X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: What brings you back into the clinic today, miss? 
Patient: I came in for a refill of my blood pressure medicine. 
Doctor: It looks like Doctor Kumar followed up with you last time regarding your hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.  Have you noticed any changes or do you have any concerns regarding these issues?  
Patient: No. 
Doctor: Have you had any fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure?
Patient: No.  
Doctor: Great. Also, for our records, how old are you and what race do you identify yourself as?
Patient: I am seventy six years old and identify as a white female.

Clinical note:
Symptoms: no fever, no chills, no cough, no congestion, no nausea, no vomiting, no chest pain, no chest pressure.
Diagnosis: hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis, kidney stones
History of Patient: 76-year-old white female, presents to the clinic today originally for hypertension and a med check, followed by Dr. Kumar, issues stable
Plan of Action: N/A
Doctor: How're you feeling today?  
Patient: Terrible. I'm having the worst headache of my life. 
Doctor: I'm so sorry. Well you are only twenty five, so let's hope this is the last of the worst. Let's see how we can best help you. When did it start? 
Patient: Around eleven in the morning. 
Doctor: Today? 
Patient: Um no yesterday. July thirty first. 
Doctor: July thirty first O eight. Got it. Did it come on suddenly? 
Patient: Yeah. 
Doctor: Are you having any symptoms with it, such as blurry vision, light sensitivity, dizziness, lightheadedness, or nausea? 
Patient: I'm having blurry vision and lightheadedness.  I also can't seem to write well. It looks so messy. I am naturally right handed but my writing looks like I am trying with my left. 
Doctor: How would you describe the lightheadedness? 
Patient: Like there are blind spots. 
Doctor: Okay. How about any vomiting? 
Patient: Um no. I feel like my face is pretty swollen though. I don't know if it's related to the headache but it started around the same time. 
Doctor: Here in the E R, we'll do a thorough exam and eval to make sure nothing serious is going on. While we're waiting for your C T results, I'm going to order a migraine cocktail and some Morphine. 
Patient: Thank. Will the nurse be in soon? 
Doctor: Yes, she'll be right in as soon as the order is placed. It shouldn't be more than a few minutes. If it takes longer, then please ring the call bell.

Clinical note:
Symptoms: sudden onset headache, blurry vision, scotoma, swelling in face.
Diagnosis: migraine.
History of Patient: 25-year-old right-handed Caucasian female, headache occurring at approximately 11 a.m. on the morning of the July 31, 2008.
Plan of Action: administered migraine cocktail, administered morphine.
Doctor: Hello, miss. What is the reason for your visit today? 
Patient: I think I have some warts on my back end where the poop comes out. 
Doctor: I see. When did you start noticing them? 
Patient: I think like three to four weeks ago. 
Doctor: Do you feel any pain or discomfort? 
Patient: It itches a little, but I haven't felt any pain yet. Is this normal for a twenty two year old? 
Doctor: I'll have to take a look, but you'll be fine. Are there any other symptoms that you are aware of?
Patient: Nope. Just the warts and itchiness.

Clinical note:
Symptoms: itching.
Diagnosis: condylomas.
History of Patient: 22-year-old female, anal region, three to four weeks ago.
Plan of Action: N/A.
Doctor: Are you taking any over the counter medicines? 
Patient: No, only the ones which were prescribed.
Doctor: No alternative medicine, naturopathy or anything?
Patient: No, only whatever is here in this prescription. 
Doctor: Okay let me take a look...so you were prescribed Salmeterol inhaler-
Patient: On as needed basis.
Doctor: Okay and the other one is Fluticasone inhaler, which is-
Patient: Which is a nasal inhaler.
Doctor: Right.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Salmeterol inhaler (as needed basis), Fluticasone nasal inhaler.
Plan of Action: Prescribed medications are Salmeterol inhaler for as needed use and Fluticasone nasal inhaler. No over the counter or alternative medicines were reported.
Doctor: Hi, how are you? 
Patient: I burned my hand.
Doctor: Oh, I am sorry. Wow!
Patient: Yeah.
Doctor: Is it only right arm?
Patient: Yes.

Clinical note:
Symptoms: Burn, right arm.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: How's your asthma since you started using your inhaler again? 
Patient: Much better. I don't know why I didn't take it with me everywhere I went. 
Doctor: It's important to carry it with you, especially during times where you're exercising or walking more than usual. 
Patient: Yeah. I think I've learned my lesson. 
Doctor: Besides asthma, do you have any other medical problems?

