + +-- Most common conditions +SELECT + description, + COUNT(*) AS frequency +FROM conditions +GROUP BY description +ORDER BY frequency DESC +LIMIT 10; + +-- 5. Financial data summary +SELECT + 'Total Healthcare Expenses' AS metric, + SUM(healthcare_expenses) AS amount +FROM patients +UNION ALL +SELECT + 'Total Healthcare Coverage', + SUM(healthcare_coverage) +FROM patients +UNION ALL +SELECT + 'Total Payer Coverage', + SUM(amount_covered) +FROM payers +UNION ALL +SELECT + 'Total Claims Outstanding', + SUM(outstanding1 + COALESCE(outstanding2, 0) + COALESCE(outstandingp, 0)) +FROM claims; + +-- 6. Encounter statistics by class +SELECT + encounterclass, + COUNT(*) AS count, + AVG(total_claim_cost) AS avg_cost, + SUM(total_claim_cost) AS total_cost +FROM encounters +GROUP BY encounterclass +ORDER BY count DESC; diff --git a/use-cases/medical-summary/docker-compose.yml b/use-cases/medical-summary/docker-compose.yml new file mode 100644 index 0000000..57b5d0c --- /dev/null +++ b/use-cases/medical-summary/docker-compose.yml @@ -0,0 +1,24 @@ +services: + postgres: + image: postgres:17-alpine + container_name: medical_summary_db + environment: + POSTGRES_DB: medical_summary + POSTGRES_USER: medical_user + POSTGRES_PASSWORD: medical_pass + ports: + - "5434:5432" + volumes: + - postgres_data:/var/lib/postgresql/data + - ./database/01-create-tables.sql:/docker-entrypoint-initdb.d/01-create-tables.sql + - ./database/02-load-initial-data.sql:/docker-entrypoint-initdb.d/02-load-initial-data.sql + - ./source-data:/docker-entrypoint-initdb.d/data:ro + - ./database/validate-data.sql:/tmp/validate-data.sql:ro + healthcheck: + test: ["CMD-SHELL", "pg_isready -U medical_user -d medical_summary"] + interval: 10s + timeout: 5s + retries: 5 + +volumes: + postgres_data: diff --git a/use-cases/medical-summary/docs/database-schema-reference.md b/use-cases/medical-summary/docs/database-schema-reference.md new file mode 100644 index 0000000..661854b --- /dev/null +++ b/use-cases/medical-summary/docs/database-schema-reference.md @@ -0,0 +1,392 @@ +# Medical Summary Database Schema + +## Entity Relationship Diagram + +```mermaid +erDiagram + organizations { + UUID id PK + VARCHAR name + TEXT address + VARCHAR city + VARCHAR state + VARCHAR zip + DECIMAL lat + DECIMAL lon + VARCHAR phone + DECIMAL revenue + INTEGER utilization + } + + providers { + UUID id PK + UUID organization FK + VARCHAR name + VARCHAR gender + VARCHAR speciality + TEXT address + VARCHAR city + VARCHAR state + VARCHAR zip + DECIMAL lat + DECIMAL lon + INTEGER utilization + } + + payers { + UUID id PK + VARCHAR name + TEXT address + VARCHAR city + VARCHAR state_headquartered + VARCHAR zip + VARCHAR phone + DECIMAL amount_covered + DECIMAL amount_uncovered + DECIMAL revenue + INTEGER covered_encounters + INTEGER uncovered_encounters + INTEGER covered_medications + INTEGER uncovered_medications + INTEGER covered_procedures + INTEGER uncovered_procedures + INTEGER covered_immunizations + INTEGER uncovered_immunizations + INTEGER unique_customers + DECIMAL qols_avg + INTEGER member_months + } + + patients { + UUID id PK + DATE birthdate + DATE deathdate + VARCHAR ssn + VARCHAR drivers + VARCHAR passport + VARCHAR prefix + VARCHAR first + VARCHAR last + VARCHAR suffix + VARCHAR maiden + VARCHAR marital + VARCHAR race + VARCHAR ethnicity + VARCHAR gender + TEXT birthplace + TEXT address + VARCHAR city + VARCHAR state + VARCHAR county + VARCHAR zip + DECIMAL lat + DECIMAL lon + DECIMAL healthcare_expenses + DECIMAL healthcare_coverage + } + + encounters { + UUID id PK + TIMESTAMPTZ start + TIMESTAMPTZ stop + UUID patient FK + UUID organization FK + UUID provider FK + UUID payer FK + VARCHAR encounterclass + VARCHAR code + TEXT description + DECIMAL base_encounter_cost + DECIMAL total_claim_cost + DECIMAL payer_coverage + VARCHAR reasoncode + TEXT reasondescription + } + + conditions { + DATE start + DATE stop + UUID patient FK + UUID encounter FK + VARCHAR code + TEXT description + } + + allergies { + DATE start + DATE stop + UUID patient FK + UUID encounter FK + VARCHAR code + VARCHAR system + TEXT description + VARCHAR type + VARCHAR category + VARCHAR reaction1 + TEXT description1 + VARCHAR severity1 + VARCHAR reaction2 + TEXT description2 + VARCHAR severity2 + } + + medications { + DATE start + DATE stop + UUID patient FK + UUID payer FK + UUID encounter FK + VARCHAR code + TEXT description + DECIMAL base_cost + DECIMAL payer_coverage + INTEGER dispenses + DECIMAL totalcost + VARCHAR reasoncode + TEXT reasondescription + } + + careplans { + UUID id PK + DATE start + DATE stop + UUID patient FK + UUID encounter FK + VARCHAR code + TEXT description + VARCHAR reasoncode + TEXT reasondescription + } + + procedures { + DATE start + DATE stop + UUID patient FK + UUID encounter FK + VARCHAR code + TEXT description + DECIMAL base_cost + VARCHAR reasoncode + TEXT reasondescription + } + + immunizations { + DATE date + UUID patient FK + UUID encounter FK + VARCHAR code + TEXT description + DECIMAL base_cost + } + + devices { + DATE start + DATE stop + UUID patient FK + UUID encounter FK + VARCHAR code + TEXT description + TEXT udi + } + + observations { + DATE date + UUID patient FK + UUID encounter FK + VARCHAR category + VARCHAR code + TEXT description + TEXT value + VARCHAR units + VARCHAR type + } + + imaging_studies { + UUID id PK + VARCHAR instance_uid PK + DATE date + UUID patient FK + UUID encounter FK + VARCHAR series_uid + VARCHAR bodysite_code + TEXT bodysite_description + VARCHAR modality_code + TEXT modality_description + VARCHAR sop_code + TEXT sop_description + VARCHAR procedure_code + } + + supplies { + DATE date + UUID patient FK + UUID encounter FK + VARCHAR code + TEXT description + INTEGER quantity + } + + payer_transitions { + UUID patient FK + VARCHAR memberid + TIMESTAMPTZ start_year + TIMESTAMPTZ end_year + UUID payer FK + UUID secondary_payer FK + VARCHAR ownership + VARCHAR ownername + } + + claims { + UUID id PK + UUID patientid FK + UUID providerid FK + VARCHAR primarypatientinsuranceid + VARCHAR secondarypatientinsuranceid + INTEGER departmentid + INTEGER patientdepartmentid + VARCHAR diagnosis1 + VARCHAR diagnosis2 + VARCHAR diagnosis3 + VARCHAR diagnosis4 + VARCHAR diagnosis5 + VARCHAR diagnosis6 + VARCHAR diagnosis7 + VARCHAR diagnosis8 + UUID referringproviderid FK + VARCHAR appointmentid + DATE currentillnessdate + DATE servicedate + UUID supervisingproviderid FK + VARCHAR status1 + VARCHAR status2 + VARCHAR statusp + DECIMAL outstanding1 + DECIMAL outstanding2 + DECIMAL outstandingp + DATE lastbilleddate1 + DATE lastbilleddate2 + DATE lastbilleddatep + VARCHAR healthcareclaimtypeid1 + VARCHAR healthcareclaimtypeid2 + } + + claims_transactions { + UUID id PK + UUID claimid FK + INTEGER chargeid + UUID patientid FK + VARCHAR type + DECIMAL amount + VARCHAR method + DATE fromdate + DATE todate + VARCHAR placeofservice + VARCHAR procedurecode + VARCHAR modifier1 + VARCHAR modifier2 + INTEGER diagnosisref1 + INTEGER diagnosisref2 + INTEGER diagnosisref3 + INTEGER diagnosisref4 + DECIMAL units + INTEGER departmentid + TEXT notes + DECIMAL unitamount + VARCHAR transferoutid + VARCHAR transfertype + DECIMAL payments + DECIMAL adjustments + DECIMAL transfers + DECIMAL outstanding + VARCHAR appointmentid + TEXT linenote + VARCHAR patientinsuranceid + VARCHAR feescheduleid + UUID providerid FK + UUID supervisingproviderid FK + } + + %% Relationships + organizations ||--o{ providers : "employs" + organizations ||--o{ encounters : "hosts" + + providers ||--o{ encounters : "provides_care" + providers ||--o{ claims : "primary_provider" + providers ||--o{ claims : "referring_provider" + providers ||--o{ claims : "supervising_provider" + providers ||--o{ claims_transactions : "provider" + providers ||--o{ claims_transactions : "supervising_provider" + + payers ||--o{ encounters : "covers" + payers ||--o{ medications : "covers" + payers ||--o{ payer_transitions : "primary_payer" + payers ||--o{ payer_transitions : "secondary_payer" + + patients ||--o{ encounters : "receives_care" + patients ||--o{ conditions : "has_condition" + patients ||--o{ allergies : "has_allergy" + patients ||--o{ medications : "takes_medication" + patients ||--o{ careplans : "follows_careplan" + patients ||--o{ procedures : "undergoes_procedure" + patients ||--o{ immunizations : "receives_immunization" + patients ||--o{ devices : "uses_device" + patients ||--o{ observations : "has_observation" + patients ||--o{ imaging_studies : "has_imaging" + patients ||--o{ supplies : "uses_supply" + patients ||--o{ payer_transitions : "has_payer_transition" + patients ||--o{ claims : "patient_claim" + patients ||--o{ claims_transactions : "patient_transaction" + + encounters ||--o{ conditions : "diagnosed_during" + encounters ||--o{ allergies : "discovered_during" + encounters ||--o{ medications : "prescribed_during" + encounters ||--o{ careplans : "planned_during" + encounters ||--o{ procedures : "performed_during" + encounters ||--o{ immunizations : "given_during" + encounters ||--o{ devices : "prescribed_during" + encounters ||--o{ observations : "recorded_during" + encounters ||--o{ imaging_studies : "performed_during" + encounters ||--o{ supplies : "used_during" + + claims ||--o{ claims_transactions : "has_transactions" +``` + +## Database Statistics + +- **Total Tables**: 18 +- **Total Records**: 1,835,567 +- **Key Entities**: + - 1,163 Patients + - 1,127 Organizations + - 5,056 Providers + - 10 Payers + - 61,459 Encounters + +## Key Relationships + +1. **Core Healthcare Entities**: + - Organizations employ Providers + - Patients receive care through Encounters + - Payers cover healthcare costs + +2. **Clinical Data**: + - Encounters generate Conditions, Procedures, Medications + - Patients have Allergies, Devices, Observations + - Imaging Studies and Supplies are linked to specific encounters + +3. **Financial Data**: + - Claims track billing for patient care + - Claims Transactions detail financial movements + - Payer Transitions track insurance changes over time + +## Indexes + +The database includes performance indexes on: + +- Patient names (last, first) +- Encounter patient references +- Encounter date ranges +- Condition, medication, observation, and procedure patient references +- Claims patient references +- Claims transaction claim references diff --git a/use-cases/medical-summary/medical-summaries/summary_001.md b/use-cases/medical-summary/medical-summaries/summary_001.md new file mode 100644 index 0000000..fd3cff4 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_001.