X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: Is there any history of heart disease in your family? 
Patient: Yes, my dad and brother had heart vessel blockage type of disease in their forties.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Positive family history of coronary artery disease in the patient's father and brother in their forties.
Plan of Action: N/A
Doctor: If I'm understanding correctly, you sustained an elbow injury during a fight with some other kids in Juvenile Hall? 
Patient: Yeah. My left elbow is killing me. 
Doctor: How old are you? 
Patient: Seventeen. 
Doctor: Are you having pain anywhere else? 
Patient: Yeah. My left ankle also hurts. 
Doctor: Are you able to walk without difficulty? 
Patient: Yeah. 
Doctor: Any knee pain? 
Patient: Not right now, but I've had left knee pain in the past. 
Doctor: Did you pass out or hurt your neck in any way? 
Patient: I didn't pass out. I hit my head against the floor when one of the kids tried to pin me down. 
Doctor: Do you have a headache, nausea, or blurry vision? 
Patient: No. 
Doctor: And no chest or abdominal pain? 
Patient: No. 
Doctor: Were there any weapons like knives or guns used during the fight? 
Patient: No.

Clinical note:
Symptoms: Pain in the left elbow and left ankle.
Diagnosis: N/A
History of Patient: The 17-year-old male sustained an elbow injury during a fight with other kids in Juvenile Hall, experiencing sudden pain in his left elbow. He also reports pain in his left ankle, with previous left knee pain. He denies passing out, neck pain, chest pain, or abdominal pain. No weapons were involved in the fight.
Plan of Action: N/A
Doctor: Hello. Before we begin your visit, I noticed some information missing. Could I verify the information with you? 
Patient: Of course. 
Doctor: Does your family have a history of any health related problems? 
Patient: Oh, yeah. A lot of my family have heart problems and cancer.
Doctor: I see. Do you know what kind of cancer? 
Patient: I'm not completely sure, but my wife may know. She's here with me right now. 
Doctor: Great. I'll bring her in. 
Guest_family. Hello. I'm his wife. 
Doctor: Do you know what type of cancer runs in his family? 
Guest_family: I do. I believe it's carcinoma. 
Doctor: Thank you. Sir, are there any other health related problems I should be aware of? 
Patient: High blood pressure and food allergies run in my family too.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Strong family history of heart disease, carcinoma, hypertension, and food allergies.
Plan of Action: N/A
Doctor: What do you do for living?
Patient: I am an officer at United States Marine office, artillery repair specialist.
Doctor: Do you drink alcohol?
Patient: I use to drink socially but stopped two years back.
Doctor: How about smoking and drugs?
Patient: No not that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs.
Plan of Action: N/A
Doctor: How are you today?
Patient: I am good. 
Doctor: What is your past medical history? 
Patient: I don't have any health problems. Not yet at least. 
Doctor: Let's keep try to keep it that way. 
Patient: Yes please.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Essentially noncontributory.
Plan of Action: N/A
Doctor: Well, I am looking at your ultrasound report and honestly the only significant finding of this area is that it shows to be related to bone. 
Patient: Oh okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: The only significant finding in the ultrasound of the area is that it shows this to be related to bone.
Doctor: Tell me about your family. Did anyone have any medical issues? 
Patient: My father is alive. He is sixty nine right now. He did have some strokes in the past. My mom on the other hand died at the age of sixty two of many kinds of heart diseases.
Doctor: What about your grandparents?
Patient: My maternal grandfather he also had heart issues and he died of a heart attack. Both he and my maternal grandma had some heart diseases. Their heart use to beat pretty fast.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Father alive age 69 with h/o TIAs, Mother died age 62 and had CHF, A-Fib, CAD, Maternal Grandfather died of an MI and had h/o SVT, Maternal Grandmother had h/o SVT
Plan of Action: N/A
Doctor: Hi there! What brings you back to see me so soon? 
Patient: Hi! I have had these sores in my mouth. 
Doctor: How long have you had the sores?
Patient: They started about ten to twelve days ago. 
Doctor: We have been currently treating your rheumatoid arthritis with methotrexate. How much have you been taking? 
Patient: Yes, we have tried lots of different treatments and methotrexate has been working well.  I have been on it for ten years now. I have been taking about twenty or twenty five M G of per week. 
Doctor: Did we recently increase your dosage? I see in your chart that we have changed your dosage a few times. 
Patient: About a year ago we lowered the dosage for twenty five M G to twenty but my arthritis flared up so we went to twenty two point five. 
Doctor: Have you ever had any side effects from the methotrexate in the past? 
Patient: No. I don't think so. 
Doctor: Are you taking any other medications? 
Patient: I had a sinus infection and the doctor put me on an antibiotic. That was about two weeks ago. 
Doctor: Do you know what the antibiotic the doctor gave you? 
Patient: I don't remember the name of the antibiotic, but I know that I have taken antibiotics before and I didn't have a problem. 
Doctor: How long was your antibiotic course? 
Patient: It was three or four days long. I had to take it three times a day. 
Doctor: Have you ever had any allergic reactions to medications? 
Patient: No. 
Doctor: Any history of mouth sores? 
Patient: No. 
Doctor: Are you taking anything to help with the pain of the mouth sores? 
Patient: I took Aspirin a month ago. I started taking it again because my mouth was sore. 
Doctor: Have you had any other problems with your skin? Any new rashes? 
Patient: No.
Doctor: Sorry to side track, but where is your accent from? My family is Cuban and my mom and you speak the same. 
Patient: What a surprise! I am Cuban. A proud fifty seven year old Cuban.

