X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: Do you have any medical problems? 
Patient: Let's see. I have diabetes, high blood pressure, high cholesterol, and osteoporosis.  
Doctor: And any surgeries? 
Patient: Several. 
Doctor: Which ones? 
Patient: I had my tonsils taken out when I was a kid. I also had my uterus removed along with my ovaries and fallopian tubes. The list goes on. I had my appendix removed and two or three of my parathyroids taken out. Despite getting some of my parathyroids removed, I still have borderline high calcium levels according to my endocrinologist. 
Doctor: Did you experience any complications during or after surgery? 
Patient: No. I forgot to mention that I had two carpel tunnel releases as well.

Clinical note:
Symptoms: N/A.
Diagnosis: Hypertension, hyperlipidemia, diabetes, osteoporosis.
History of Patient: Tonsillectomy in childhood, hysterectomy, salpingoophorectomy, appendectomy, parathyroidectomy (with residual borderline elevated calcium levels), two carpal tunnel releases.
Plan of Action: N/A.
Doctor: What is your family medical history? 
Patient: My mother passed away from complications with Huntington Disease. She was diagnosed and had been having treatments at U I H C. My grandmother and two of my aunts also passed away from Huntington as well. 
Doctor: I am so sorry. Do you have siblings?
Patient: Yes! I have one sister. She is thirty eight. She has a lot of metal issues. She has attempted suicide two times. 
Doctor: Are you close with her? 
Patient: No. Not really. 
Doctor: Are you married? 
Patient: Yes.
Doctor: Do you have children? 
Patient: Yes. We have two adopted kids.

Clinical note:

Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Mother died at age 60 from complications of Huntington Disease (diagnosed at UIHC), grandmother and two aunts also died from Huntington Disease. Patient's 38-year-old sister has attempted suicide twice. Patient and his wife have two adopted children.
Plan of Action: N/A.
Doctor: Any medical problems on your mom or dad's side? 
Patient: My dad has lupus and his brother has Addison's disease. High blood pressure also runs in the family. 
Doctor: Is your dad being treated for lupus? 
Patient: Yes, he follows up with his rheumatologist pretty regularly.

Clinical note:

Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Father has systemic lupus erythematosus (SLE), uncle has Addison's disease. High blood pressure also runs in the family.
Plan of Action: N/A.
Doctor: I will do a quick exam on you.
Patient: What kind of exam? 
Doctor: I'm just checking for lymph nodes. Whenever there is an infection those guys are the first ones to be noticed with swelling.
Doctor: Okay, so let's first check your neck area. It looks good. I don't feel any inflamed lymph node. Your armpits look good too and the last place to check is your groin area. It is all good. No sign of infection.

Clinical note:

Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: What are some medications you are on?
Patient: I am on pain pills.
Doctor: Do you know their names?
Patient: Yes. Oxycontin and Vicodin.
Doctor: Okay that helps.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: I am looking at the list of your medication.
Patient: Okay.
Doctor: All I can see is Risperdal and Invega.
Patient: I think that is correct.
Doctor: Are you not taking anything else?
Patient: Yes, I take some multivitamins, but do I need to mention it?
Doctor: Yes, you should. We need to know everything.
Patient: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Good morning, ma'am. 
Patient: Oh, good morning, doctor. 
Doctor: Please, tell me about your living situation. 
Patient: Well, right now, I live at home with my kids and my dad. 
Doctor: I see here that you're not able to go up the stairs well, can you tell me more about that?
Patient: Yeah, I can't use the stairs without holding the rail the entire time. 
Doctor: Holding the rail makes navigating the stairs easier? 
Patient: Yeah, but I still move very slow. 
Doctor: I see. Do you smoke?
Patient: Yeah, I smoke about a pack to a pack and a half a day. 
Doctor: What about exercise? Do you workout? 
Patient: No, I don't regularly workout, I've never been good at it.