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #001 + +- **Date of Service:** 2021-11-19 +- **Patient:** Carlos172 Mayert710 +- **DOB:** 1983-04-22 (Age: 38) +- **Gender:** Female +- **Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Symptom evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 38-year-old female who presents with chronic condition monitoring. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Intramuscular injection + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_002.md b/use-cases/medical-summary/medical-summaries/summary_002.md new file mode 100644 index 0000000..a8b3b35 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_002.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #002 + +- **Date of Service:** 2021-11-18 +- **Patient:** Jospeh459 Gerhold939 +- **DOB:** 1941-12-04 (Age: 79) +- **Gender:** Male +- **Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Nausea and vomiting + +## HISTORY OF PRESENT ILLNESS + +This is a 79-year-old male who presents with persistent cough and fever. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Electrical cardioversion + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_003.md b/use-cases/medical-summary/medical-summaries/summary_003.md new file mode 100644 index 0000000..78d43f5 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_003.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #003 + +- **Date of Service:** 2021-11-18 +- **Patient:** Kit446 Hills818 +- **DOB:** 1986-01-02 (Age: 35) +- **Gender:** Female +- **Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Labor pains and contractions + +## HISTORY OF PRESENT ILLNESS + +This is a 35-year-old female who presents with labor pains and contractions. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Childbirth + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_004.md b/use-cases/medical-summary/medical-summaries/summary_004.md new file mode 100644 index 0000000..ffcc1a2 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_004.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #004 + +- **Date of Service:** 2021-11-18 +- **Patient:** Carol737 Lesch175 +- **DOB:** 1964-04-23 (Age: 57) +- **Gender:** Male +- **Encounter Type:** Inpatient + +--- + +## CHIEF COMPLAINT + +General medical evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 57-year-old male who presents with general medical evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Combined chemotherapy and radiation therapy (procedure) +- Hearing examination (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_005.md b/use-cases/medical-summary/medical-summaries/summary_005.md new file mode 100644 index 0000000..c872c6b --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_005.md @@ -0,0 +1,51 @@ +# Medical Visit Summary #005 + +- **Date of Service:** 2021-11-18 +- **Patient:** Remedios388 Fahey393 +- **DOB:** 1958-01-09 (Age: 63) +- **Gender:** Female +- **Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 63-year-old female who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 114.0/72.0 mmHg, HR 95.0 bpm, RR 13.0/min, Height 5.1 ft (155.4 cm), Weight 159.0 lbs (72.1 kg), BMI 29.9 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +- **1. Health Maintenance (Z00.00)** + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) +- Medication Reconciliation (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_006.md b/use-cases/medical-summary/medical-summaries/summary_006.md new file mode 100644 index 0000000..adebb7f --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_006.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #006 + +- **Date of Service:** 2021-11-18 +- **Patient:** Frances376 Smitham825 +- **DOB:** 1938-09-30 (Age: 83) +- **Gender:** Male +- **Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for hyperlipidemia + +## HISTORY OF PRESENT ILLNESS + +This is a 83-year-old male who presents with follow-up for hyperlipidemia. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_007.md b/use-cases/medical-summary/medical-summaries/summary_007.md new file mode 100644 index 0000000..ee064dc --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_007.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #007 + +- **Date of Service:** 2021-11-17 +- **Patient:** Dominga527 Kuphal363 +- **DOB:** 1998-09-16 (Age: 23) +- **Gender:** Female +- **Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for normal pregnancy + +## HISTORY OF PRESENT ILLNESS + +This is a 23-year-old female who presents with follow-up for normal pregnancy. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Auscultation of the fetal heart +- Evaluation of uterine fundal height + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_008.md b/use-cases/medical-summary/medical-summaries/summary_008.md new file mode 100644 index 0000000..b4b58e5 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_008.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #008 + +- **Date of Service:** 2021-11-17 +- **Patient:** Ula130 Beatty507 +- **DOB:** 1926-10-13 (Age: 95) +- **Gender:** Female +- **Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Symptom evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 95-year-old female who presents with symptom evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 153.0/117.0 mmHg, HR 91.0 bpm, RR 12.0/min, Height 5.4 ft (165.3 cm), Weight 167.6 lbs (76.0 kg), BMI 27.8 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_009.md b/use-cases/medical-summary/medical-summaries/summary_009.md new file mode 100644 index 0000000..fb623ba --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_009.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #009 + +- **Date of Service:** 2021-11-17 +- **Patient:** Bonita405 Bernier607 +- **DOB:** 1985-04-03 (Age: 36) +- **Gender:** Female +- **Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for normal pregnancy + +## HISTORY OF PRESENT ILLNESS + +This is a 36-year-old female who presents with follow-up for normal pregnancy. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Auscultation of the fetal heart +- Evaluation of uterine fundal height + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_010.md b/use-cases/medical-summary/medical-summaries/summary_010.md new file mode 100644 index 0000000..2ff0f12 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_010.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #010 + +- **Date of Service:** 2021-11-17 +- **Patient:** Concha418 Adams676 +- **DOB:** 1975-04-02 (Age: 46) +- **Gender:** Female +- **Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Chronic condition monitoring + +## HISTORY OF PRESENT ILLNESS + +This is a 46-year-old female who presents with medication management. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Intramuscular injection + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_011.md b/use-cases/medical-summary/medical-summaries/summary_011.md new file mode 100644 index 0000000..275e2a2 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_011.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #011 + +- **Date of Service:** 2021-11-16 +- **Patient:** Sherilyn598 O'Keefe54 +- **DOB:** 1977-12-20 (Age: 43) +- **Gender:** Female +- **Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Routine follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 43-year-old female who presents with routine follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Intramuscular injection + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_012.md b/use-cases/medical-summary/medical-summaries/summary_012.md new file mode 100644 index 0000000..8ca4df0 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_012.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #012 + +- **Date of Service:** 2021-11-16 +- **Patient:** Jesse626 Senger904 +- **DOB:** 1951-09-18 (Age: 70) +- **Gender:** Male +- **Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Persistent cough and fever + +## HISTORY OF PRESENT ILLNESS + +This is a 70-year-old male who presents with persistent cough and fever. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_013.md b/use-cases/medical-summary/medical-summaries/summary_013.md new file mode 100644 index 0000000..b5827dd --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_013.md @@ -0,0 +1,50 @@ +# Medical Visit Summary #013 + +- **Date of Service:** 2021-11-16 +- **Patient:** Roberto515 Quiroz936 +- **DOB:** 2013-11-19 (Age: 7) +- **Gender:** Male +- **Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 7-year-old male who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 108.0/82.0 mmHg, HR 62.0 bpm, RR 15.0/min, Height 4.3 ft (130.8 cm), Weight 73.0 lbs (33.1 kg), BMI 19.3 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Medication Reconciliation (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_014.md b/use-cases/medical-summary/medical-summaries/summary_014.md new file mode 100644 index 0000000..592886c --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_014.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #014 + +- **Date of Service:** 2021-11-16 +- **Patient:** Melodie819 Cormier289 +- **DOB:** 1988-08-04 (Age: 33) +- **Gender:** Female +- **Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Routine follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 33-year-old female who presents with routine follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Subcutaneous immunotherapy + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_015.md b/use-cases/medical-summary/medical-summaries/summary_015.md new file mode 100644 index 0000000..3754c01 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_015.md @@ -0,0 +1,50 @@ +# Medical Visit Summary #015 + +- **Date of Service:** 2021-11-16 +- **Patient:** Allyson474 Gibson10 +- **DOB:** 1994-08-02 (Age: 27) +- **Gender:** Female +- **Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 27-year-old female who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 136.0/74.0 mmHg, HR 96.0 bpm, RR 15.0/min, Height 5.4 ft (165.8 cm), Weight 146.2 lbs (66.3 kg), BMI 24.1 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_016.md b/use-cases/medical-summary/medical-summaries/summary_016.md new file mode 100644 index 0000000..8a77adb --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_016.