Clinical note:
Symptoms: Sores in the mouth, discomfort.
Diagnosis: N/A
History of Patient: The patient, a 57-year-old Cuban female, presents with sores in her mouth that have been present for the last 10-12 days. She has a long history of severe and debilitating rheumatoid arthritis and has been successfully treated with methotrexate for the past ten years. Her dosage has varied between 20 and 25 mg per week. Recently, her dosage was decreased from 25 mg to 20 mg, but due to a flare of rheumatoid arthritis, it was increased to 22.5 mg per week. She has had no problems with methotrexate as far as she knows. She also took an NSAID about a month ago, which was recently continued because of the ulcerations in her mouth. About two weeks ago, she was placed on an antibiotic for a suspected upper respiratory infection, although she does not remember the name of the antibiotic. She has no other problems with her skin and no previous history of fever blisters.
Plan of Action: N/A
Doctor: Hello, miss. How are you feeling today? 
Patient: Terrible. My allergies are killing me right now. 
Doctor: Do you have a history of allergies? 
Patient: Yeah, I do. I had them all the time when I lived in Seattle, but they got a lot worse when I moved here. I am a strong German woman and I hate how something as little as allergies gets the best of me. 
Doctor: Why did you move here? 
Patient: I wanted to experience different cities since I'm only twenty three. 
Doctor: That sounds exciting. Back to your allergies now. Do you take any medication to relieve your symptoms? 
Patient: Here's a list of past and current medications I'm taking. 
Doctor: Thank you. Let me take a look. I see you took Claritin and Zyrtec in the past, correct? Did those help you? 
Patient: Yeah, that's correct. They were working for a bit, but then they stopped working after a while. 
Doctor: I see. Your notes say you took Allegra after, correct? 
Patient: Correct. I tried out Allegra last summer, but I don't know if it was doing its job. I tried it again two weeks ago because my allergies were getting bad, but it still didn't work. 
Doctor: I see. Your notes state you've tried some nasal sprays, correct? 
Patient: Yeah, I did. I wanted to see if they would work. 
Doctor: Were you prescribed these nasal sprays? 
Patient: Nope. I bought them at my local pharmacy. 
Doctor: Sounds good. I'm looking at your medical history, and it sates here you have asthma too, correct? 
Patient: Yeah, I've had it for a long time, but it hasn't gotten worse. 
Doctor: I see. Do you think you need any medication to help alleviated your asthma? 
Patient: No. It doesn't bother me as much as my allergies.

Clinical note:
Symptoms: Allergies causing discomfort.
Diagnosis: N/A
History of Patient: 23-year-old white female presents with a complaint of allergies. She used to have allergies when she lived in Seattle but thinks they are worse in her current location. In the past, she has tried Claritin and Zyrtec, both of which worked for a short time but then seemed to lose effectiveness. She has also used Allegra, which did not appear to work well. She has used over-the-counter nasal sprays but no prescription nasal sprays. She also has asthma but does not require daily medication for it and does not think it is flaring up.
Plan of Action: N/A
Doctor: How are you doing young man? 
Patient: I'm good. Thank you. 
Doctor: Let's see how your chest is doing. 
Patient: Okay. 
Doctor: Chest measurements look nice. No issue there. The outline also looks great. Also, there is no hunchback?

