X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: Hi there! I am Doctor Smith. 
Patient: Hello! It is nice to meet you. 
Doctor: Let's start with your family medical history. 
Patient: My mother had breast cancer. My father had lung cancer that ended up taking his life. He was seventy nine when he passed. My mother also passed but not from an illness but from an infection she got after having an elective surgery.  
Doctor: I am so sorry for your loss. How old was your mother when she passed? 
Patient: Thank you. She was eighty one when she passed. I am an orphan now. My only living sibling died at forty. He had a hard life. He struggled with mental illness. 
Doctor: How did your brother pass away? 
Patient: He had pancreatitis. Oh, my dad had glaucoma. 
Doctor: You have had a lot of loss.
Patient: Yes, I have. My good friend passed away a year and a half ago. It has been a lot.  
Doctor: I have a support group I can refer you to for people to have been through loss. Would you be interested a referral, sir? 
Patient: Yes. I would like that. Thank you.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Family history includes mother's breast cancer, father's lung cancer and glaucoma, brother's pancreatitis and mental illness. Both parents deceased, sibling deceased at age 40. Patient has also experienced loss of a friend.
Plan of Action: Referral to a support group for coping with loss.
Doctor: I will ask some simple questions, okay?
Patient: Hm
Doctor: How old are you and how would you define yourself in terms of ethnicity?
Patient: Well, I am forty seven and would proudly call myself as Latin American. 
Doctor: Great. What brings you to the emergency room? 
Patient: I had a blood test before and then it came out to be high potassium. I also went to a regular clinic the other day as I was feeling very weak and extremely tired.
Doctor: Okay.
Patient: My potassium came out to be seven and it was highlighted in red. That really scared me, so I wanted to know everything what's going on inside me. I told the emergency doctors too that all these weakness and tiredness is going on for more than half a year. 
Doctor: Did you noticed any other symptoms other than weakness? 
Patient: Yes, there was the fever and chills. I was sweating a lot in the nights, and I also had weight loss of around twenty pounds. During that time, I sometimes have nausea and was throwing up a lot. I was not eating. I always felt dizzy every time I tried to stand. 
Doctor: Did you have wet cough?
Patient: No, not wet cough but I did notice back pain gets intense on the upper side whenever I coughed, like in my ribs. I normally massage that area and it gets better. 
Doctor: Any shortness of breath? 
Patient: Nope. 
Doctor: How about while sleeping or doing something else?
Patient: Not while sleeping, but I did notice that if I'm walking for two to three blocks then I get out of breath easily. Previously it was not like this. I used to jog for two to three miles without even a single breath loss.
Patient: I noticed one more thing. I feel like my balls on one side are getting big. 
Doctor: Which side left or right?
Patient: I think its left. 
Doctor: For how long?
Patient: I guess over the past year. I did see someone when all of this started, and he put me on some antibiotics, but nothing changed. For last few months there is yellow fluid coming out of it too. 
Doctor: Did you ever get any type of injury in the area?
Patient: No. 
Doctor: What about your bowel movements?
Patient: Nope everything is as usual. 
Doctor: Any change in urinary habits?
Patient: Nope.
Doctor: Any changes in your skin? Any rash? Any kind of eyesight issue?
Patient: Nope, no changes.
Doctor: What about pain? Like headache or any joint pain? 
Patient: Nope, no pain anywhere.

Clinical note:
Symptoms: High potassium, weakness, extreme tiredness, fever, chills, night sweats, weight loss (20 pounds), nausea, vomiting, dizziness upon standing, intense upper back pain during coughing, shortness of breath with exertion, enlargement of testicle (left side), yellow fluid discharge from testicle.
Diagnosis: N/A.
History of Patient: Symptoms include high potassium, weakness, extreme tiredness persisting for more than six months, fever, chills, night sweats, weight loss, nausea, vomiting, dizziness upon standing, intense upper back pain during coughing, shortness of breath with exertion, enlargement of left testicle with yellow fluid discharge for the past year. Previous treatment with antibiotics did not alleviate Symptoms.
Plan of Action: Further evaluation and investigation of Symptoms.
Doctor: Have you ever had surgery, ma'am?
Patient: Yeah, I've had a few. First, I had, um, tubal ligation, and three milk ducts removed.
Doctor: What year was that in?
Patient: That was in, um, nineteen seventy nine. 
Doctor: Great, thank you. What else have you had done? 
Patient: I had a breast biopsy in nineteen eighty nine, and a colonoscopy in two thousand seven. 
Doctor: Thank you, do you have any children? 
Patient: Well, doctor, I've been pregnant four times, but I've had three children. 
Doctor: I'm so sorry to hear that. Did you have a C section with any of them? 
Patient: No, doctor. I had a natural birth for all of them.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Underwent tubal ligation and removal of three milk ducts in 1979, breast biopsy in 1989, and colonoscopy in 2007. Gave birth to three children without cesarean section.
Plan of Action: N/A.
Doctor: Did you had any surgery in the past? 
Patient: No.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Denies any past surgeries.
Plan of Action: N/A.
Doctor: Any allergies?
Patient: Yes just molds.
Doctor: Okay so molds reaction.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Allergic reaction to molds.
Plan of Action: N/A.
Doctor: Hi there, how are you dear?
Patient: I am fine, thank you.
Guest_family: Hi Doctor, I am her mother.
Doctor: Nice to meet you. So I see you have been referred by Doctor X.
Guest_family: Yes, she is our family doctor.
Doctor: Okay, so you noticed some behavioral problems with your daughter and reported to her, is that right?
Guest_family: Yes, I have been noticing them for a while. She loses her focus quickly. We also got a few complaints from school regarding her behavior. We also met a couple of other doctors but they diagnosed her with Attention Deficit Hyperactivity Disorder.
Doctor: Well, looking at her reports I am afraid it looks like she does have A D H D, but the good news is we can treat her, so don't worry.
Guest_family: Okay. 
Doctor: I am going to prescribe her some medicines which will help her deal with this.
Guest_family: Thank you. 
Doctor: So, I will write her a prescription for Adderall and Clonidine. They have some really good results in treating A D H D. Which pharmacy do you go to?
Guest_family: We go to Costco pharmacy by the X Y Z corner.
Doctor: Okay, I will send it there.
Patient: Thank you doctor, it was nice meeting you.
Doctor: Nice meeting you too, take care.