Clinical note:
Symptoms: Difficulty navigating stairs without holding onto railing, slow movement on stairs.
Diagnosis: N/A.
History of Patient: Lives at home with children and father, struggles with stairs without railing, smokes 1-1/2 packs of cigarettes a day, no regular exercise routine.
Plan of Action: N/A.
Patient: My physician did a blood test. My potassium is high. He recommended me to meet you.
Doctor: Okay. I did not get the blood report yet. I am waiting for your doctor's office to send it to me. Is it only your potassium that is elevated?
Patient: Yes, that's what they told me.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Elevated potassium levels reported from blood test.
Plan of Action: Await blood report from patient's physician's office to confirm potassium elevation and determine further steps.
Guest_family: He was going to buy me a surprise but met with this car accident.
Doctor: I am sorry! He does have multiple trauma due to the accident, and he will require aftercare. 
Guest_family: Yeah.

Clinical note:
Symptoms: Multiple trauma due to car accident.
Diagnosis: N/A.
History of Patient: Patient involved in car accident, resulting in multiple trauma.
Plan of Action: Aftercare required for patient's injuries sustained in the accident.
Doctor: So, what is your family's living situation at home?
Guest_family: Um, he lives at home with me, and his father. 
Doctor: May I assume that you are his biological parents? 
Guest_family: Yes, that's correct. 
Doctor: Great, does he have any siblings? 
Guest_family: No, right now, he's an only child. 
Doctor: What grade is he in? 
Guest_family: He's in the third grade. 
Doctor: Great, and is he doing well in school? 
Guest_family: Yes, he's doing quite well.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Good afternoon, what gender do you identify with?
Patient: Thank you for asking, I identify as a female.
Doctor: Thank you. Do you know of any chronic illnesses?
Patient: No, but can you give me some examples of what you mean?
Doctor: Well, high blood pressure, osteoarthritis, diabetes, depression, anything like that ring any bells?
Patient: Oh, no, I don't have anything like that.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Do you have any major medical conditions that I should know about? 
Patient: What, like cancer? 
Doctor: It doesn't have to be that serious, but is there anything you take medicine for? 
Patient: Oh, I have allergies and asthma.

Clinical note:

Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Allergies and asthma.
Plan of Action: N/A.
Doctor: Can you tell me something about your mom and dad?  Like any diseases they have had?
Patient: Sure, my dad died of heart attack when he was sixty five and my mom died of stroke when she was seventy.
Doctor: How's about siblings, miss? Any health issues?
Patient: No, my brother is healthy.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Father died of heart attack at 65, mother died of stroke at 70. Brother reported as healthy.
Plan of Action: N/A.
Doctor: Does anyone in your family suffer from any health problems? 
Patient: No one comes to mind. 
Doctor: Great.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Tell me, what's going on? 
Guest_family: She is complaining of weakness on the right side of her face.
Patient: And I feel the right side is drooping.
Doctor: Okay, let me look at it.

Clinical note:
Symptoms: Weakness on the right side of the face, right-sided facial drooping.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: My chart here says that you're eighty three years old, is that correct, ma'am? 
Patient: Yes doctor, that's correct, I just had my birthday. 
Doctor: Happy belated birthday! How have you been doing since your last visit?
Patient: Well, my cancer hasn't needed phlebotomies for several months now, which is good. 
Doctor: That's great, you have been treated for polycythemia vera, correct? 
Patient: Yes, that's the one. 
Doctor: I also see you're unassisted today, which is also great. 
Patient: Yeah, having some independence is nice.