Clinical note:
Symptoms: N/A
Diagnosis: CHEST: Normal AP diameter and normal contour without any kyphoscoliosis.
History of Patient: N/A
Plan of Action: N/A
Doctor: I see here that Doctor- 
Patient: Yes, Doctor X referred me. My thyroid is an absolute mess. I have never been in so much pain in my seventy one years. 
Doctor: I'm so sorry to hear that. I hope we're able to get you the care that you need. 
Patient: I've been coughing up a storm. It's gotten to be way too enlarged. 
Doctor: It's good that you're here today to get the surgery rolling. 
Patient: I signed the paperwork and everything. 
Doctor: I'll go over the risk and benefits one more time. Any questions for me?
Patient: When is the earliest I can get this done again? 
Doctor: Given your symptoms, I'd like to get you in in the next few days.

Clinical note:
Symptoms: Increasingly symptomatic large nodular thyroid goiter, coughing.
Diagnosis: N/A
History of Patient: The patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter. She presented now after informed consent for the procedure, understanding the inherent risks and complications and risk-benefit ratio.
Plan of Action: N/A
Doctor: Are you allergic to any medications?
Patient: No, I am not allergic to any drugs.
Doctor: Okay. Are you sure?
Patient: Yes.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No drug allergies.
Plan of Action: N/A
Doctor: I see here that you're allergic to grapefruit and peanuts. Do you happen to be allergic to any medications you've taken in the past? 
Patient: Nah, just allergic to grapefruit and peanuts. 
Doctor: Gotcha. Do you carry an Epi pen around with you? 
Patient: I try to bring it with me everywhere I go.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: There are no known allergies.
Plan of Action: N/A
Doctor: So, tell me about your family, any illness or anything that runs in the family.
Patient: Um, not that I know of. 
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Unremarkable.
Plan of Action: N/A
Doctor: Any medical issues in the past? 
Patient: No, I have a very clean history. 
Doctor: That's good for you. Any kind of surgery or hospitalization? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Noncontributory.
Plan of Action: N/A
Doctor: Let's talk a little bit about your family, okay?
Doctor: Does anyone in your family had any medical issues? 
Patient: Yeah, my parents died of cancer.
Doctor: Which cancer? How old were they? 
Patient: I don't know which cancer they had, but my mother was forty two and dad was sixty two.
Doctor: Who else is there in the family? 
Patient: Oh, I have a big family. I have four sisters, one brother and two half brothers. One of my half brother's has asthma.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Mother died at age 42 of unknown type cancer. Father died at age 62 of unknown type cancer. Patient has 4 sisters, 1 brother, and 2 half-brothers. One of the half-brothers has asthma.
Plan of Action: N/A
Doctor: So, tell me something, does asthma run in your family? 
Patient: No, I think I am the only one who has it. Even my parents were surprised when I developed it, as no one else has it. 
Doctor: Yeah, it happens.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: No significant family history.
Doctor: Welcome in, sir. I am Doctor Gray. 
Patient: Thank you. It's nice to meet you. 
Doctor: What is your past medical history? 
Patient: I had surgery on my shoulder thirteen years ago and after the surgery I lost my sense of smell. I still can't smell. I also can't see very well in my right eye. 
Doctor: How old are you? 
Patient: I am seventy six. 
Doctor: Do you get headaches? 
Patient: No. 
Doctor: Do you have any nasal drainage? 
Patient: No.
Doctor: Do you ever experience any weakness or numbness throughout or localized to an area of the body. 
Patient: No. 
Doctor: Have you had any resent weight loss?
Patient: No.

Clinical note:
Symptoms: Decreased vision in the right eye, anosmia (loss of sense of smell).
Diagnosis: N/A
History of Patient: 76-year-old male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.
Plan of Action: N/A
Doctor: Do thyroid problems run in your family?
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Noncontributory.
Doctor: Are you taking any medicines?
Patient: Just Tylenol for my pain.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Tylenol for pain.
Doctor: Good afternoon, sir. Did you see the nurse already? 
Patient: Yes, I just saw her. 
Doctor: Great, you're seventy eight years old, correct?  
Patient: Yes, I'm not as young as I used to be.
Doctor: Who is? What seems to be the problem today, sir? 
Patient: I have right hand pain, and it's been there for a while now. 
Doctor: Are you having numbness sir? 
Patient: Yes, and I can't move it very well, either. 
Doctor: Which fingers are you having these symptoms in? 
Patient: Well, I told you it's all in the right hand, but it's in the index and middle fingers. 
Doctor: Are your fingers catching? 
Patient: What does that mean, doctor?
Doctor: Are you having any problems extending your fingers?
Patient: Yes, they seem to lock up when I try to extend my fingers. 
Doctor: Have you seen another doctor for this? 
Patient: Yes, I had an E M G and it showed, um, carpal tunnel on both hands. 
Doctor: It's in both hands, but the right is worse than the left, correct? 
Patient: Yes, that's correct. 
Doctor: What treatments have you had for this? 
Patient: I only had an injection so far. 
Doctor: Did this help at all?
Patient: Well, some, but it was really only temporary relief. Is there surgery for this? 
Doctor: Yes, I think you'd be a good candidate for surgery. 
Patient: What are the risks of infection from the surgery?
Doctor: It's less than one percent. We use prophylactic antibiotics to control for infection the entire time. 
Patient: Even though it's on my hand, will I be asleep for this procedure? 
Doctor: Yes, you won't feel a thing. 
Patient: Okay, yes. I'd like to do the surgery.