Clinical note:
Symptoms: Asthma Symptoms.
Diagnosis: Asthma.
History of Patient: Asthma.
Plan of Action: N/A.
Doctor: Do you smoke? 
Patient: No, I quit before I had my daughter. 
Doctor: Are you currently pregnant?
Patient: No, I'm not. 
Doctor: Did you have any complications with the birth of your daughter? 
Patient: I actually had a C section. 
Doctor: Have you had any other surgeries in the past? 
Patient: I got my appendix out a few years ago. 
Doctor: Do you have any other issues, like high blood pressure or heart disease?
Patient: No. 
Doctor: Do you have diabetes? 
Patient: No. 
Doctor: Are there any problems with the lungs, thyroid, kidney, or bladder? 
Patient: No. 
Doctor: So, how long ago did you hurt your lower back? 
Patient: It was about four or five years ago now, when I was in a car crash. 
Doctor: What kind of treatments were recommended? 
Patient: They didn't recommend P T, and I didn't really have any increased back pain after the accident.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions. Quit smoking prior to past childbirth, not currently pregnant. Had C-section and appendectomy. Involved in motor vehicle accident 4-5 years ago, didn't require physical therapy, no increased back pain reported after accident.
Plan of Action: N/A.
Doctor: Any know drug allergies? 
Patient: No.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: No known drug allergies.
Plan of Action: N/A.
Doctor: Hi there, sir! How are you today? 
Patient: Hello! I am good.
Doctor: I would like to start with your family medical history today. What do you know about their medical history? 
Patient: My mother and father both had heart disease. Well, my mother had complication from her heart disease and that is how she passed.  My father was only in his forty's when he died. 
Doctor: I am so sorry the hear that. 
Patient: Thank you. I have two brothers, one whom I don't speak to very much anymore. I don't know if he has any health problems. My other brother is healthy with no issues. Both my uncles on my mother's side had polio, I think. 
Doctor: Tell me more about your uncles with polio. They both had polio? 
Patient: One of them had to wear crutches due to how bad his leg deformans were and then the other had leg deformities in only one leg.  I am fairly certain that they had polio.  
Doctor: Do you know of any other family member with neurological conditions?
Patient: No. None that I know of. 
Doctor: Do you have any children? 
Patient: Yes. I have one child. 
Doctor: Is your child healthy and well? 
Patient: Yes.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Mother died of complications from heart disease, father died of heart disease in his 40s. Two living brothers, one with unknown medical history, the other apparently healthy. One healthy child. Maternal uncles had polio, one wore crutches due to severe leg deformans, the other had leg deformities in one leg. No other family members with neurological conditions known.
Plan of Action: N/A.
Doctor: Can you tell me about any diseases that run in your family? 
Patient: Sure, my brother has a prostate cancer.
Doctor: Okay, brother.
Patient: My father had brain cancer.
Doctor: Okay, dad.
Patient: Then on both sides of my family there are many heart related issues.
Doctor: Okay.
Patient: And my brother and sister both have diabetes.
Doctor: Okay.
Patient: Yes, that's it.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Brothers had prostate cancer, father had brain cancer. Heart disease on both sides of the family. Diabetes in brother and sister.
Plan of Action: N/A.
Doctor: Good afternoon, ma'am. Welcome to A B C D General Hospital. Before we begin, I just need to confirm some background information on you. 
Patient: Good afternoon, doctor. Absolutely, that's no problem. 
Doctor: First, how old are you?
Patient: I'm nineteen, sir. 
Doctor: Good, and your chart says you identify as Caucasian. Is that correct? 
Patient: Yes, sir, that's correct. 
Doctor: Great, what seems to be problem today, ma'am?
Patient: I've had this bunion on my foot for such a long time. 
Doctor: How long has this bunion been present? 
Patient: At this point, um, I don't even remember how long it's been. 
Doctor: Do you have any other conditions that I should be aware of?
Patient: Actually, yes. I have a history of, um, Charcot Marie tooth disease. 
Doctor: That's good to know, thank you. 
Patient: I would like to have surgery to cut this bunion off, I can't take it anymore.

Clinical note:
Symptoms: Worsening bunion deformity.
Diagnosis: N/A.
History of Patient: History of Charcot-Marie-Tooth disease. Desires surgical treatment for bunion deformity.
Plan of Action: N/A.
Doctor:  Are you taking any medications?
Patient: No, I don't believe in meds.
Doctor: Oh really, let me check your list.
Patient: Yeah never.
Doctor: Wow amazing.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Any past medical history? 
Guest_family: She has a history of peptic ulcer disease and we think she may have had a possible stroke three or four years ago. I would have to double check. 
Doctor: Let me see if I can find it in her records.  
Doctor: Does she see a neurologist? 
Guest_family: Um I'm not sure. I can call her son? 
Doctor: Yes, if you could find out that'd be great.  
Guest_family: She's also experiencing some memory loss as of one to two years ago. I think that's it for medical history.

Clinical note:
Symptoms: Memory loss.
Diagnosis: N/A.
History of Patient: History of peptic ulcer disease (PUD), possible stroke three or four years ago, memory difficulty in the past 1-2 years.
Plan of Action: N/A.
Doctor: How old are you? 
Patient: I am forty four. 
Doctor: Are you right handed or left handed? 
Patient: I'm right handed. 
Doctor: Tell me what happened. 
Patient: I don't know. I woke up over this numbness on my left side of the body. I remember it was on July twenty nineth. 
Doctor: Was there any sensation like having pins and needles? Was there any weakness? Is there any change in your visual or mental status? Were you able to walk? 
Patient: I was able to walk and there was no weakness or any other thing you mentioned. 
Doctor: When did you first start noticing these symptoms? 
Patient: There was nothing around Independence Day. It all started after that. At first, I felt that my right hand is very clumsy, and it is kind of stiff. Then I noticed leaning towards the right when walking. It was strange. Happened around July seventh.
Doctor: Did you recently have any cold or flu like symptoms? 
Patient: No. 
Doctor:  Were diagnosed with a thing called multiple sclerosis? 
Patient: No. 
Doctor: Did you ever have a feeling where you felt like there's an electric is going up or down your spine? 
Patient: No. 
Doctor: How about any fatigue or pain? Any frequency in your urination? Any urgency in that? 
Patient: No.