Clinical note:
Symptoms: N/A.
Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD).
History of Patient: Patient experiencing behavioral problems, difficulty focusing, and complaints from school. Previously diagnosed with ADHD by other doctors.
Plan of Action: Prescription of Adderall and Clonidine for treatment of ADHD.
Doctor: He had circumcision?
Patient: Yes.
Doctor: Do you remember the date?
Patient: No I do not. But it should be in the chart.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Underwent circumcision; date not remembered, to be found in medical chart.
Plan of Action: N/A.
Doctor: Good morning, sir. You're sixty one years old, correct? 
Patient: Good morning, doctor. Yes, that's correct. 
Doctor: Great, and you identify as Caucasian, right? 
Patient: Yes, that's correct as well. 
Doctor: Thank you, do you have any medical conditions that I should know about? 
Patient: Yes, I have diabetes. 
Doctor: How are you handling your diabetes?
Patient: Well, I've had diabetes for a long time but had never been treated for it.
Doctor: Okay, thank you for telling me. What seems to be the problem today? 
Patient: I've been working in my garage over the past few days, and I have this redness and swelling in my right foot. 
Doctor: Do you have any itchiness or pain?
Patient: Yes, and it's getting worse. 
Doctor: Have you seen any other doctors about this? 
Patient: Um, yes. I went to the A B C D General Hospital E R and they gave me an evaluation there. 
Doctor: Do you have any images from this visit? 
Patient: Um, yes. I have them right here. 
Doctor: Okay, these show a foreign body in the foot. 
Patient: But what about all the stuff on the outside of my foot?
Doctor: Well, that's consistent with cellulitis. 
Patient: What's that?
Doctor: It's a skin infection we clean it up in surgery.
Patient: What kind of procedure can we do? 
Doctor: We should do an irrigation debridement for the cellulitis, and remove the foreign body. I think that will really help. 
Patient: Yes, I agree, doctor.

Clinical note:
Symptoms: Redness, swelling, itching, pain in right foot.
Diagnosis: Cellulitis, foreign body in foot.
History of Patient: Patient, a 61-year-old Caucasian male with uncontrolled diabetes mellitus, noticed redness and swelling in right foot after working in garage. Presented to ABCD General Hospital ER where evaluation revealed cellulitis and a foreign body in foot. Recommended irrigation debridement and removal of foreign body.
Plan of Action: Irrigation debridement and removal of foreign body from right foot to address cellulitis.
Doctor: Hello, sir. How are you doing today? 
Patient: I'm flustered. I brought my wife so she can speak for me. 
Doctor: Hello, ma'am. What seems to be the problem with your husband? 
Guest_family: He's been having some problems with his skin in his private region. He's too shy to talk about it himself.

Clinical note:
Symptoms: Skin problems in private region.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Are you married, ma'am?
Patient: Yes, to my wonderful husband. 
Doctor: Does he help you out around the house? 
Patient: Yes, he is just wonderful. 
Doctor: So, do you drink or smoke? 
Patient: No, I don't do any of that. 
Doctor: How about more illicit substances, do you use any of that?
Patient: No, absolutely not.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient:  Denies tobacco, alcohol, and illicit drug use.
Plan of Action: N/A.
Doctor: Anything else going on from head to toe?
Patient: No doctor, everything else is fine.
Doctor: Are you sure?
Patient: Yes I am sure.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Denies any issues from head to toe.
Plan of Action: N/A.
Guest_family: How's my husband doing? Sorry, I had to take a call outside. 
Doctor: He's doing much better. He'll be going home today with a prescription for Zithromax. 
Guest_family: I'm glad he's able go home and get some rest. 
Doctor: However, I'd like to still see him in the office next week for a reevaluation.
Guest_family: Great. Can we make the appointment right now? 
Doctor: Yes, the front desk will be able to help you with that.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: Patient discharged home with a prescription for Zithromax. Scheduled for reevaluation in the office within a week.
Doctor: How long have you been running a fever? 
Patient: It's been on and off for a few days now. I'm also having chills. 
Doctor: Have you taken anything for the fever? 
Patient: Tylenol and Advil. I've been taking them interchangeably. 
Doctor: When was the last time you took your temperature? 
Patient: An hour ago. The thermometer read one O one point four. 
Doctor: Are you experiencing any other symptoms, such as shortness of breath, nausea, vomiting, diarrhea, or others? 
Patient: I've been having a stronger urge to pee a lot more than usual. Not sure if that's related. 
Doctor: It could be. We're still waiting on your urine results. Do you have a history of cataracts or glaucoma?
Patient: No. 
Doctor: Okay, great. Any signs of pneumonia or valley fever?
Patient: Nothing of the sort. 
Doctor: What about blood in your vomit or feces?
Patient: Nope. 
Doctor: Any neurological symptoms like T I A or C V A? That is slurred speech or stroke symptoms.
Patient: Luckily, no. I don't have seizures or anything like that. 
Doctor: Great to here. With the pandemic I wanted to check on your mental health too. Any depression or anxiety?
Patient: I have always been a homebody. This is normal for me. Nothing like that in my head. 
Doctor: Cool. Do you have any issues with blood disorders?
Patient: Nothing like that.