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #016 + +**Date of Service:** 2021-11-16 +**Patient:** Erin498 Mann644 +**DOB:** 1999-03-22 (Age: 22) +**Gender:** Male +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Symptom evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 22-year-old male who presents with routine follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_017.md b/use-cases/medical-summary/medical-summaries/summary_017.md new file mode 100644 index 0000000..f166198 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_017.md @@ -0,0 +1,50 @@ +# Medical Visit Summary #017 + +**Date of Service:** 2021-11-15 +**Patient:** Teddy976 Batz141 +**DOB:** 2018-06-11 (Age: 3) +**Gender:** Male +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 3-year-old male who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 121.0/80.0 mmHg, HR 67.0 bpm, RR 16.0/min, Height 3.5 ft (106.9 cm), Weight 36.6 lbs (16.6 kg), BMI 14.5 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Medication Reconciliation (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_018.md b/use-cases/medical-summary/medical-summaries/summary_018.md new file mode 100644 index 0000000..12fdadb --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_018.md @@ -0,0 +1,49 @@ +# Medical Visit Summary #018 + +**Date of Service:** 2021-11-15 +**Patient:** Lavone763 Swaniawski813 +**DOB:** 1999-10-11 (Age: 22) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for normal pregnancy + +## HISTORY OF PRESENT ILLNESS + +This is a 22-year-old female who presents with follow-up for normal pregnancy. Patient has a history of normal pregnancy and reports gradual worsening of symptoms over the past few days. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Normal pregnancy + - Continue current management + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Auscultation of the fetal heart +- Blood typing RH typing + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_019.md b/use-cases/medical-summary/medical-summaries/summary_019.md new file mode 100644 index 0000000..a3209d7 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_019.md @@ -0,0 +1,51 @@ +# Medical Visit Summary #019 + +**Date of Service:** 2021-11-15 +**Patient:** Alexandria361 Hilll811 +**DOB:** 2003-09-22 (Age: 18) +**Gender:** Female +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 18-year-old female who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 147.0/97.0 mmHg, HR 90.0 bpm, RR 16.0/min, Height 5.5 ft (167.3 cm), Weight 108.0 lbs (49.0 kg), BMI 17.5 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Hypertension + - Continue current management + - amLODIPine 2.5 MG Oral Tablet as prescribed + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) +- Medication Reconciliation (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_020.md b/use-cases/medical-summary/medical-summaries/summary_020.md new file mode 100644 index 0000000..f4f4126 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_020.md @@ -0,0 +1,50 @@ +# Medical Visit Summary #020 + +- **Date of Service:** 2021-11-15 +- **Patient:** Loretta235 Bosco882 +- **DOB:** 1965-02-08 (Age: 56) +- **Gender:** Female +- **Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 56-year-old female who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 149.0/97.0 mmHg, HR 96.0 bpm, RR 13.0/min, Height 5.4 ft (165.3 cm), Weight 179.7 lbs (81.5 kg), BMI 29.8 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_021.md b/use-cases/medical-summary/medical-summaries/summary_021.md new file mode 100644 index 0000000..73d99d1 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_021.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #021 + +**Date of Service:** 2021-11-15 +**Patient:** Eleni953 Hilpert278 +**DOB:** 1990-10-28 (Age: 31) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for normal pregnancy + +## HISTORY OF PRESENT ILLNESS + +This is a 31-year-old female who presents with follow-up for normal pregnancy. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Auscultation of the fetal heart +- Evaluation of uterine fundal height + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_022.md b/use-cases/medical-summary/medical-summaries/summary_022.md new file mode 100644 index 0000000..9b42ef6 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_022.md @@ -0,0 +1,46 @@ +# Medical Visit Summary #022 + +**Date of Service:** 2021-11-15 +**Patient:** Billie243 Grady603 +**DOB:** 2014-11-23 (Age: 6) +**Gender:** Male +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 6-year-old male who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 123.0/70.0 mmHg, HR 100.0 bpm, RR 15.0/min, Height 3.8 ft (114.9 cm), Weight 44.3 lbs (20.1 kg), BMI 15.3 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_023.md b/use-cases/medical-summary/medical-summaries/summary_023.md new file mode 100644 index 0000000..c16a8f4 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_023.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #023 + +**Date of Service:** 2021-11-14 +**Patient:** David908 Dicki44 +**DOB:** 2005-10-23 (Age: 16) +**Gender:** Female +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Symptom evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 16-year-old female who presents with routine follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_024.md b/use-cases/medical-summary/medical-summaries/summary_024.md new file mode 100644 index 0000000..9be25ce --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_024.md @@ -0,0 +1,51 @@ +# Medical Visit Summary #024 + +**Date of Service:** 2021-11-14 +**Patient:** Scottie437 Kerluke267 +**DOB:** 1960-01-17 (Age: 61) +**Gender:** Male +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 61-year-old male who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 137.0/80.0 mmHg, HR 78.0 bpm, RR 12.0/min, Height 6.1 ft (186.8 cm), Weight 187.8 lbs (85.2 kg), BMI 24.4 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) +- Medication Reconciliation (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_025.md b/use-cases/medical-summary/medical-summaries/summary_025.md new file mode 100644 index 0000000..ee0c14c --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_025.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #025 + +**Date of Service:** 2021-11-14 +**Patient:** Dann525 Wisoky380 +**DOB:** 1944-09-12 (Age: 77) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for hyperlipidemia + +## HISTORY OF PRESENT ILLNESS + +This is a 77-year-old female who presents with follow-up for hyperlipidemia. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_026.md b/use-cases/medical-summary/medical-summaries/summary_026.md new file mode 100644 index 0000000..0478cfc --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_026.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #026 + +**Date of Service:** 2021-11-14 +**Patient:** Dino214 Schultz619 +**DOB:** 2009-11-18 (Age: 11) +**Gender:** Male +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Severe abdominal pain + +## HISTORY OF PRESENT ILLNESS + +This is a 11-year-old male who presents with chest pain and shortness of breath. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Concussion with no loss of consciousness + - Continue current management + - Follow-up in 4-6 weeks or as needed + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_027.md b/use-cases/medical-summary/medical-summaries/summary_027.md new file mode 100644 index 0000000..2b0444e --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_027.md @@ -0,0 +1,51 @@ +# Medical Visit Summary #027 + +**Date of Service:** 2021-11-14 +**Patient:** Aurelio227 Wehner319 +**DOB:** 1970-03-15 (Age: 51) +**Gender:** Male +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 51-year-old male who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 137.0/75.0 mmHg, HR 61.0 bpm, RR 16.0/min, Height 5.4 ft (163.3 cm), Weight 166.4 lbs (75.5 kg), BMI 28.3 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) +- Medication Reconciliation (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_028.md b/use-cases/medical-summary/medical-summaries/summary_028.md new file mode 100644 index 0000000..1e6b4b4 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_028.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #028 + +**Date of Service:** 2021-11-14 +**Patient:** Christia477 Ritchie586 +**DOB:** 1993-05-23 (Age: 28) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Labor pains and contractions + +## HISTORY OF PRESENT ILLNESS + +This is a 28-year-old female who presents with labor pains and contractions. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Childbirth + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_029.md b/use-cases/medical-summary/medical-summaries/summary_029.md new file mode 100644 index 0000000..79abd13 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_029.