X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: Do you or have you used tobacco products,sir? 
Patient: No. I have never been a smoker. 
Doctor: Do you have any history of alcohol or recreational drugs use? 
Patient: I have never been a drug user, but I used to drink a little, but it was never a problem. I don't drink any more. 
Doctor: What do you do for a living? 
Patient: I am retired. I used to be an insurance salesman.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Retired insurance salesman, denies history of tobacco or illicit drug use, no history of alcohol abuse, currently abstinent from alcohol.
Plan Of Action: N/A.
Doctor: Any old or new medications I should know about? 
Patient: Nope.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: Good afternoon, sir. My nurse has it written down here that that you're a thirty three year old black male, is that correct? 
Patient: Yes, doctor, that's correct. 
Doctor: Great, what seems to be the problem today, sir? 
Patient: Well, I think I'm having some sexual dysfunction. I was wondering if Cialis would help. 
Doctor: What makes you think this, sir? 
Patient: Well, I did a quiz online on the Cialis website and I didn't score in the normal range, so I figured I would come in. 
Doctor: Is there anything else of note, sir? 
Patient: Well, there may be some decreased desire, but honestly, I don't think that's the main problem here. I'd like to have my erections last longer, doctor. 
Doctor: What was this quiz like? 
Patient: Well, on the quiz, I said that less than half of the time I'm able to get an erection and keep an erection after penetration. 
Doctor: Are you having difficulty maintaining an erection until completion? 
Patient: Well, I'd say there's slight difficulty. 
Doctor: Okay, do you have any significant medical conditions in the past that you have been treated for? 
Patient: No, not that I know of. 
Doctor: What about testicular infections? 
Patient: No, that sounds painful, but no. 
Doctor: Have you had any traumatic injuries to the groin? 
Patient: No, not that I can remember. 
Doctor: What about hernias? You can get them from playing sports or lifting weights. Have you ever had one of these? 
Patient: No, that doesn't sound familiar either.

Clinical note:
Symptoms: Sexual dysfunction, decreased desire, difficulty maintaining erection until completion.
Diagnosis: N/A.
History of Patient: 33-year-old black male presenting with sexual dysfunction, desires longer-lasting erections, took an online quiz on the Cialis website which indicated suboptimal erectile function, reports slight difficulty maintaining erection until completion, no significant past medical history, no history of testicular infections or groin injuries, no history of hernias.
Plan Of Action: Considering prescription of Cialis for improved erectile performance.
Doctor: We were not able to find the cause of your pain right now, but in the future, we will do a few more tests and then we can have a diagnosis.
Patient: Will you give me some medicine for my stomach pain? And what about that feeling to throw up all of the time?
Doctor: Yes, I will write a prescription. It will help you both with your pain and nausea.

Clinical note:
Symptoms: Sexual dysfunction, decreased desire, difficulty maintaining erection until completion, nausea, abdominal pain.
Diagnosis: N/A.
History of Patient: 33-year-old black male presenting with sexual dysfunction, desires longer-lasting erections, took an online quiz on the Cialis website which indicated suboptimal erectile function, reports slight difficulty maintaining erection until completion, experiencing nausea and abdominal pain of uncertain etiology, no significant past medical history, no history of testicular infections or groin injuries, no history of hernias.
Plan Of Action: Considering prescription of Cialis for improved erectile performance. Further evaluation and investigation required for nausea and abdominal pain.
Doctor: You had a bad acidity problem?
Patient: Yes I was vomiting too.
Doctor: What came out in the vomit?
Patient: It was all brown colored things like coffee.
Doctor: But nothing anymore, right?
Patient: Yes I am all better.
Doctor: Great!
Patient: They told me I can go home.
Doctor: Yes your blood count looks good, I just want you to continue Nexium forty M G once a day.
Patient: I will do that.

Clinical note:
Symptoms: Coffee-ground emesis, vomiting, acidity problem, resolved.
Diagnosis: Severe gastritis.
History of Patient: Patient experienced coffee-ground emesis and vomiting due to severe gastritis, Symptoms resolved, stable condition at discharge.
Plan Of Action: Patient to continue Nexium 40 mg once daily.
Doctor: How long have you been feeling weakness and fatigue? 
Patient: Well, I'd say it's been a lot worse this week. I haven't had much of an appetite either. 
Doctor: Have you lost weight as a result? 
Patient: I've lost about eight pounds, which is the most I've ever lost in a week's time. 
Doctor: Wow, that's concerning. Are you experiencing any nausea, vomiting, diarrhea, or abdominal pain? 
Patient: No. 
Doctor: How about chest pain, shortness of breath, cough, or heart racing? 
Patient: No. 
Doctor: Any neurological symptoms, such as numbness or tingling? 
Patient: No. 
Doctor: We'll get to the bottom of this. I'm waiting for your lab report to come back and then we can figure out the next steps.