Clinical note:
Symptoms: Fever on and off for a few days, chills, stronger urge to urinate.
Diagnosis: N/A.
History of Patient: No history of cataracts, glaucoma, pneumonia, valley fever, blood in vomit or feces, neurological Symptoms (TIA or CVA), seizures, depression, anxiety, or blood disorders.
Plan of Action: Patient has been taking Tylenol and Advil interchangeably for fever. Waiting for urine results. Mental health check performed; patient denies depression or anxiety.
Doctor: Hello, miss. It looks like some information is missing for your profile. Is it fine if I ask you a few questions? 
Patient: Of course. Go ahead. 
Doctor: Do you currently smoke? 
Patient: No, I finally stopped smoking cigarettes. 
Doctor: Did you smoke before? 
Patient: I did. I smoked a half a pack for about twenty years. 
Doctor: Well, it's good to hear that you've stopped. I encourage you to continue to not smoke. 
Patient: I agree. I need to change up my lifestyle. 
Doctor: Last question. Do you drink alcohol? 
Patient: No, I don't. I don't like anything that has alcohol. I can't stand the taste of it. If I do it is rare.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Former smoker (half a pack/day for 20 years), currently abstinent. Rarely consumes alcohol due to dislike of taste.
Plan of Action: N/A.
Doctor: Hello, sir. So, remind me, how long ago was your procedure? 
Patient: Let me think. Now, it's been about four months. I just turned fifty nine.
Doctor: Okay, and just to refresh your memory, we did a percutaneous screw fixation of a Schatzker I V tibial plateau fracture, and we've managed those toe fractures nonoperatively. 
Patient: Which toes did I break? 
Doctor: You broke your second and fifth toes.
Patient: Do you have the x rays? Can I see where the breaks are? 
Doctor: Absolutely, if you look here, right here is where the breaks are. These are called the metatarsal heads. 
Patient: Wow, that's right where it hurts. 
Doctor: Yep, and where are you living now? 
Patient: Thankfully, I left the nursing home, and I'm back in my own house now. 
Doctor: That's really good. Are you in any pain today?
Patient: No, not today. 
Doctor:  Great, have you been going to P T? 
Patient: Yeah, I've been going about two or three times a week. 
Doctor: Are there any signs of infection, like drainage from the incision?
Patient: Nope, the wound healed up nicely. I'll be able to wear shorts again. 
Doctor: Great, are you having any fever symptoms, like cough, runny nose, sore throat, fatigue, anything like that? 
Patient: No, but I have had some tingling in both my feet. I don't know if its related to surgery. If I'm remembering the names right, um, I have a history of spinal stenosis and neuropathy in my legs. 
Doctor: With your history of spinal stenosis, the broken toes, and the surgery, that's a pretty normal side effect.

Clinical note:
Symptoms: Tingling in both feet.
Diagnosis: N/A.
History of Patient: 59-year-old male, 4 months post percutaneous screw fixation of Schatzker IV tibial plateau fracture and nonoperative management of second through fifth metatarsal head fractures. Currently at home after leaving nursing home facility. Pain well controlled. Working with physical therapy 2-3 times a week. No drainage or fever. History of spinal stenosis with lower extremity neuropathy.
Plan of Action: N/A.
Doctor: Do you currently smoke? Or did you smoke in the past? 
Patient: Quit in nineteen seventy two. 
Doctor: Great to hear. Are you working right now? 
Patient: Yeah, I work at a nursing home.  
Doctor: Does your job allow you to take time for yourself? 
Patient: Yeah, my job is very supportive. I've actually been trying to lose weight. So far, I've lost a good amount since starting a new diet several months back.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Works at a nursing home. Nonsmoker since 1972. Currently attempting weight loss with success on a new diet, having lost several pounds in recent months.
Plan of Action: N/A.
Doctor: Hello. Are you ready for your surgery today? 
Patient: Can we reschedule? I'm too scared to do it. 
Doctor: It'll be fine. Don't worry too much about it. Have you ever had a surgery before?
Patient: Never. What if something goes wrong? 
Doctor: You have nothing to worry about. I've done this procedure multiple times, and everyone was fine after. 
Patient: Thank you, Doctor. Let's get started then.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient expresses fear and reluctance regarding surgery, stating it is their first surgery and expressing concern about potential complications.
Plan of Action: Surgery scheduled, reassurance provided by the doctor.
Doctor: What is your family medical history? 
Patient: I don't really remember anyone having any major health problems. 
Doctor: Okay. 
Patient: Everyone is pretty healthy. 
Doctor: That is fortunate. 
Patient: Yeah, it is.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient reports no major health problems in family medical history, stating that everyone is generally healthy.
Plan of Action: N/A.
Doctor: How's it going? I haven't seen you in a long time. 
Patient: Hey, Doctor. My headaches have been getting worse. 
Doctor: Remind me again. Does you family have a history of migraines. 
Patient: I don't think so. 
Doctor: Okay. Let's perform some tests.