Clinical note:
Symptoms: Left hemibody numbness, stiffness and clumsiness in right hand, listing to the right when walking.
Diagnosis: N/A.
History of Patient: Symptoms started on 7/29/93 with left hemibody numbness, followed by stiffness and clumsiness in right hand on 7/7/93, and listing to the right when walking. Denied recent colds/flu-like illness, history of multiple sclerosis, Symptoms of Lhermitte's or Uhthoff's phenomena.
Plan of Action: N/A.
Doctor: You had a heart surgery, right?
Patient: Yes, that is right.
Doctor: Pacemaker?
Patient: Yes, they did that.
Doctor: What else? What other surgeries?
Patient: I have had a hysterectomy.
Doctor: Okay.
Patient: Yeah.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Heart surgery including pacemaker placement, hysterectomy.
Plan of Action: N/A.
Doctor: How old are you, young boy?
Patient: I am twenty nine. 
Doctor: And you got right side shoulder pain? Is this something new?
Patient: Yes. That is right.
Doctor: What were you doing when this happened?
Patient: I think I was picking up a stack of cardboard, then putting it down on the ground and twisting to the right side. And sometimes I was throwing them a little bit as well.
Doctor: Okay, and how far you were lifting them or bending?
Patient: Around here, till waist level.
Doctor: Okay.
Patient: I heard a pop and since then there is pain in this area. I can't lift heavy items. Basically I have no strength.
Doctor: Okay. And this all started from June thirty two thousand and four?
Patient: Yes, that's right. The pain is in the lateral part of the back of my shoulder. 
Doctor: How did you lose your arm if I may ask?
Patient: Motorcycle accident.

Clinical note:

Symptoms: New onset right shoulder pain localized to posterior and lateral aspects, exacerbated by lifting activities.
Diagnosis: N/A.
History of Patient: Pain began approximately one week ago when lifting stacks of cardboard, felt a popping sensation on 06/30/04, persistent shoulder pain with lifting activities.
Plan of Action: N/A.
Doctor: When did the nausea and vomiting start? 
Patient: About a few hours ago. I can't seem to stomach anything. 
Doctor: How many episodes of vomiting have you had? 
Patient: At least four. 
Doctor: Any abdominal pain, fever, chill, or other symptoms? 
Patient: Just nausea and vomiting. It's been so terrible. 
Doctor: I'll order you some Zofran to help bring the nausea to bay. One moment while I put the order in.

Clinical note:
Symptoms: Nausea, vomiting.
Diagnosis: N/A.
History of Patient: Nausea and vomiting started a few hours ago, at least four episodes of vomiting, no other Symptoms reported.
Plan of Action: Prescribing Zofran to alleviate nausea.
Doctor: Good afternoon, ma'am. 
Patient: Good afternoon, doctor. 
Doctor: Is this your assistant, ma'am? 
Patient: Yes, she helps me out all day.  
Doctor: Great, do you have your food diary sheets? 
Patient: Yes, can you give them to her, please? 
Doctor: Thank you. What are you doing for exercise? 
Patient: Um, right now, I walk around at the mall to get my steps in every day.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Is he currently taking any medication? 
Guest_family: No.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Hello, sir. I see your last visit was on July two thousand and seven. What was the reason for that visit?  
Patient: My asthma was acting up, and it felt like I couldn't breathe. 
Doctor: Do you have a history of asthma? 
Patient: Not that I know of, but I know I always get this really bad cough where I cough up some nasty phlegm. 
Doctor: I see. I'm looking at your report and it says you have a history of pneumonia.

Clinical note:
Symptoms: Difficulty breathing, cough with phlegm.
Diagnosis: N/A.
History of Patient: Previous visit in July 2007 for asthma Symptoms, history of pneumonia.
Plan of Action: N/A.
Doctor: Do you know about any medical traits in your family? 
Patient: No, everyone in my family is quite healthy. I'm not aware of any medical problems. 
Doctor: Are you sexually active? 
Patient: Yes, I am with my boyfriend. 
Doctor: Do you take any drugs or alcohol or smoke? 
Patient: No, none of them.

Clinical note:

Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Completely unremarkable family medical history. Patient has boyfriend and is sexually active. Denied drug, alcohol, or tobacco use.
Plan of Action: N/A.
Doctor: Any past medical history? 
Patient: Um there were a couple times where I noticed my blood pressure was high but that's improved as of late. 
Doctor: When did these episodes occur? 
Patient: About a year ago. 
Doctor: Did you follow up with your previous doctor? 
Patient: Yeah, my old doctor knows. 
Doctor: Okay then. Let's see. Have you been checking your own blood pressure as a result? 
Patient: No not really.  
Doctor: It looks like your blood pressure was normal today, which is a good sign. 
Patient: Great. 
Doctor: Hm any allergies to medications? 
Patient: None that I know of. 
Doctor: And it looks like you have gained about fourteen pounds since last year. Any new diet changes or stressors? 
Patient: I lost my job last January and it took a pretty big toll on me. 
Doctor: I'm sorry to hear that. How have you been coping? 
Patient: I'm doing better now but I need to watch what I eat. I tend to eat a lot more when I'm stressed. It's something I'm working on.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Episodes of high blood pressure about a year ago, weight gain of approximately 14 pounds since last year, attributed to stress after losing job in January.
Plan of Action: N/A.
Doctor: Are you allergic to anything?
Patient: Yes, I am allergic to Penicillin.
Doctor: Any other drugs that you could be allergic to?
Patient: Nope that is all.
Doctor: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Allergic to Penicillin, no known allergies to other drugs.
Plan of Action: N/A.
Guest_clinician: What brought them in today? 
Doctor: Poor renal sufficiency, possibly due to dehydration or diabetic nephropathy. She also has high blood pressure and low blood sugar as a result of missing meals regularly.