Clinical note:
Symptoms: N/A.
Diagnosis: Polycythemia vera.
History of Patient: Cancer hasn't required phlebotomies for several months, patient has been treated for polycythemia vera.
Plan of Action: N/A.
Doctor: So, do you have any family history of cancer?
Patient: Well, yes, but I can't remember who had what kind. 
Doctor: Still, that's helpful, thank you. What about heart disease?
Patient: That too, there's some history of heart disease, but I can't remember who.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Family history of cancer and heart disease, specifics unknown.
Plan of Action: N/A.
Doctor: As far as you know, are there any major health conditions that you know about? 
Patient: What do you mean by that? 
Doctor: Anything like cancer, or arthritis, do those sound familiar?
Patient: Oh, um, no nothing like that.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Denied knowledge of any major health conditions such as cancer or arthritis.
Plan of Action: N/A.
Doctor: Do you have any medical history that we should be aware of? 
Patient: I have type two diabetes. My numbers always come high.
Doctor: Okay, anything else? 
Patient: I also have high cholesterol.
Doctor: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: Type 2 diabetes, high cholesterol.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Hello. How are you feeling today? 
Patient: Great. I'm just here for my yearly physical. 
Doctor: Oh, good. I see your past medical history is missing. Do you, by chance, know if you've had any health related problems before? 
Patient: Uhm. Let me check my notes on my phone. I knew this question would pop up, but I always forget. Oh, perfect. You can take a look at them. 
Doctor: Thank you. I just want to verify the information with you. You had asthma, nasal inflammation, and some abnormal growth on you neck, correct? 
Patient: If it's on there, then it's true. I usually don't remember these kinds of things. My wife is usually here with me. She knows all about my health.

Clinical note:
Symptoms: N/A.
Diagnosis: Asthma, nasal inflammation, abnormal growth on neck (per patient's notes).
History of Patient: N/A.
Plan of Action: N/A.
Doctor: How's the little one doing?
Guest_family: She is doing okay. 
Doctor: How long was your pregnancy?
Guest_family: Thirty six weeks.
Doctor: Was your delivery normal or C section?
Guest_family: It was a C section. 
Doctor: How much did she weigh? 
Guest_family: She was eight pounds and three ounces.
Doctor: Tell me what's the issue?
Guest_family: Yeah, she has a history of seizures. It looks like she is having pain in her tummy and is throwing up. 
Doctor: What else did you notice?
Guest_family: It looks like she is having some rashes on her skin. There is vomiting for sure. She also feels bloated. She also complains of pain in her tummy. Sometimes she does scratch her mouth. We also noticed some swelling around her lips, eyes and face.
Doctor: It looks like she's having some food intolerance.

Clinical note:

Symptoms: Seizures, abdominal pain, vomiting, skin rash, bloating, scratching mouth, swelling around lips, eyes, and face.
Diagnosis: Food intolerance (suspected).
History of Patient: Born via C-section at 36 weeks, weighed 8 lbs 3 oz, history of seizures.
Plan of Action: N/A.
Doctor: What medications are you taking right now?
Patient: I am taking Advair and Allegra.
Doctor: Okay is it helping you?
Patient: I don't know, I am not sure the Allegra is helping. But I do take them regularly.
Doctor: But is it like better than Claritin?
Patient: Yes, I think so.
Doctor: Okay that's good.
Patient: Shall I continue?

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Anybody sick in family?
Patient: No one.
Doctor: How about any illnesses that run in your family?
Patient: No, everyone is healthy.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Hi again! How has your acne been since you started the spironolactone? 
Patient: It has been improving.  
Doctor: Have you experienced any increased thirst, mood changes or unusual fatigue? 
Patient: No.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Well, I don't think you need any restraints as you are doing fine. I do want to make sure you have a chair and bed monitor since you have a history of multiple falls. They can help detect fall. 
Patient: I don't want that, I will manage. 
Doctor: Are you sure?
Patient: Yes!

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: History of multiple falls.
Plan of Action: Recommending chair and bed monitor for fall detection, patient declined.
Doctor: Do you know when was the last time you got a tetanus shot?
Patient: No I don't remember.
Doctor: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Hi there! How are you today? 
Patient: Hi! I am good. 
Doctor: Welcome in! 
Patient: Thank you. 
Doctor: Lets start with a little social history. Are you a tobacco or alcohol user? 
Patient: No. 
Doctor: Are you married? Do you have children? 
Patient: I am not married but I do have a two year old son. 
Doctor: Do you currently see a gynecologist? 
Patient: Yes. She is in Bartow. 
Doctor: Great.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Tell me about your family medical history. 
Patient: My family is pretty healthy. I don't know of any health problems.