Clinical note:
Symptoms: Weakness, fatigue, decreased appetite, weight loss (8 pounds in a week).
Diagnosis: N/A.
History of Patient: Patient complains of feeling weak and fatigued, no appetite over the past week, lost 8 pounds during this period, denies chest pain, palpitations, shortness of breath, coughing, nausea, vomiting, abdominal pain, or focal neurological deficits.
Plan Of Action: Awaiting lab report for further evaluation and determination of next steps.
Doctor: I see here that you have no surgical history. Is this correct? 
Patient: Yes, indeed. At least for now. Who knows what the future will bring.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: So, sir, tell me about your knees, how long have they been bothering you? 
Patient: Well, I'm sixty nine years old now, so I'm not as young as I used to be. But, these old knees have been bothering me for a couple years now. 
Doctor: What kind of symptoms do you notice in these knees? 
Patient: I hear clicking noises, which really bothers me when I'm going up stairs. There's also some stiffness when I try to move them. 
Doctor: Were you previously a pretty active guy? 
Patient: I absolutely used to be, and had no problems, but now this pain is affecting my daily life and activities.

Clinical note:
Symptoms: Bilateral knee pain, clicking noises, stiffness.
Diagnosis: N/A.
History of Patient: 69-year-old male presenting with bilateral knee pain for a couple of years, clicking noises and stiffness affecting daily activities.
Plan Of Action: N/A.
Doctor: You smoke or drink?
Patient: Nope, I never did any such thing. 
Doctor: Any drugs? 
Patient: Never. 
Doctor: Are you still working? 
Patient: I'm retired. I used to work. I used to work in Morse chain. I also used to deliver newspapers. But now I'm retired, and I enjoy life.
Doctor: Are you married? 
Patient: I was happily married. But then my husband died.
Doctor: Do you live alone or with family?
Patient: I live alone. I do have family who lives very close by in the neighborhood. I have a niece who lives with her family in my house on Temple Street.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Retired from Morse Chain and newspaper delivery, widowed, lives alone but has family members living nearby.
Plan Of Action: N/A.
Doctor: As far as you know, is there any family history of cancer? 
Patient: Yes, actually, my mom told me that someone had cervical cancer. 
Doctor: What about heart disease, does that sound familiar? 
Patient: Yes, I know someone had heart disease, and another person had heart failure.
Doctor: Good to know, what about the lungs, any history there? 
Patient: I know someone had C O P D. 
Doctor: Do you know of anyone with dementia or Alzheimer's?
Patient: Yes, my uncle has dementia right now, actually.
Doctor: I'm sorry to hear that, that's a hard disease to see your family go through. What about diabetes, does anyone have that?  
Patient: Thank you doctor, it's hard. Yes, my dad has the sugar.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Family history remarkable for cervical cancer, heart disease, heart failure, COPD, dementia, diabetes, and congestive heart failure.
Plan Of Action: N/A.
Doctor: Can you give me a quick run down of her medical history? 
Guest_family: Sure. It's a bit long, sadly.  
Doctor: I'm sorry to hear that. 
Guest_family: She was recently diagnosed with dementia. She's also suffered from high blood pressure for some time now.  
Doctor: When was she diagnosed with dementia? 
Guest_family: Six months ago. 
Doctor: Any history of heart disease, diabetes, or stroke? 
Guest_family: No, but she's not able to control her bladder well which leads to her having frequent accidents. Oh and she's had back pain for several years along with degenerative changes to her spine. Poor thing. I can't help but feel so bad for her situation. It definitely hasn't been easy.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient's medical history includes hypertension, dementia (diagnosed six months ago), urinary incontinence, chronic back pain (present for several years), and degenerative changes to the spine.
Plan Of Action: N/A.
Doctor: Hi, there. How are you both doing? What brings you two to the Emergency Department?
Guest_family: Hi, Doctor. We're both doing fine. I brought my daughter in today because she's been feeling sick. 
Doctor: I see. Let me ask your daughter a few questions before we start. Hi, ma'am. I understand you feel sick. Before we begin I just want to confirm some information with you. Where is your primary residency? 
Patient: My mom can give you the address. I still live with her. 
Doctor: Thank you. One last question. Do you smoke? 
Patient: Nope. My Mother has forbidden smoking in her home.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient lives at home with her mother, brought to the Emergency Department by her mother due to feeling sick, no smoking in the home.
Plan Of Action: N/A.
Doctor: Are you married, sir? 
Patient: Yes, I'm lucky to have, and live with my lovely wife.
Doctor: That's very nice. Did you speak with the nurse before I came in here?
Patient: Yes, she was lovely as well, I hope you're paying them well. 
Doctor: We take good care of them. They'll be happy to hear that. Let me look, she should have left me some notes, um, yep, these look good, I agree with all of this. This looks good.   
Patient: Thank you, Doctor.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient is married and lives with his wife. Nursing notes were reviewed and agreed upon by the doctor.
