X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: Did you have any medical issues?
Patient: Nope.
Doctor: What about surgery.
Patient: No, I never had a surgery.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No medical issues or surgeries
Plan of Action: N/A
Doctor: You are not allergic to anything?
Patient: No, I am not.
Doctor: Any food or other pollen?
Patient: No, I am not allergic to anything.
Doctor: Great!

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: None
Doctor: April twenty two three we checked your list of medications. 
Doctor: We saw that it lifts up in the morning and evening.
Doctor: Yeah.
Patient: Yeah.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: List of medications checked on April 22, 2003, with morning and evening dosages
Plan of Action: N/A
Doctor: How old is the baby? 
Guest_family: He is twenty one months old. 
Doctor: What brings you here today?
Guest_family: I have concerns about his motor development. Many times he seems to have lazy eyes and sometimes I can notice his jaw quivering. 
Doctor: How was your pregnancy? 
Guest_family: I had no complications in my pregnancy with him. My labor was very spontaneous, and it was a normal delivery. 
Doctor: Is this the only child?
Guest_family: No, I have two more kids. 
Doctor: How much did he weigh at birth? 
Guest_family: He was around eight pounds and ten ounces. 
Doctor: Did you remember his milestones?
Guest_family: Yes, I have all of it written down for all of my three kids and I brought this with me. He sat on his own by seven months. He was able to stand by eleven months and crawled around sixteen months but he was not walking until eighteen months. 
Doctor: What issues are he facing right now? 
Guest_family: He falls a lot. He cannot walk properly. He is kind of in toeing on his left. He's able to feed himself properly. He also throws, um, he picks up the things and throws them. His upper body looks strong. 
Doctor: How about his speech? How many words do you think he knows? 
Guest_family: He knows more than twenty words for sure. 
Doctor: Is he able to speak two word phrases? 
Guest_family: Yes. He says things like ,”give me,” and, “come here.” 
Doctor: Any other unusual behavior that you noticed? Any seizures or just the quivering movement of the jaw? 
Guest_family: No, it was only this and we have noticed this since birth. I don't know if it is related but I did notice that his left eye deviates outside.

Clinical note:
Symptoms: Delayed motor development, "jaw quivering," "lazy eye," falls frequently, in toeing on left, transient left exotropia
Diagnosis: N/A
History of Patient: 21-month-old male with uncomplicated pregnancy, normal delivery, delayed milestones (sitting at 7 months, standing at 11 months, crawling at 16 months, cruising at 18 months), currently unable to walk, upper body strength and coordination normal, speaks two-word phrases, no seizures, jaw quivering since birth, transient left exotropia
Plan of Action: N/A
Doctor: What brings you back into the clinic today?
Patient: I have been having some severe bruising. I have been taking Coumadin for three months now. Am I taking to much Coumadin? 
Doctor: You are taking a normal start dose. Some people do not metabolize the medication as well as others. I would like to get you tested for hypersensitivity. After we get the test results back, we will be able to adjust your dosage accordingly.  
Patient: Okay.

Clinical note:
Symptoms: Severe bruising
Diagnosis: Probable Coumadin hypersensitivity
History of Patient: Taking Coumadin for three months, concerns about dosage
Plan of Action: Testing for hypersensitivity to Coumadin, dosage adjustment pending test results
Doctor: Let me examine you. Tell me, did you have any fever or chills, any sweating or that sort of thing?
Patient: Um no.
Doctor: How about abnormal weight loss or weight gain?
Patient: No. 
Doctor: Are you experiencing any chest pain on exertion or shortness of breath normally or when you try to sleep?
Patient: No, no chest pain and shortness of breath.
Doctor: Let me see your legs. They look good I don't see any pedal edema. Usually that happens due to excess water retention. Any palpitations?
Patient: No.
Doctor: Any feeling of numbness or tingling? Did you faint or lose consciousness anytime?
Patient: No and no.
Doctor: Okay, good!
Doctor: Any double and or blurred vision? 
Patient: No.
Doctor: Any difficulty hearing or any wired continuous sound you may hear?
Patient: No.
Doctor: Okay, um tell me if you had any um, allergies, or sneezing, or runny nose?
Patient: No, no really.
Doctor: Okay, got it.
Doctor: Any indigestion, or heart burn? Did you notice any blood in stool or black stool? 
Patient: No.
Doctor: Any diarrhea or vomiting?
Patient: Nope. 
Doctor: Are you feeling thirsty frequently?
Patient: No, just normal.
Doctor: Okay.
Doctor: And I see you got a urine test, so no pus cells or blood present.
Patient: Yes. 
Doctor: Any pain while passing urine though? Any blood?
Patient: No.
Doctor: And how is the urine frequency? Do you have to wake up at night to urinate?
Patient: Well, my frequency is normal. I don't have to wake up at night for urinating. 
Doctor: How bout the stream while passing urine? You think it's normal or somewhat slow? 
Patient: No, it's absolutely normal.
Doctor: Okay, so any cough or cold like symptoms any sputum? 
Patient: Nope.
Doctor: No wheezing, right?
Patient: Yes, no wheezing.
Doctor: I don't see any lesions, that's good. Any mood swings, feeling depressed or have anxiety? 
Patient: No.
Doctor: Any joint pain in the legs, back or anywhere? 
Patient: Um no.
Doctor: Okay, so no erythema in the joints. Any heat or cold intolerance?
Patient: No.
Doctor: Okay, any difficulty swallowing? Let me check here, lymph nodes look fine. And do you bleed easily and does the bleeding stop normally? 
Patient: Oh yes!
Doctor: Do you bruise easy?
Patient: No, not really. 
Doctor: Okay. Any abnormal skin lesions?
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: No fevers, chills, sweats, weight loss, weight gain, exertional chest pain, orthopnea, PND, palpitations, paresis, paresthesias, syncope, double vision, blurred vision, tinnitus, decreased auditory acuity, rhinorrhea, sneezing, indigestion, heartburn, diarrhea, blood in stools, black stools, change in bowel habits, dysuria, hematuria, pyuria, polyuria, nocturia, slow urinary stream, wheezing, cough, sputum production, skin lesions, nonhealing lesions, joint pain, bone pain, back pain, erythema at joints, heat intolerance, cold intolerance, polydipsia, easy bruising, easy bleeding, swollen lymph nodes.
History of Patient: N/A
Plan of Action: N/A
Doctor: Are you allright?
Patient: Yes I am fine.
Doctor: That's great.
Patient: Thanks.
Doctor: I think you can go home now.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Stable
Doctor: I'm reviewing my notes from your last visit. Your last visit was on May tenth two thousand four, correct? 
Patient: Yes, that's right. 
Doctor: Has there been any change since your last visit? 
Patient: Well, I'm having some increased paranoia. 
Doctor: Have you been treated, and are you taking medicine for this? 
Patient: Yes, and it's actually gotten a lot better with the medicine another doctor gave me.