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: Do you smoke? 
Patient: No, I don't. Smoking is gross. 
Doctor: I agree. Do you drink alcohol?
Patient: Yes. 
Doctor: How much do you drink per day or week? 
Patient: When I get off work usually have a glass of wine. I don't ever have more then one glass. 
Doctor: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: The nurse applied antibiotic ointment and a bandage to your foot. Did she go over how to change the bandage at home? 
Patient: Yes.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Hello. Before we begin, I need you to confirm some information for me. 
Patient: What kind of information? 
Doctor: About your family. Do you know if you have certain medical conditions that run in your family? 
Patient: Nope. My family is very healthy.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: How about any breathing issues or asthma?
Patient: Actually, I have a history of asthma.
Doctor: Oh okay, and was it severe or mild?
Patient: Well, it was not severe but still remarkable.
Doctor: Hm, alright.  Anything else?
Patient: Yes, I also struggled with a serious acne problem.
Doctor: Got it.

Clinical note:
Symptoms: N/A.
Diagnosis: Asthma, history of serious acne.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: How's she doing? 
Guest_family: She's had better days. 
Doctor: Aw and why's that? 
Guest_family: She's been really congested recently. Snorting a lot more, too. She's onlt eleven and I think it is odd she snores so much. I took her to see the allergist and he said it's not her allergies so we stopped giving her Allegra. 
Doctor: Does she happen to snore at night? 
Guest_family: No, not really. 
Doctor: Hm. 
Guest_family: And while we're here, I also wanted you to check out her toe. The right big toe appears a bit red to me. The skin around it has been peeling for the last week and a half. 
Doctor: Lemme take a look. Have you applied anything to the area?

Clinical note:
Symptoms: Congestion, snorting, redness and peeling of skin around right big toe.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: Examination of the toe area.
Doctor: Why are you holding your face?
Patient: Ah! Have pain in my tooth.
Doctor: Oh, how bad is it?
Patient: Oh, awfully bad.
Doctor: I am so sorry.

Clinical note:
Symptoms: Pain in tooth.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Have you had similar symptoms before? 
Patient: No never like this.
Doctor: Any other complaints you have had in the past?
Patient: Just some knee pain issues.
Doctor: Okay, so chronic knee pain.
Patient: Yes.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Chronic knee pain.
Plan of Action: N/A.
Doctor: Can you tell me about any cancers in your family?
Patient: Yes, my sister has ovarian cancer, and my father has liver cancer.
Doctor: Oh I am so sorry.
Patient: That is okay.
Doctor: Any heart conditions?
Patient: My mom and dad both have heart disease. My dad has diabetes too.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor:  Can you tell me what problems you have had in the past. Or what medical issues are currently going on?
Patient: You mean my heart problem and things?
Doctor: Yes.
Patient: Okay, I have hypertension and kidney problems since many years.
Doctor: Okay.
Patient: I get frequent urinary infections.
Doctor: Your urine creatinine is normal.
Patient: Okay. I also have severe aortic stenosis.

Clinical note:

Symptoms: N/A,
Diagnosis: N/A,
History of Patient: Hypertension, kidney problems, frequent urinary infections, severe aortic stenosis.,
Plan of Action: N/A.
Doctor: Does anyone else in your family have aneurysm problem?
Patient: Well, my grandmother had it. She actually passed away due to brain aneurysm. 
Doctor: Oh, okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Patient's grandmother passed away due to brain aneurysm.
Plan of Action: N/A.
Doctor: What is wrong with your back honey?
Patient: Oh, it all started off with a little pimple on the buttock.  I was soaking it at home with hot water and stuff, but it did not improve. I hope this is not cancer. I am only twenty four. 
Doctor: Okay what exactly are you experiencing?
Patient: I have pain.
Doctor: So you came to the hospital on the first and they did an I and D in E D?
Patient:   Yes I was admitted to the hospitalist service with high blood sugars. My African American father was so scared. 
Doctor: Okay sugars high. Do you know the number? How high?
Patient: No, I do not know that but they found positive bacteria or some sort of thing in my blood culture. 
Doctor:  So today we are evaluating you for surgery?
Patient: Yes.