Clinical note:
Symptoms: Hypoglycemia, hypertension, renal insufficiency.
Diagnosis: N/A.
History of Patient: Poor renal sufficiency possibly due to dehydration or diabetic nephropathy, high blood pressure, hypoglycemia due to irregular meal consumption.
Plan of Action: N/A.
Patient: Doc what are you going to diagnose me as?
Doctor: We are looking at blood born pathogen exposure secondary to needlestick. 
Patient: Yes, I was also thinking around contamination.

Clinical note:
Symptoms: N/A.
Diagnosis: Blood-borne pathogen exposure secondary to contaminated needlestick.
History of Patient: N/A.
Plan of Action: N/A.
Guest_clinician: She was in a car crash, correct? 
Doctor: Correct. About two days ago. I believe it was a head on collision.

Clinical note:

Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Involved in a car crash approximately two days ago, possibly a head-on collision.
Plan of Action: N/A.
Doctor: Any allergies I should know about? 
Patient: Nope, no allergies for me.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Hello sir. Let me first start by asking your age. How old are you? 
Patient: I'm twenty four.  
Doctor: So, what brought you here? How can I help you? 
Patient: I was out for fishing this weekend, I think I got into some poison ivy and I have these rashes all over my chest, legs, arms and also some are on my back. 
Doctor: You seem so confident of it being poison ivy has it happened before? 
Patient: Oh yes, it has happened several times before. It usually takes some time to get over. Last time I was here Doctor Blackman gave me a steroid injection. 
Doctor: Okay, let me check my records. It looks like he gave you eighty milligrams of depomedrol. How was it last time after the injection? 
Patient: It worked fine. It did take us some time to get rid of it. 
Doctor: Did you take any medicine or anything else this time?
Patient: I took over the counter Benadryl. Also, I'm applying cortisone cream on the rashes. 
Doctor: Did they help you? 
Patient: I saw a little bit of improvement. But this weekend it seemed to have been worst.
Doctor: No worries, let's set you up for another injection.

Clinical note:

Symptoms: Rash on chest, legs, arms, and back (likely due to poison ivy exposure).
Diagnosis: N/A.
History of Patient: Recurrent outbreaks of poison ivy rash, previously treated with Depo-Medrol 80 mg injection, currently using over-the-counter Benadryl and cortisone cream with some improvement.
Plan of Action: N/A.
Doctor: You had mentioned that cancer runs in your family. What type of cancer? 
Patient: Skin cancer. 
Doctor: Any other health problems in the family? 
Patient: High blood pressure.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Family history of skin cancer and high blood pressure.
Plan of Action: N/A.
Doctor: Hi, what brings you here today?
Patient: I feel this lump on the upper side of my breast. 
Doctor: Both sides? 
Patient: No, only on the left side. 
Doctor: Do you feel it deep inside or on the outer side?
Patient: Only on the outer side.

Clinical note:
Symptoms: Lump on the upper outer quadrant of the left breast.
Diagnosis: Suspicious calcifications upper outer quadrant, left breast.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: I understand that you are new to the clinic. Welcome. 
Patient: Yes, I am new here. I have lived in Arizona for the last four years. I am from Maine. That is where I grow up and most of my family still lives there.  
Doctor: What line of work are you in? 
Patient: I am a homemaker. I used to clean house, a while back.  
Doctor: Do you have children? 
Patient: I have two children but only one of them is still with us. My oldest son passed away from ulcerative colitis complications three years ago.  
Doctor: I am so sorry to hear that!

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Originally from Maine, lived in Arizona for 4 years. Has 2 children, one deceased from complications of ulcerative colitis. Predominantly a homemaker but has done domestic cleaning work in the past.
Plan of Action: N/A.
Doctor: You okay there? 
Patient: Uh yeah, sorry. I'm just trying to adjust the stretcher. 
Doctor: Want some help? 
Patient: No, thank you. I think I got it. 
Doctor: So how're you doing? 
Patient: Fine, but I have this weird lump in my chest. 
Doctor: When did you first notice it? 
Patient: It's been there for a while. I'd say almost half a year. 
Doctor: Have you seen anyone for it? 
Patient: No, not until now. 
Doctor: Is it causing you pain? And has it changed in size at all?
Patient: Not really. It's just noticeable when I run my fingers over it. 
Doctor: Have you spotted any swelling or redness to the area? Any drainage? 
Patient: No. 
Doctor: I see. Okay. Let me take a look and then I'll have you walk down the hall to get an Xray so we can see what's going on.

Clinical note:
Symptoms: Lump in the chest wall, no pain, no change in size, noticeable when touched.
Diagnosis: N/A.
History of Patient: Lump noticed almost half a year ago, no previous medical consultation.
Plan of Action: Examination followed by X-ray to assess the lump.
Doctor: Hello, so you are here for follow up today. 
Patient: Yes, very much. 
Doctor: I will ask you some regular questions, okay? 
Patient: Sure. 
Doctor: Any pain in urination? 
Patient: Nope. 
Doctor: Any fever or chills? 
Patient: Neither of them. 
Doctor: Have you noticed any blood while urinating? Any blood in your urine? 
Patient: Nope. I do leak, especially when I'm changing my positions like from sitting to standing so I do feel there is some involuntary urination. It's more like a urge. I'm loading data in like every one hour in the morning, especially when I take that Lasix. 
Doctor: Does it taper off in the afternoon or night? 
Patient: It tapers off in the afternoon. And by the night I don't do not feel anything. 
Doctor: Any leakage in the night? 
Patient: Nope. 
Doctor: Do you apply a lot of force to urinate? 
Patient: Nope. 
Doctor: How about this stream? Is it good or less? Are you emptying well? And what about the bowel movement? 
Patient: The stream is good. It does feel like all is out in one go. I do not have any kind of bowel issues. I'm using my vaginal cream. Sometimes I feel difficulty in doing so because I feel that there is still something coming out from the vagina and I'm afraid that there might be a prolapse. 
Doctor: Don't worry, I will look into it.