Clinical note:
Symptoms: Increased paranoia
Diagnosis: N/A
History of Patient: Reviewed notes from 05/10/2004, addition of paranoia, much improved with current medication
Plan of Action: N/A
Doctor: I just met with one of my patients whom I believe has pertussis. 
Guest_clinician: Second case of the day. What's their name and date of birth? 
Doctor: Hm give me a second to pull up their information.

Clinical note:
Symptoms: Suspected pertussis
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Public Health Department notified
Doctor: Have you ever had psychiatric or psychological treatment? 
Patient: Uh no, no treatments whatsoever. I mean I do find myself in low moods every now and again when I'm dealing with certain stressors, but the decreased moods rarely ever long lasting.

Clinical note:
Symptoms: Mildly low mood during certain stressors
Diagnosis: N/A
History of Patient: Denied history of psychiatric or psychological treatment, transient low moods during stressors
Plan of Action: N/A
Doctor: Do you remember when your last flu vaccine was?
Patient: I don't remember what month, but it was in nineteen ninety nine. 
Doctor: Good, and do you remember your last pneumonia vaccine? 
Patient: Let me look at my notes here, um, it was in nineteen ninety six. 
Doctor: Thank you, now, tell me more about your parents. Do you know their medical histories?
Patient: Let me think, my dad is still around, he had a stroke. Oh yeah, and he has high blood pressure. 
Doctor: How old is your father?
Patient: He's seventy nine now. 
Doctor: Good, what about your mother? 
Patient: She died when she was seventy four, she had heart failure and emphysema.
Doctor: I'm sorry to hear that. Do you have any brothers or sisters?
Patient: Thank you doctor, no, its just me and my Dad now.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Last flu vaccine in 1999, last pneumonia vaccine in 1996, father aged 79 with history of stroke and hypertension, mother deceased at age 74 due to heart failure and emphysema, no siblings
Plan of Action: N/A
Doctor: How are you doing today, ma'am?
Patient: I'm doing just fine.
Doctor: Any kind of alcohol consumption?
Patient: Nope.
Doctor: Have you ever taken any kind of illegal drugs?
Patient: Nope.
Doctor: What about smoking?
Patient: No. 
Doctor: Are you still working? 
Patient: No, sir. I had issues with my knees, and they had to put in the new ones. I was kind of disabled and that's why I retired.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Retired on disability due to knee replacements, no history of smoking, alcohol consumption, or illegal drug use
Plan of Action: N/A
Doctor: Do you have any chest pain?
Patient: No, I don't.
Doctor: Any breathlessness?
Patient: Yes, I do get breathless only when I have to do some form of exertion like walking a long time or running.
Doctor: Okay. How about any bowel issues?
Patient: No, I don't have any stomach problems except I have to go frequently to use a bathroom.
Doctor: Okay frequency. How about any prolonged bleeding issues or anything like that sort?
Patient: No nothing like that.