Plan Of Action: N/A.
Doctor: Hi. How are you doing, sir? 
Patient: Hi. I am doing fine. 
Doctor: The nurse told me that you are on disability from work now. What happened? 
Patient: I got hurt at work and now I am on disability. 
Doctor: What did you do for work? How long ago was your injury? 
Patient: I worked on the pipeline. The accident was five years ago.
Doctor: Which condition led to the disability? 
Patient: I don't know really. I sent in all the notes for my doctor for evaluation and they approved the disability. 
Doctor: Okay. Do you live alone or with family? 
Patient: I live with my wife. 
Doctor: Are you a smoke or have you ever been? 
Patient: I used to smoke. I quit years ago. 
Doctor: How long ago did you quit? 
Patient: Oh, about twenty years ago. 
Doctor: How many years did you smoke? And how much did you smoke?
Patient: Probably twenty years. I was up to two packs a day. I feel way better now. 
Doctor: That's great. Any use of alcohol or illicit drugs? 
Patient: Nope. 
Doctor: What do you do for fun? Do you have any hobbies? 
Patient: I don't really do much these days. Work was my hobby. 
Doctor: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient previously worked in pipeline work but has been on disability for five years, unsure about the specific condition leading to disability. He smoked two packs of cigarettes daily for 20 years but quit about 20 years ago. Denies alcohol or illicit drug use. Lives with his wife and does not have any hobbies.
Plan Of Action: N/A.
Doctor: How're you doing today? 
Patient: Overall, pretty good. 
Doctor: Any plans for the weekend? 
Patient: No, not really. Just dog sitting my friend's golden. 
Doctor: Gotcha. That's still nice. We used to have a golden when I was a kid. They're the sweetest dogs. 
Patient: They are very sweet. 
Doctor: Okay, so you're in for a follow up for your neck and back pain. 
Patient: Yessir.  
Doctor: Have you been going to pain management? 
Patient: Yeah, I go once every week or so.  
Doctor: How's your pain now? 
Patient: Manageable, I guess.  
Doctor: Is the pain still keeping you up at night? 
Patient: Not like it used to.  
Doctor: Good, great to hear.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Follow-up evaluation and management of chronic neck and back pain. Patient attends pain management appointments once every week or so. Pain is described as manageable and not keeping the patient up at night like it used to.
Plan Of Action: N/A.
Doctor: Let's see. Are you taking any medications? 
Patient: No, none right now.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: Do you smoke cigarettes? 
Patient: Yes. I smoke. 
Doctor: How much do you smoke per day? 
Patient: About a pack or two a day. 
Doctor: Do you drink alcohol?
Patient: No. It is very rare that I will have a drink. 
Doctor: What is your family medical history? 
Patient: Well, I don't know very much about my dad's side of the family but my dad did pass away from renal cancer. 
Doctor: I am so sorry for your loss. 
Patient: Thank you. 
Doctor: What about your mother or siblings? Do they have any health conditions?
Patient: No. They don't have any health problems. That I know of.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Smokes 1-2 packs of cigarettes per day, rare alcohol use, father passed away from renal cancer, no known health problems in mother or siblings.
Plan Of Action: N/A.
Doctor: So, ma'am, what do you do for a living? 
Patient: Actually, I'm retired, I don't work at all anymore. 
Doctor: Congratulations on your retirement. Where did you go to college?
Patient: Oh, I didn't go to college, I stopped after high school. 
Doctor: That's understandable. Do you have children?
Patient: Yes, my husband and I were blessed with three wonderful children. 
Doctor: Fantastic, do they live at home?
Patient: Nope, we got them all out of there. They're all grown now. 
Doctor: Do you drink or smoke?
Patient: No, I never had either. 
Doctor: What about harder substances?
Patient: No, absolutely not.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Retired, married with three grown children, high school level education, does not smoke, drink, or use illicit substances.
Plan Of Action: N/A.
Doctor: You are five feet four inches.
Patient: Yes.
Doctor: Weight one ninety seven.
Patient: Okay.
Doctor: Your blood pressure is one twenty five over seventy five.
Patient: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: VITAL SIGNS: Bloodpressure is 125/75.  His weight is 197 with height 5 feet 4 inches
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: Do you smoke or drink? 
Patient: Never smoked a cigarette a day in my life. As for alcohol, I'll drink socially with friends and family.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Non-smoker, social drinker.
Plan Of Action: N/A.
Doctor: How's he feeling today? 
Guest_family: I think this is the worst he's been feeling all week. 
Doctor: I'm sorry to hear that he hasn't been feeling well. What symptoms has he been having? 
Guest_family: He's been very congested as of late and seems to be coughing a lot more than usual. He was also running a fever yesterday.  
Doctor: I see. What was his temperature? 
Guest_family: The thermometer was reading one hundred and one degrees Fahrenheit. Does he need to go to the hospital? 
Doctor: Let me evaluate and see what we can do for him today. 
Guest_family: Thank you, doctor. 
Doctor: I suspect that he has an upper respiratory infection, possible pertussis. Is he still experiencing apnea?