Clinical note:
Symptoms: Urinary incontinence (especially changing positions), urge incontinence, daytime voiding every 1 hour in the morning (especially after taking Lasix), nocturia (0), difficulty applying vaginal cream due to feeling of vaginal protrusion.
Diagnosis: N/A.
History of Patient: No dysuria, gross hematuria, fever, or chills. Nocturnal incontinence. No straining to urinate. Good stream, emptying well. No bowel issues.
Plan of Action: Examination to assess for vaginal prolapse.
Doctor: Have you lost weight?
Patient: No, I haven't, you can ask my daughter.
Doctor: How about anything like fever, nausea, vomiting, pain?
Patient: No.
Doctor: And as we discussed you have problem talking and comprehending. 
Patient: Yes.
Doctor: And you get urine infections too?
Patient: Yes. 
Doctor: And as discussed, your drainage is similar to past episodes when you had such infection? 
Patient: Yes.

Clinical note:
Symptoms: Difficulty expressing herself, comprehension of speech intact, drainage similar to past episodes of urinary tract infections.
Diagnosis: N/A.
History of Patient: Denies weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. History of chronic urinary tract infections.
Plan of Action: N/A.
Doctor: Do you use tobacco products? Cigarettes, chewing tobacco or vaping? 
Patient: I used to smoke a pack a day.  I quit that awful habit in nineteen eighty five. 
Doctor: Do you work? 
Patient: I am retired.
Doctor: Wonderful. Is your husband retired with you?
Patient: Yes. We both are. I cannot imagine working a full time job at seventy six years old.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Former smoker, quit in 1985. Retired at 76 years old.
Plan of Action: N/A.
Doctor: Hi there, how are you?
Patient: I am okay.
Doctor: So, I see you turned eighty-eight yesterday, happy birthday!
Patient: Thank you! 
Doctor: And you are referred by Doctor X, he is your primary physician, right?
Patient: Correct! I am also seeing Doctor Y for my leukemia. 
Doctor: Hm he mentioned that it's chronic lymphocytic leukemia.
Patient: Yes.
Doctor: Okay.
Doctor: And you are also seeing Doctor Z for your heart related problems.
Patient: That is correct.
Doctor: So, tell me what is happening with you?
Patient: For the past one week I am having this increased shortness of breath and having difficulty breathing from past few nights while sleeping.
Doctor: Okay.
Patient: And this morning I was having difficulty catching my breath. I am also having wheezing since morning.
Doctor: Let me examine you, can you come forward and sit-up here? Any chest discomfort or acute chest pain or anything of that sort? Any pain of the left arm?
Patient: No.
Doctor: Any dizziness, feeling like fainting or light headedness or losing control?
Patient: No.
Doctor: Well, I don't think there is any sign of cardiovascular accident or heart attack, so that's that. You do have mild peripheral edema. We need to treat that.
Patient: Okay.

Clinical note:

Symptoms: Increased shortness of breath, difficulty breathing, orthopnea (especially over the past few nights), mild increase in peripheral edema, active wheezing with dyspnea.
Diagnosis: N/A.
History of Patient: No chest discomfort, acute chest pain, dizziness, fainting, or lightheadedness reported. No signs of cardiovascular accident or heart attack.
Plan of Action: Treatment for mild peripheral edema needed.
Doctor: Ready to go home?
Patient: I just can't wait.
Doctor: Sure. I can understand.
Patient: Bye Doctor.
Doctor: Yes. See you soon.

Clinical note:

Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Hello, sir. How are you today? Can you confirm your age?
Patient: Fifty eight. I feel like my balance is off, and I've been feeling tired and weak. 
Doctor: How long have you been experiencing this? 
Patient: It's been going on for six to eight weeks. 
Doctor: I see. Did you feel any other symptoms? 
Patient: I haven't, but this might not be related. I had pneumonia ten days before this all started. 
Doctor: Interesting. Did you take any medication for that? 
Patient: I did, but I don't know how to pronounce it. I wrote it down for you to read. Here it is. 
Doctor: Let me take a look. I see you took a full course of amoxicillin, right? 
Patient: Yeah, that's right. 
Doctor: How did you feel after you finished the antibiotics? 
Patient: Terrible. I felt like I couldn't control my body. My balance got even worse, and I felt even more tired and weak.
Doctor: Oh, wow. Do you know why your balance and coordination worsened? 
Patient: I did fall recently, but I know for a fact my balance was off before my fall. 
Doctor: How high were you when you fell?
Patient: I think I was three or five feet high when I fell. 
Doctor: Did you fall on your back?
Patient: No, I fell on my feet. Just kidding, I fell on my back.  
Doctor: Funny. Did anything hurt after your fall?
Patient: Not really, but I've been having some back pain in my lower and mid back. 
Doctor: Did you always have that pain? 
Patient: No, I haven't. It comes and goes. 
Doctor: Have you done anything to treat it? 
Patient: I started to see a chiropractor like five days ago. He adjusts my neck and lower back. 
Doctor: I see. Did you start having problems with your balance after this? 
Patient: No. I was still having problems with that before I saw the chiropractor. 
Doctor: Okay. So, it wasn't the result of the adjustments. Is there anything else that may have caused it? 
Patient: I was taking this other medicine for ten days, but I don't remember what it was for. Here is the name of the medication. I wrote it on another paper. 
Doctor: It looks like you took Cipro. This is usually used to treat a U T I. Were you aware you had a U T I?
Patient: Oh, yeah. I forgot about that. I thought I had one, so I went to another doctor to get some medication. 
Doctor: I see. I have one more question. Do you have any trouble controlling your bowel movements or attempting to go to the bathroom? 
Patient: Nope. I feel like I'm able to go to the bathroom whenever I want.