Clinical note:
Symptoms: Right hand pain, numbness, decreased range of motion in the middle and index fingers, catching and locking of the right middle finger.
Diagnosis: Carpal tunnel syndrome diagnosed on bilateral hands, with the right hand being worse than the left. Positive EMG findings as well as clinical findings.
History of Patient: N/A
Plan of Action: The patient underwent an injection which provided temporary relief. Due to the temporary relief from the injection, the patient has consented to undergo surgery for the above-named procedure. All risks and complications were discussed with the patient, and consent was obtained.
Doctor: Hi are you married? 
Patient: Yes, I am. 
Doctor: Do you have kids? 
Patient: Yes, I had a son, but unfortunately, he died in a car accident. It was five years ago. 
Doctor: Where do you work? 
Patient: I work in a pharmaceutical company as a salesperson. 
Doctor: Do you smoke or drink or at any time tried any illicit drug? 
Patient: No, I've never smoked. I have tried a beer once, but I never liked it. 
Doctor: What about drugs? 
Patient: No, never did that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Married with one son who passed away in a car accident five years ago. Works as a salesperson in a pharmaceutical company. Denied tobacco, alcohol, or illicit drug use.
Plan of Action: N/A
Doctor: Are you going to visit rehab?
Patient: Yes, what choice do I have?
Doctor: Yes, please do visit Mercy Manor for P T and Rehab.
Patient: Yes, I will.
Doctor: That will help your right side hip pain.
Patient: I think so too.

Clinical note:
Symptoms: Right hip pain.
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Patient to undergo physical therapy and rehabilitation at Mercy Manor to address right side hip pain.
Doctor: Can you tell me about your Immunizations?
Patient: Yeah, I had them all. 
Doctor: Good, looks like you are up to date.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Up-to-date with immunizations.
Doctor: Welcome back to the clinic. How are you feeling today? 
Patient: Thank you. I am doing better. 
Doctor: It looks like we are following up on your severe osteoarthritis in both knees. And you also have been experiencing some flexion contracture limitations. 
Patient: Um hum.
Doctor: How is your physical therapy going? 
Patient: It is going really well. She kicks my butt but it seems to be helping. Doing my exercises at home is really helping. 
Doctor: Were you not doing them in the beginning? 
Patient: No, I wasn't. She got on me to start doing them and I have definitely seen the difference. 
Doctor: Have you experienced any worsening of pain since you were last seen? 
Patient: Well, the right knee is worse than the left? It mostly hurts after physical therapy. 
Doctor: Can you describe what the pain feels like? 
Patient: It feels achy. 
Doctor: Is it a continuous pain, or? 
Patient: No. It is not all the time. Every once and a while. It feels stiff all the time. 
Doctor: Any weakness or instability? 
Patient: No. 
Doctor: Any burning sensations associated with the pain? 
Patient: No. 
Doctor: How long have you been dealing with this? 
Patient: Several months. 
Doctor: Have you had any trouble sleeping?  
Patient: No. When I sit down or lie down at night there's no pain.
Doctor: So, the pain is when you are weight bearing, right? 
Patient: Yeah. And it hurts when I move around. It makes it difficult to do things. 
Doctor: Have you noticed any pain with the cold weather change? 
Patient: No, I have not noticed anything. 
Doctor: I am just going to take a look here. 
Patient: Okay. 
Doctor: I don't see any swelling or redness. And I don't feel any warmth coming from the area. Have you noticed any of these symptoms? 
Patient: Nope. 
Doctor: Any radiating pain through the knees here? 
Patient: No. 
Doctor: Any pain any where else in the body? 
Patient: No, just the knees. 
Doctor: So, no pain in the hips or back? 
Patient: Nope.