Clinical note:
Symptoms: Headaches getting worse.
Diagnosis: N/A.
History of Patient: Patient reports worsening headaches. No known family history of migraines.
Plan of Action: Perform tests to assess the cause of headaches.
Doctor: Hello, this is your follow up visit, right? Welcome back! Have you been taking your Plaquenil for lupus, ma'am? 
Patient: Yeah, I am. 
Doctor: Your prescription is two hundred M G twice a day, correct? 
Patient: Yeah, that's it. 
Doctor: Do you have your eye report with you today? 
Patient: Yes, doctor. Here you go. 
Doctor: Good, thank you, what seems to be the problem today?
Patient: Well, I'm having some aches and pains in my hands and elbows. 
Doctor: When did this pain start?
Patient: It's been a few weeks now. 
Doctor: Is there any associated trauma? Did you fall? 
Patient: No, no falls or anything. It just started one day, and it's really bothering me. 
Doctor: Are you having any fever or chills, or cold or flu like symptoms? 
Patient: No, I'm not. 
Doctor: How about swelling? Are any of your joints swollen? 
Patient: No, everything is normal there. Of note, I have been losing a lot of hair recently. 
Doctor: Okay, that's interesting.

Clinical note:
Symptoms: Aches and pains in hands and elbows, hair loss.
Diagnosis: N/A.
History of Patient: Patient reports experiencing aches and pains in hands and elbows for a few weeks, denies trauma, fever, chills, or joint swelling. Also notes recent increase in hair loss.
Plan of Action: N/A.
Doctor: So, I know you're technically not allowed to drink, but I'm required to ask this anyway. Do you drink at all? 
Patient: No, actually. I try to steer clear of drinking while training for my marathon. 
Doctor: When is that by the way? 
Patient: Next summer. 
Doctor: Wow, good luck. It'll be yet another big accomplishment. 
Patient: Thank you. 
Doctor: And how about smoking of any kind? 
Patient: Nope.

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: Let us start with your family medical history. 
Patient: I have a lot of diabetes in the family. 
Doctor: Who has diabetes? 
Patient: My father had diabetes. He passed away. 
Doctor: I am so sorry. How did he pass away? 
Patient: He had cancer. He actually had breast cancer. 
Doctor: That is incredibly rare. Is your mother still with us? 
Patient: Yes, she is. She just had her eighty ninth birthday. Next year we are going to plan a big birthday bash for her. 
Doctor: Do you have any siblings? 
Patient: Yes. I have a sister. She has diabetes too. 
Doctor: Do you know of any family members with neurological disorders such as M S, epilepsy, or Huntington's? 
Patient: No. I don't know of anything like that.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Father had diabetes and breast cancer, mother is alive at age 89, sister has diabetes. No known family history of neurological disorders.
Plan of Action: N/A.
Doctor: How're your other children doing? 
Guest_family: Not so wonderful. They're all on antibiotics. 
Doctor: For the same? 
Guest_family: Yep. They all have ear infections and chest colds. 
Doctor: Your hands are full then. 
Guest_family: Tell me about it, doctor. I can't seem to catch much of a break. 
Doctor: It's definitely been a tough winter for you and your family.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: All siblings are on antibiotics for ear infections and URIs
Plan of Action: N/A
Doctor: Do you use tobacco or other drugs? 
Patient: No. 
Doctor: Do you drink? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Is this your mother with you today?
Patient: Yes, this is my mommy. 
Doctor: Great, welcome, what did you do this this ankle, young lady? 
Patient: Well, I was running when I twisted my ankle. 
Doctor: Which ankle did you twist? 
Patient: It was my right ankle. 
Doctor: Where does it hurt the worst? 
Patient: Right here, on the outside of my ankle. 
Doctor: Do you have a primary care physician?
Guest_family: Yeah, we go to Doctor Brown. 
Doctor: Do you have any other injuries to speak of? 
Patient: No, it's just my ankle really.

Clinical note:
Symptoms: right ankle pain on the lateral aspect
Diagnosis: N/A
History of Patient: twisted right ankle while running, no other injuries, brought in by mother, primary care physician is Dr. Brown
Plan of Action: N/A
Doctor: Good afternoon, young lady. 
Patient: Hello, doctor. 
Doctor: What grade are you in, young lady?
Patient: I'm in middle school, um, I'm in the eighth grade. 
Doctor: Do you play any sports? 
Patient: Yes, I love to play basketball. 
Doctor: Good, are both of your parents at home? 
Patient: Yes, I live with my mom and dad. 
Doctor: Do you have any siblings? 
Patient: Yes, I have a little brother, um, he's nine now. 
Doctor: Great, have you started your periods? 
Patient: Um, yes, my first one was in September.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: She is currently an eighth grader at Middle School and is interested in basketball.  She lives with both of her parents and has a 9-year-old brother.  She had menarche beginning in September.
Plan of Action: N/A
Doctor: How many children do you have, ma'am?
Patient: I was blessed with four beautiful children.
Doctor: That's wonderful. Did you have any complications with the pregnancies?
Patient: Actually, I had two c sections for both of my sons.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Cesarean section x 2
Plan of Action: N/A
Patient: I'm right handed. 
Doctor: Tell me what brings you here, sir? 
Patient: I'm having these cramps in my feet, in my hand and I just wanted to get checked. It has been happening for like six months. I develop muscle contractions in my toes and both feet. It only happens in night. 
Doctor: How frequent is it? 
Patient: Around three times a week. 
Doctor: What do you do when you have these cramps? 
Patient: I try to stand and it helps me relieve some of the discomfort. I noticed my toes are kind of extended. Whenever I step on the ground, it seems to pop into place. With all these cramps, I've started having pain in my calf. Sometimes because of that I could not sleep, or it wakes me up in the night. Similar to my toes, these cramps have also started coming up in my hands. They are not that strong or frequent. They're completely random and not in the nighttime. Sometimes my thumb gets so flexed that I have to move it to bring it to the right position and to relieve the cramp. 
Doctor: Did you ever have this symptom before? 
Patient: No, not like this. 
Doctor: Are you taking any medications? 
Patient: Yeah, I took an antibacterial called Bactrim around nine months ago. I was taking it briefly before, but now I'm taking it consistently. I cannot think of anything that is causing it. 
Doctor: Do you have any other medical condition?
Patient: I have H I V for the last twenty one years and I was taking antiretroviral medications for it. I stopped those medications around six or seven years ago. 
Doctor: Why did you stop the medications? 
Patient: I could not tolerate them. They were making my stomach weak. 
Doctor: Do you know your C D four count?
Patient: It was three hundred and twenty six. I never developed autoimmune deficiency syndrome. I think I should restart my medicines.