Clinical note:
Symptoms: Exertional shortness of breath, frequent urination
Diagnosis: N/A
History of Patient: Denies chest pain, GI problems, bleeding disorders or bleeding history
Plan of Action: N/A
Doctor: Does she lives with anyone? 
Guest_family: Yes, we all stay together, so just the immediate family. My parents, me and my sister.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Lives with parents
Plan of Action: N/A
Doctor: Hi, the weather outside is beautiful, did you get some sunshine?
Patient: Yes in fact I came in walking.
Doctor: Great way to get some exercise in.
Doctor: ok so what's going on?
Patient: I am having a bellyache.
Doctor: Since when?
Patient: Oh, it's been a while now.
Doctor: Can you tell me more about your pain like how did it start and what exactly are you feeling?
Patient:  Ok so the pain started as dullache but it is constant right here in the middle upper part of my stomach. And sometimes it is moving to the back.
Doctor: Can you tell me if it is stabbing pain and if it is related to any specific time of the day?
Patient: Sure, so i do get episodes of stabbing pain but they are not related to meals. Once the wave comes it lasts for only a minute or so.
Doctor: Can you tell me when exactly you noted it?
Patient: Approximately six months back. I took over the counter antacids and got some relief so i did not go to doctor. But two months back it got worse, I do get occasional nausea and vomiting.
Doctor: I can see that they found H pylori positive infection and treated you with triple drug therapy for two weeks and then gave you antacid omeprazole. But it did not improve your pain.
Patient: Yeah that's right.
Patient: Do you know I lost twenty pound of weight since all these symptoms began but i have been also admitted for poor appetite.
Doctor: Ok tell me how are your bowel movements and if you see any blood in stools?
Patient: I get two to three loose bowel movements a day but no blood in stool or anywhere. 
Doctor: Are you taking any pain medication over the counter? Do you drink alcohol and maybe you are vomiting blood?
Patient: No no, nothing like that.
Doctor: Can you tell me if any change in position changes the quality of pain? do you have any fever?
Patient: No position changing have no effect, no fever or anything.
Doctor: Have you been exercising before all this?
Patient: Yes I have had very active and healthy lifestyle.

Clinical note:
Symptoms: Chronic abdominal pain described as dull, achy, constant, located in the middle upper part of the stomach with occasional radiation to the back. Occasional episodes of stabbing epigastric pain unrelated to meals, lasting only minutes. Occasional nausea and vomiting. Weight loss of twenty pounds since Symptoms began. Poor appetite. Two to three loose bowel movements a day without blood in stool.
Diagnosis: N/A
History of Patient: Pain started approximately six months ago. Self-medicated with over-the-counter antacids initially. Found to be H. pylori positive and treated with triple therapy for two weeks, followed by omeprazole, without relief. Active and healthy lifestyle prior to Symptoms.
Plan of Action: N/A
Doctor: Any specific family medical history that I should be aware of? 
Patient: No. 
Doctor: Anyone in your family, even grandparents, if you know them, did they have diabetes or high blood pressure? 
Patient: No. 
Doctor: Anyone else sick at home? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Noncontributory. No specific family medical history provided.
Plan of Action: N/A
Doctor: What is your family medical history? 
Patient: My mother has high blood pressure, and she had a stroke last year. 
Doctor: Is your mother still with us after the stroke?
Patient: Yeah. She is doing well.
Doctor: Good. What about your father's medical history? 
Patient: My father died in a car accident, when he was forty. 
Doctor: I am so sorry to hear that. 
Patient: Thank you.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Mother is alive with history of hypertension and stroke, father deceased due to motor vehicle accident at age 40
Plan of Action: N/A
Doctor: Anyone in your family have a history of drug or alcohol abuse?
Patient: No.
Doctor: Any other medical conditions that might run in your family?
Patient: Nope.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Noncontributory
Plan of Action: N/A
Doctor: Do you drink?
Patient: Like, every day?
Doctor: No, just in general. 
Patient: No, I don't drink at all. 
Doctor: Do you smoke? 
Patient: No, I don't do that at all, either.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Patient does not drink alcohol or smoke
Plan of Action: N/A
Doctor: Any drug allergies?
Patient: Ah yes, I am allergic to... what's the name of the drug? It's called Napro-
Doctor: Naprosyn?
Patient: Yes, Naprosyn.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Allergic to Naprosyn
Plan of Action: N/A
Doctor: Hi, how old are you madam?
Patient: I am ninety three. I am a super duper old Swedish woman.
Doctor: Ha! Not so old okay!
Patient: I had vomiting episodes and I am feeling very nauseous.
Doctor: Oh I am so sorry to hear that.
Patient: I have pain in urination too, I think I might have the U T I?
Doctor: Let's see here. So you already have a right hip issue, bone disease, hypertension, depression, and heart rhythm disorder for a long time.
Patient: Yes that is correct.
Doctor: Let me see what we can do here.
Patient: Thank you doctor.

Clinical note:
Symptoms: Vomiting, nausea, pain in urination
Diagnosis: Urinary tract infection (UTI)
History of Patient: Chronic right hip pain, osteoporosis, hypertension, depression, chronic atrial fibrillation
Plan of Action: N/A
Doctor: Do you drink? 
Patient: No, never!
Doctor: Did you ever smoke?
Patient: No.
Doctor: How about drugs? Marijuana or anything? 
Patient: Well, I always stayed away from drugs.
Doctor: Good. And what is your living arrangement? Do you stay with your kids?
Patient: I live at my place. My kids visit me but mostly I live alone. 
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No history of smoking, alcohol, or drug use, lives at home
Plan of Action: N/A
Doctor: Good afternoon, how old are you? 
Patient: Hello Doctor, I'm fifty four years old. 
Doctor: What gender do you identify with? 
Patient: I identify as a female. 
Doctor: Thank you. What symptoms are you experiencing in your right hand? 
Patient: I have numbness and tingling in my right hand. 
Doctor: Are there any specific fingers that you feel it in?
Patient: I really feel it in my fifth, fourth, and third fingers.
Doctor: What kind of treatments have you done for this pain? 
Patient: I've taken antiinflammatories, stayed away from sports and stuff like that, and rested. 
Doctor: Has this helped at all?
Patient: No, not at all, its still numb and tingling. 
Doctor: This sounds like carpal tunnel, there's a quick, minimally invasive surgery I can do on this hand, since it hasn't responded to nonoperative treatments. I think that'll really help. 
Patient: I'd like to do that, what's the name of the procedure?  
Doctor: Its called a carpal tunnel release.