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #029 + +**Date of Service:** 2021-11-14 +**Patient:** Janeth814 Grant908 +**DOB:** 1995-12-10 (Age: 25) +**Gender:** Female +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Medication management + +## HISTORY OF PRESENT ILLNESS + +This is a 25-year-old female who presents with symptom evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_030.md b/use-cases/medical-summary/medical-summaries/summary_030.md new file mode 100644 index 0000000..0a5cef1 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_030.md @@ -0,0 +1,50 @@ +# Medical Visit Summary #030 + +**Date of Service:** 2021-11-14 +**Patient:** Buddy254 Gislason620 +**DOB:** 2021-03-07 (Age: 0) +**Gender:** Male +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 0-year-old male who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 103.0/81.0 mmHg, HR 99.0 bpm, RR 13.0/min, Height 2.4 ft (71.9 cm), Weight 18.5 lbs (8.4 kg) +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Medication Reconciliation (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_031.md b/use-cases/medical-summary/medical-summaries/summary_031.md new file mode 100644 index 0000000..3bd8576 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_031.md @@ -0,0 +1,49 @@ +# Medical Visit Summary #031 + +**Date of Service:** 2021-11-13 +**Patient:** Dorotea472 Botello137 +**DOB:** 1986-07-19 (Age: 35) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for normal pregnancy + +## HISTORY OF PRESENT ILLNESS + +This is a 35-year-old female who presents with follow-up for normal pregnancy. Patient has a history of normal pregnancy and reports gradual worsening of symptoms over the past few days. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Normal pregnancy + - Continue current management + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Auscultation of the fetal heart +- Blood typing RH typing + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_032.md b/use-cases/medical-summary/medical-summaries/summary_032.md new file mode 100644 index 0000000..8a3fc01 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_032.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #032 + +**Date of Service:** 2021-11-13 +**Patient:** Miguel815 Krajcik437 +**DOB:** 1993-02-27 (Age: 28) +**Gender:** Male +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Routine follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 28-year-old male who presents with symptom evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_033.md b/use-cases/medical-summary/medical-summaries/summary_033.md new file mode 100644 index 0000000..27eedf2 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_033.md @@ -0,0 +1,51 @@ +# Medical Visit Summary #033 + +**Date of Service:** 2021-11-13 +**Patient:** Monroe732 Streich926 +**DOB:** 1971-11-13 (Age: 50) +**Gender:** Male +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 50-year-old male who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 124.0/77.0 mmHg, HR 62.0 bpm, RR 13.0/min, Height 5.7 ft (174.1 cm), Weight 201.5 lbs (91.4 kg), BMI 30.2 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) +- Medication Reconciliation (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_034.md b/use-cases/medical-summary/medical-summaries/summary_034.md new file mode 100644 index 0000000..5a242cb --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_034.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #034 + +**Date of Service:** 2021-11-13 +**Patient:** Ashton21 Mitchell808 +**DOB:** 2003-05-17 (Age: 18) +**Gender:** Female +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Routine follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 18-year-old female who presents with chronic condition monitoring. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Intramuscular injection + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_035.md b/use-cases/medical-summary/medical-summaries/summary_035.md new file mode 100644 index 0000000..47ada17 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_035.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #035 + +**Date of Service:** 2021-11-13 +**Patient:** Suzan149 Franecki195 +**DOB:** 2008-09-22 (Age: 13) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Routine follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 13-year-old female who presents with symptom evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Subcutaneous immunotherapy + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_036.md b/use-cases/medical-summary/medical-summaries/summary_036.md new file mode 100644 index 0000000..c81f9ec --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_036.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #036 + +**Date of Service:** 2021-11-13 +**Patient:** Bibi254 Stoltenberg489 +**DOB:** 2005-09-17 (Age: 16) +**Gender:** Female +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Routine follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 16-year-old female who presents with medication management. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_037.md b/use-cases/medical-summary/medical-summaries/summary_037.md new file mode 100644 index 0000000..6613e77 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_037.md @@ -0,0 +1,50 @@ +# Medical Visit Summary #037 + +**Date of Service:** 2021-11-13 +**Patient:** Josefina523 Deckow585 +**DOB:** 1986-06-14 (Age: 35) +**Gender:** Female +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 35-year-old female who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 148.0/107.0 mmHg, HR 84.0 bpm, RR 13.0/min, Height 5.1 ft (156.0 cm), Weight 228.0 lbs (103.4 kg), BMI 42.5 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_038.md b/use-cases/medical-summary/medical-summaries/summary_038.md new file mode 100644 index 0000000..fbe06f3 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_038.md @@ -0,0 +1,50 @@ +# Medical Visit Summary #038 + +**Date of Service:** 2021-11-13 +**Patient:** Zachariah133 Bergstrom287 +**DOB:** 1913-07-15 (Age: 108) +**Gender:** Male +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for streptococcal sore throat (disorder) + +## HISTORY OF PRESENT ILLNESS + +This is a 108-year-old male who presents with follow-up for streptococcal sore throat (disorder). Patient has a history of streptococcal sore throat (disorder) and reports gradual worsening of symptoms over the past few days. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** Temp 99.9°F (37.7°C) +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Streptococcal sore throat (disorder) + - Continue current management + - Penicillin V Potassium 500 MG Oral Tablet as prescribed + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Throat culture (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_039.md b/use-cases/medical-summary/medical-summaries/summary_039.md new file mode 100644 index 0000000..4bad27b --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_039.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #039 + +**Date of Service:** 2021-11-13 +**Patient:** Yuriko393 Rogahn59 +**DOB:** 2005-05-07 (Age: 16) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for normal pregnancy + +## HISTORY OF PRESENT ILLNESS + +This is a 16-year-old female who presents with follow-up for normal pregnancy. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Auscultation of the fetal heart +- Evaluation of uterine fundal height + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_040.md b/use-cases/medical-summary/medical-summaries/summary_040.md new file mode 100644 index 0000000..f946775 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_040.md @@ -0,0 +1,49 @@ +# Medical Visit Summary #040 + +**Date of Service:** 2021-11-13 +**Patient:** Kristi306 Anderson154 +**DOB:** 1983-06-03 (Age: 38) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for normal pregnancy + +## HISTORY OF PRESENT ILLNESS + +This is a 38-year-old female who presents with follow-up for normal pregnancy. Patient has a history of normal pregnancy and reports gradual worsening of symptoms over the past few days. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Normal pregnancy + - Continue current management + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Auscultation of the fetal heart +- Blood typing RH typing + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_041.md b/use-cases/medical-summary/medical-summaries/summary_041.md new file mode 100644 index 0000000..003f02a --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_041.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #041 + +**Date of Service:** 2021-11-13 +**Patient:** Alberta625 Waters156 +**DOB:** 1969-10-19 (Age: 52) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Difficulty breathing + +## HISTORY OF PRESENT ILLNESS + +This is a 52-year-old female who presents with difficulty breathing. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Sprain of wrist + - Continue current management + - Ibuprofen 200 MG Oral Tablet as prescribed + - Follow-up in 4-6 weeks or as needed + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_042.md b/use-cases/medical-summary/medical-summaries/summary_042.md new file mode 100644 index 0000000..0be77bb --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_042.md @@ -0,0 +1,51 @@ +# Medical Visit Summary #042 + +**Date of Service:** 2021-11-13 +**Patient:** Angel97 Jacobi462 +**DOB:** 1970-11-06 (Age: 51) +**Gender:** Male +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 51-year-old male who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 114.0/75.0 mmHg, HR 62.0 bpm, RR 12.0/min, Height 5.9 ft (180.6 cm), Weight 202.2 lbs (91.7 kg), BMI 28.1 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) +- Medication Reconciliation (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_043.md b/use-cases/medical-summary/medical-summaries/summary_043.md new file mode 100644 index 0000000..1d86fb0 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_043.md @@ -0,0 +1,50 @@ +# Medical Visit Summary #043 + +**Date of Service:** 2021-11-13 +**Patient:** Lizette501 Nikolaus26 +**DOB:** 1963-07-26 (Age: 58) +**Gender:** Female +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 58-year-old female who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 127.0/85.0 mmHg, HR 85.0 bpm, RR 16.0/min, Height 5.1 ft (155.4 cm), Weight 149.7 lbs (67.9 kg), BMI 28.1 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_044.md b/use-cases/medical-summary/medical-summaries/summary_044.md new file mode 100644 index 0000000..f6a6992 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_044.