Clinical note:
Symptoms: Congestion, increased coughing, fever (temperature of 101°F).
Diagnosis: Upper respiratory infection, possible pertussis.
History of Patient: Patient experiencing congestion, increased coughing, and fever; possibility of pertussis indicated by doctor, inquiring about presence of apnea.
Plan Of Action: Doctor to evaluate and determine appropriate course of action.
Doctor: Okay, let me quickly examine him. Mom do you give the permission? I will quickly check his genitalia. Can you pull his pants down?
Guest_family: Sure, you can check. 
Doctor: Well, everything looks fine, his penis and testes are normal shape and size for his age. No fluid accumulation or swelling in the scrotum area, no evidence of herniation there.

Clinical note:
Symptoms: N/A.
Diagnosis: EXTERNAL GENITALIA: Normal for age.  Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: We can release you from the hospital today if we have a safe place for you to go. Is there a parent or guardian we can release you to?  
Patient: I am in foster care. My foster mom is going out of town on the nineteenth to the twenty third.  
Doctor: In that case, we will have to keep you in the hospital until your foster mom returns from her trip.  
Patient: Can my mom and grandmother come and visit me here on Thursday? That is the day they usually come to visit me at my foster home.  
Doctor: Yes. I think we can make some arrangements to make that happen.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient is in foster care, foster mom will be out of town from the 19th through the 23rd, likely requiring hospitalization in respite care during that time as no other foster care arrangements are available. Patient's biological mom and grandmother typically visit on Thursdays for about an hour.
Plan Of Action: N/A.
Doctor: Do you know about any medical issues running in your family?
Patient: Yeah, almost everyone had diabetes.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Multiple family members have diabetes mellitus.
Plan Of Action: N/A.
Doctor: Do you have any past or present medical conditions? 
Patient: No.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: None.
Plan Of Action: N/A.
.
Doctor: Do you have any family history of lung disease, thromboembolism, pulmonary embolism, stroke, or heart disease.  
Patient: No.  My parents are healthy with no medical issues.  
Doctor: How many children do you have? 
Patient: I have five kids. 
Doctor: Do your children have any health condition? 
Patient: My children are all healthy with no medical problems.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: No family history of lung disease, thromboembolism, pulmonary embolism, stroke, or heart disease. Patient's parents are healthy with no medical issues. Patient has five healthy children with no medical problems.
Plan Of Action: N/A.
Doctor: Do you smoke or drink alcohol?
Patient: Nope.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: No tobacco or alcohol use.
Plan Of Action: N/A.
Doctor: Do you know of any medical problems that run in your family? 
Patient: I have no idea to be quite honest with you. My parents never shared their medical history with me and neither did their parents with them. I don't think they want any of us to worry. 
Doctor: Oh wow, I understand. It can be hard for many people to share intimate details about their health to others, even when it comes to disclosing medical info to their own children. For now, I'll put unknown but please let me know if anything changes. 
Patient: Will do. Thanks for understanding. 
Doctor: Of course. It's not totally uncommon for people to not know their family history.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Family medical history is unknown as patient's parents never shared their medical history, nor did their parents with them.
Plan Of Action: N/A.
Doctor: Hello again, how are you doing, miss? 
Patient: I'm good. Thank you. How about you? 
Doctor: All good here too. I know you are an established patient of dermatology here and was last seen in our office on July thirteenth, two thousand and four.  I will be asking you a few questions just to check whether the entry in our record is updated or not.
Doctor: How old are you now? 
Patient: Twenty nine. 
Doctor: Where are you from originally? 
Patient: I'm from Vietnam. 
Doctor: I am seeing you today as a referral from A B C for reevaluation. 
Patient: Yes, for my hand eczema. 
Doctor: So, let's see what you have been treated with. Your record here says with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion. Does this sound right to you? 
Patient: Yes, that's correct. 
Doctor: Are you washing your hands in Cetaphil cleansing lotion? 
Patient: Yes, I'm doing all that. 
Doctor: What brings you here today? 
Patient: I'm having this flaring. My hands are all dry. I have these like cracks in my hands. I have been washing with the soap and the lotions that you prescribed, but still, it is happening. Maybe because of cracks or what, I don't know, but the Cetaphil cleansing lotion, whenever I'm applying that it is causing me a lot of burning pain. I have been wearing gloves though. 
Doctor: Are you married? 
Patient: Still, a single. I'm not even looking for a husband yet. 
Doctor: Are you working somewhere? 
Patient: Not currently.

Clinical note:
Symptoms: Dry, cracked hands; flaring of hand eczema; burning pain when applying Cetaphil cleansing lotion.
Diagnosis: Hand eczema.
History of Patient: 29-year-old Vietnamese female, established patient of dermatology, last seen on 07/13/04. Referred by ABC, D.O. for reevaluation of hand eczema. Previously treated with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion. Experiencing dry, cracked hands despite treatment, with burning pain when applying Cetaphil cleansing lotion. Patient is single and currently unemployed.
Plan Of Action: N/A.
Doctor: You have been diagnosed with allergic rhinitis, right? For how many years?
Patient: Um, I would say around four years now. Oh my God it has been so, so many medications that I had to take for this. 
Doctor: Yeah, it's hard to control. Are you diabetic? 
Patient: No, I don't have any such conditions.
Doctor: So no hypertension or any kidney diseases?
Patient: Nope.
Doctor: Every been diagnosed with tuberculosis, asthma, or lung disease?
Patient: No I have not.

Clinical note:
Symptoms: N/A.
Diagnosis: Allergic rhinitis.
History of Patient: Patient has been diagnosed with allergic rhinitis for approximately four years and has been treated with numerous medications. She denies any history of diabetes, hypertension, or renal disease. Additionally, she has never been diagnosed with tuberculosis, asthma, or lung disease.
Plan Of Action: N/A.
Doctor: Hm how would you describe her diet? 
Doctor: Does she eat solid food?  
Guest_family: Mostly thin liquids and ground meat. 
Doctor: I see.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient's diet consists mainly of thin liquids and ground meat.
Plan Of Action: N/A.
Doctor: Hello there, I am Doctor Nathan. 
Patient: Hello.  
Doctor: How old are you?
Patient: I am forty eight?
Doctor: Do you get regular periods? 
Patient: No, I didn't get any periods for the last year after my surgery. 
Doctor: Any hot flashes?
Patient: Yes, it's been happening for the last several months. Sometimes I feel hot even in a fully air conditioned room. Other times I just feel like opening the refrigerator and standing in front of it.
Doctor: Any other symptoms?
Patient: I am also experiencing a lot of mood swings for the last few weeks.
Doctor: Based on all the symptoms my assessment would be mood swings along with postsurgical menopause. That would be the cause for your hot flashes.