Clinical note:
Symptoms: feet and hand cramps, muscle contractions in toes and feet, calf pain, thumb flexion cramps
Diagnosis: N/A
History of Patient: experiencing cramps in feet and hands for the past six months, foot cramps more notable than hand cramps, cramps occur exclusively at night, occur about three times per week, standing relieves discomfort, toes in extended position during cramps, calf pain follows foot cramps, hand cramps less severe and frequent, occur randomly, thumb flexion cramps, started taking Bactrim nine months ago, history of HIV for 21 years, stopped antiretroviral medications six or seven years ago due to stomach upset, CD4 count of 326, never developed AIDS, considering resuming antiretroviral treatment
Plan of Action: N/A
Doctor: So, this is your follow up? How are you doing so far with Lamictal? 
Patient: Yes, it's the follow up. Lamictal was okay. There was no side effect with that. But I had twitching in my muscles a lot of times. It was not generalized, but I was very afraid that this will happen. 
Doctor: What time of day was it? That you had these episodes. 
Patient: Mostly in the mornings. 
Doctor: I have your recent E E G report. It did show multiple spikes and some complexes on both the sides, but it is more prominent on left.
Patient: I have been taking my medications very regularly and  I was getting a good amount of sleep as well. 
Doctor: Are you able to drive? 
Patient: Yes. 
Doctor: Is there any change in your social history or any other symptoms that arise or, or is it same as before? 
Patient: Looks same to me.

Clinical note:
Symptoms: myoclonic jerking, twitching in muscles, mostly in the mornings
Diagnosis: N/A
History of Patient: tolerated Lamictal well, recurrence of myoclonic jerking since last consultation, no generalized seizures, recent EEG showed polyspike and slow wave complexes bilaterally, more prominent on the left, compliant with medications, getting good sleep, continues to drive
Plan of Action: N/A
Doctor: What types of surgeries have you had in the past?
Patient: I had gall bladder and appendix surgery then they also took out my ovaries.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: cholecystectomy, appendectomy, oophorectomy
Plan of Action: N/A
Doctor: Have you had any surgeries in the past? 
Patient: Yeah, I have, I actually had it to repair an undescended testicle. 
Doctor: Oh, wow, do you remember it at all? 
Patient: No, nothing about it, I had that done when I was a baby.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: surgery for undescended testicle during infancy
Plan of Action: N/A
Doctor: Do you smoke cigarettes? 
Patient: I don't smoke cigarettes but I do have one on a rare occasion.
Doctor: Do you drink alcohol or use any recreational drugs? 
Patient: I don't drink but I do occasionally smoke weed. 
Guest_family: He has a drink every now and again when we get together with friends. 
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.
Plan of Action: N/A
Doctor: Do you smoke or drink? 
Patient: No, neither. 
Doctor: Any history of drug abuse? 
Patient: No, I have never used any illegal drugs in my life.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: denies use of alcohol, illicit drugs, or tobacco
Plan of Action: N/A
Guest_clinician: Is the patient being admitted for disseminated C M V infection? 
Doctor: Yes. I suspect they have possible C M V pneumonitis as well. 
Guest_clinician: Are they on immunosuppressants? 
Doctor: Yes. They have polymyositis and they're taking Prednisone and Methotrexate.  
Guest_clinician: Got it.

Clinical note:
Symptoms: N/A
Diagnosis: disseminated CMV infection with possible CMV pneumonitis, polymyositis
History of Patient: N/A
Plan of Action: N/A
Doctor: Alright we already spoke about your past medical history, anything else you might want to add?
Guest_family: Oh, dad did you also talk about your depression?
Doctor: Depression? I don't think we spoke about that.
Patient: Yeah we didn't, it slipped out of my mind.
Guest_family: My father has a history of depression and anxiety.
Doctor: Okay, let me make a note of it.

Clinical note:
Symptoms: N/A
Diagnosis: anxiety, depression
History of Patient: N/A
Plan of Action: N/A
Doctor: How are you?
Patient: Not good. 
Doctor: What brings you here today?
Patient: This ulcer in my ankle is just not healing. 
Doctor: Is it on both sides?
Patient: No, just on the right side.