Clinical note:
Symptoms: Numbness and tingling in right hand, particularly in fifth, fourth, and third fingers
Diagnosis: Carpal tunnel syndrome
History of Patient: Failed conservative management including anti-inflammatories, rest, and avoiding sports; elected for carpal tunnel release surgery
Plan of Action: Carpal tunnel release surgery
Guest_family: Congestion and cough.
Doctor: Oh, how long?
Guest_family: It's been three weeks now.
Doctor: Okay.
Guest_family: He has been like this for so long, but nothing else.
Doctor:  How about fever nausea vomiting diarrhea?
Guest_family: No fever, no vomiting, nothing else. 
Doctor: Okay great.

Clinical note:
Symptoms: Congestion, cough
Diagnosis: N/A
History of Patient: Congestion for three weeks, coughing, no fevers, no vomiting
Plan of Action: N/A
Doctor: What do you do? Are you working or in school?
Patient: I am in school.
Doctor: Good.
Patient: Thanks.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Patient is currently in school
Plan of Action: N/A
Doctor: Do you have any children, ma'am? 
Patient: Yes, I have a wonderful baby girl at home. 
Doctor: Wonderful, were there any complications with your pregnancy or delivery? 
Patient: Nope, everything went very smooth. I'm thankful. 
Doctor: Good, have you ever been hospitalized for any issue?
Patient: No, thankfully. 
Doctor: Good, so I can assume you've never had surgery?
Patient: Correct, I never have.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Pregnancy and delivery without complications, no history of hospitalizations or surgeries
Plan of Action: N/A
Doctor: Any past surgeries that I should know of?
Patient: I had a hip replacement years ago.
Doctor: Both hips?
Patient: My left.
Doctor: Total?
Patient: Yeah.
Doctor: Got it.
Patient: I also had my uterus and appendix removed. I was young when I had my appendix taken out.
Doctor: Do you happen to remember who did your most recent surgeries?
Patient: Wish I did. I'd have to look back at my records and get back to you. I have everything at home.
Doctor: That's no problem. I should be able to look it up from my end, too.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Left total hip replacement many years ago, hysterectomy, appendectomy at a young age
Plan of Action: N/A
Doctor: Where do you live? 
Patient: I live with my mother around the corner where the Whole Foods is. I have been there for a few years now. 
Doctor: Are you the mother of the patient? 
Guest_family: Yes, I'm the mother. 
Doctor: How are you dealing with everything? 
Guest_family: We just want what is best for him. We want to support him in every possible way. He has only one elder sister. She lives in Texas and she also wants the same for him. Before he started living with us, he has been living in the A B C D places and some were in very bad condition. He was not striving there. That's why we asked him to move in with us.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: PSYCHIATRIC: The patient lives with his mother and has been staying with her for a few years now.  We have talked to her.  She is very supportive.  His only sister is also very supportive of him.  He has lived in the ABCD houses in the past.  He has done poorly in some of them.
Plan of Action: N/A
Doctor: Are you taking any medications? 
Patient: Yes, I am taking Accutane for my acne issues. 
Doctor: Okay, any other medicines? 
Patient: No, just that.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: taking Accutane for acne, no other medications
Plan of Action: N/A
Doctor: Do you have any history of surgeries, sir? 
Patient: The most recent was seven years ago. I had a craniotomy. I had a brain hemorrhage and there was bleed inside and outside the brain that they had to fix. 
Doctor: How was the recovery for that? 
Patient: I took a while but the doctors said I had a normal recovery time. 
Doctor: That is good. Have you had any other surgeries? 
Patient: I had surgery on my leg for a fracture. They put some pins in my leg. 
Doctor: Okay. 
Patient: I had some kind of surgery done on my stomach when I was a kid. I am not sure what the surgery was. All I know is that it was a very common procedure with no complications. 
Doctor: Okay. Is that all? 
Patient: Yep. That's it.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: 1. Surgery on stomach as a child. Type unknown, common procedure with no complications. 2. Surgery for leg fracture with pins inserted. 3. Craniotomy seven years ago for intracranial hemorrhage/subdural hematoma.
Plan of Action: N/A
Doctor: Do you have any past medical problems that I should know about? 
Patient: Well, what exactly do you mean by that, doctor? 
Doctor: Well, it could be anything from A D H D to depression to epilepsy. 
Patient: Oh, no. I don't have anything like that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: So, lets talk about your family, anybody in your family have any neurological problems?
Patient: No, I don't think so, my parents did experience some memory loss but that was when they were in their nineties. And I am assuming it was mostly from the old age rather than any neuro problem. 
Doctor: Yeah, that is true. And how about your brothers and sisters, do you have any? 
Patient: Oh yeah, I have five siblings and they are pretty healthy! I mean all of them are doing good, no one has any memory issues as far as I know or any neuro related illness. 
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. No neurological illnesses in the family.
Plan of Action: N/A
Doctor: Do you have any family history of heart disease? 
Patient: My mother has coronary artery disease.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Mother Has Coronary Artery disease
Plan of Action: N/A
Patient: Um, do I have to follow some special or soft diet?
Doctor: No, nothing like that. You can have a normal diet. Whatever you like to eat. 
Patient: At this age, my diet is very limited. I am going to be eighty-two next month.
Doctor: Well, I don't think you need to restrict your diet. You can follow your regular diet.
Patient: Alright, thank you.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Regular diet suitable for age
Doctor: Do migraine headaches run in the family?
Patient: My mother gets migraines and she told me that it runs on her side of the family. 
Doctor: Any family history of blood clots? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: maternal family history of migraine headaches, no family history of blood clots
Plan of Action: N/A
Doctor: Are you married? 
Patient: I was, but my husband died thirty years ago. 
Doctor: Are you working? 
Patient: Nope. 
Doctor: What is your highest degree? 
Patient: I did high school. I was living alone for fifteen years until December of ninety four. 
Doctor: How is your living situation now? Who is taking care of you? 
Patient: My daughters have started taking care of me on a shareable basis. 
Doctor: Do you smoke? Or drink or have ever used any drugs. 
Patient: Nope.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: widowed for over 30 years, lived alone for 15 years until December 1994, daughters now share the task of caring for her, high school education, no history of tobacco, alcohol, or illicit drug use
Plan of Action: N/A
Doctor: Do you smoke, or have you smoked in the past? 
Patient: Yeah, I quit two years ago. But before that I used to smoke two packs per day. I first started smoking as a teenager. 
Doctor: Do you drink at all?  
Patient: I used to drink six packs of beer plus two additional drinks a day for many years. Good news is that I've been dry for two years now. 
Doctor: Any illicit drug use, such as cocaine, marijuana or heroin? 
Patient: No none of that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: former heavy smoker (2 packs per day), quit 2 years ago, former heavy alcohol use (6 packs of beer plus 2 drinks per day), has been dry for 2 years, denies illicit drug use
Plan of Action: N/A
Doctor: Hello, miss. How are you doing today? It looks like we are evaluating C O P D and emphysema.
Patient: Yes, the last time I was seen in Pulmonary Medicine Clinic was March two thousand and four. 
Doctor: It has been quite some time. How are you feeling?
Patient: I have actually been hospitalized for psychiatric problems and now live in a nursing facility. Things have not been too great. I don't like living there.
Doctor: I understand the frustration. When you live in a nursing facility you lose a lot of your freedom.
Patient: I want to live back in my apartment, but I know I am too ill to care for myself. 
Doctor: In spite of all of that how are your respiratory issues?
Patient: I feel pretty stable. I still have shortness of breath when I do activities, but with my condition I feel like that is something I will have to live with.
Doctor: Unfortunately, that is the nature of the disease. I am happy to see that the pulmonary disease has not changed significantly since your last visit. 
Patient: The only thing that seems to have changed is that I have a small cough and produce some mucus. 
Doctor: Okay. Do you have any fever or chills?
Patient: No, none of that. 
Doctor: Do you experience any chest pains? I want to check especially since you have been coughing up some mucus. 
Patient: No, I luckily do not have any chest pains.

