X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: What seems to be the problem today? 
Patient: I've been having headaches for a while now. 
Doctor: How long have you been having these headaches? 
Patient: Um, I had my first one about two months ago. 
Doctor: Did you suddenly start having them, or was it more gradual? 
Patient: Um, I'd say it was more gradual. 
Doctor: Where do you feel your headaches? 
Patient: Right here, between my eyes. 
Doctor: How would you describe your symptoms? 
Patient: I'd say it feels like a pressure sensation. 
Doctor: What's the intensity of these headaches? 
Patient: Um, they're about moderately severe, I guess. 
Doctor: Do these headaches interfere with your ability to do your activities? 
Patient: Yes, they do. My regular activities are significantly more difficult now. 
Doctor: Do you have any sinus congestion? 
Patient: Yeah, I do. I also have some light sensitivity. 
Doctor: Are you stressed out at work? 
Patient: Yes, I have a very stressful job, doctor. 
Doctor: Are you sleeping well? 
Patient: Well, no not at all. I even try to have a little drink before bed, and it doesn't help. 
Doctor: Do you have any oral symptoms, like vomiting or pain in your jaw? 
Patient: No, nothing like that.

Clinical note:
Symptoms: headaches for two months, pressure sensation behind eyes, moderately severe intensity, difficulty with regular activities, sinus congestion, light sensitivity
Diagnosis: N/A
History of Patient: gradual onset of headaches, worsened by stress, lack of sleep, and alcohol consumption, no vomiting or jaw pain
Plan of Action: N/A
Doctor: Do you have any medical conditions that I should know about?
Patient: No, not that I know of. 
Doctor: So, there's no history of depression, or cancer, or high blood pressure? 
Patient: No, it's not ringing any bells.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Patient: I am having stomach pain. 
Doctor: Hm, any nausea or vomiting? 
Patient: Yes, both.

Clinical note:
Symptoms: abdominal pain, nausea, vomiting
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Have you been experiencing any mental difficulties or confusion? 
Patient: No. 
Doctor: Any hallucinations? Are you seeing hearing thing that is not real? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No mental difficulties or confusion, no hallucinations, no headaches, no visual, hearing, or swallowing difficulties, no changes in bowel or urinary habits
Plan of Action: N/A
Doctor: Good afternoon, which gender do you identify with? 
Patient: Good afternoon, doctor, thank you for asking, I identify as a female.
Doctor: Great, thank you. Have you ever had surgery on this knee? 
Patient: Yes, I actually had an A C L reconstruction done in March of two thousand eight. Um, it didn't go well, so they did a revision at the end of that year, in December.
Doctor: I see, thank you. What about your upper body? Is there any history of surgery there? 
Patient: Actually, yes, I had surgery on my arm when I was six.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: upper body surgery
Plan of Action: N/A
Doctor: Welcome in, sir. 
Patient: Thank you. 
Doctor: What do you do for work? 
Patient: I am professor at the college up on the hill.
Doctor: What do you teach? 
Patient: I teach history and the bible. 
Doctor: Do you drink alcohol or use tobacco products? 
Patient: No. I do not partake in either of those activities. 
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Do you have any major medical conditions that I should know about? 
Patient: Yeah, I have a history of thyroid problems, actually. 
Doctor: I'm seeing here that you have a history of allergies too, is that correct? 
Patient: Oh yes, that's right too.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: history of allergies, history of thyroid problems
Plan of Action: N/A
Guest_clinician: How's the patient? 
Doctor: He's stable. Heart rate sixty five. Normal rhythm. Oxygen ninety seven percent on room air.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Tell me about your past problems. 
Patient: Sure. I just came into the hospital I think about three weeks back for recurrent urine infections.
Doctor: Yes it says here that you have bladder problems from a long time, mostly related to tone and capacity.
Patient: Yes that is why they put catheter in me.
Doctor: Okay and you have recently had right side C V A?
Patient: Yes, because of my heart problems they had to put pacemaker in.
Doctor: Okay. Good.
Patient: I have hereditary diabetes.
Doctor: Okay and your neural problem is associated to that as well.
Patient: That's right.
Doctor: You have pain on the right side now?
Patient: Yes, because of my stroke.
Doctor: And you take thyroid medications too?
Patient: Yes, for my hypothyroidism.
Doctor: Okay.
Patient: Yeah.
Doctor: What surgeries have you had in the past?
Patient: I have had many surgeries. They took out my gall bladder, then colon cancer surgery was in nineteen ninety eight. 
Doctor: And now pacemaker placement, right?
Patient: Yes, that is correct.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Recurrent urinary tract infections, chronic incontinence, bladder atony, right-sided cerebrovascular accident (CVA), atrial fibrillation status post pacemaker, type 2 diabetes with neuropathy, pain on the right side from stroke, hypothyroidism
Plan of Action: N/A
Doctor: Do you have any major medical conditions running in your family history that you know about?
Patient: No, there's nothing of note. 
Doctor: So, there's no history of arthritis, or cancer that you're aware of?
Patient: No, not that I know of.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: So, does high blood pressure run in your family?
Patient: Um, no it's just me.
Doctor: Okay and this was your first time? 
Patient: Yes. 
Doctor: Because I am looking at your previous charts and I don't see it mentioned before.
Patient: Oh yeah first time it shot up this high. I never had a high blood pressure problem before.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Now, let's talk about your family history. Have any of them had cancer? 
Patient: Actually, yes, I know a few family members have, but I can't remember who had what kind. 
Doctor: That's okay. What about heart disease? Can you remember anyone having that? 
Patient: Yes, that rings some bells. 
Doctor: Thank you, has anyone in your family had a joint replacement? 
Patient: I know that a lot of my family has had arthritis in the past, but I can't remember whether or not they had joint replacements, honestly.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: cancer and heart disease
Plan of Action: N/A
Doctor: Hi, how are you?
Patient: I am good, how about you?
Doctor: Well, I am good too, thank you for asking. So, what brings you here? 
Patient: Um, I have developed this painful ulcer on my hip. 
Doctor: Oh, let me take a look. Which side?
Patient: On my right hip. 
Doctor: Okay, I see it. Looks like you have developed pressure ulcer.