Clinical note:

Symptoms: Balance issues, fatigue, weakness, back pain (lower and mid-back).
Diagnosis: N/A.
History of Patient: Symptoms started six to eight weeks ago, preceded by pneumonia treated with amoxicillin. Balance issues worsened after finishing the antibiotic course, back pain started after a recent fall (landing on back), receiving chiropractic treatment for back pain, recently treated for a urinary tract infection (UTI) with Cipro.
Plan of Action: N/A.
Doctor: Have you had any illnesses in the past? 
Patient: Nope.
Doctor: Anything that is worth mentioning?
Patient: Nope.
Doctor: Sure?
Patient: Yes.

Clinical note:

Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Denies past illnesses or significant medical history.
Plan of Action: N/A.
Doctor: Good afternoon, sir. My nurse tells me you're twenty eight years old, is that correct? 
Patient: Good morning, doctor. Yes, that's correct. 
Doctor: So, what happened?
Patient: Well, I punched a wall about three days ago. 
Doctor: Which hand is it?
Patient: It's my right hand. 
Doctor: Is this your dominant hand?
Patient: Unfortunately, yes, it is. 
Doctor: Where does it hurt?
Patient: Um, it's right here on the outside of my hand. 
Doctor: What kind of treatments have you had?
Patient: I went to the E D, and they pushed some of the joints in my hand back, and they put me in a splint, so I've been wearing that ever since. 
Doctor: How is your pain today? 
Patient: Compared to when it started, it's much better today. 
Doctor: How would you describe your pain today?
Patient: Today, I'd say it's minimal pain.
Doctor: Good, do you have any numbness or tingling today?
Patient: No, thankfully not.

Clinical note:

Symptoms: Right hand pain (ulnar-sided), improved since injury, minimal pain currently, no numbness or tingling.
Diagnosis: N/A.
History of Patient: 28-year-old right-hand dominant patient punched a wall 3 days ago, received treatment in the emergency room with joints pushed back and placed in a splint, pain has improved since then.
Plan of Action: N/A.
Doctor: Hello there, how are you?
Patient: I am good, thank you.
Doctor: He is my colleague Doctor Mason, and he will be assisting me today and taking down notes.
Guest_clinician: Hi there.
Patient: Hello. 
Doctor: Is it okay with you if he can join us?
Patient: Sure, no problem. 
Doctor: Great, thank you
Doctor: Doctor Mason can you take down the notes.
Guest_clinician: Sure.
Doctor: Patient looks well developed and well nourished. He is alert with not acute distress. 
Guest_clinician: Got it.
Doctor: Patient had a head injury, but he is fully conscious. G C S is fifty and nontoxic. 
Guest_clinician: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient had a head injury but is fully conscious with a Glasgow Coma Scale (GCS) of 15 and non-toxic appearance.
Plan of Action: N/A.
Doctor: Anyone sick in your family?
Patient: No.
Doctor: How about anyone with the same disorders?
Patient: No, I don't know.
Doctor: Okay don't you worry.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient denies anyone in the family being sick or having similar disorders.
Plan of Action: N/A.
Doctor: How did the patient do on the activity test?
Guest_clinician: Patient was good. I have advised him to continue with his normal activities as long as he is feeling fine.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: Advised patient to continue normal activities as long as feeling fine.
Doctor: How old was he when he were first evaluated in the other hospital?
Guest_family: He was seven.
Doctor: Which hospital was that again?
Guest_family: It was at U I H C.
Doctor: So what exactly happened? 
Guest_family: He was doing all good like seven months before his evaluation, then he started having some dizzy spells, which like stayed for several seconds to a minute. They were not regular, but he was able to continue his activity immediately after these dizzy spells. 
Doctor: Did the intensity change? 
Guest_family: Oh yes. This, these spells, they became more frequent, and they were now for longer periods. By the time we came for the first evaluation, they were like two to three times per day. 
Doctor: How long were they in the duration? 
Guest_family: They lasted for like two to three minutes. 
Doctor: Was there any other associated disorder or anything? 
Guest_family: Yeah, around three months before his evaluation his hands, they started becoming stressed, like stiffer and felt tighter during these spells. He also felt very weak and tired after these episodes.

Clinical note:
Symptoms: Dizzy spells lasting several seconds to one minute, increasing in frequency and duration over time, occurring 2-3 times per day and lasting 2-3 minutes. Right upper extremity tonic and flexed during episodes. Postictal fatigue.
Diagnosis: N/A.
History of Patient: Patient initially evaluated at UIHC at 7 years of age. Started experiencing dizzy spells 7 months prior to evaluation, initially lasting several seconds to a minute. Spells became more frequent and prolonged, occurring 2-3 times per day and lasting 2-3 minutes. In the 3 months prior to evaluation, right upper extremity would become tonic and flexed during episodes, and patient experienced postictal fatigue.
Plan of Action: N/A.
Doctor: Do you have major illnesses in the family like diabetes or high B P?
Patient: No nothing. No major illnesses.
Doctor: Okay.
Patient: Yes.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Good morning, sir. 
Patient: Good morning, doctor. 
Doctor: I just need some background information before we begin today. 
Patient: Sure. 
Doctor: Good, have you ever had surgery, sir? 
Patient: Yeah, actually I've had it on my knee, a nose job, and, um, carotid sinus surgery.