Clinical note:
Symptoms: Pain in the back.
Diagnosis: N/A.
History of Patient: Started with a pimple on the buttock, soaked it at home with hot water but no improvement, concerned about cancer at age 24. Admitted to hospitalist service on the first with high blood sugars, father was scared. Positive bacteria found in blood culture.
Plan of Action: Evaluating patient for surgery.
Doctor: Hi there! I have the results from your ultrasound. You have kidney stones in the ureter close to the bladder.
Patient: Oh no. 
Doctor: This explains the pain you have been having on your left side. Are you still experiencing nausea and vomiting? 
Patient: Yes, I have been. 
Doctor: I would like to set you up with a consult with a consult with a surgeon.
Patient: Okay.

Clinical note:
Symptoms: Pain on the left side, nausea, vomiting.
Diagnosis: Kidney stones in the ureter close to the bladder.
History of Patient: Experiencing pain on the left side, nausea, and vomiting.
Plan of Action: Consultation with a surgeon recommended.
Doctor: Any known drug allergies? 
Patient: No.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Your daughter had an exposure to the ant bait but we are not sure if she actually ingested any of it. Poison Control confirmed that even if she did ingest the small amount that she was found with, it is likely nontoxic. Do you have any questions? 
Guest_family: No.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Daughter had exposure to ant bait, unsure if ingestion occurred. Poison Control confirmed exposure likely nontoxic.
Plan of Action: N/A.
Doctor: Hello, sir. How are you today?
Patient: I am alright. I am here for a check up since I am feeling kind of dizzy lately. 
Doctor: That is not good. How long has this been happening?
Patient: A few months. This happened to my sister too. I think she is still dealing with it. 
Doctor: Is there any other family medical history I should know about? Migraines or cancer?
Patient: No. Not that I know of. The rest of my family seems pretty healthy.

Clinical note:
Symptoms: Dizziness.
Diagnosis: N/A.
History of Patient: Experiencing dizziness for a few months, similar Symptoms observed in sister.
Plan of Action: N/A.
Doctor: Do you know anyone in your family whose had cancer? 
Patient: No one that I know.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Okay so your blood report is back and the cardiac enzyme we were looking for are negative. 
Patient: Okay.
Doctor: Your blood urea nitrogen, also known as B U N, is within normal limits and hydrogen is stable. Creatinine is also within the normal range.
Patient: Great!

Clinical note:
Symptoms: N/A.
Diagnosis: Normal blood urea nitrogen (BUN) and creatinine levels.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Are you on any medications?
Patient: No, not taking any medications.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Hi, how are you doing today? 
Patient: I've been better. Thank you. 
Doctor: So, you are here for your follow up right? Remind me how often are you coming here? 
Patient: That's right. I'm coming around between a month or two. 
Doctor: Yeah, it's every four to eight weeks. 
Patient: I'm not taking any medicine now. I just wanted to let you know. 
Doctor: Yeah, I can see it in your record. It says that you are off of all the immunosuppression. So, just let me check. It says here that you do have mild chronic G V H D. It is not that bad that I should be worried about any therapy or anything else. How long ago did you get that transplant? 
Patient: I think it was around four and a half years ago. I'm feeling much better after that. I do have complaints of blood in my stool. But after you sent me to that doctor, that gastro doctor, I feel good. I know they said that they removed something, but I'm not sure, but after that it has been improved a lot. 
Doctor: Okay, let me see in my chart. You had some rectal bleeding issues because of which I referred you to the gastroenterologist. A complete endoscopy was performed, which was both on the upper and the lower side. There was no evidence of ulcers or any other abnormality. That's  good news, right? 
Patient: Yeah, I agree. That was a relief. 
Doctor: They did find some polyps and they removed it. They turned out to be benign, so nothing to worry about there. 
Patient: Yeah, I remember this said they removed something, but I forgot the name. 
Doctor: Is there any other issue that I can help you with? 
Patient: I don't know. I feel a lot of fatigue and like I'm not able to do things like I used to do before. I get tired very easily. I don't know if it is related to something or not, but things have been weird. I'm not able to do even the minor things like I lift two boxes and I'm done for the day. Is it something that I should be worried about? 
Doctor: It looks like you have a mild iron deficiency. I will work on that with you, don't worry.