Clinical note:
Symptoms: N/A
Diagnosis: pressure ulcer
History of Patient: N/A
Plan of Action: N/A
Doctor: Okay, tell me what's going on and what's brought you here. 
Guest_family: I am her mother. She has this blister on the side of her head right above her ear, here. I was just worried and concerned about my baby. 
Doctor: How old is the baby? When did you first notice it?
Guest_family: She is just fourteen days old. Let me tell you from the beginning. On Friday, when I was taking her for a bath, I noticed a blister near her umbilicus area. We went to our doctor on Saturday, and they did a test. 
Doctor: Did you get the test result?
Guest_family: I got it today. Here is the report. 
Doctor: Okay, let me have a look. It says she is having a growing M R S A.
Guest_family: Yeah, I've been diagnosed with that too. And I am on medications. I had it on my buttock area. 
Doctor: Okay, so you know about it, and I don't have to explain it more.
Guest_family: Yeah. 
Doctor: So how is the blister on the umbilicus now?
Guest_family: She has been doing good. We put on some bacitracin ointment, and it almost healed up. But today I noticed that another small blister on her head. It really scared me, and I did not want to take any chance. That's why I reached out to the Infectious Disease center. I know it is private. But still, I don't want to take any chance with my baby's health. I called the center directly and they asked me to come to the hospital. 
Doctor: You did good. I will start the treatment. How are her eating and sleeping habits?
Guest_family: She hasn't missed any of her meals. She is taking around two ounces of milk in every feed. I don't think I have any issues with her eating or sleeping. 
Doctor: Did she have any fever?
Guest_family: Not that I noticed. 
Doctor: Has she been lethargic or crying more than normal?
Guest_family: No. 
Doctor: Any other changes in her daily routine that you might have noticed?
Guest_family: No, I didn't notice any changes.

Clinical note:
Symptoms: blister on umbilicus, small blister on left temporal area
Diagnosis: MRSA infection
History of Patient: blister noticed near umbilicus on Friday, diagnosed with MRSA, treated with bacitracin ointment, another small blister noticed on left temporal area, mother also diagnosed with MRSA on buttocks
Plan of Action: treatment initiated for MRSA infection, monitoring for fever, lethargy, changes in eating or sleeping habits
Patient: I am in pain. I get these frequent episodes of pain and discomfort in my head. 
Doctor: Is it in any side of head or is it overall?
Patient: Sometimes it is overall and other times just on any one side. Doctor: This sounds like it is a migraine headache.

Clinical note:
Symptoms: frequent episodes of pain and discomfort in head, sometimes overall and other times on one side
Diagnosis: migraine headache
History of Patient: N/A
Plan of Action: N/A
Doctor: Good afternoon, young man. Is this your mother? 
Patient: Hi, doctor. Yes, this is my mom. 
Doctor: Good, can you tell me more about your son, ma'am?
Guest_family: Sure, well, he's six years old now, and we're here to follow up his A D H D medicines. 
Doctor: He's been taking Adderall, correct? How long has he been taking this?
Guest_family: It's been about a month now. 
Doctor: How has he responded to the Adderall?
Guest_family: The first day he took it, truthfully, he was wonderful. There's been a lot of improvement in his behavior, and he's really been doing well, so far. 
Doctor: That's great!
Guest_family: Yes, but I have two concerns. When he takes the medicine first thing in the morning it seems to take a while to kick in, and then it wears off at about two P M and he has problems in the evening. 
Doctor: Has he had problems with his appetite? 
Guest_family: Um, he did at first, but it's been coming back. It's more of a problem in the morning when he first takes the medicine in the morning, not so much in the afternoon after it wears off. 
Doctor: Have you gotten any reports from his teachers? 
Guest_family: They have seen a dramatic improvement with it. 
Doctor: Has he taken every dose?
Guest_family: Well, I missed one last weekend, and he was just horrible. 
Patient: Yeah, mommy, I thought I needed it, but you didn't give it to me.