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #044 + +**Date of Service:** 2021-11-12 +**Patient:** Cornelia505 Gibson10 +**DOB:** 1963-08-16 (Age: 58) +**Gender:** Female +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Medication management + +## HISTORY OF PRESENT ILLNESS + +This is a 58-year-old female who presents with symptom evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_045.md b/use-cases/medical-summary/medical-summaries/summary_045.md new file mode 100644 index 0000000..6700e34 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_045.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #045 + +**Date of Service:** 2021-11-12 +**Patient:** Randal152 Herman763 +**DOB:** 1931-10-16 (Age: 90) +**Gender:** Male +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Symptom evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 90-year-old male who presents with chronic condition monitoring. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 164.0/116.0 mmHg, HR 80.0 bpm, RR 15.0/min, Height 5.8 ft (175.6 cm), Weight 187.6 lbs (85.1 kg), BMI 27.6 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_046.md b/use-cases/medical-summary/medical-summaries/summary_046.md new file mode 100644 index 0000000..150d430 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_046.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #046 + +**Date of Service:** 2021-11-12 +**Patient:** Johnny786 Blick895 +**DOB:** 2019-10-02 (Age: 2) +**Gender:** Male +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for fracture of rib + +## HISTORY OF PRESENT ILLNESS + +This is a 2-year-old male who presents with follow-up for fracture of rib. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_047.md b/use-cases/medical-summary/medical-summaries/summary_047.md new file mode 100644 index 0000000..2aa5a6e --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_047.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #047 + +**Date of Service:** 2021-11-12 +**Patient:** Pauletta164 Brown30 +**DOB:** 2001-09-21 (Age: 20) +**Gender:** Female +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Symptom evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 20-year-old female who presents with symptom evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_048.md b/use-cases/medical-summary/medical-summaries/summary_048.md new file mode 100644 index 0000000..59e4232 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_048.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #048 + +**Date of Service:** 2021-11-12 +**Patient:** Anna632 Davis923 +**DOB:** 1993-08-13 (Age: 28) +**Gender:** Female +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Routine follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 28-year-old female who presents with routine follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_049.md b/use-cases/medical-summary/medical-summaries/summary_049.md new file mode 100644 index 0000000..6defd2a --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_049.md @@ -0,0 +1,46 @@ +# Medical Visit Summary #049 + +**Date of Service:** 2021-11-12 +**Patient:** Brandon214 Watsica258 +**DOB:** 2020-12-04 (Age: 0) +**Gender:** Female +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 0-year-old female who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 132.0/76.0 mmHg, HR 71.0 bpm, RR 15.0/min, Height 2.3 ft (70.8 cm), Weight 20.7 lbs (9.4 kg) +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_050.md b/use-cases/medical-summary/medical-summaries/summary_050.md new file mode 100644 index 0000000..e60a6e2 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_050.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #050 + +- **Date of Service:** 2021-11-12 +- **Patient:** Pei116 Williamson769 +- **DOB:** 2003-10-08 (Age: 18) +- **Gender:** Female +- **Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Chronic condition monitoring + +## HISTORY OF PRESENT ILLNESS + +This is a 18-year-old female who presents with medication management. Patient has a history of chronic low back pain (finding) and reports gradual worsening of symptoms over the past few days. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +- **1. Chronic low back pain (finding)** + - Continue current management + - Ibuprofen 400 MG Oral Tablet [Ibu] as prescribed + - Follow-up in 4-6 weeks or as needed + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_051.md b/use-cases/medical-summary/medical-summaries/summary_051.md new file mode 100644 index 0000000..0128df5 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_051.md @@ -0,0 +1,51 @@ +# Medical Visit Summary #051 + +**Date of Service:** 2021-11-12 +**Patient:** Abel832 Dooley940 +**DOB:** 2004-09-23 (Age: 17) +**Gender:** Male +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 17-year-old male who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 115.0/79.0 mmHg, HR 94.0 bpm, RR 15.0/min, Height 5.5 ft (168.1 cm), Weight 125.2 lbs (56.8 kg), BMI 20.1 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Anticipatory guidance (procedure) +- Assessment of anxiety (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_052.md b/use-cases/medical-summary/medical-summaries/summary_052.md new file mode 100644 index 0000000..cd33854 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_052.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #052 + +**Date of Service:** 2021-11-11 +**Patient:** Kit446 Hills818 +**DOB:** 1986-01-02 (Age: 35) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for normal pregnancy + +## HISTORY OF PRESENT ILLNESS + +This is a 35-year-old female who presents with follow-up for normal pregnancy. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Auscultation of the fetal heart +- Evaluation of uterine fundal height + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_053.md b/use-cases/medical-summary/medical-summaries/summary_053.md new file mode 100644 index 0000000..b4546d0 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_053.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #053 + +**Date of Service:** 2021-11-11 +**Patient:** Tyrell880 Fadel536 +**DOB:** 2007-07-08 (Age: 14) +**Gender:** Male +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Routine follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 14-year-old male who presents with medication management. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Subcutaneous immunotherapy + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_054.md b/use-cases/medical-summary/medical-summaries/summary_054.md new file mode 100644 index 0000000..c36ab85 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_054.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #054 + +**Date of Service:** 2021-11-11 +**Patient:** Katharyn928 Toy286 +**DOB:** 1967-10-06 (Age: 54) +**Gender:** Female +**Encounter Type:** Inpatient + +--- + +## CHIEF COMPLAINT + +General medical evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 54-year-old female who presents with general medical evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Combined chemotherapy and radiation therapy (procedure) +- Hearing examination (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_055.md b/use-cases/medical-summary/medical-summaries/summary_055.md new file mode 100644 index 0000000..24f3b8b --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_055.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #055 + +**Date of Service:** 2021-11-11 +**Patient:** Edmund685 Tillman293 +**DOB:** 1986-07-31 (Age: 35) +**Gender:** Male +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Routine follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 35-year-old male who presents with chronic condition monitoring. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_056.md b/use-cases/medical-summary/medical-summaries/summary_056.md new file mode 100644 index 0000000..9cc9d34 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_056.md @@ -0,0 +1,50 @@ +# Medical Visit Summary #056 + +**Date of Service:** 2021-11-11 +**Patient:** Ciara810 Effertz744 +**DOB:** 1996-09-05 (Age: 25) +**Gender:** Female +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 25-year-old female who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 119.0/79.0 mmHg, HR 64.0 bpm, RR 15.0/min, Height 5.4 ft (164.5 cm), Weight 167.6 lbs (76.0 kg), BMI 28.1 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Full-time employment (finding) + - Continue current management + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Assessment of anxiety (procedure) +- Assessment of health and social care needs (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_057.md b/use-cases/medical-summary/medical-summaries/summary_057.md new file mode 100644 index 0000000..f113d5a --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_057.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #057 + +**Date of Service:** 2021-11-11 +**Patient:** Man114 Kassulke119 +**DOB:** 2003-06-12 (Age: 18) +**Gender:** Female +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Symptom evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 18-year-old female who presents with routine follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_058.md b/use-cases/medical-summary/medical-summaries/summary_058.md new file mode 100644 index 0000000..77741dc --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_058.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #058 + +**Date of Service:** 2021-11-11 +**Patient:** Dewitt635 Bernier607 +**DOB:** 1953-09-21 (Age: 68) +**Gender:** Male +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for first degree burn + +## HISTORY OF PRESENT ILLNESS + +This is a 68-year-old male who presents with follow-up for first degree burn. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_059.md b/use-cases/medical-summary/medical-summaries/summary_059.md new file mode 100644 index 0000000..0ed562d --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_059.