Clinical note:
Symptoms: Postsurgical menopause, Mood swings..
Diagnosis: N/A.
History of Patient: Patient's diet consists mainly of thin liquids and ground meat.
Plan Of Action: N/A.
Doctor: Any change in appetite? 
Patient: Um, no.
Doctor: Any stomach pain or change in bowel movement?
Patient: No.
Doctor: Any history of bowel issues? 
Patient: No, not really.
Doctor: Any hernia problem? 
Patient: No.
Doctor: Any history of stomach ulcer?
Patient: No.
Doctor: Did you notice any rectal bleeding? 
Patient: No.
Doctor: Any liver issues or jaundice?
Patient: Um, no.
Doctor: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Denies any history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits, liver problems, or inflammatory bowel problems.
Plan Of Action: N/A.
Doctor: Do you drink alcohol? 
Patient: Nope! I use to occasionally, very long time ago. But not anymore.
Doctor: Okay and how bout cigarettes? Do you smoke or vape?
Patient: No, none of those.
Doctor: And no drugs and stuff, right? No snorting, I V or anything right?
Patient: Right, I don't do drugs either, never did. Even though pot is legal here, I never ever felt like trying. 
Doctor: That's a good thing. 
Patient: Yeah.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Denied tobacco, alcohol, and illicit drug use. Patient mentioned occasional alcohol use in the past but not anymore. Patient also stated never using drugs, including marijuana, despite its legality.
Plan Of Action: N/A.
Doctor: Let me check your neck, it looks nice and symmetrical. Your thyroid looks normal it is not enlarged.
Doctor: Does it hurt you when I press on your neck?
Patient: No.
Doctor: Neck is nontender. 
Doctor: Okay, I don't see any bulging of external jugular vein. 
Patient: These medical terms I don't understand. 
Doctor: Oh, I am talking about the vein in your neck, it shows no bulging. No abnormal masses present. Can you turn your head from left to right and right to left, any pain in your neck or difficulty turning?
Patient: No. 
Doctor: Can you rotate your head clockwise and anti clockwise.
Patient: Sure.
Doctor: Any pain?
Patient: No.
Doctor: Okay, let me just make a note here full range of motion with no pain.

Clinical note:
Symptoms: N/A.
Diagnosis: NECK: Supple and symmetric.  No masses. Thyroid midline, non enlarged.  No JVD.  Neck is nontender.  Full range of motion without pain.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: Hello, miss. It looks like you are here for your yearly physical. How is everything going? 
Patient: Great, I think. I just got a mammogram and nothing showed up. I still am taking my multivitamin and low dose aspirin. 
Doctor: Great to hear. Has there been any changes in drinking and smoking?
Patient: No changes. Check the chart, I answered that last time. 
Doctor: Great. Looks like drinking and smoking is off the menu. In regard to the mammogram, do you make sure to do self breast examinations? I believe I showed you how to do this last time. 
Patient: No, I do not. I don't see a point if I come and do the mammogram. 
Doctor: I highly suggest you start doing so. Sometimes people do not get mammograms for a few years and it is important to make sure nothing is growing. 
Patient: Yeah, I know. I am just lazy. Recently it has been hard to do a lot of my selfcare routines. I do not even exercise anymore.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Not exercising, does not perform self breast examinations, recent unremarkable mammogram, takes low-dose aspirin and multivitamin daily, wears seatbelt, does not smoke or drink alcohol.
Plan Of Action: N/A.
Doctor: Hello. How are you doing today? 
Patient: I want to get surgery on my leg. 
Doctor: Have you ever had a surgery. 
Patient: I did. Here's a list of them. 
Doctor: Looks like you had eye surgery, cataract surgery, and lumbar decompression, correct? 
Patient: Yeah. So, what options do I have for surgery? 
Doctor: I need to see what the problem is first.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Previous surgeries include eye surgery, cataract surgery, and lumbar decompression.
Plan Of Action: N/A.
Doctor: Hi you guys, how are you?
Patient: I am good, he is my stepdad. 
Guest_family: Hi Doctor, how are you?
Doctor: I am fine, thank you. So, she gets seizures? 
Guest_family: Yes.
Doctor: And when did it start? 
Guest_family: She was fourteen or thirteen. I think fourteen.
Patient: Dad I was fourteen, when it started. 
Doctor: Fourteen, okay. Are you taking anything for it?
Guest_family: Yeah, she is on medication.
Doctor: Anybody else in the family have a similar problem? 
Guest_family: No, but her sixteen year old brother suffers from N S V T and he sees a specialist. 
Doctor: Okay, any other siblings or family members with medical conditions? 
Guest_family: Other kids in the family are doing fine, but her maternal grandma suffers from high blood pressure and diabetes. 
Doctor: Okay. Sorry but I must ask this, any recent death in the family in past one year child or adult? 
Guest_family: Thankfully no!