Clinical note:
Symptoms: delayed onset of medication effectiveness in the morning, medication wearing off in the afternoon, appetite issues initially improving, behavioral problems without medication
Diagnosis: ADHD
History of Patient: improvement in behavior with Adderall medication, concerns about medication timing and effectiveness
Plan of Action: continue monitoring medication effectiveness and side effects, ensure consistent dosing schedule
Doctor: Is there any family medical history? 
Patient: I have a whole list. See, my grand aunt had a stroke. My M G had heart issues same as my mom, who died of a heart attack at sixty three. My father had some sort of cancer. I don't know what exactly. And my sisters have blood pressure issues. 
Doctor: Wow, that sure is a list. Anyone with diabetes? 
Patient: No. Well, that is one thing that skipped my family.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Family history of heart issues, stroke,blood pressure.
Plan of Action: N/A.
Doctor: Does he have any known drug allergies? 
Guest_family: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Good morning, can you tell me more about your son, ma'am. 
Guest_family: Sure, he's forty six, White, and he has Down syndrome.
Doctor: Great, thank you. Is he still having problems with his hypothyroidism and onychomycosis? 
Guest_family: Yes, that's correct doctor. 
Doctor: Has he remained complaint with his Lamisil? 
Guest_family: Yes, he's taken six weeks of it with no problems. 
Doctor: Good, so we'll do an A L T blood test today.
Guest_family: Why is that doctor? 
Doctor: Well, at his last appointment in April, he had an elevated T S H level. So, we should recheck that today. 
Guest_family: Yes, I remember that. 
Doctor: Has he been taking his Levothroid daily as well? 
Guest_family: Yes, he has, he doesn't like it, but I help him with it, and he eventually takes it. 
Doctor: Good, thanks for taking care of him, Mom.  
Guest_family: Oh, it's my job. 
Doctor: Does he take any other medications? 
Guest_family: He has some medicated eye drops for his cornea.

Clinical note:
Symptoms: N/A
Diagnosis: hypothyroidism, onychomycosis
History of Patient: finished six weeks of Lamisil without problems, elevated TSH in April, started on Levothroid 0.1 mg daily
Plan of Action: recheck ALT and TSH levels, continue Levothroid for hypothyroidism, monitor compliance with medications
Doctor: Do you have any questions regarding your surgery? 
Patient: Yes, I do, multiple.
Doctor: Go ahead shoot.
Patient: I have them all written down on this.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: How about any drugs, alcohol, or tobacco? 
Patient: No, no, and no.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Hey, how are you?
Patient: I think I am better.
Doctor: So you do not have any more nausea or vomiting?
Patient: No I don't.
Doctor: How about any acidity?
Patient: I think it's all better. 
Doctor: Great.

Clinical note:
Symptoms: severe nausea and vomiting (resolved)
Diagnosis: likely gastroenteritis
History of Patient: N/A
Plan of Action: N/A
Doctor: How are you?
Patient: I am good.
Doctor: That's great. You are stable.
Patient: Can I go home now?
Doctor: Yes, you can.
Patient: Thank you!

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Good afternoon, young man, are these your parents?
Patient: Yes, doctor. 
Doctor: Can you tell me more about your son, please? 
Guest_family: Well, he is seven years old, and he has had diarrhea for four days, and he's been throwing up for three days. 
Patient: Yeah, my brother has been doing this too. 
Guest_family: We had some chicken one day, and then we had more of it the next day. After they ate it they started to feel bad and still feel bad. 
Doctor: How many times has he had diarrhea per day since this began? 
Guest_family: Well, it's been about five or six times a day for the last four days. 
Doctor: How many times has he thrown up per day?
Guest_family: Um, it has been frequent. 
Doctor: Has he been throwing up today? 
Patient: No, I haven't today. 
Doctor: Has he gone to the bathroom today?
Patient: Yes, I peed this morning. 
Doctor: Has he had any fever symptoms?
Guest_family: Yes, he had a fever of one hundred three last night. 
Doctor: Has he eaten any solid food?
Patient: Yeah, I had half a hamburger and some milk last night.
Doctor: Was he able to keep the food down?
Guest_family: No, he threw it up. 
Doctor: What has he drank? 
Guest_family: Um, Pedialyte, Gatorade, white grape juice, and seven up, the soda.

Clinical note:
Symptoms: diarrhea (5-6 times a day for the last four days), vomiting (frequent for the last three days, less frequent in the last two days), fever of 103 last night
Diagnosis: N/A
History of Patient: Symptoms started after eating chicken, patient had diarrhea and vomiting after eating, brother also experienced similar Symptoms, patient had half a hamburger and some milk last night which he vomited, has been drinking Pedialyte, Gatorade, white grape juice, and 7Up
Plan of Action: N/A
Doctor: Welcome into the clinic! I would like to start with your past medical history.  
Patient: I have high blood pressure and macular deterioration. Last year I caught pneumonia but that has cleared up.
Doctor: Okay.  What brings you in today? 
Patient: I have had this cough and pain on the right side of my abdomen. 
Doctor: How long has this been going on? 
Patient: Two days. I have had body aches and have been feeling nauseous too. 
Doctor: Have you had a fever? 
Patient: I think so. I was chilled and my forehead was warm. The cough is a dry sounding cough. 
Doctor: Does the abdominal pain come during one of these coughing episodes? 
Patient: Yes.