Clinical note:
Symptoms: N/A
Diagnosis: nonhealing right ankle stasis ulcer
History of Patient: N/A
Plan of Action: N/A
Doctor: Do you remember the details of your surgery, sir?
Patient: No, can you remind me?
Doctor: We did a left inguinal hernia repair.
Patient: Thank you for reminding me.
Doctor: You have a history of prostate cancer as well, correct?
Patient: Yes, they said it was Gleason, um, three plus four. 
Doctor: Yes, that sounds familiar. What medicines are you taking right now?
Patient: I'm taking Lupron, currently.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: status post left inguinal hernia repair, prostate cancer (Gleason 3+4) diagnosed in December 2004, currently receiving Lupron
Plan of Action: N/A
Doctor: How many people do you have in your family?
Patient: Well, I have four children, all healthy with no medical conditions. 
Doctor: Wow, that's great!
Patient: My father passed away at the age of sixty nine due to C V A. And my mom died exactly ten years later, her heart just suddenly stopped. She was seventy nine. 
Doctor: Okay. And do you have siblings?
Patient: Well, believe it or not I had eleven siblings, including me twelve. 
Doctor: Wow!
Patient: Yes, I lost six of them. Four of them to diabetes, one of my brothers passed away at the age of seventy two and we could never determine the reason my sister died.
Doctor: Hm okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Father died at age 69 due to CVA, Mother died at age 79 from sudden cardiac arrest, 12 siblings (6 deceased), 4 siblings died (4 from diabetes, 1 cause unknown, 1 from heart failure at age 72), patient has 4 children with no known medical problems
Plan of Action: N/A
Doctor: You are referred for some abdominal infection right? 
Patient: Yes, they told me I might have C Diff?
Doctor: Yes that's what we will evaluate you for.

Clinical note:
Symptoms: N/A
Diagnosis: C. diff colitis
History of Patient: N/A
Plan of Action: N/A
Doctor: Hi, how are you doing? How old are you?
Patient: I am good, how are you? I am seventy two years old.
Doctor: Good. How can I help?
Patient: Actually, there is a wooden splinter stuck beneath my left fifth fingernail. I am an American farmer by blood, so this has happened before.
Doctor: Oh, when did this happen, sir?
Patient: Yesterday evening around four P M.
Doctor: Okay, then what did you do?
Patient: Then I tried to remove it with tweezers at home, but it did not come out. So, I want you to remove this. 
Doctor: Okay let me see.
Patient: Yeah, here.
Doctor: Okay. Can you tell me when the last time you had a tetanus shot?
Patient: Oh it's been so long. I would say it has been over ten years since I have had any tetanus shot.
Doctor: Okay and are you allergic to anything?
Patient: Oh yes. I am allergic to horse serum. I think it is added in vaccinations?
Doctor: Oh, okay. 
Patient: But I don't want any tetanus vaccine now. 
Doctor: Oh! But you need it.
Patient: I know, but I get a bad reaction to vaccines so I don't want it.
Doctor: Okay. let me fine some alternative.
Patient: Thanks.

Clinical note:
Symptoms: wooden splinter lodged beneath left fifth fingernail
Diagnosis: N/A
History of Patient: sustained injury yesterday at 4 p.m., attempted removal with tweezers at home, requesting medical assistance for removal
Plan of Action: N/A
Doctor: Have you had a recent vaccination? 
Patient: I had a flu shot last winter but I have not had and recent vaccines. 
Doctor: Do you have any planned in the near future? 
Patient: I was going to get another flu shot but I don't think I am due for that for another three months. 
Doctor: Great.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: How old are you? 
Patient: Seventy one. 
Doctor: Are you right handed or left handed? 
Patient: Right handed. 
Doctor: What exactly happened? 
Patient: I, I had this bad headache on fifth of November and then I had a big sneeze, like it was too loud. I had-- it was going on for like three to four days. Then, on the seventh, I had this severe pain over my left eye and I kind of lost my vision there. 
Doctor: When did you see changes in your eyelid? 
Patient: Yeah, on the following day, it seemed like swelling and then my eyelid, it began like pulling down and getting down. Kind of drooping. We went to a local doctor, and he did some x rays. 
Doctor: Yeah, I have your brain C T report from there. There is no sign of any kind of bleeding, but I do see a torturous blood vessel there. 
Patient: Yeah, after looking at this report they transferred us here to the U I H C on the twelfth.

Clinical note:
Symptoms: cataclysmic headache on 11/5/92 associated with a violent sneeze, acute pain and loss of vision in left eye on 11/7/92, left pupil enlargement, left upper eyelid drooping
Diagnosis: tortuous left middle cerebral artery
History of Patient: headache lasting 3-4 days, vision loss and eyelid changes observed subsequently
Plan of Action: N/A
Doctor: I see here that you're in for a med refill. Is that correct? 
Patient: Yep. I ran out of Klonopin one or two days ago. 
Doctor: What are you taking it for? And how long have you been on it? 
Patient: Panic attacks. I have really bad episodes without it. Um I think I started it about four months ago. I could be wrong though. I've lost track of time.
Doctor: Who usually prescribes it to you? 
Patient: My doctor back in Georgia. 
Doctor: Do you happen to have their name or contact info on hand? 
Patient: No, unfortunately.  
Doctor: How much Klonopin do you take for your panic attacks? 
Patient: I take a pretty low dose. I think I'm on zero point five milligrams a day. Is there any way you could verify the dosage? 
Doctor: I can try to look it up online. When were you last prescribed Klonopin? 
Patient: Over two months ago I think. 
Doctor: Let me pull up the page and see if we can figure out your dosage and when you're due for a refill based on your doctor's orders.  
Patient: Okay, thank you. 
Doctor: Are you experiencing any symptoms currently, such as headache, nausea, vomiting, shortness of breath or chest pain?
Patient: Not right now, no. I did have some nausea yesterday. Oh and I guess I had a slight headache when I woke up this morning, but that's about it.