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #059 + +**Date of Service:** 2021-11-11 +**Patient:** Scarlet110 Gaylord332 +**DOB:** 1973-01-03 (Age: 48) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Difficulty breathing + +## HISTORY OF PRESENT ILLNESS + +This is a 48-year-old female who presents with difficulty breathing. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_060.md b/use-cases/medical-summary/medical-summaries/summary_060.md new file mode 100644 index 0000000..3687db3 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_060.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #060 + +**Date of Service:** 2021-11-11 +**Patient:** Scarlet110 Gaylord332 +**DOB:** 1973-01-03 (Age: 48) +**Gender:** Female +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Medication management + +## HISTORY OF PRESENT ILLNESS + +This is a 48-year-old female who presents with medication management. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Intramuscular injection + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_061.md b/use-cases/medical-summary/medical-summaries/summary_061.md new file mode 100644 index 0000000..8d2246d --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_061.md @@ -0,0 +1,55 @@ +# Medical Visit Summary #061 + +**Date of Service:** 2021-11-11 +**Patient:** Calvin845 Schiller186 +**DOB:** 1964-09-28 (Age: 57) +**Gender:** Male +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for hyperlipidemia + +## HISTORY OF PRESENT ILLNESS + +This is a 57-year-old male who presents with follow-up for hyperlipidemia. Patient has a history of full-time employment (finding) and reports gradual worsening of symptoms over the past few days. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Full-time employment (finding) + - Continue current management + - Simvastatin 10 MG Oral Tablet as prescribed + - Follow-up in 4-6 weeks or as needed + +2. Victim of intimate partner abuse (finding) + - Continue current management + - Simvastatin 10 MG Oral Tablet as prescribed + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Assessment of substance use (procedure) +- Assessment using Alcohol Use Disorders Identification Test - Consumption (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_062.md b/use-cases/medical-summary/medical-summaries/summary_062.md new file mode 100644 index 0000000..8e4b1e7 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_062.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #062 + +**Date of Service:** 2021-11-11 +**Patient:** Kari181 Douglas31 +**DOB:** 1990-12-28 (Age: 30) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for normal pregnancy + +## HISTORY OF PRESENT ILLNESS + +This is a 30-year-old female who presents with follow-up for normal pregnancy. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Depression screening +- Physical exam following abortion + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_063.md b/use-cases/medical-summary/medical-summaries/summary_063.md new file mode 100644 index 0000000..7f51d74 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_063.md @@ -0,0 +1,46 @@ +# Medical Visit Summary #063 + +**Date of Service:** 2021-11-10 +**Patient:** Eustolia154 Barton704 +**DOB:** 2011-01-15 (Age: 10) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Follow-up for acute viral pharyngitis (disorder) + +## HISTORY OF PRESENT ILLNESS + +This is a 10-year-old female who presents with follow-up for acute viral pharyngitis (disorder). Patient has a history of acute viral pharyngitis (disorder) and reports gradual worsening of symptoms over the past few days. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** Temp 99.0°F (37.2°C) +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Acute viral pharyngitis (disorder) + - Continue current management + - Clindamycin 300mg as prescribed + - Follow-up in 4-6 weeks or as needed + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_064.md b/use-cases/medical-summary/medical-summaries/summary_064.md new file mode 100644 index 0000000..e2025f7 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_064.md @@ -0,0 +1,51 @@ +# Medical Visit Summary #064 + +**Date of Service:** 2021-11-10 +**Patient:** Maxie520 Green467 +**DOB:** 2009-10-21 (Age: 12) +**Gender:** Female +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 12-year-old female who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 119.0/71.0 mmHg, HR 63.0 bpm, RR 15.0/min, Height 5.3 ft (160.1 cm), Weight 114.6 lbs (52.0 kg), BMI 20.3 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Anticipatory guidance (procedure) +- Assessment of substance use (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_065.md b/use-cases/medical-summary/medical-summaries/summary_065.md new file mode 100644 index 0000000..85ce147 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_065.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #065 + +**Date of Service:** 2021-11-10 +**Patient:** Ula130 Beatty507 +**DOB:** 1926-10-13 (Age: 95) +**Gender:** Female +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Persistent cough and fever + +## HISTORY OF PRESENT ILLNESS + +This is a 95-year-old female who presents with minor injury follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_066.md b/use-cases/medical-summary/medical-summaries/summary_066.md new file mode 100644 index 0000000..edbb71f --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_066.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #066 + +**Date of Service:** 2021-11-10 +**Patient:** José Emilio366 Cadena322 +**DOB:** 1955-12-26 (Age: 65) +**Gender:** Male +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Routine follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 65-year-old male who presents with symptom evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_067.md b/use-cases/medical-summary/medical-summaries/summary_067.md new file mode 100644 index 0000000..0277e1b --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_067.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #067 + +**Date of Service:** 2021-11-10 +**Patient:** Lawrence741 Lueilwitz711 +**DOB:** 1990-10-24 (Age: 31) +**Gender:** Male +**Encounter Type:** Outpatient + +--- + +## CHIEF COMPLAINT + +Medication management + +## HISTORY OF PRESENT ILLNESS + +This is a 31-year-old male who presents with routine follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_068.md b/use-cases/medical-summary/medical-summaries/summary_068.md new file mode 100644 index 0000000..fa10a2e --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_068.md @@ -0,0 +1,50 @@ +# Medical Visit Summary #068 + +**Date of Service:** 2021-11-10 +**Patient:** Antione404 Hamill307 +**DOB:** 2010-10-27 (Age: 11) +**Gender:** Male +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 11-year-old male who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 108.0/77.0 mmHg, HR 76.0 bpm, RR 15.0/min, Height 4.5 ft (138.6 cm), Weight 75.4 lbs (34.2 kg), BMI 17.8 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Health Maintenance (Z00.00) + - All screening tests up to date + - Continue current preventive measures + - Next annual physical in 12 months + +## PROCEDURES PERFORMED + +- Medication Reconciliation (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_069.md b/use-cases/medical-summary/medical-summaries/summary_069.md new file mode 100644 index 0000000..ded257f --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_069.md @@ -0,0 +1,49 @@ +# Medical Visit Summary #069 + +**Date of Service:** 2021-11-10 +**Patient:** Barbara209 Acevedo301 +**DOB:** 1965-09-12 (Age: 56) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Severe headache and nausea + +## HISTORY OF PRESENT ILLNESS + +This is a 56-year-old female who presents with severe abdominal pain. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Laceration of forearm + - Continue current management + - Naproxen sodium 220 MG Oral Tablet as prescribed + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Suture open wound + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_070.md b/use-cases/medical-summary/medical-summaries/summary_070.md new file mode 100644 index 0000000..a94049a --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_070.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #070 + +**Date of Service:** 2021-11-10 +**Patient:** Mariette443 Gusikowski974 +**DOB:** 1992-10-14 (Age: 29) +**Gender:** Female +**Encounter Type:** Ambulatory + +--- + +## CHIEF COMPLAINT + +Symptom evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 29-year-old female who presents with symptom evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Depression screening +- Physical examination following birth + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_071.md b/use-cases/medical-summary/medical-summaries/summary_071.md new file mode 100644 index 0000000..ac894e2 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_071.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #071 + +**Date of Service:** 2021-11-09 +**Patient:** Willodean275 Hyatt152 +**DOB:** 1988-12-13 (Age: 32) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Labor pains and contractions + +## HISTORY OF PRESENT ILLNESS + +This is a 32-year-old female who presents with labor pains and contractions. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Childbirth +- Episiotomy + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_072.md b/use-cases/medical-summary/medical-summaries/summary_072.md new file mode 100644 index 0000000..5259685 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_072.md @@ -0,0 +1,58 @@ +# Medical Visit Summary #072 + +**Date of Service:** 2021-11-09 +**Patient:** Shirlene698 Bergnaum523 +**DOB:** 1917-05-15 (Age: 104) +**Gender:** Female +**Encounter Type:** Wellness + +--- + +## CHIEF COMPLAINT + +Annual physical examination and health maintenance + +## HISTORY OF PRESENT ILLNESS + +This is a 104-year-old female who presents with no acute complaints for routine health maintenance and preventive care screening. + +## PHYSICAL EXAMINATION + +- **Vital Signs:** BP 136.0/85.0 mmHg, HR 89.0 bpm, RR 15.0/min, Height 5.2 ft (159.7 cm), Weight 154.5 lbs (70.1 kg), BMI 27.5 +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Full-time employment (finding) + - Continue current management + - Hydrochlorothiazide 25 MG Oral Tablet as prescribed + - amLODIPine 2.5 MG Oral Tablet as prescribed + - Follow-up in 4-6 weeks or as needed + +2. Stress (finding) + - Continue current management + - Hydrochlorothiazide 25 MG Oral Tablet as prescribed + - amLODIPine 2.5 MG Oral Tablet as prescribed + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Assessment of health and social care needs (procedure) +- Assessment of substance use (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_073.md b/use-cases/medical-summary/medical-summaries/summary_073.md new file mode 100644 index 0000000..1b38f12 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_073.