Clinical note:
Symptoms: cough (dry sounding), pain on the right side of abdomen, body aches, nausea, fever (chilled with warm forehead)
Diagnosis: N/A
History of Patient: Symptoms present for two days, abdominal pain occurs during coughing episodes
Plan of Action: N/A
Doctor: Good afternoon, dear, how old are you?
Patient: I'm fourteen years old. 
Doctor: Good, and what brings you in for a visit today? 
Patient: My left knee hurts really bad. 
Doctor: Oh no, how long has this knee been hurting you? 
Patient: Well, since the fall of two thousand seven. 
Doctor: Have you seen another doctor for this? 
Patient: Mom, can you tell the doctor?
Guest_family: Yes, actually, we went to another orthopedist in November of two thousand seven.
Doctor: I see, and what did this doctor recommend?
Guest_family: We got an MRI, I have a disc with the images, and the report as well right here, if you want to take a look at it. 
Doctor: Thank you, yes, so this shows left patellar chondromalacia. Has she been to P T?
Guest_family: We got a referral for P T, but they only wanted to do, um, let me look at my notes, patellar tracking exercises. 
Doctor: I see, has she been wearing her brace? 
Guest_family: Yes, she has been. I've been making sure of it. 
Doctor: That's good, and how is your pain today, dear? 
Patient: P T only made the pain much worse, it hurts so much.
Guest_family: Yes, she's in a lot of pain, is there anything else we can do, besides P T?
Doctor: Well, we're in a pretty difficult spot here. The majority of my patients get significantly better by just going to P T. 
Guest_family: Is there any surgery to fix this? 
Doctor: Usually, we manage this for six months without surgery, and she hasn't reached that milestone yet. But, because her pain is getting so severe, I can do a lateral capsular release on this knee. 
Guest_family: What is that?
Doctor: It's a small procedure, minimally invasive, and we can do it outpatient. Her kneecap is partially dislocating, so this surgery will get everything back into alignment. 
Guest_family: Okay, what is the risk of infection?
Doctor: The risk of infection is actually less than one percent. We use antibiotics to control for infection.
Patient: Will I be asleep for this?
Doctor: Yes, you won't feel a thing. 
Patient: Will I need to go back to P T?
Doctor: Yes, you'll need to go some after the surgery to make sure everything heals up okay. The other risks include bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling.
Guest_family: I think we'd like to do the surgery. What do you think, honey?
Patient: Yeah, I think so too, I want to get back to playing soccer.

Clinical note:
Symptoms: left knee pain.
Diagnosis: left patellar chondromalacia.
History of Patient: since the fall of two thousand seven, seen another orthopedist in November of two thousand seven, MRI done, referral for P T.
Plan of Action: lateral capsular release surgery recommended, outpatient procedure, risks discussed including infection, anesthesia, need for postoperative rehab.
Doctor: What brings you here today?
Patient: I have pain in my tummy.
Doctor: When did you first notice it?
Patient: It started suddenly around noon.

Clinical note:
Symptoms: pain in my tummy.
Diagnosis: left patellar chondromalacia.
History of Patient: started suddenly around noon.
Plan of Action: N/A
Doctor: Welcome to the clinic., ma'am 
Patient: Thank you. 
Doctor: What brings you into see me? 
Patient: I have been struggling with pain and stiffness in my right neck and shoulder. 
Doctor: How long has this been going on for? 
Patient: Maybe for about four months. 
Doctor: In these past four months have your symptoms becomes worse or has it improved at all? 
Patient: It has been getting worse. The pain is worse at night. It wakes me up at night. I haven't had a good night sleep in four months. 
Doctor: Have you experienced any pain or numbness in your arm, wrist, or hand? 
Patient: Yes! About two weeks after the pain started, I was having some numbness and painful cramping in these two fingers here. 
Doctor: The right hand and the first and second finger? 
Patient: Yes. 
Doctor: How old are you? 
Patient: I am forty six. 
Doctor: Are you left or right handed? 
Patient: Right. It was a throbbing pain in my hand. 
Doctor: Have you had any other pain anywhere else in your body? 
Patient: I few times I had some numbness in both of my legs. It started with a pinching from my tailbone area. 
Doctor: Did you experience any trauma neck, head or back? 
Patient: No. I don't know where this pain came from. Oh, every once and a while I have this electric shock like sensation shooting down my spine when move my neck certain way.
Doctor: Any pain or symptoms in your left arm or shoulder? 
Patient: No. 
Doctor: Have you had any visual changes or disturbances?
Patient: No. 
Doctor: Any difficulties with your bowels or your bladder? 
Patient: No. 
Doctor:  Have you been taking any thing for the pain? 
Patient: I have been taking Naprosyn.
Doctor: Has the Naprosyn help relieve your pain? 
Patient: Only a little bit. 
Doctor: Okay.