Clinical note:
Symptoms: nausea, slight headache
Diagnosis: panic attacks
History of Patient: N/A
Plan of Action: Refill Klonopin medication, verify dosage and refill schedule online
Doctor: How are you? I haven't seen you in a long time.
Patient: I'm doing fine. I hurt my hand the other day. 
Doctor: How did that happen? 
Patient: My husband and I moved into our new home, and we were building a desk. I tried to nail something in, and I hammered my hand. 
Doctor: Oh, no. So, you and your husband live together now? 
Patient: Yeah. We do. We just got married.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Patient: Man, what a night.  
Doctor: What kind of car were you driving that night? 
Patient: I was driving my small sports car through an intersection when another car hit me from the left side. The impact forced my car off the road and into a utility pole. 
Doctor: I'm so sorry to hear that. I'm glad that you are here in one piece. Were you wearing your seatbelt? 
Patient: Yeah, I had my belt on and everything. 
Doctor: Good.  
Patient: Unfortunately, the driver was drunk and ran a traffic signal.  
Doctor: That's such a shame. Do you remember how fast the car was going when it collided into you?
Patient: If I had to guess maybe eighty miles per hour. It looks like the driver who hit me was already cited by police.  
Doctor: Did you lose consciousness at all?  
Patient: Yeah, I briefly lost consciousness when help arrived at the scene. I felt an immediate headache when I regained consciousness. I also had lower back and neck pain.  
Doctor: Did you get out of the car by yourself?  
Patient: Yeah, I got out by myself. Once I made it out, the Rescue Squad drove me to Saint Thomas Memorial Hospital. I was seen in the emergency room and later discharged. 
Doctor: This was on January fifteenth, correct? 
Patient: Yessir.

Clinical note:
Symptoms: headache, lower back pain, neck pain
Diagnosis: N/A
History of Patient: Motor vehicle accident on January fifteenth, 2001, patient was driving a small sports car, collision occurred when another car hit patient's car from the left side, patient was wearing a seatbelt, impact forced patient's car off the road into a utility pole, other driver was drunk and ran a traffic signal, estimated impact speed was 80 miles per hour, patient briefly lost consciousness at the scene, patient was able to exit the vehicle and was transported to St. Thomas Memorial Hospital by Rescue Squad, evaluated in the emergency room and later discharged
Plan of Action: N/A
Doctor: How're you doing? 
Patient: Good for the most part. I'm still pretty tired most days, but I'm trying to stay more active. I'm wondering if it has to do with my sugar levels? 
Doctor: Hm let's see. I'd like to check your glucose and lipid panels and get you back in here again.  
Patient: And oh I've noticed some blood in my stool. I'm not sure if it's related. 
Doctor: How long has that been going on? 
Patient: Maybe a week or so?  
Doctor: Are you having any other symptoms? Black or tarry stool? Nausea, vomiting, diarrhea? Lightheadedness?  
Patient: No, none of that.  
Doctor: I'd like to order a hemoccult then. It's going to check to see if you're still having blood in your stool. 
Patient: Can I do this at the blood work place? 
Doctor: Yes, they'll be able to help you and answer any additional questions you may have. 
Patient: Okay. I'll try to go in tomorrow. 
Doctor: Remember you need to fast for the lipid panel, so I'd recommend going in early tomorrow morning before eating breakfast. 
Patient: Okay, got it. 
Doctor: And before I send you on your way, have you been able to schedule your yearly mammogram? 
Patient: Oh shoot. I still need to do that. I'll call them tomorrow.

Clinical note:
Symptoms: occasional tiredness
Diagnosis: N/A
History of Patient: Concerns about sugar levels, noticed blood in stool for approximately a week, no other Symptoms reported
Plan of Action: Check glucose and lipid panels, order Hemoccult test to check for blood in stool, schedule yearly mammogram
Doctor: Hello, ma'am. How are you doing?
Patient: My knees hurt. They've been slowly getting worse each year. Life's getting hard at seventy two. 
Doctor: I'm sorry to hear that. Have you always had knee pain? 
Patient: I have. Both knees are messed up. 
Doctor: Are you able to do any activities still? 
Patient: Nope. I just sit all day. 
Doctor: I see. We can offer to do arthroplasty to fix your knees.
Patient: What's that? 
Doctor: It's like a reconstruction of your joints. It'll help increase your ability to do daily activities. 
Patient: I'm up for it. I need to get my life going. 
Doctor: Sounds great. I just want to confirm some information. Would you say your quality of life and daily activities is decreasing? 
Patient: Oh, yeah. These knees are making my life terrible.

Clinical note:
Symptoms: bilateral knee pain
Diagnosis: N/A
History of Patient: History of bilateral knee pain for years, progressively worsening, decreasing quality of life and activities of daily living (ADLs)
Plan of Action: Proceed with arthroplasty (joint reconstruction) for both knees
Doctor: How's he doing? 
Guest_family: Not so great. He's been out of it. He hasn't been acting like himself. 
Doctor: How long has it been since you noticed any behavioral changes? 
Guest_family: A few days now. 
Doctor: Is he complaining of any pain? 
Guest_family: Yeah he's been- 
Doctor: He's been? 
Guest_family: Sorry, my phone was on vibrate and I had to turn it off. 
Doctor: No problem. 
Guest_family: He's been pointing to his stomach and saying it hurts. 
Doctor: Is he having any other symptoms? 
Guest_family: He's told me he feels queasy. I took his temperature the other night and he was running a fever of one O two. 
Doctor: Any vomiting with the nausea? 
Guest_family: Yeah, he's thrown up a handful of times.