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Stepdaughter experiences seizures since the age of 14, currently on medication. Patient's 16-year-old brother has incessant nonsustained ventricular tachycardia. Maternal grandmother has hypertension and diabetes. No recent deaths in the family in the past year among children or adults.
Plan Of Action: N/A.
Doctor: Do you have any known allergies to medications? 
Patient: None whatsoever.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: Did you have your vaccines?
Patient: Yeah. 
Doctor: Did you skip any? 
Patient: No, I had all of them and am up to date with my immunizations.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: Hi, how can I help you, ma'am?
Patient:  I have no complaints.
Doctor: Okay but tell me what is going on and we can figure this out.
Patient: Okay so my right hand and left foot was very swollen and very painful, and that's why I came to emergency room. 
Doctor: Do you have urine bag?
Patient: Yes, I could not go so they put it in.
Doctor: Yes, it looks like five hundred M L came out. So possible urinary obstruction. Also, they started you on steroids and colchicine. How are you feeling now?
Patient:  I am feeling a little better, my pain is improving, and the swelling is getting better.
Doctor:  Okay that is good. Any fever and chills?
Patient: No, no fever.
Doctor: Any problem with urination like pain or frequency or blood in urine?
Patient: No but I am not able to empty my bladder well, the pee has decreased a lot, I could not urinate.
Doctor: Okay I will evaluate that. How about any cough, blood in sputum?
Patient: No nothing like that.
Doctor:  Any chest pain, or difficulty breathing?
Patient: No pain, I can breathe well.
Doctor: Okay that sounds good.

Clinical note:
Symptoms: Swelling and pain in right hand and left foot, difficulty urinating, decreased urine output.
Diagnosis: Possible urinary obstruction.
History of Patient: Patient presented to the emergency room with swollen and painful right hand and left foot, difficulty urinating, and decreased urine output. Foley catheter inserted with 500 mL urine output. Started on steroids and colchicine, with improvement in pain and swelling.
Plan Of Action: Further evaluation for urinary obstruction.
Doctor: Does low blood pressure run in your family?
Patient: No. As far as I know, no one else has it. 
Doctor: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: Were you ever diagnosed with any kind of cancer in the past?
Patient: No.
Doctor: Did you ever had any rashes? Was there any change in your moles?
Patient: No.
Doctor: Any sudden weight loss history? 
Patient: No. 
Doctor: How about your energy level how do you feel?
Patient: I feel great, my energy level is quite good.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: No history of cancer, change in moles, rashes, or sudden weight loss. Patient reports good energy level.
Plan Of Action: N/A.
Doctor: What medications are you currently taking? 
Patient: I am a diabetic, so I take Insulin. 
Doctor: How much Insulin do you take? 
Patient: It varies from day to day.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient is diabetic and takes insulin, dosage varies.
Plan Of Action: N/A.
Doctor: Anything else that is going on?
Patient: Just some pain in the buttock.
Doctor: Okay.
Patient: I do not have anything else.
Doctor: Okay no fever, nausea, anything of that sort?
Patient: Nope.

Clinical note:
Symptoms: Pain in the buttock.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: You recently turned sixty seven, correct?
Patient: Yes. Sixty seven years young.
Doctor: Are you right or left handed?
Patient: Right.
Doctor: When were you first diagnosed with Parkinson's? 
Patient: September first of nineteen ninety five. 
Doctor: Do you remember who diagnosed you?
Patient: A local doctor I was seeing at the time. A year before my diagnosis, I had a few falls and episodes of lightheadedness. I also noticed that I was staggering a lot more when walking. 
Doctor: Did you lose consciousness during any of your falls?
Patient: Not that I know of. I had noticed that I was losing my normal voice to a degree. On top of losing my normal voice, my handwriting became smaller and smaller. I don't ever remember writing so small. Something seemed really off to me.
Doctor: I'm sure that was difficult to experience. 
Patient: It was very difficult. Two months prior to being diagnosed, I started to move much slower than before.
Doctor: By slower, do you mean the movements of your arms and legs were slower and impaired?
Patient: Yes. I was prescribed Sinemet back in September of nineteen ninety five.
Doctor: Did you notice any improvement while taking it?
Patient: None. I was pretty disappointed and discouraged as a result. I have problems with coordination and walking without staggering even today.
Doctor: Noting that it's February thirteenth nineteen ninety six. 
Patient: I felt weak in the morning and worse as the day went on.
Doctor: Are you experiencing any other symptoms, such as stroke like events, vision changes, seizures, or problems with moving and coordinating your arms?
Patient: No.
Doctor: Any headache, nausea, vomiting, chills, or fever?
Patient: No.