Clinical note:
Symptoms: Localized pain to the bilateral knees, right worse than left, described as occasional aching, associated with stiffness and weakness. Pain worsens after physical therapy, mainly when weight-bearing and with ambulation. No swelling, redness, or warmth observed. No burning sensations. Duration of Symptoms is several months. No sleep loss or instability reported. No hip or back pain. No radiating pain. No pain with weather changes.
Diagnosis: Grade IV osteoarthritis of bilateral knees with flexion contracture.
History of Patient: Patient reports improvement with physical therapy exercises, especially after being encouraged to perform them regularly. Pain is primarily felt in the right knee, occasionally aching and causing stiffness. Symptoms have persisted for several months, mainly aggravated by weight-bearing and movement. No associated Symptoms such as swelling, redness, or warmth. No sleep disturbances or instability noted. No pain reported in the hips or back. No radiating pain or pain with weather changes.
Plan of Action: Continue with physical therapy exercises. Monitor pain and assess response to treatment. Consider additional interventions if necessary.
Doctor: Hi, what is going on?
Guest_family: She was doing well until this morning, but now she can barely move her right arm and is having speech issues. She can't seem to comprehend words. I think it is a stroke. 
Doctor: We see this a lot at A B C Medical Center. I am glad you came. You just saw Doctor H, right?
Guest_family: Yes. We did a C T head scan and labs. 
Doctor: Okay. Where is she living? With you?
Guest_family: No. She is at the Life Care Center. 
Doctor: Ma'am, do you have headache or chest pain?
Patient: What? What? Huh?
Guest_family: She has not complained of anything like that. 
Doctor: Ma'am. Do you have vision issues?
Patient: What? I can see. Of course I can see. 
Doctor:  Any shortness of breath?
Guest_family: She is breathing fine. 
Doctor: Have your symptoms improved at all? Or have they worsened since this morning?
Guest_family: No. They have stayed constant.

Clinical note:
Symptoms: Right-sided arm weakness with speech difficulties. Difficulty expressing herself. Difficulty comprehending words.
Diagnosis: N/A
History of Patient: The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain, and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors.
Plan of Action: N/A
Doctor: I think you have a muscular strain. 
Patient: Yeah.
Doctor: So right side shoulder strain and maybe a little bit of nerve compression.
Patient: Oh really!
Doctor: Maybe. I will do further evaluation and treatment.
Patient: Okay.

Clinical note:
Symptoms: Right shoulder pain, most likely secondary to muscular strain
Diagnosis: very mild evidence of impingement
History of Patient: N/A
Plan of Action: Further evaluation and treatment will be done.
Doctor: Can you tell me more about your daughter, ma'am?
Guest_family: Sure, well she's fourteen now, um, she's right handed, and she just started high school. 
Doctor: Has she ever had surgery?  
Guest_family: Yeah, she had an, um, lipomyomeningocele repair when she was about three days old, and then again when she was three and a half years old. 
Doctor: When was her last surgery? 
Guest_family: Um, it was in March of nineteen ninety five. 
Doctor: How did she do following the second surgery? 
Guest_family: She did well, honestly. 
Doctor: So, what brings you in for a visit today? 
Patient: Well, I've been having some leg pain on the side of my legs. 
Doctor: How long have you had this pain? 
Patient: It's been several months at this point. 
Doctor: When is your pain the worst? 
Patient: Um, it's the worst at night, I have to take medicine for the pain. 
Doctor: What do you take? 
Guest_family: She takes Advil, Motrin, and Tylenol P M. 
Doctor: Wow, that's a lot. Looks like you have some patch sensory loss in the L four to S one region. Are you going to the bathroom regularly? 
Patient: Yeah, there's no problems there. I do have some loss of feeling in my big toe and calf though.

Clinical note:
Symptoms: She has been having some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM. She has some loss of feeling in her big toe and calf.
Diagnosis: Denies any new bowel or bladder dysfunction or increased sensory loss. She had some patchy sensory loss from L4 to S1.