Clinical note:
Symptoms: shortness of breath with activities, occasional cough, small amount of sputum production
Diagnosis: COPD, emphysema
History of Patient: hospitalized for psychiatric problems, currently living in a nursing facility but wants to return to her apartment
Plan of Action: N/A
Doctor: You can continue working, I just want you to be careful.
Patient: Thanks Doctor. I will be.
Doctor: Great.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: released to regular work
Doctor: Can you confirm your age for me, ma'am? 
Patient: Sure, I'm fifty six years old. 
Doctor: Great, so what brings you in to see me today? 
Patient: Um, I'm peeing a lot, and I'm having  a little bit blood in that urine as well. 
Doctor: Have you ever had a cystoscopy? 
Patient: Yes, it was unremarkable, that's what they told me. 
Doctor: When are your episodes for the most part? 
Patient: Um, usually during the day. I don't usually have them at night.
Doctor: Are you having any pain with urination? 
Patient: No, no pain. 
Doctor: Aside from the little bit of blood, can you tell if there's any pus in your urine? 
Patient: No, I don't have any of that, it's just the little bit of blood. 
Doctor: Have you taken any medications for this? 
Patient: Um, I had Ditropan, and it didn't do very well. 
Doctor: Well, this ultrasound of the kidney is also unremarkable, so at this time I think we should try a different medication.