Clinical note:

Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Are you still working?
Patient: No, I am retired now. I used to work for the U S postal service as an electronic technician but took retirement one year earlier due to my disability.
Doctor: Ah okay. And who is in your family?
Patient: Well, I stay with my wife and daughter in our apartment.
Doctor: Okay. Do you smoke?
Patient: No.
Doctor: How about alcohol? 
Patient: I use to drink occasionally, that too very rare, but after my symptoms stated I stopped completely.
Doctor: Any use of recreational or illegal drugs? 
Patient: Nope.
Doctor: Did you travel anywhere recently?
Patient: No, it's been really long since I traveled anywhere.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Retired one year prior to assessment due to disability. Formerly employed as an electronic technician for the US Postal Service. Lives with wife and daughter in an apartment. Denied smoking history. Used to drink alcohol rarely but stopped entirely with the onset of Symptoms. Denied history of drug abuse. Denied recent travel history.
Plan of Action: N/A.
Doctor: Good afternoon, how are you today? 
Patient: I am good Doctor, thanks for asking.
Doctor: This is my colleague Doctor White, and she will be taking the notes. Is it okay if she joins us? 
Patient: Oh sure, no problem.
Doctor: Thank you.
Guest_clinician: Hello, I am Doctor White, nice to meet you.
Patient: Nice to meet you too.
Doctor: Okay, can you breathe in and out for me? Deep breaths please.
Patient: Okay.
Doctor: Okay breath sounds are clear. Lung function looks good. Symmetrical rise and fall in chest as patient breathes. I am going to palpate your chest, it's just a routine exam.
Patient: Sure.
Doctor: Doctor White can you make a note, no egophony or tactile fremitus.
Guest_clinician: Sure.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Routine examination conducted by Doctor, assisted by Doctor White. Patient reports feeling well.
Plan of Action: N/A.
Doctor: Where do you live?
Patient: I live in a board and care. It is a nice small care home with some very nice and supportive people. It is just next to the Safeway on Village Drive. 
Doctor: Nice. It looks like you love living there. 
Patient: Oh yes. I feel very relaxed there. 
Doctor: Did you consume alcohol in any way? 
Patient: No Sir. 
Doctor: Any tobacco consumption? 
Patient: Never in my life. 
Doctor: Did you ever try any kind of illicit drugs? Any I V drugs? 
Patient: No. I have always kept myself away from all those things.

Clinical note:
Symptoms: None.
Diagnosis: None.
History of Patient: Patient resides in a board and care facility near Safeway on Village Drive. Denies alcohol, tobacco, or illicit drug use.
Plan of Action: N/A.
Doctor: Have you had any surgeries in the past?
Patient: Actually, yes, I had my gallbladder removed in nineteen ninety two.
Doctor: Great, any other surgeries? Think back a little further? 
Patient: Oh yeah, I had my appendix out in nineteen eighty eight.

Clinical note:
Symptoms: None.
Diagnosis: None.
History of Patient: Patient underwent gallbladder removal surgery in 1992 and appendectomy in 1988.
Plan of Action: N/A.
Doctor: How are feeling now after the treatment?
Patient: I am feeling pretty fair, improving slowly.
Doctor: Okay?
Patient: Okay.

Clinical note:
Symptoms: Patient reports feeling fair, with slow improvement.
Diagnosis: N/A.
History of Patient: Patient received treatment and is experiencing gradual improvement.
Plan of Action: Continue monitoring patient's progress.
Doctor: Sir? Can you hear me? Are you Mister Smith's wife? 
Guest_family: Yes. I am his wife. 
Doctor: How old is he? Can you tell me a little bit of how your husband's condition has come to this point? His level of consciousness is concerning. 
Guest_family: He is eighty five. He took the entire M G of Xanax. He is only supposed to take point one twenty five M G of Xanax.  That is why he is like this.  
Doctor: It looks like your husband was admitted to the emergency room the night before.  How did these injuries to his face happen? 
Guest_family: He fell off his wheelchair.  
Doctor: The Adult Protective Services said they found your husband in the home barley conscious. How long had he been that way? 
Guest_family: All day. 
Doctor: Do you know what other medications your husband has taken other than the Xanax?  
Guest_family: He didn't take his regular medications for two days.

Clinical note:
Symptoms: Decreased level of consciousness, facial injuries, possible elderly abuse, history of falling from wheelchair.
Diagnosis: N/A (awaiting further evaluation).
History of Patient: Patient experienced decreased mental status for a whole day following an accidental overdose of Xanax and lack of Sinemet and other home medications for the past 2 days.
Plan of Action: Evaluate for possible overdose, assess facial injuries, investigate possible elder abuse, administer appropriate medications including Sinemet, monitor for improvement in mental status.
Doctor: How have you been feeling? Is the Wellbutrin keeping your mood stabilized? 
Patient: I have been feeling good. The Wellbutrin is working well for me.  
Doctor: It is important to not consume any alcohol or recreational drugs while taking Wellbutrin.  
Patient: I don't drink or do drugs.