History of Patient: She is a 14-year-old right-handed female who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 03/95. She did well.
Plan of Action: N/A
Guest_clinician: How is the patient's condition now? 
Doctor: Well, he has improved clinically but would require acute care.
Guest_clinician: Oh, I see.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Clinically improved, however, requiring acute care.
Doctor: Good morning, ma'am. Can you confirm your age for me, please? 
Patient: Good morning, I'm sixty five years old, doctor. 
Doctor: How are you recovering from your operation? 
Patient: I'm doing okay. Can you remind me what operation I had? 
Doctor: Um, we did a left upper lobectomy for your stage I A non small cell lung cancer. 
Patient: Thank you, doctor. 
Doctor: Absolutely, do you have the results of your pelvic C T? 
Patient: Yes, I have the report right here. 
Doctor: Thank you, so this shows an enlarging simple cyst of the left kidney. 
Patient: What can we do about this? 
Doctor: Well, that's why we did the barium swallow, which showed a small hiatal hernia with minimal reflux. 
Patient: Oh, yeah, I remember that. 
Doctor: So, I have your x rays from November twenty third two thousand nine here, we did an A P and lateral view, and they're normal. 
Patient: Oh, well that's good too.  
Doctor: Are you having any pain with swallowing food? 
Patient: Yes, I get some chest pain, but I'd say it's pretty mild. Look at my calf, doctor, it's much bigger than the right one. 
Doctor: Chest pain is probably due to tertiary contractions with some delayed emptying. Is it tender? 
Patient: No, there's no real tenderness. 
Doctor: How long has this calf been enlarged? 
Patient: Um, it's been several months at this point. 
Doctor: Have you ever had D V T? 
Patient: Yes, um, in nineteen seventy five, and in nineteen eighty five. 
Doctor: Are you having any abnormal weight loss? 
Patient: No, everything is normal there, and I'm eating normally. 
Doctor: What about any cold or flu symptoms? Any fever or chills?  
Patient: No, that's all fine too. 
Doctor: Any new aches or pains? 
Patient: No, all my muscles feel pretty good. 
Doctor: Have you had a cough, or coughed up any blood. 
Patient: That's a negative, doctor. 
Doctor: What about shortness of breath while at rest or difficulty breathing with exercise? 
Patient: No, that's normal too. I'm breathing just fine.

Clinical note:
Symptoms: She continues to have periodic odynophagia and mid thoracic dysphagia. She has also had increased size of the left calf without tenderness, which has not resolved over the past several months.
Diagnosis: She underwent left upper lobectomy for stage IA non-small cell lung cancer. She has an enlarging simple cyst of the left kidney and a small sliding hiatal hernia with minimal reflux. PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates.
History of Patient: She has had a previous DVT in 1975 and 1985.
Plan of Action: N/A
Doctor: Let's talk about your family's medical history.
Patient: Hm, well both my father and my brother had colon cancer. My daughter was detected with breast cancer.
Doctor: Do you remember what her age was?
Patient: Yeah, she was forty.
Doctor: I see. Anything else?
Patient: Well, I have a heart condition and high blood pressure. I also had a stroke.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Positive for heart disease, hypertension, and cerebrovascular accidents. Family history is positive for colon cancer affecting her father and a brother. The patient has a daughter who was diagnosed with breast cancer at age 40.
Plan of Action: N/A
Doctor: Any fever?
Patient: No.
Doctor: No nausea and vomiting or black stool? Did you notice any blood in your stools? 
Patient: Nope, nothing like that.
Doctor: Did you notice any blood in urine or painful urination?
Patient: No.
Doctor: Okay, any chest pain?
Patient: Um, no.
Doctor: Any shortness of breath, cough or cold like symptoms?
Patient: Nope.
Doctor: No diabetes or thyroid problem, right?
Patient: Absolutely not!
Doctor: Looks like you have no history of C V A or stroke.
Patient: Correct.
Doctor: Everything else looks fine.
Patient: Cool. 
Doctor: Your eyes, nose, and throat look good.

Clinical note:
Symptoms: N/A
Diagnosis: CONSTITUTIONAL: No fever. ENT: Not remarkable. RESPIRATORY: No cough or shortness of breath. CARDIOVASCULAR: The patient denies chest pain. GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed. GENITOURINARY: No dysuria. No hematuria. ENDOCRINE: Negative for diabetes or thyroid problems. 
History of Patient: NEUROLOGIC: No history of CVA or TIA. Rest of review of systems is not remarkable.
Plan of Action: N/A
Doctor: How are you doing miss? How are your sugar numbers coming along? 
Patient: I'm doing good. Thank you. Sugar has consistently been one hundred and thirty five or under it. 
Doctor: How are you checking it? 
Patient: I have a glucose monitor at home I'm using that only. 
Doctor: Nice. Did you eat anything in the morning today? 
Patient: No, I'm fasting for my test. 
Doctor: Okay, let's see. We have an Accu Chek here in our office. I will do a quick sugar test for you, and this will be a fasting sugar test. It will be just a quick prick on your finger. 
Patient: Don't worry doctor. I'm used to poking my finger all the time. 
Doctor: Let's see what we got here. Your reading says one hundred and twenty. I will write it down for my record. Are you being active? 
Patient: Yes, I'm exercising as a rule three times every week. I don't miss it. 
Doctor: Do you feel any tingling or numbness or any kind of cramps? 
Patient: Nope. 
Doctor: Any kind of blurry vision? 
Patient: Nope. 
Doctor: Any weight loss? 
Patient: Not that I notice.