Clinical note:
Symptoms: abdominal pain, nausea, vomiting, fever, altered mental status
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Further evaluation and management of abdominal pain, nausea, vomiting, fever, and altered mental status
Doctor: Good morning, sir. Remind me please, when was your surgery? 
Patient: Hello, doctor. It was about a week ago now. 
Doctor: Great, and just to remind you, you had a removal of Ex Fix from the right knee with an M U A following O R I F of a right tibial plateau fracture. 
Patient: Yes, that all sounds familiar. What's M U A? 
Doctor: It stands for manipulation under anesthesia. We bent the knee in order to forcibly break up some scar tissue. 
Patient: Oh, wow. 
Doctor: Yeah, it's great, eliminates some need for P T in fact. How are you doing today? 
Patient: Overall, my pain is under control. 
Doctor: Are you having any flu like, or infection symptoms?
Patient: No, nothing like that at all. 
Doctor: So, no fever, or chills, or sweating at night. 
Patient: Yeah, nothing like that. 
Doctor: Great. I see you're having some drainage from the pin sites, but that doesn't bother me too much. 
Patient: Okay, good. I was getting worried. 
Doctor: No need to worry. Are you doing your range of motion exercises? Those are imperative. 
Patient: Yes, doctor. I am. 
Doctor: Good, and do you have any numbness or tingling? 
Patient: No, doctor. I don't have any of that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Approximately one week status post removal of Ex-Fix from the right knee with manipulation under anesthesia (MUA) following open reduction internal fixation (ORIF) of right tibial plateau fracture, well-controlled pain, mild drainage from pin sites, just started range of motion exercises for the right knee, no fevers, chills, or night sweats, no numbness or tingling
Plan of Action: Continue range of motion exercises, monitor pin sites for drainage, follow-up as scheduled
Doctor: So just a few quick questions before we wrap up. Do you smoke or drink? 
Patient: I drink sometimes. I've never smoked. 
Doctor: Any drug use? 
Patient: No. 
Doctor: Are you sexually active? 
Patient: Uh I was back in Haiti, but that was back in eighty two. I had several male partners, but no sex since moving here. 
Doctor: Did you use protection in your previous encounters? 
Patient: Most of the time, yes. 
Doctor: Any history of S T Ds? 
Patient: No. 
Doctor: Are you currently working? 
Patient: Yep. I work for a car dealership down the street.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: He occasionally drinks and is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982 which he described as "very active." Denies intravenous drug use.  The patient is currently employed.
Plan of Action: N/A
Doctor: Are you taking any medications for your pain?
Patient: Yeah, occasionally.
Doctor: Which one?
Patient: Just a regular pain medicine.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Occasional acetaminophen for pain management
Doctor: Good morning, sir, I hear you're a patient of Doctor A. 
Patient: Yes, that's correct. 
Doctor: Did she refer you to me?
Patient: Yeah, I'm fifty five, so I'm not too young anymore, but I have developed iron deficiency anemia with blood in my stool. At least, that's what she's told me so far.  
Doctor: Are you having diarrhea?
Patient: Yeah, I am.
Doctor: How would you describe the frequency?
Patient: I'd say it's chronic at this point. 
Doctor: How long have you known you have anemia? 
Patient: Um, it's been a few months now. 
Doctor: What markers were evaluated in order to diagnose this? 
Patient: I had, um, an unusual pruritus, and I had a C B C. 
Doctor: Do you have the results of that? 
Patient: Yes, right here. 
Doctor: Thank you, so this shows a hemoglobin of nine, and M C V of sixty five. 
Patient: Are those high? 
Doctor: Well, actually, both of those are low. 
Patient: Oh, okay. 
Doctor: How long have you had blood in your stool?
Patient: Um, it's been about five months now.
Doctor: What has the color been like?
Patient: Well, it's been both dark and bright blood, actually? 
Doctor: When was your last colonoscopy?
Patient: It was about three years ago, I had it with Doctor X. I did it in Las Cruces. 
Doctor: Was there any abnormality found? 
Patient: Yeah, I had polyps removed. 
Doctor: Were those polyps evaluated?
Patient: Yeah, the doctors said they were, um, hyperplastic. They diagnosed me with, um, lymphocytic colitis. 
Doctor: I see, when was the last time you were treated for diarrhea? 
Patient: At this point, it's been more than three years.

Clinical note:
Symptoms: iron deficiency anemia, blood in stool, chronic diarrhea, unusual pruritus
Diagnosis: hyperplastic polyps, lymphocytic colitis
History of Patient: Anemia diagnosed months ago with CBC showing hemoglobin of 9 and MCV 65, blood in stool for the last 5 months, last colonoscopy performed 3 years ago by Dr. X in Las Cruces with removal of hyperplastic polyps and Diagnosis of lymphocytic colitis
Plan of Action: Further evaluation and management of iron deficiency anemia, investigation and treatment of chronic diarrhea and blood in stool, consider repeat colonoscopy for surveillance and evaluation
Doctor: Good afternoon, before we begin, what are your pronouns?
Patient: I identify as a female, and I use she her pronouns. 
Doctor: Thank you, so, have you ever had surgery? 
Patient: Yes, I actually have a list of them written down.
Doctor: That's really helpful, may I see it? 
Patient: Absolutely, here you go. 
Doctor: Thank you. So I see you've had a multiple bowel surgeries, including, um, a hysterectomy, rectocele repair, and an appendectomy. Do all of those sound familiar. 
Patient: Yep, I got this list from all of the surgeons. 
Doctor: Are there any other major conditions I should be aware of? 
Patient: Yes, actually, I have another list, um, I have polymyalgia rheumatica. 
Doctor: That's all great information to know, thank you very much.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy.  She also has a Diagnosis of polymyalgia rheumatica.
Plan of Action: N/A