Clinical note:
Symptoms: Staggering gait, falls, episodes of lightheadedness, loss of voice, small handwriting, bradykinesia, problems with coordination and walking without staggering, weakness worsening throughout the day.
Diagnosis: Parkinson's Disease.
History of Patient: 67-year-old right-handed female diagnosed with Parkinson's Disease on September 1, 1995, by a local physician. Experienced staggering gait, falls, and episodes of lightheadedness for one year prior to Diagnosis. Noticed loss of voice and small handwriting. Started experiencing bradykinesia two months prior to Diagnosis. Started Sinemet in September 1995 with no improvement. Continues to have coordination problems and staggering gait as of February 13, 1996.
Plan Of Action: N/A.
Doctor: Hi there! How are the both of you doing today? 
Guest_family: I am doing well but my son is sick.  He is two and a half years old. 
Doctor: What are his symptoms?
Guest_family: He has a bad cough. He's been sick for the last three or four days. It sounds like there is phlegm rattling around in there when he coughs. He had a bad coughing fit this morning. I got nervous and decided to bring him in. 
Doctor: During his coughing episode this morning, did you notice any loss of breath or gasping for air? 
Guest_family: No. 
Doctor: Has he had a runny nose? 
Guest_family: No. 
Doctor: Any fever? 
Guest_family: No. He has not been eating much.  
Doctor: Is anyone else in the household sick? 
Guest_family: No. 
Doctor: Is anyone in the household a smoker? 
Guest_family: No.

Clinical note:
Symptoms: Bad cough with phlegm, decreased appetite.
Diagnosis: N/A.
History of Patient: Two-and-a-half-year-old male has been sick for the past three to four days. Mother describes congested sounds with cough and decreased appetite. No fever or runny nose. Nobody else at home is currently ill. No cigarette smoke exposure. Brought to the emergency room after a bad coughing spell, with no apnea during the episode.
Plan Of Action: N/A.
Doctor: Any medical diseases in the family? 
Patient: Yeah, mainly heart issues. My father died from heart attack. 
Doctor: What about your mother? 
Patient: She had the second type of diabetes.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Father died of myocardial infarction (heart attack). Mother has type II diabetes.
Plan Of Action: N/A.
Doctor: So just to double check. No past medical history? 
Patient: Yes, sir. None.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: Do you drink or smoke, ma'am?
Patient: No, I don't do any of that. 
Doctor: Good, what about harder drugs? 
Patient: No, none of that either. 
Doctor: Very good. Do you have any history of S T D that you know about?
Patient: No, there's no history of any of that there.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Denies smoking, alcohol abuse, illicit drug use, and history of STDs.
Plan Of Action: N/A.
Doctor: What medications are you taking? 
Patient: I take Prilosec and Tramadol when I have back pain.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Prilosec,Tramadol as needed for back pain.
Plan Of Action: N/A.
Doctor: Any drug allergies? 
Patient: No.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: No known drug allergies.
Plan Of Action: N/A.
Doctor: How often are you vomiting?
Patient: At least three times until my stomach is empty.
Doctor: Can you think of something this is related to?
Patient: Just when I eat raw carrots and celery.
Doctor: Do you get belly pain?
Patient: Yes.

Clinical note:
Symptoms: Vomiting after eating raw carrots and celery, abdominal pain.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: Good morning, ma'am. Can you confirm your age for me? 
Patient: Well, doctor, I'm sixty six years old now. 
Doctor: Thank you, so, how is your knee doing today? Hope the osteoarthritis is getting better. 
Patient: It's so bad, doctor. 
Doctor: Have you had any improvement with the rest and antiinflammatories we've talked about before? 
Patient: No, they haven't helped at all. 
Doctor: I see, you'd be a good candidate for a knee replacement. 
Patient: What's the risk of infection from the surgery? 
Doctor: Historically, it's less than one percent, we use prophylactic antibiotics to control for infection the entire time. 
Patient: Great, and will I be asleep for this? 
Doctor: Yes, you won't feel a thing.

Clinical note:
Symptoms: Knee pain due to osteoarthritis.
Diagnosis: N/A.
History of Patient: 66-year-old female with knee osteoarthritis, failed conservative management, considering knee replacement surgery.
Plan Of Action: Risks and benefits of knee replacement surgery discussed, informed consent obtained.
Doctor: How old are you? 
Patient: I am twenty four. 
Doctor: What brings you in today? 
Patient: I have been having this back pain for a long time. I thought I should come and get it checked out because it has not gotten any better.

Clinical note:
Symptoms: Chronic back pain.
Diagnosis: N/A.
History of Patient: 24-year-old female with chronic back pain.
Plan Of Action: N/A.
Doctor: Any medical issues running in your family? 
Patient: I don't know anything about that. 
Doctor: You know anyone in your family or relatives who ever had diseases like diabetes or any heart issues? 
Patient: Nope.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Doctor: Hello, miss. Could you verify your age, please? 
Patient: I'm fifty five years old. 
Doctor: Great. What is the reason for your visit today? 
Patient: I've been having a lot of problems recently, so I decided to come get it checked out by you. 
Doctor: I see. What kind of problems are you experiencing? 
Patient: Oh, it's a long list. Here it is. 
Doctor: Thank you. Let me take a look. Looks like you have some general allergies and food allergies, loss of taste, problems with your G I tract, asthma, G E R D, and dry mouth or xerostomia. 
Patient: Yeah, that sounds about right. I think I forgot to add it, but I also have bad allergies during the spring time. 
Doctor: Oh, I see. I would describe that as environmental inhalant allergies.