Clinical note:
Symptoms: N/A
Diagnosis: Her blood sugars have usually been less than or equal to 135 by home glucose monitoring. Her fasting blood sugar today is 120 by our Accu-Chek.
History of Patient: Overall, she has been doing well. She is exercising three times per week. Review of systems is otherwise unremarkable.
Plan of Action: N/A
Doctor: How did your last visit go with the cardiologist? 
Patient: Good.  
Doctor: It looks like they diagnosed you with sick sinus syndrome. Do you have any questions about this new diagnosis? 
Patient: No, she explained everything to me. I'm planning to follow-up with her in the next two weeks. 
Doctor: Great. So it looks like your past medical history is the same? Nothing new other than the sick sinus syndrome.

Clinical note:
Symptoms: N/A
Diagnosis: Sick sinus syndrome
History of Patient: The rest of her past medical history remained the same.
Plan of Action: N/A
Doctor: So Mister J, where do you stay?
Patient: Oh, I stay at a care facilit. It's very near to your clinic. Have you heard about this place called South Valley Care Center?
Doctor: Oh yes, I have heard of it.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: The patient has been residing at South Valley Care Center.
Plan of Action: N/A
Doctor: How are you Mister James?
Patient: I have been better!
Doctor: Oh, tell me what's going on with you?
Patient: I have this leg pain on my left side. 
Doctor: Hm, left leg pain?
Patient: Yeah.

Clinical note:
Symptoms: Left leg pain.
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Have you ever had an allergic reaction to drugs you've taken in the past? 
Patient: More than once. I've reacted poorly to sulfa drugs, penicillin, and some mycins. I also think I'm allergic to contrast medium.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins.
Plan of Action: N/A
Doctor: Hey, do you smoke cigarettes?
Patient: Yes I do smoke. Do you?
Doctor: Nope. Are you planning on quitting?
Patient: No, I just smoke one pack per day, it's not bad.
Doctor: Oh my God. No. It is bad. You should think about quitting.
Patient: Okay I will think about it.
Doctor: Where do you work?
Patient: I work at local christmas tree farm.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: The patient works at a local Christmas tree farm. He smokes cigarettes approximately one pack per day.
Plan of Action: N/A
Doctor: Are you still working?
Patient: Retired some time ago.
Doctor: What was your profession?
Patient: I used to work at a car repair shop called Champion Automotive Company.
Doctor: Nice. How did you enjoy the work?
Patient: I liked it a lot, but there came a time where I knew it was the end of the road for me. I'm really enjoying retirement. 
Doctor: I bet. I have cousin who owns a car repair shop. He's almost always busy. 
Patient: Yeah, it can be a lot sometimes.
Doctor: Any smoking, drinking, or hard drugs?
Patient: I can confidently say no to each one. 
Doctor: Great to hear.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Retired employee of Champion Automotive Co. Denies use of TOB/ETOH/Illicit drugs
Plan of Action: N/A
Guest_clinician: Do you have his full medical history? 
Doctor: Yes, I confirmed with his wife. He had a CABG done in ninety one. He has a history of radical prostate cancer for which he underwent a radical prostatectomy and nephrectomy.  
Guest_clinician: Any additional surgeries? 
Doctor: Yes. He had lumbar surgery twice before. He suffered from lumbar stenosis many years ago in the sixties and seventies. He's actually due for another lumbar surgery with Doctor Y. He takes Percocet daily for his back pain.  He also has a history of hypertension and hyperlipidemia.  
Guest_clinician: I think I got it all down.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia. Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.
Plan of Action: N/A
Doctor: Do you have any history of major surgeries? 
Patient: No. Nothing major.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Nothing significant.
Plan of Action: N/A
Doctor: Good morning, sir. 
Patient: Good morning, doctor. 
Doctor: Before we begin, have you ever had surgery?
Patient: Yes, I had a vasectomy some time ago.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Vasectomy.
Plan of Action: N/A
Doctor: Okay, so let's go over your medications. I'd like you to take these to help your muscle spasms. 
Patient: Sounds good. 
Doctor: I've prescribed eight hundred milligrams of Ibuprofen to be taken every eight hours as needed along with Tylenol number three every six hours as needed. 
Patient: What does the number three stand for? 
Doctor: Tylenol number three is combined with Codeine. 
Patient: Okay, I see. 
Doctor: And finally, I'm prescribing Methocarbamol seven fifty milligrams which needs to be taken four times a day for maximum relief. Do you have any questions for me? 
Patient: No, I think you answered them all.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Medications includes Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.
Doctor: How are you doing today, sir? 
Patient: Honestly, I'm pretty sick today. I've got a lot going on. 
Doctor: How long have you been feeling this way?
Patient: Well, it's been off and on for about a month now. 
Doctor: Has it been getting worse recently? 
Patient: Yeah, it has over the last couple weeks. 
Doctor: What are your symptoms? 
Patient: Well, I'm coughing up this yellow phlegm. It feels like everything is in my chest. 
Doctor: What medications have you been taking for this?
Patient: I've been taking Allegra D sometimes, but I'm almost out. I need a refill. 
Doctor: What other problems are you having? 
Patient: My foot keeps breaking out. 
Doctor: Has this improved at all? 
Patient: Well, it was for a while, but now it's really bad again. 
Doctor: Have you been diagnosed with any conditions before? 
Patient: I had, um, tinea pedis before. 
Doctor: How was this treated?
Patient: They gave me Nizoral cream.
Doctor: It has been getting warmer recently, I don't think that this isn't necessarily a coincidence that you're having these symptoms now.
Patient: Yeah, I work in the flint and it's really hot and humid down there.  
Doctor: What else are you dealing with, sir? 
Patient: I have this wart on my right middle finger, are you able to freeze it off? 
Doctor: Have you ever done that before? 
Patient: Yeah, you have done it before, and it went away. 
Doctor: If we've done it before, we can do it again. 
Patient: Cool, can we do blood work, too? I want to check on my prostate. 
Doctor: Well, that's called P S A. 
Patient: Can I have that done? I'm concerned. I am fifty after all. 
Doctor: Sure, we can check your cholesterol too. I know you have history of it being high. 
Patient: You know, I've been working on that. I quit smoking for a while, but I got back into it. 
Doctor: That's good, it's really hard to quit. 
Patient: Yeah, I tried chewing tobacco, but it's not the same. 
Doctor: Be sure to keep trying to quit smoking.