Clinical note:
Symptoms: Stable mood, positive response to Wellbutrin.
Diagnosis: Depression.
History of Patient: Patient reports feeling good with Wellbutrin treatment for depression.
Plan of Action: Continue Wellbutrin regimen, advise against alcohol or recreational drug consumption.
Doctor: Tell me a little bit about your family history. 
Patient: My dad and grandpa both had type two diabetes. My son is struggling with type one diabetes at the moment.  
Doctor: I'm sorry to hear that. Does anyone in your family have heart problems? 
Patient: No. 
Doctor: How about cancer? 
Patient: Two of my cousins had breast cancer.

Clinical note:
Symptoms: No specific Symptoms reported.
Diagnosis: Family medical history assessment.
History of Patient: Patient reports family medical history related to heart disease, cancer (breast cancer in cousins), and diabetes (type II diabetes in father and grandfather, type I diabetes in son).
Plan of Action: Document family medical history for reference and potential future screenings or interventions.
Doctor: Where do you work, miss? 
Patient: Well, you see, I am a civil engineer. Right now, due to pandemic like everyone else I am working from home. 
Doctor: Are you working full time or is your disability affecting that?
Patient: No, I can only work on half time. This disability does not let me work full time. I need to go to physical therapy quite frequently on and off and I also have a baby who consumes a lot of my time. 
Doctor: Do you smoke or drink? 
Patient: No, I've never done any of them.

Clinical note:
Symptoms: None reported.
Diagnosis: Occupational status and lifestyle assessment.
History of Patient: Patient is a civil engineer working from home, currently working half-time due to disability, frequent physical therapy appointments, and childcare responsibilities. Patient denies smoking or alcohol use.
Plan of Action: Acknowledge patient's current work situation and schedule, consider adjustments or accommodations as needed, and provide support for managing disability and childcare responsibilities.
Doctor: Do you know any familiar diseases in your family? 
Patient: Do you mean like B P, high sugar? 
Doctor: Yes.
Patient: No, no one in my family has anything like that.
Doctor: Great.

Clinical note:
Symptoms: None reported.
Diagnosis: Family medical history assessment.
History of Patient: Patient denies any family history of hypertension or diabetes.
Plan of Action: No immediate action required regarding family medical history.
Doctor: Have you had any anxiety attacks lately? 
Patient: No.
Doctor: Have you felt depressed or had any mood swing problems? 
Patient: No.
Doctor: Any phobias?
Patient: No, not really. 
Doctor: Okay.

Clinical note:
Symptoms: None reported.
Diagnosis: Psychiatric assessment.
History of Patient: Patient denies recent anxiety attacks, depression, mood swing problems, or phobias.
Plan of Action: No immediate action required regarding psychiatric Symptoms.
Doctor: Do you have a history of mental illness or psychological disease? 
Patient: No.

Clinical note:
Symptoms: None reported.
Diagnosis: None.
History of Patient: Patient denies any past mental illness or psychological disease.
Plan of Action: No immediate action required regarding mental health.
Doctor: Hello sir. How are you doing today? You still look a little uncomfortable. Is there still pain?
Patient: Yeah. Still a good amount of pain. I did not take my pain medication this morning though. Not sure if that will make a huge difference. 
Doctor: That is possibly why you are still in pain. How is movement? Can you get out of the house and get around?
Patient: Yes. I am quite happy that I can do my daily activities. I can get up with minimal assistance and do many activities out of the house. I think I am gaining muscle from moving around more too. 
Doctor: How is the home exercise program going?
Patient: I am loving pool therapy. I really feel like that is helping. I do the home exercises sometimes twice a day. I really want to get back to normal.

Clinical note:
Symptoms: Significant morning pain, improving functionality. Increased muscle girth noted. Positive response to home exercise and pool therapy.
Diagnosis: Pain management needed; improving muscle strength and function.
History of Patient: Morning pain persists; overall improvement in activity levels.
Plan of Action: Continue home exercise and pool therapy. Review pain management options for morning pain.
Doctor: Have you had any surgeries in the past?
Patient: Yes, I had knee surgery.
Doctor: Which knee?
Patient: Right.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient underwent knee surgery on the right knee.
Plan of Action: Further assessment of knee function and pain management for the right knee.
Doctor: Are you sexually active? 
Patient: Yes. 
Doctor: How many partners do you have? 
Patient: Just one. 
Doctor: Is this a monogamous relationship? 
Patient: Yes. 
Doctor: What gender is you partner? 
Patient: He is a male. We have been together for three years. He is H I V positive.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient reports being in a monogamous relationship with an HIV-positive male partner for three years.
Plan of Action: Offer counseling on safe sexual practices and regular testing for sexually transmitted infections.
Doctor: I remember you mentioned that you had one operation done in the past. 
Patient: I had a lymph node biopsy back in September of O three. 
Doctor: Did it come back negative? 
Patient: Fortunately, yes.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Had a lymph node biopsy in September 2003, which came back negative.
Plan of Action: N/A.
Doctor: It looks like you have an extensive medical history. 
Patient: I blame my heart. It's caused me the most trouble. I had coronary artery bypass surgery in twenty ten along with an angioplasty. 
Doctor: I'm sorry that your heart has been giving you so much trouble. I'm happy that you're here with us today and taking the right measures to keep yourself healthy. 
Patient: Oh, and I forgot to mention that I've had prostate biopsies in the past. 
Doctor: When did you have the biopsies done? 
Patient: Last year. 
Doctor: Did they come back negative? 
Patient: Yes, fortunately. I guess my prostate isn't as troublesome as my heart. 
Doctor: I understand.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Coronary artery bypass surgery and angioplasty in 2010, prostate biopsies done last year which came back negative.
Plan of Action: N/A.