Clinical note:
Symptoms: pain in my tummy.
Diagnosis: left patellar chondromalacia.
History of Patient: started suddenly around noon, since the fall of two thousand seven, seen another orthopedist in November of two thousand seven, MRI done, referral for P T.
Plan of Action: N/A
Doctor: Is this baby number two? 
Patient: Yes, this is baby number two. 
Doctor: How many times have you been pregnant, including miscarriages or abortions if any? 
Patient: I've been pregnant two times in total. No miscarriages or abortions. 
Doctor: When was your last period? 
Patient: About a month ago. 
Doctor: And how would you describe your periods? Light, normal, heavy? 
Patient: Pretty normal. 
Doctor: Any abnormal pap smears? 
Patient: No, fortunately they've all been normal. 
Doctor: That's wonderful to hear. And my last question for you is if you've ever gotten a mammogram? 
Patient: I haven't gotten one before. Do I need to get one? I just turned thirty nine. What's the recommended age again? 
Doctor: It depends. For example, the recommended age would be younger for someone who has a family history of breast cancer. Given that you don't have a positive family history of breast cancer, I'd advise getting one in a few years at the age of forty five.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: lateral capsular release surgery recommended, outpatient procedure, risks discussed including infection, anesthesia, need for postoperative rehab, mammogram advised at the age of forty five
Doctor: Okay, I want you to follow up with our hand therapist Doctor X at her A B C D office in one to two weeks. 
Patient: Okay, I will make an appointment today.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Follow up with Dr. X in ABC Office in 1 to 2 weeks
Doctor: So we're here to follow up on a few things. I'd like to know how you're keeping up with your blood sugar checks. 
Patient: I've been checking my blood sugar one to two times a day. 
Doctor: Have you been keeping a log? 
Patient: Uh yeah, but I need to be better at it. 
Doctor: Do you have the log with you today? 
Patient: Yep, in fact it's right here. Let me grab it for you. 
Doctor: Great. 
Patient: Here ya go. 
Doctor: Thank you. And have you been watching your cholesterol intake since getting blood work done? Your labs show your cholesterol levels are a bit elevated. I'd like for you to monitor your cholesterol and go in for another set of labs before our next visit. 
Patient: Do I need to fast for it again? 
Doctor: Yes, you'll need to fast. I'd recommend going in early in the morning before eating any breakfast.  
Patient: That sounds like a good plan. 
Doctor: And as for your sinusitis, how have you been feeling since finishing your course of antibiotics? 
Patient: Much better. No more headaches and a stuffy nose.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Follow up on blood sugar checks, cholesterol monitoring, and sinusitis; recommend another set of labs for cholesterol, fasting required; sinusitis improved after antibiotics
Doctor:  What brings you in today? 
Patient: My back started hurting last night. I have a stomachache. I have had pain with urination for the last two days.  
Doctor: Do you have any other symptoms? 
Patient: I just started coughing and now I have a fever.  
Doctor: Do you have any history of kidney stones? 
Patient: Yes.  I had kidney stones less than a year ago.  I had a urinary tract infection at the same time.  It was awful.

Clinical note:
Symptoms: back pain, stomachache, pain with urination, cough, fever
Diagnosis: N/A
History of Patient: history of kidney stones less than a year ago, concurrent urinary tract infection
Plan of Action: N/A
Guest_clinician: When did she have lumbar discitis? 
Doctor: A little over a year ago. She received antibiotic therapy and ended up having debridement and instrumentation with Doctor XYZ.  
Guest_clinician: How's she doing today? 
Doctor: Really quite well. 
Guest_clinician: She also had a P E with that prior hospitalization, correct? 
Doctor: Yes.

Clinical note:
Symptoms: N/A
Diagnosis: lumbar discitis, pulmonary embolus
History of Patient: lumbar discitis occurred a little over a year ago, treated with antibiotics, debridement, and instrumentation with Dr. XYZ; patient doing quite well
Plan of Action: N/A
Doctor: Do you have sugar or blood pressure problems?
Patient: Oh, I have high blood pressure but it's well under control. I make sure to keep it under normal range.
Doctor: Good. Any other health issues?
Patient: Yeah, I have history of high triglycerides. But otherwise, I am pretty healthy. 
Doctor: Okay. Do you smoke?
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: history of high blood pressure well under control, history of high triglycerides, otherwise generally healthy, nonsmoker
Plan of Action: N/A
Doctor: Hello, miss. The nurse who seated you tells me you are here for a second opinion on surgery. 
Patient: Hello, doctor. Yes, I have been told that both eyes need cataract extraction. I came for a second opinion because I will only have surgery if necessary. I am nervous.
Doctor: What is the reason for the extraction? 
Patient: I am not exactly sure because the other doctors said a bunch of medical terms. I have had laser in my eyes though. That was for macular degeneration. Doctor X said I had neurovascular age-related macular degeneration. 
Doctor: Do you know what laser you had on your eyes?
Patient: No. I just know laser was done by Doctor X four times to the macula on the right and two times on the left.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: cataract extraction recommended for both eyes, patient nervous about surgery, past ocular surgery history significant for neurovascular age-related macular degeneration, laser treatments done by Dr. X.
Plan of Action: N/A.
Doctor: Any allergies? 
Patient: Um yeah. I'm trying to remember the name. It's a pain killer that starts with an L. Oh Lortab. 
Doctor: What happens when you take Lortab? 
Patient: Really bad hives. I've only ever taken it once. 
Doctor: I'll make note of that in your chart so we have it in your records.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: Note patient's allergy to Lortab, which causes really bad hives upon ingestion, documented in patient's chart.
Doctor: Do you have any known drug allergies?  
Patient: No, none that I know of.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Welcome in. 
Patient: Thank you. 
Doctor: What do you do for work? 
Patient: I work in Human Resources for the State of Maryland. 
Doctor: Do you live alone or with others? 
Patient: I live alone. 
Doctor: Do you smoke cigarettes? 
Patient: I used to smoke like a chimney. I quit smoking a while back. I had been smoking for about sixteen years. 
Doctor: That's great! When did you quit? 
Patient: I quit in nineteen eighty four. That is also the year I quit drinking. 
Doctor: What was the reason behind quitting drinking? 
Patient: I had a drinking problem. I am in A A. I have been in A A since I quit. 
Doctor: That's great. Keep up the hard work. 
Patient: Thank you. 
Doctor: Do you have any history of recreational or I V drug use? 
Patient: Yes. I used to take pills, but I never got into needle drugs. Thank God.  I went through treatment, all those years back. I started going to A A and got my life together. 
Doctor: Do you have any other risk factors for H I V? Like multiple sex partners? 
Patient: No. I had my last H I V test over two years ago. I have been with the same guy for over two years. 
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: He has a history of illicit drug use, but denies IV drug use.  He denies any HIV risk factors and states that his last HIV test was over two years ago.
Plan of Action: N/A
Doctor: Hi, tell me about your family? Did anyone have any medical diseases?
Patient: Both of my parents were healthy, but my maternal grandfather had a stroke.
Doctor: Did anyone in your family ever have migraines? 
Patient: No, not that I know.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: maternal grandfather had a history of stroke, mother and father were healthy, no history of migraines in the family
Plan of Action: N/A
Doctor: Do you have any chronic medical conditions that I should know about? 
Patient: What do you mean by that, doctor? 
Doctor: Well, it could be anything from high blood pressure, to depression, to cancer. Do any of those sound familiar? 
Patient: Oh, yeah, I have a few things like that. I have anemia, high cholesterol, and, um, hypothyroidism.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: anemia, high cholesterol, hypothyroidism
Plan of Action: N/A
Doctor: How old are you? 
Patient: Oh, I am fifty eight now. 
Doctor: So, you are here today because you are having some vision difficulties? Tell me about what has been going on, ma'am. 
Patient: Yeah. Okay. It all started a year ago. It started with losing the color in my vision. 
Doctor: Was the loss sudden or gradual? 
Patient: Gradual. And now I am starting to have blurry vision. 
Doctor: When did that start happening? 
Patient: I noticed it two months ago. 
Doctor: Is the blurred vision an all blur or is there a blind spot of blurred vision. 
Patient: It is an all over vision blur and then I have on blind spot in my right eye. 
Doctor: Have you had any fluctuations in your symptoms in the last year? Have you gained any vision back? 
Patient: Some days I feel like things are a little better but not much. I have basically been the same. 
Doctor: Have you experienced any weakness, dizziness, vertigo, nausea or vomiting? 
Patient: No. 
Doctor: Any double vision or headaches? 
Patient: No. 
Doctor: Any pain in or behind the eye at all?
Patient: No. 
Doctor: Any other health concerns or complains? 
Patient: No. Just the vision problems. 
Doctor: Alright! Let me take a look here.