Clinical note:
Symptoms: He has been sick for a month intermittently, but over the last couple of weeks, it is worse. He is having a lot of yellow phlegm when he coughs. It feels like it is in his chest. His foot continues to break out, which was getting better for a while but is now bad again.
Diagnosis: N/A
History of Patient: He was diagnosed with tinea pedis previously and has been using Nizoral cream for it. He works in a hot and humid environment, which may be exacerbating his Symptoms. He has a wart on his right middle finger, which he wants to be frozen off. He is interested in getting blood tests done, specifically for his prostate (PSA) and cholesterol, as he has a history of high cholesterol. He mentions quitting smoking previously but has since relapsed and finds it difficult to quit.
Plan of Action: Refill prescription for Allegra-D, freeze wart on right middle finger, order blood tests for PSA and cholesterol, encourage patient to quit smoking.
Doctor: Hi, how's it going? 
Patient: Not too bad, can't complain.  
Doctor: It looks like the weather's been warming up, which is nice. 
Patient: Yeah, I can't wait to spend some time with my kids this afternoon. 
Doctor: Aw, how many kids do you have? 
Patient: Two. 
Doctor: And are you single, dating, married? 
Patient: I've been married to my wife for about ten years now. 
Doctor: Congratulations! That's a decade, my friend. 
Patient: Hah, it sure is. 
Doctor: Are you from the area? 
Patient: I was actually born in Oklahoma.  
Doctor: How long- 
Patient: Moved up here in O seven. 
Doctor: Awesome. I moved here in O nine, so two years after you.  
Patient: No way! How funny. Where from?
Doctor: I'm originally from Kentucky. And I have to do the routine ask, but any drinking, smoking, or illicit drug use? 
Patient: No to all of the above. 
Doctor: Got it.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No known exposures. Married with 2 children. Patient is born and raised in Oklahoma.
Plan of Action: N/A
Doctor: Looks like the nurse came in and asked you everything. Ah, she has everything documented here, but I will ask one more time. So, tell me, where do you live? 
Patient: Oh, it's a senior citizen house. They have many nursing aids there. 
Doctor: Do you smoke? 
Patient: No. 
Doctor: Do you work? 
Patient: Ah, right now I can't because of this disability, but I used to work as the security guard.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: He lives in a senior citizens building with daily nursing aids. He previously was a security guard, but is currently on disability.
Plan of Action: N/A