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #073 + +**Date of Service:** 2021-11-06 +**Patient:** Isabelle619 Runte676 +**DOB:** 1978-10-29 (Age: 43) +**Gender:** Female +**Encounter Type:** Inpatient + +--- + +## CHIEF COMPLAINT + +General medical evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 43-year-old female who presents with general medical evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Surgical manipulation of joint of knee + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_074.md b/use-cases/medical-summary/medical-summaries/summary_074.md new file mode 100644 index 0000000..b26c747 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_074.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #074 + +**Date of Service:** 2021-11-05 +**Patient:** Randal152 Herman763 +**DOB:** 1931-10-16 (Age: 90) +**Gender:** Male +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Minor injury follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 90-year-old male who presents with rash and itching. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_075.md b/use-cases/medical-summary/medical-summaries/summary_075.md new file mode 100644 index 0000000..8c214f2 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_075.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #075 + +**Date of Service:** 2021-11-04 +**Patient:** Breanne585 Leffler128 +**DOB:** 1966-03-20 (Age: 55) +**Gender:** Female +**Encounter Type:** Inpatient + +--- + +## CHIEF COMPLAINT + +General medical evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 55-year-old female who presents with general medical evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Combined chemotherapy and radiation therapy (procedure) +- Hearing examination (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_076.md b/use-cases/medical-summary/medical-summaries/summary_076.md new file mode 100644 index 0000000..22b1084 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_076.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #076 + +**Date of Service:** 2021-11-04 +**Patient:** Scarlet110 Gaylord332 +**DOB:** 1973-01-03 (Age: 48) +**Gender:** Female +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Rash and itching + +## HISTORY OF PRESENT ILLNESS + +This is a 48-year-old female who presents with rash and itching. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_077.md b/use-cases/medical-summary/medical-summaries/summary_077.md new file mode 100644 index 0000000..d8c847b --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_077.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #077 + +**Date of Service:** 2021-11-03 +**Patient:** Chan58 Hartmann983 +**DOB:** 1994-11-23 (Age: 26) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Labor pains and contractions + +## HISTORY OF PRESENT ILLNESS + +This is a 26-year-old female who presents with labor pains and contractions. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Childbirth +- Epidural anesthesia + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_078.md b/use-cases/medical-summary/medical-summaries/summary_078.md new file mode 100644 index 0000000..4543cb7 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_078.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #078 + +**Date of Service:** 2021-11-01 +**Patient:** Jacquelynn434 Morar593 +**DOB:** 1960-09-23 (Age: 61) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Severe abdominal pain + +## HISTORY OF PRESENT ILLNESS + +This is a 61-year-old female who presents with severe abdominal pain. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_079.md b/use-cases/medical-summary/medical-summaries/summary_079.md new file mode 100644 index 0000000..4ccdce2 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_079.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #079 + +**Date of Service:** 2021-10-31 +**Patient:** Armando772 Hilll811 +**DOB:** 1945-11-04 (Age: 75) +**Gender:** Male +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Acute back pain + +## HISTORY OF PRESENT ILLNESS + +This is a 75-year-old male who presents with minor injury follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Catheter ablation of tissue of heart + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_080.md b/use-cases/medical-summary/medical-summaries/summary_080.md new file mode 100644 index 0000000..11f1cce --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_080.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #080 + +**Date of Service:** 2021-10-31 +**Patient:** Sherry479 Barrows492 +**DOB:** 1964-05-31 (Age: 57) +**Gender:** Female +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Acute back pain + +## HISTORY OF PRESENT ILLNESS + +This is a 57-year-old female who presents with nausea and vomiting. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_081.md b/use-cases/medical-summary/medical-summaries/summary_081.md new file mode 100644 index 0000000..1ece04a --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_081.md @@ -0,0 +1,49 @@ +# Medical Visit Summary #081 + +**Date of Service:** 2021-10-30 +**Patient:** Isabelle619 Runte676 +**DOB:** 1978-10-29 (Age: 43) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +High fever and chills + +## HISTORY OF PRESENT ILLNESS + +This is a 43-year-old female who presents with difficulty breathing. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Injury of medial collateral ligament of knee + - Continue current management + - Ibuprofen 200 MG Oral Tablet as prescribed + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Knee X-ray + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_082.md b/use-cases/medical-summary/medical-summaries/summary_082.md new file mode 100644 index 0000000..917317a --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_082.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #082 + +**Date of Service:** 2021-10-29 +**Patient:** Abraham100 Koss676 +**DOB:** 1946-08-12 (Age: 75) +**Gender:** Male +**Encounter Type:** Inpatient + +--- + +## CHIEF COMPLAINT + +General medical evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 75-year-old male who presents with general medical evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Combined chemotherapy and radiation therapy (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_083.md b/use-cases/medical-summary/medical-summaries/summary_083.md new file mode 100644 index 0000000..978774e --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_083.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #083 + +**Date of Service:** 2021-10-29 +**Patient:** Randal152 Herman763 +**DOB:** 1931-10-16 (Age: 90) +**Gender:** Male +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Acute back pain + +## HISTORY OF PRESENT ILLNESS + +This is a 90-year-old male who presents with minor injury follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_084.md b/use-cases/medical-summary/medical-summaries/summary_084.md new file mode 100644 index 0000000..4fb1bd7 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_084.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #084 + +**Date of Service:** 2021-10-29 +**Patient:** Nieves278 Strosin214 +**DOB:** 1965-02-26 (Age: 56) +**Gender:** Female +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Acute back pain + +## HISTORY OF PRESENT ILLNESS + +This is a 56-year-old female who presents with acute back pain. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_085.md b/use-cases/medical-summary/medical-summaries/summary_085.md new file mode 100644 index 0000000..f88189b --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_085.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #085 + +**Date of Service:** 2021-10-28 +**Patient:** Jospeh459 Gerhold939 +**DOB:** 1941-12-04 (Age: 79) +**Gender:** Male +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Minor injury follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 79-year-old male who presents with minor injury follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Electrical cardioversion + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_086.md b/use-cases/medical-summary/medical-summaries/summary_086.md new file mode 100644 index 0000000..de05a92 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_086.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #086 + +**Date of Service:** 2021-10-28 +**Patient:** Scarlet110 Gaylord332 +**DOB:** 1973-01-03 (Age: 48) +**Gender:** Female +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Minor injury follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 48-year-old female who presents with minor injury follow-up. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_087.md b/use-cases/medical-summary/medical-summaries/summary_087.md new file mode 100644 index 0000000..bcda841 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_087.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #087 + +**Date of Service:** 2021-10-26 +**Patient:** Jesse626 Senger904 +**DOB:** 1951-09-18 (Age: 70) +**Gender:** Male +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Rash and itching + +## HISTORY OF PRESENT ILLNESS + +This is a 70-year-old male who presents with acute back pain. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_088.md b/use-cases/medical-summary/medical-summaries/summary_088.md new file mode 100644 index 0000000..2ed8a0f --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_088.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #088 + +**Date of Service:** 2021-10-26 +**Patient:** Warren653 Ullrich385 +**DOB:** 1916-03-28 (Age: 105) +**Gender:** Male +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Nausea and vomiting + +## HISTORY OF PRESENT ILLNESS + +This is a 105-year-old male who presents with persistent cough and fever. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Electrical cardioversion + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_089.md b/use-cases/medical-summary/medical-summaries/summary_089.md new file mode 100644 index 0000000..1b41eb8 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_089.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #089 + +**Date of Service:** 2021-10-25 +**Patient:** Sung603 Weber641 +**DOB:** 1914-12-20 (Age: 106) +**Gender:** Male +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Persistent cough and fever + +## HISTORY OF PRESENT ILLNESS + +This is a 106-year-old male who presents with persistent cough and fever. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Electrical cardioversion + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_090.md b/use-cases/medical-summary/medical-summaries/summary_090.md new file mode 100644 index 0000000..d6057b8 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_090.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #090 + +**Date of Service:** 2021-10-24 +**Patient:** Shirlene698 Pfeffer420 +**DOB:** 1968-01-07 (Age: 53) +**Gender:** Female +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Nausea and vomiting + +## HISTORY OF PRESENT ILLNESS + +This is a 53-year-old female who presents with acute back pain. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_091.md b/use-cases/medical-summary/medical-summaries/summary_091.md new file mode 100644 index 0000000..7a2b2ec --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_091.md @@ -0,0 +1,49 @@ +# Medical Visit Summary #091 + +**Date of Service:** 2021-10-24 +**Patient:** Carmelina668 Morissette863 +**DOB:** 1979-04-20 (Age: 42) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Chest pain and shortness of breath + +## HISTORY OF PRESENT ILLNESS + +This is a 42-year-old female who presents with severe abdominal pain. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Laceration of forearm + - Continue current management + - Naproxen sodium 220 MG Oral Tablet as prescribed + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Suture open wound + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_092.md b/use-cases/medical-summary/medical-summaries/summary_092.md new file mode 100644 index 0000000..416720e --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_092.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #092 + +**Date of Service:** 2021-10-24 +**Patient:** Santina680 Kub800 +**DOB:** 1934-09-09 (Age: 87) +**Gender:** Female +**Encounter Type:** Inpatient + +--- + +## CHIEF COMPLAINT + +General medical evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 87-year-old female who presents with general medical evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Cytopathology procedure preparation of smear genital source (procedure) +- Manual pelvic examination (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_093.md b/use-cases/medical-summary/medical-summaries/summary_093.md new file mode 100644 index 0000000..2d90010 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_093.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #093 + +**Date of Service:** 2021-10-24 +**Patient:** Santina680 Kub800 +**DOB:** 1934-09-09 (Age: 87) +**Gender:** Female +**Encounter Type:** Inpatient + +--- + +## CHIEF COMPLAINT + +General medical evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 87-year-old female who presents with general medical evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Mammography (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_094.md b/use-cases/medical-summary/medical-summaries/summary_094.md new file mode 100644 index 0000000..53e3a99 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_094.md @@ -0,0 +1,57 @@ +# Medical Visit Summary #094 + +**Date of Service:** 2021-10-23 +**Patient:** Yuriko393 Rogahn59 +**DOB:** 2005-05-07 (Age: 16) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Difficulty breathing + +## HISTORY OF PRESENT ILLNESS + +This is a 16-year-old female who presents with severe headache and nausea. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +1. Cardiac Arrest + - Continue current management + - 1 ML Epinephrine 1 MG/ML Injection as prescribed + - 3 ML Amiodarone hydrocholoride 50 MG/ML Prefilled Syringe as prescribed + - Follow-up in 4-6 weeks or as needed + +2. History of cardiac arrest (situation) + - Continue current management + - 1 ML Epinephrine 1 MG/ML Injection as prescribed + - 3 ML Amiodarone hydrocholoride 50 MG/ML Prefilled Syringe as prescribed + - Follow-up in 4-6 weeks or as needed + +## PROCEDURES PERFORMED + +- Catheter ablation of tissue of heart +- Echocardiography (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_095.md b/use-cases/medical-summary/medical-summaries/summary_095.md new file mode 100644 index 0000000..882844f --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_095.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #095 + +**Date of Service:** 2021-10-22 +**Patient:** Randal152 Herman763 +**DOB:** 1931-10-16 (Age: 90) +**Gender:** Male +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Severe abdominal pain + +## HISTORY OF PRESENT ILLNESS + +This is a 90-year-old male who presents with chest pain and shortness of breath. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_096.md b/use-cases/medical-summary/medical-summaries/summary_096.md new file mode 100644 index 0000000..c52c4e7 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_096.md @@ -0,0 +1,44 @@ +# Medical Visit Summary #096 + +**Date of Service:** 2021-10-21 +**Patient:** Jospeh459 Gerhold939 +**DOB:** 1941-12-04 (Age: 79) +**Gender:** Male +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Minor injury follow-up + +## HISTORY OF PRESENT ILLNESS + +This is a 79-year-old male who presents with nausea and vomiting. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Electrical cardioversion + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_097.md b/use-cases/medical-summary/medical-summaries/summary_097.md new file mode 100644 index 0000000..050d796 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_097.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #097 + +**Date of Service:** 2021-10-21 +**Patient:** Scarlet110 Gaylord332 +**DOB:** 1973-01-03 (Age: 48) +**Gender:** Female +**Encounter Type:** Emergency + +--- + +## CHIEF COMPLAINT + +Severe abdominal pain + +## HISTORY OF PRESENT ILLNESS + +This is a 48-year-old female who presents with chest pain and shortness of breath. Symptoms began approximately 2-4 hours prior to presentation. Patient denies recent trauma or similar episodes. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_098.md b/use-cases/medical-summary/medical-summaries/summary_098.md new file mode 100644 index 0000000..fdc60e3 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_098.md @@ -0,0 +1,45 @@ +# Medical Visit Summary #098 + +**Date of Service:** 2021-10-20 +**Patient:** Carol737 Lesch175 +**DOB:** 1964-04-23 (Age: 57) +**Gender:** Male +**Encounter Type:** Inpatient + +--- + +## CHIEF COMPLAINT + +General medical evaluation + +## HISTORY OF PRESENT ILLNESS + +This is a 57-year-old male who presents with general medical evaluation. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +## PROCEDURES PERFORMED + +- Combined chemotherapy and radiation therapy (procedure) +- Hearing examination (procedure) + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_099.md b/use-cases/medical-summary/medical-summaries/summary_099.md new file mode 100644 index 0000000..f13f90c --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_099.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #099 + +**Date of Service:** 2021-10-20 +**Patient:** Lyle846 Abshire638 +**DOB:** 1933-07-05 (Age: 88) +**Gender:** Male +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Acute back pain + +## HISTORY OF PRESENT ILLNESS + +This is a 88-year-old male who presents with persistent cough and fever. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/medical-summaries/summary_100.md b/use-cases/medical-summary/medical-summaries/summary_100.md new file mode 100644 index 0000000..357ecd5 --- /dev/null +++ b/use-cases/medical-summary/medical-summaries/summary_100.md @@ -0,0 +1,40 @@ +# Medical Visit Summary #100 + +**Date of Service:** 2021-10-19 +**Patient:** Jesse626 Senger904 +**DOB:** 1951-09-18 (Age: 70) +**Gender:** Male +**Encounter Type:** Urgentcare + +--- + +## CHIEF COMPLAINT + +Rash and itching + +## HISTORY OF PRESENT ILLNESS + +This is a 70-year-old male who presents with rash and itching. No significant associated symptoms reported. + +## PHYSICAL EXAMINATION + +- **General:** Patient appears comfortable, alert and oriented +- **HEENT:** Normocephalic, atraumatic, pupils equal and reactive +- **Cardiovascular:** Regular rate and rhythm, no murmurs +- **Pulmonary:** Clear to auscultation bilaterally +- **Abdomen:** Soft, non-tender, non-distended +- **Extremities:** No edema, pulses intact +- **Neurologic:** Alert and oriented, no focal deficits + +## ASSESSMENT AND PLAN + +ALLERGIES: NKDA (No Known Drug Allergies) + +## DISPOSITION + +Patient discharged in stable condition with appropriate follow-up instructions. + +--- + +_Provider: Dr. [Provider Name]_ +_Date Generated: 2025-07-17 14:07_ diff --git a/use-cases/medical-summary/source-data/allergies.csv.gz b/use-cases/medical-summary/source-data/allergies.csv.gz new file mode 100644 index 0000000..4c2b582 Binary files /dev/null and b/use-cases/medical-summary/source-data/allergies.csv.gz differ diff --git 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