Clinical note:
Symptoms: progressive loss of color vision, gradual onset of blurry vision, blind spot in right eye, mild fluctuations in Symptoms
Diagnosis: N/A
History of Patient: Symptoms started one year ago, blurred vision developed two months ago, no other associated Symptoms such as weakness, dizziness, vertigo, nausea, vomiting, double vision, or headaches
Plan of Action: N/A
Doctor: How are you feeling today? 
Patient: I have been having some trouble breathing.  I had tightness in my chest after walking up stairs. 
Doctor: Let me listen to your lungs.

Clinical note:
Symptoms: trouble breathing, tightness in chest after walking upstairs
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Good afternoon, ma'am. Before we begin, can you confirm your age for me, please? 
Patient: Sure, I'm fifty six years old. 
Doctor: Great, thank you. What seems to be the problem today? 
Patient: Well, I have a history of systemic lupus erythematosus. 
Doctor: How have you been treated for this in the past? 
Patient: Um, I went to a rheumatologist about four months ago, I had discomfort in both of my hands. 
Doctor: Which hand was worse? 
Patient: My left was worse than my right at that time. 
Doctor: Have you seen anyone else for this?
Patient: Um, I came in on October thirtieth two thousand seven. I was having the same problem. 
Doctor: What did they do for you at that time? 
Patient: They have me a trial of Elavil because they thought it was, um, ulnar or radial neuropathy. 
Doctor: Did they give you any topical creams? 
Patient: Yeah, they gave me a prescription for Zostrix but I couldn't fill it because of my insurance. 
Doctor: I see, have your symptoms gotten worse since they began? 
Patient: Yeah, especially here, at the base of my left hand, like around my wrist.
Doctor: Which fingers do you feel it in? If any? 
Patient: Right here, doctor. 
Doctor: Okay, these are your second, third, and fourth fingers. Do you have any other symptoms of note? 
Patient: Um, actually yeah, I've been having some respiratory problems for the last three days or so. 
Doctor: What symptoms have you been experiencing? 
Patient: Um, I've had a dry cough and I feel like I've had a fever but I haven't taken my temperature. 
Doctor: Have you had any night sweats or chills? 
Patient: No, not that I can remember. 
Doctor: Have you had any chest pain or discomfort?
Patient: No. 
Doctor: What about shortness of breath, or G I problems? 
Patient: Thankfully, no.