Clinical note:
Symptoms: frequent urination, microscopic hematuria (blood in urine), episodes mostly during the day, no pain or pus in urine
Diagnosis: overactive bladder with microscopic hematuria
History of Patient: cystoscopy was unremarkable, previous medication (Ditropan) did not work well, renal ultrasound unremarkable
Plan of Action: trying a different medication for overactive bladder
Doctor: Any health issues on your mom or dad's side? 
Patient: No, we're a pretty healthy family.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Hello sir, how are you? 
Patient: I don't know, I don't know whether I am good, or my problem is getting worse and that is the reason I got myself to your clinic for a neurological consult. 
Doctor: Hm, don't worry! We will take care of you, let me start by taking some details. 
Patient: Sure!
Doctor: So were you referred by someone or-
Patient: Oh, no I referred myself to your clinic. 
Doctor: Okay. And what is your age? 
Patient: I am sixty four years young!
Doctor: Ah, that's clever, you certainly look very young. And which is your dominant hand? Are you left handed, or right?
Patient: I am right handed. 
Doctor: So, tell me what is going on with you?
Patient: Well, lately I am having difficulty remembering names and phone numbers or even events. 
Doctor: Well, it's not uncommon.
Patient: I know, but I am usually very good at remembering things. I would have not worried that much, but it was brought to my attention by my clerical staff.
Doctor: Oh, okay. What do you do? 
Patient: Well, I was the catholic priest at my parish, like we have our own small administrative district and church. 
Doctor: Okay, and when did you notice first that you are forgetting things? 
Patient: Around twelve months back. 
Doctor: And did it cause any problem at work or any mishaps? 
Patient: No, not at all! No social or professional faux pas whatsoever. 
Doctor: Okay, I have my notes let me put the date, oh what is the date-
Patient: It's twenty eighth of February.
Doctor: Thank you!

Clinical note:
Symptoms: difficulty remembering names, phone numbers, and events
Diagnosis: N/A
History of Patient: self-referred for neurological consult due to difficulty remembering, noticed around 12 months ago, no significant impact on social or professional life
Plan of Action: N/A
Doctor: All right, you can go home now.
Patient: Thank you doctor.
Doctor: You can stay at your friend's place and make sure to take good care of yourself.
Patient: Yes.
Doctor: Make sure you follow up with Doctor X on Monday or Tuesday. I know that Doctor Y already discussed his plans. Continue taking your medicines except Prozac. Okay?

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Discharged to home, staying with a friend, follow-up with Dr. X on Monday or Tuesday, continue usual medications except Prozac
Doctor: Do you smoke or drink? 
Patient: Nope, I've never touched a cigarette nor do I plan on ever doing so. Same goes for alcohol.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Hi there! Welcome to the Neurology clinic, sir. 
Patient: Hi! Thank you. 
Doctor: What brings you in to the clinic today? 
Patient: I was diagnosed with binocular diplopia twenty five years ago but I haven't had much of an issue with it until about a year ago. 
Doctor: What did you notice as far as symptoms?
Patient: Suddenly, I started having double vision.
Doctor: Did the double vision happen more than one time? 
Patient: It has been happening almost every day off and on through out the day. 
Doctor: How long do the episodes last? 
Patient: They last for only a few minutes at a time. When I was first diagnosed years ago it happened for a year and then it stopped happening. It was not happening as often as it is now. 
Doctor: Did you ever receive any treatment for your binocular diplopia? 
Patient: No. It spontaneously resolved and so I didn't need to seek any treatment. Back when all this was happening it had two episodes of a drooping eyelid. I thought I had myasthenia gravis but I was told that that was probably not the case. 
Doctor: What eyelid was drooping? 
Patient: I don't remember? 
Doctor: What is your dominate hand? 
Patient: I am right handed. 
Doctor: And how old are you? 
Patient: I am sixty seven. 
Doctor: Involving the double vision, does it become worse when looking at distant objects? 
Patient: Yes. 
Doctor: When you look at objects off to either side of midline does it become worse?
Patient: Yes. That makes it worse too. When I put my hand over one eye is goes away.
Doctor: Do you have any other symptoms related to the vision issues? 
Patient: No.

Clinical note:
Symptoms: horizontal binocular diplopia, worse with distant objects and off-center gaze, resolves with covering one eye, no other associated Symptoms
Diagnosis: binocular diplopia
History of Patient: diagnosed 25 years ago, resolved spontaneously, reoccurred a year ago, worsened frequency and duration, no treatment received previously, evaluated for myasthenia gravis but ruled out
Plan of Action: N/A
Doctor: How old is your son? 
Guest_family: He is almost five and a half years old now. 
Doctor: What seems to be the problem? 
Guest_family: He has a lot of pain about both feet, and if you look at it, it looks like his feet rotate inwards. 
Doctor: Okay, let me see, okay, um, he has rocker bottom feet.  
Guest_family: Okay. 
Doctor: I believe he would benefit from a subtalar arthrodesis, possible autograft, and lengthening of the Achilles. I'll go over the details of that procedure right now. 
Guest_family: Can we do the surgery soon?
Doctor: Yes we can. But we'll probably need to do another procedure until his foot matures some more.   This is a stabilizing measure.
Guest_family: What are the risks of infection if we do the surgery? 
Doctor: Historically, the risk of infection is very low, usually less than one percent. 
Guest_family: How do you get the risk so low? 
Doctor: We use prophylactic antibiotics to minimize the infection risk. 
Guest_family: Will he be able to walk again right after the surgery? 
Doctor: No, he'll need to stay off it for a while, we call this nonweightbearing. It will only be for some time after the procedure, it's not permanent.  
Guest_family: What are the rest of the risks?
Doctor: The total risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time. I would not worry about these risks, though. The risk is low. 
Guest_family: Okay. Let's do the surgery.