Clinical note:
Symptoms: General allergies, food allergies, loss of taste, GI tract problems, asthma, GERD, xerostomia, environmental inhalant allergies.
Diagnosis: N/A.
History of Patient: 55-year-old female presents with a variety of Symptoms including allergies, loss of taste, GI tract issues, asthma, GERD, xerostomia, and environmental inhalant allergies.
Plan Of Action: N/A.
Doctor: Are you a smoker? 
Patient: Yes. 
Doctor: Do you use alcohol or any recreational drugs? 
Patient: I have been in treatment for heroin and alcohol in the past. 
Doctor: Any current use of drugs or alcohol? 
Patient: I did do a little bit of coke today. 
Doctor: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient admits to smoking, heroin use, alcohol abuse, and cocaine use.
Plan Of Action: N/A.
Doctor: Do you take any- 
Patient: Meds? 
Doctor: Yes. 
Patient: I do. I take Allegra for seasonal allergies. I also take something that starts with a P. I'm blanking on the name. My other doctor prescribed it to me for exercise induced asthma. 
Doctor: Oh, do you mean Proventil? 
Patient: Yes, that's it! I keep that on hand in case my asthma gets outta control. 
Doctor: Is it up to date? 
Patient: You mean is it expired? No, I don't think so. It hasn't been long since I visited the pharmacy. 
Doctor: Good. I always like to advise my patients to check expiration dates.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient takes Allegra for seasonal allergies and Proventil for exercise-induced asthma.
Plan Of Action: N/A.
Doctor: Welcome into the office. 
Patient: Thank you. 
Doctor: Let us start with your family medical history. 
Patient: That is going to be a hard one. I was adopted and I do not know any family medical history. 
Doctor: Okay. That is alright.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient's family medical history is unobtainable as they were adopted and have no knowledge of it.
Plan Of Action: N/A.
.
Doctor: So, I see you were diagnosed with an acid reflux problem and high blood pressure twenty years back? 
Patient: Yes.
Doctor: And then you also have arthritis and Parkinson's.
Patient: Yes, both.
Doctor: Also, you had a brain stroke?
Patient: Yes, mini stroke! 
Doctor: Ah, yes. We also call it as T I A. 
Patient: Okay.
Doctor: And currently are you on any medications?
Patient: Just Coumadin, for my chronic A Fib. I have been on it three years. 
Doctor: Yeah, atrial fibrillation.
Patient: Yes.

Clinical note:
Symptoms: N/A.
Diagnosis: GERD (acid reflux), hypertension, arthritis, Parkinson's disease, TIA (mini stroke), chronic atrial fibrillation.
History of Patient: Diagnosed with GERD and hypertension 20 years ago, also diagnosed with arthritis and Parkinson's disease, experienced a mini stroke (TIA), currently on Coumadin for chronic atrial fibrillation for three years.
Plan Of Action: N/A.
Doctor: Good morning, ma'am. 
Patient: Good morning, doctor. 
Doctor: How are you feeling today? 
Patient: Honestly, I'm feeling a little bit better. 
Doctor: That's good to hear, ma'am.

Clinical note:
Symptoms: The patient states she is feeling a bit better..
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
Guest_clinician: I see here that he may need antibiotic therapy for possible cellulitis of his lower extremities. 
Doctor: According to the patient, his symptoms started getting progressively worse over the past two days. 
Guest_clinician: Does he have a history of cellulitis? 
Doctor: No.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Symptoms started getting progressively worse over the past two days, no history of cellulitis reported.
Plan Of Action: Questionable need for antibiotic therapy for possible lower extremity cellulitis.
Doctor: Good afternoon, young man. 
Patient: Good afternoon, doctor. 
Doctor: How old are you, sir?
Patient: I'm thirteen. 
Doctor: So, what brings you in today?
Guest_family: Well, at first, we went to Sierra Pacific Orthopedic Group, and he had an M R I that showed, um, O C D in the left knee. 
Doctor: Yes, I see that from the report. 
Guest_family: So, we're here for a second opinion on that.
Doctor: Yes, we should do surgery on this knee. There's gross instability of the fragment, and we don't want that get worse. 
Guest_family: Okay, that's about what we've heard so far. What are the risks of infection of the procedure? 
Doctor: It's less than one percent. We use antibiotics to control for infection. Other risks include bleeding, changes in sensation of the limb, changes in motion, failure to relieve pain or restore the articular cartilage, the possible need for another procedure, and possible early arthritis. I would not worry, though. These things are rare.
Guest_family: Okay, will he be asleep the entire time?
Doctor: Yes, he won't feel a thing. 
Guest_family: Okay, my husband agrees. We want to do the surgery.

Clinical note:
Symptoms: Persistent left knee pain.
Diagnosis: Unstable OCD (osteochondritis dissecans) lesion of the left knee.
History of Patient: 13-year-old male initially seen at Sierra Pacific Orthopedic Group, MRI demonstrated unstable OCD lesion of the left knee, presented for a second opinion, surgery recommended due to instability of the fragment, risks and benefits of surgery discussed, risks include anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to relieve pain or restore articular cartilage, possible need for other surgical procedures, and possible early arthritis, parents agreed to the plan.
Plan Of Action: Surgery recommended to address the unstable OCD lesion in the left knee.