Clinical note:
Symptoms: discomfort in both hands (left worse than right), dry cough, subjective fever
Diagnosis: systemic lupus erythematosus
History of Patient: bilateral hand discomfort, previous visit on October 30, 2007, trial of Elavil for ulnar or radial neuropathy, prescription for Zostrix cream
Plan of Action: routine follow-up evaluation
Doctor: Do you remember the name of the medication you are taking?
Patient: I have two, but I do not remember their name or why I am taking it.
Doctor: That is fine, we will figure it out.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: I wanted to talk to you about your family medical history. 
Patient: Okay, how this will be helpful?
Doctor: Family history plays an invaluable role in your health. It provides us with important clues and insight to predict and detect diseases before obvious symptoms appear. 
Patient: My mom dealt a long time with anxiety and stress disorder.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Patient admits a family history of anxiety, stress disorder associated with mother.
Plan of Action: N/A
Doctor: Okay, let's review your family history.
Patient: Ready when you are.
Doctor: Does anyone in your family have high blood pressure or high cholesterol?
Patient: Both my parents have high blood pressure.
Doctor: Are they being treated for it?
Patient: Um yes. Oh they also have E T.
Doctor: Do any of your siblings have it as well?
Patient: No.
Doctor: Does anyone in your family have an autoimmune disorder.
Patient: Hm. Give me a second to think. Does lupus count?
Doctor: Yes. Who do you know that has lupus?
Patient: My cousin.
Doctor: On your mom or dad's side?
Patient: Uh mom.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Both parents have ET and hypertension.  Maternal cousin with lupus.
Plan of Action: N/A
Doctor: What are you taking as a maintenance treatment?
Patient: Oh, I take Flonase.
Doctor: And do you have a lot of issues after taking that?
Patient: No I do not.
Doctor: That is good.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Hello. Looks like we are here for a six months follow up. How are we doing?
Patient: I have stayed relatively the same. My main complaint is that I feel tired throughout the day. The C P A P is doing fine and I wake up refreshed, but I don't like how I crash. 
Doctor: Alright. How are the thyroid issues?
Patient: I seem to be fine. My thyroid gland does not seem enlarged and I can breathe like normal. No fever or anything. 
Doctor: Have you experienced any of the following: temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, or diarrhea?
Patient: Nothing of the kind. 
Doctor: How has you weight been?
Patient: It has been stable. 
Doctor: Any muscle weakness closest to the body's center?
Patient: No, nothing like that. Not bad for forty five.

Clinical note:
Symptoms: fatigue throughout the day
Diagnosis: N/A
History of Patient: patient is 45 years old, last visit about 6 months ago, health remained unchanged since last visit, using CPAP and wakes up feeling refreshed but tends to tire out later in the day, not having signs or Symptoms of thyroid excess or hypothyroidism, stable weight, not reporting proximal muscle weakness
Plan of Action: N/A
Doctor: So I understand you had a fainting episode yesterday? 
Patient: Yes, I did. 
Doctor: Has this happened to you before? 
Patient: Yes. It happens whenever needles are involved.  
Doctor: You had a Vasovagal Syncope. How are you feeling today? 
Patient: I feel normal today.

Clinical note:
Symptoms: fainting episode
Diagnosis: Vasovagal Syncope
History of Patient: N/A
Plan of Action: N/A
Doctor: Hello, how are you?
Patient: I am not so good. 
Doctor: Oh, what is going on with you? 
Patient: Well, I have lot of swelling in my legs.
Doctor: Hm, okay.

Clinical note:
Symptoms: swelling in legs
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Hi there, sir! I am Doctor Frankland. 
Patient: Hi! It's nice to meet you. 
Doctor: What brings you into see me today? 
Patient: I have had this pain in my finger and wrist for about a month. I have had some numbness too. The numbness started in the finger and is now in the wrist too.
Doctor: Which wrist and finger is it that is hurting? 
Patient: The left one and the middle finger, here. 
Doctor: What was to time frame of the procreation of the numbness from the finger to the wrist?  
Patient: It started when I woke up and then by the end of the day my wrist was numb too. 
Doctor: When did you start experiencing pain in the wrist area? 
Patient: A few days after the numbness started. 
Doctor: Which hand is your dominate hand? 
Patient: I am left handed. 
Doctor: What do you do for work? 
Patient: I am a cook. I also cut the fish for the whole restaurant.  I cut fish for hours in the mornings and it has been a struggle and it is aggravating my finger and wrist. 
Doctor: How old are you? 
Patient: I am forty four. 
Doctor: Do you have any history of injuring a neck injury? 
Patient: No. 
Doctor: Any neck pain or weakness? 
Patient: No. 
Doctor: Any difficulties with bowel movements or urination? 
Patient: No.

Clinical note:
Symptoms: pain in left middle finger and wrist, numbness starting in finger and spreading to wrist
Diagnosis: N/A
History of Patient: 44 years old, left-handed, one month history of numbness and pain in left middle finger and wrist, numbness started in finger and spread to wrist within a day, pain in wrist developed few days later, worsened by cutting fish for prolonged periods, no history of neck injury, no neck pain or weakness, no difficulties with bowel movements or urination
Plan of Action: N/A
Doctor: Good morning.  How are you feeling today? 
Patient: I feel good, considering.  I slept well last night.  
Doctor: Are you expensing any pain or discomfort? 
Patient: No. I feel fine.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: How are you doing with everything?
Patient: I'm good. It's hard when you are in quarantine. I hope things will get back to normal soon. 
Doctor: So, you are here for your breast examination. 
Patient: Yes, it was due for so long. 
Doctor: I'm going to touch both of your breasts one by one to check for any lump or kind of mass. Okay?
Patient: Yeah. 
Doctor: Okay, so both looks good. Are you feeling any pain while I'm touching?
Patient: No, I don't feel any pain. 
Doctor: That's good, no masses, no pain and I do not feel anything in your armpit area.