Clinical note:
Symptoms: significant feet pain, planovalgus deformity, flexible vertical talus
Diagnosis: rocker bottom feet, flexible vertical talus
History of Patient: pain and deformity in both feet, feet appear to rotate inwards, 5-year-old male
Plan of Action: subtalar arthrodesis, possible autograft, Achilles lengthening, stabilizing measure, potential need for additional surgery when foot matures, risks discussed including anesthesia, infection, bleeding, changes in sensation and motion of extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time
Doctor: Are you up to date on your vaccines? 
Patient: I've actually never been vaccinated before. My parents don't believe in vaccines.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Hi there! Welcome in, sir. 
Patient: Hi! Thank you. 
Doctor: What is your past medical history? 
Patient: No. I don't have any health problems. 
Doctor: Do you have a primary care doctor? 
Patient: No. I don't have health insurance right now.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: denies any past medical history, currently uninsured without a primary care physician
Plan of Action: N/A
Doctor: Are you married, ma'am? 
Patient: Yes. 
Doctor: Do you smoke, use alcohol or use recreational drugs? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A.
Patient: In the past I was very very fat! Actually, I was morbidly obese. I also had high blood pressure, but after my surgery it got resolved. 
Doctor: So, everything is okay now?
Patient: Yeah.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: morbid obesity, hypertension (now resolved)
Plan of Action: N/A
Doctor: So, you were referred by Doctor X.
Patient: Yeah.
Doctor: According to him, I see no changes or correction to your present illness, right? 
Patient: Yeah, I think so.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Do you have any related family history? 
Patient: You mean like heart issues in the family?
Doctor: Yeah, something like that.
Patient: My brother died of heart attack. It was sudden everyone was shocked. 
Doctor: How old was he?
Patient: He was not that old; he was just in his fifties.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: So, tell me what's going on? What brings you to the emergency?
Patient: I felt like my heart will explode. I have never felt palpitations like this. I am feeling so weak.
Doctor: When did it start?
Patient: This afternoon.
Doctor: Hm, so your blood pressure is one ninety five by eighty three and your heart rate is one twenty one which is quite high.
Doctor: We have started you on I V Metoprolol. This will help to bring your heartrate down. 
Doctor: And you said you are sixty six?
Patient: Yes.
Guest_family: My mom has stopped taking her medications. 
Doctor: I can tell from her reports. Her blood pressure is quite high.
Guest_family: It's been several months since she last took her medicines. 
Doctor: Well, that's not good!
Doctor: And does she drink and smoke?
Guest_family: Yes, both.
Doctor: How much do you drink Ma'am? Is it occasional?
Guest_family: She drinks a lot!
Patient: Well, I drink about four to five glasses of wine every day. I drank last night. 
Doctor: Well, I think you need to cut down on it.
Patient: I am trying doctor and honestly these are all withdrawal symptoms. I have never felt like this before.
Doctor: Hm, I understand. For now I have put you on five M G of Metoprolol and looks like your blood pressure is under control and your heart rate has come down to seventy.

Clinical note:
Symptoms: feeling like heart will explode, palpitations, weakness
Diagnosis: hypertension, withdrawal Symptoms from alcohol
History of Patient: palpitations and weakness started this afternoon, high blood pressure (195/83) and heart rate (121) on arrival at emergency room, received 5 mg IV Metoprolol to reduce heart rate, blood pressure and heart rate improved after treatment, regular alcohol consumption of 4-5 glasses of wine daily, last drink was yesterday evening
Plan of Action: N/A
Doctor: Hello, how are you today?
Patient: I am here for a breast cancer screening. 
Doctor: Have you gotten a mammogram before?
Patient: Yes, I have. I also try to keep up with my self examinations every few weeks.   
Doctor: That is great. I am happy to see you on top of your preventative healthcare. 
Patient: I try to be as careful as I can since my sister had breast cancer.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: sister had breast cancer
Plan of Action: N/A
Doctor: Good morning, sir. 
Patient: Good morning, doctor. 
Doctor: So, what seems to be the problem today, sir? 
Patient: Well, I've had toe problems in the past. 
Doctor: I see, what about the rest of the lower body, any problems there?
Patient: Actually, yes, I've had left knee issues in the past, too.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: toe problems, left knee pain
Plan of Action: N/A
Doctor: Do you have a history of any health conditions that I should be aware of, ma'am? 
Patient: Um, yeah, I had a mastectomy, and chest tube placement. 
Doctor: Oh, wow. Do you have any chronic conditions? 
Patient: Yeah, I have chronic A F I B.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: mastectomy, chest tube placement, chronic atrial fibrillation
Plan of Action: N/A
Doctor: How have you been handing erectile dysfunction since your last visit, sir? 
Patient: Well, I've been taking the Cialis, it's the, um, ten M G version. 
Doctor: Have you seen any improvement? 
Patient: Yes, I've had some, which is good. 
Doctor: Have you had any side effects? 
Patient: No, none yet.
Doctor: Good, can you describe your erections for me, sir?
Patient: Well, they're firm now, and I can penetrate again for about ten minutes. 
Doctor: Good, are you having any chest pain? 
Patient: No sir, I stopped using my nitroglycerin too. 
Doctor: Good, are you having any fever or chills? 
Patient: No, nothing like that. 
Doctor: Are you having any pain with urination, or blood in the urine? 
Patient: No, nothing like that, sir, everything is normal.
Doctor: How often do you urinate during the day? 
Patient: I go about every three hours or so, I have a good stream and everything. 
Doctor: Do you wake up at night to go to the bathroom?
Patient: No, I sleep through the night very well.
Doctor: Good, do you have any other conditions that I should know about? 
Patient: Well, I have a history of elevated P S A, and I had a biopsy in June when I had a, um, high grade P I N. 
Doctor: Do you know what that P S A value was? 
Patient: It was eleven point six. 
Doctor: Thank you, I see here on Doctor X's notes that there were two specimens that were too small to evaluate.