Clinical note:
Symptoms: N/A
Diagnosis: The breasts show no masses or tenderness.  No axillary adenopathy.
History of Patient: N/A
Plan of Action: N/A
Doctor: How's your wife doing? I think the last time I saw her was two weeks ago. She was telling me about the remodeling you've been doing around the house. 
Patient: She's doing well, thanks for asking. Oh yeah, the remodeling has been a lot. I didn't think it'd take as long as it has. 
Doctor: Yeah, it can take some time. We remodeled our kitchen three years ago and it turned our lives upside down. So tell me, how's training going for you? I believe you were telling me that you have a five k coming up. 
Patient: Yeah, it's two weeks away. I've been jogging and doing cross country track about five times a week. I also lift twice a week on my better days. 
Doctor: That's great! And no smoking or drinking, correct? 
Patient: Nope.  
Doctor: How's work been treating ya? 
Patient: Pretty darn well actually. I go into the allergy and immunology clinic four days outta the week. I like that my hours are flexible. My patients also haven't run away from me yet, which is always a good sign.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: My nurse tells me you're thirty four years old, is that correct? 
Patient: Yes, I just had my birthday, doctor. 
Doctor: You identify as African American, correct? 
Patient: Yes, that's right, sir.
Doctor: You're here for a follow up? What brings you back in today? 
Patient: Well, I don't really have a single acute complaint, but I have a muscle sprain in my upper back. 
Doctor: Is there an injury associated with this pain, ma'am? 
Patient: I think it has to do with me lifting weights. 
Doctor: Yes, that's common. Is this messing with your ability to work? 
Patient: No, it's not really. 
Doctor: What do you do for a living? 
Patient: I'm a housekeeper, it's my profession. 
Doctor: Are you having trouble sleeping at night? 
Patient: Yes, it's not severe, but I'm having some trouble. 
Doctor: With ten being the worst pain imaginable, how would you rate your pain today? 
Patient: I'd say it's usually a two out of ten. 
Doctor: When it's the worst, how would you rate it? 
Patient: When that happens, I'd say it's a three or a four. 
Doctor: Do you take any medicines for this pain?  
Patient: Over the counter medications usually help the pain go away. 
Doctor: Do you have any other complaints? 
Patient: No, just this muscle pain. 
Doctor: Do you have any loss of balance when you hold something with this arm? 
Patient: No, my strength and everything is normal there. 
Doctor: Do you have any signs of infection? That'd be anything like fever or chills, anything like that?
Patient: No, I don't have anything like that.

Clinical note:
Symptoms: muscle sprain in upper back, trouble sleeping at night
Diagnosis: N/A
History of Patient: 34 years old, African American female, routine follow-up, muscle sprain from lifting, housekeeper by profession, pain rated 2 out of 10, worsens to 3 or 4, relieved with over-the-counter medication, no other associated complaints, no neurological deficits or specific problems, denies Symptoms associated with opportunistic infection
Plan of Action: N/A
Doctor: How can I help you today.  
Patient: I have been having irregular periods.  
Doctor: When was your last menstrual period? 
Patient: My last period was on June first two thousand and four.  
Doctor: Are you currently sexually active? Is there a possibility of pregnancy? 
Patient: No! There is no possibility that I am pregnant.  I have not had sex in two years.  
Doctor: How old where you when you had your first menstrual period? 
Patient: I was ten years old when I got my first period.  My cycle has never been regular. It runs in my mom's side of the family.  
Doctor: What is your family history of reproductive health conditions on your mom's side of the family?  
Patient: My mom and my aunt have both had total hysterectomies.  
Doctor: Is there any other personal medical history I should know about? 
Patient: I see Doctor X Y Z Allen for my abnormal heart valve condition.  I am on S B E prophylaxis.  I have to limit my activity because of my heart condition.  
Doctor: Do you avoid decongestants? 
Patient: Yes.

Clinical note:
Symptoms: irregular periods
Diagnosis: N/A
History of Patient: irregular periods since menarche at age 10, family history of reproductive health conditions (mom and aunt had total hysterectomies), abnormal heart valve condition requiring SBE prophylaxis, activity limitation due to heart condition, avoidance of decongestants
Plan of Action: N/A
Doctor: How have you been feeling? How is your leg feeling?
Patient: My right leg is in a lot of pain. The nurse just changed the bandage. I only have a rash where the bandage is. 
Doctor: It looks like we have you taking Vicodin for the pain. Is the medication not helping? 
Patient: The pain medication is horrible. I have been throwing up, off and on. I have been constipated since I have been here.  
Doctor: I'll note that. Vomiting since February nineteen of two thousand seven. I am sorry to hear that. I will make a change to the medication and get you something for the constipation issue. 
Patient: Thank you. 
Doctor: Have you had any shortness of breath, chest pain or coughing up blood? 
Patient: No. 
Doctor: Any joint pain, headaches or rashes? 
Patient: No. Just a rash where the bandages are like I said earlier. I also want to discuss this acne while I am here. I have had it for about two years. It's nothing big, just mild to moderate in severity.

Clinical note:
Symptoms: pain in right leg, rash where bandage is, acne (mild to moderate severity)
Diagnosis: N/A
History of Patient: pain in right leg, rash where bandage is, acne for about two years (mild to moderate severity), vomiting off and on since February 19, 2007, constipation since being on pain medication
Plan of Action: change medication for pain, prescribe medication for constipation
Doctor: Does anyone in your family have a neurological disorder? 
Patient: No, not to my knowledge.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Do you smoke, sir? 
Patient: Well, I used to a long time ago, but I don't anymore. 
Doctor: Good, what about alcohol, do you drink?
Patient: Well, my wife and I have a drink or two a day.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: very remote history of tobacco use, one to two alcoholic drinks per day, married
Plan of Action: N/A