Clinical note:
Symptoms: Erectile dysfunction, mild improvement with Cialis 10 mg, firm erections, no chest pain, no nitroglycerin usage, no fever, no chills, no dysuria, no gross hematuria, no nocturia, daytime frequency every three hours, good stream, history of elevated PSA, high grade PIN, PSA 11.6
Diagnosis: N/A
History of Patient: Erectile dysfunction, improvement with Cialis 10 mg, no side effects, history of elevated PSA, high grade PIN, PSA 11.6
Plan of Action: Review Dr. X's notes
Doctor: I am afraid, I don't have better news for you, your reports confirm cancer.
Patient: We were suspecting it all along, but now since it is confirmed it's just hard to accept.
Doctor: I am sorry, I totally understand. Do you want some time?
Patient: No, I am okay.
Doctor: Hm, you also have hypertension and diabetes.
Patient: Yeah, that I know.
Doctor: Did you have any chest pain or shortness of breath or uneasiness?
Patient: No, I don't have any heart condition.
Doctor: Okay and no dizziness or loss of consciousness or stroke like symptoms?
Patient: No.
Doctor: Okay. Well, your B M I looks fine, that means you are not overweight. 
Patient: Hm.

Clinical note:
Symptoms: N/A
Diagnosis: Hypertension, diabetes, cancer
History of Patient: Positive for hypertension, diabetes, cancer. Negative for heart disease, obesity, stroke
Plan of Action: N/A
Doctor: Are you married? 
Patient: Yes. I am happily living together with my husband and my four kids. 
Doctor:  Oh, do you smoke? 
Patient: Nope. 
Doctor: What about alcohol or any other kind of drug use? 
Patient: Nope.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Married, living with husband and 4 children, denies tobacco, alcohol, and illicit drug use
Plan of Action: N/A.
Doctor: Anyone in the family had any medical issues? 
Patient: Oh yes. 
Doctor: Can you please elaborate?
Patient: So, my mother's side family had heart issues. My dad's sister had sugar problem.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Family history of coronary artery disease on mother's side, family history of diabetes mellitus on father's side
Plan of Action: N/A.
Doctor: And you are not allergic to anything right?
Patient: That's right.
Doctor: Any drugs or pollens or anything?
Patient: Nope nothing.
Doctor: Good.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No known allergies
Plan of Action: N/A
Doctor: Has the redness worsened over the last few days? 
Guest_clinician: I think so. Her right big toe looks worse to me. 
Doctor: Is she otherwise healthy? 
Guest_clinician: Um besides her toe and some nasal congestion, she's doing fine.

Clinical note:
Symptoms: Redness and worsening of the right big toe, chronic nasal congestion and fullness
Diagnosis: N/A
History of Patient: Redness and worsening of the right big toe, chronic nasal congestion and fullness
Plan of Action: N/A
Doctor: You had a surgery on your breasts?
Patient: Yes, they removed lump from my left breast.
Doctor: Okay, and what other surgeries have you had?
Patient: I do not have a gall bladder, then I had a breast augmentation, I have had heart surgeries three times and they have removed half of my pancreas. 
Doctor: Okay.
Patient: And knee surgery too, on the left side.
Doctor: Okay. What type of heart surgery did you have?
Patient: Cardiac ablation.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery, removal of half of the pancreas
Plan of Action: N/A
Doctor: What happened?
Guest_clinician: She was brought to emergency by her son. Apparently, she is doing fine, no distress. She is alert, and I was able to communicate with her and take her history, she was cooperative and calmy responded to all my questions. 
Doctor: Okay, that's good.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Alert, no distress, calm, cooperative, communicative
Plan of Action: N/A.
Doctor: What is your family medical history? 
Patient: My family has high blood pressure and diabetes. 
Doctor: Do you have any family history of nervous system disorder or disease such as multiple sclerosis, Alzheimer's disease, Parkinson's disease, epilepsy, or stroke? 
Patient: No. 
Doctor: Do you have any children, miss? 
Patient: Yes. I have a son, he was born on October thirty first, two thousand and eight.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Family history of high blood pressure and diabetes, no family history of nervous system disorders, one child (son) born on October 31, 2008
Plan of Action: N/A
Doctor: Have you ever had any heart problems in the past?
Patient: I remember I did have something heart related but I don't know what that was. I do not understand any medical terms.
Doctor: Okay that's fine, I completely understand. We will try to look for your  past medical history.
Patient: I do have hypertension and diabetes, you know that right?
Doctor: Yes, type two diabetes. Do you know of any other things that you had in the past?
Patient: Yes, four years back I had lung embolism. I also get frequent urine infections.
Doctor: Okay. And I can see on the file that you have high cholesterol and a gastric ulcer too.
Patient: Yes, that's about right.
Doctor: Okay. What surgeries have you had in the past?
Patient: I have had my appendix taken out, then C Section, cataract surgery and hernia repair done in the past.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: History of heart disease, hypertension, type II diabetes, pulmonary embolism four years ago, hyperlipidemia, peptic ulcer disease, recurrent urinary tract infections, surgeries: appendectomy, cesarean section, cataract surgery, hernia repair
Plan of Action: N/A