Clinical note:
Symptoms: Fatigue, easy tiredness, blood in stool.
Diagnosis: Mild chronic graft-versus-host disease (GvHD), mild iron deficiency.
History of Patient: Received transplant approximately four and a half years ago, experienced rectal bleeding issues, underwent complete endoscopy revealing benign polyps which were removed.
Plan of Action: Addressing iron deficiency with patient.
Doctor: Are you feeling any pain?
Patient: No, I feel great. 
Doctor: Is there any other medical issue that we should be worried about? 
Patient: No, it feels like I'm young again. I'm able to do all my activities.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Thank you for coming in to see us at A B C D General Hospital today. 
Patient: I wish I wasn't here right now. 
Doctor: I understand, before we begin, how old are you? 
Patient: I'm seventy seven years young. 
Doctor: Which race, and gender do you identify with?
Patient: I'm an African American woman. 
Doctor: What's seems to be causing you pain today? 
Patient: I've had this bunion on my foot for as long as I can remember. 
Doctor: Is the pain worsening?  
Patient: Yes, it is so painful, I've tried to avoid surgery for so long, but I want this bunion gone.
Doctor: How have you managed this bunion in the past? 
Patient: I've used antiinflammatories, rested, changed my activities, I've done everything, but this pain is getting worse and worse.  I need it gone.

Clinical note:
Symptoms: Painful bunion on foot.
Diagnosis: N/A.
History of Patient: Patient has had bunion for an extended period, pain worsening despite various management strategies.
Plan of Action: Considering surgical intervention for bunion removal due to worsening pain.
Doctor: Do you have diabetes or blood pressure problems? 
Patient: Yes, I have hypertension but no diabetes. 
Doctor: Alright.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Hypertension, no diabetes.
Plan of Action: N/A.
Doctor: How are you dealing with your pain now? 
Patient: Oh no, I have no issues with my pain. Today I'm here for a different cause. I'm having this weakness all around on my left side, especially in my arm. I feel like I cannot lift anything like even a glass of water. It's hard for me to lift it up. I'm not able to walk properly, let alone the balancing and everything else. It's just that my whole left side seems to be weak.

Clinical note:
Symptoms: Weakness on the left side, particularly in the arm, difficulty lifting objects and walking, balance issues.
Diagnosis: N/A.
History of Patient: Experiencing weakness throughout the left side of the body, affecting arm mobility, walking, and balance.
Plan of Action: N/A.
Doctor: Did you have any medical disorders previously, sir? 
Patient: I have diabetes. Also, I was quite overweight. 
Doctor: Are you taking any medications for that? 
Patient: Yes, I was still taking something called Zyprexa, but I stopped it after my last regular weight check. Also, I never took anything for diabetes. I also have chronic bronchitis for… I don't know… many years. 
Doctor: Do you smoke? 
Patient: Oh yes, I am a smoker. 
Doctor: How many cigarettes do you take in a day? 
Patient: Maybe up to sixty a day.

Clinical note:
Symptoms: N/A.
Diagnosis: Diabetes, chronic bronchitis.
History of Patient: Patient previously overweight, stopped Zyprexa after weight check, chronic bronchitis for many years, heavy smoker (up to sixty cigarettes per day).
Plan of Action: N/A.
Doctor: Lets talk about your ears. Any continuous ringing or thumping noises you may hear? 
Patient: No, nothing like that.
Doctor: Any hearing problems?
Patient: Um, no.
Doctor: Any dizziness or spinning sensation?
Patient: Nope.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Denies continuous ringing or thumping noises in ears, hearing problems, dizziness, or spinning sensation.
Plan of Action: N/A.
Doctor: Good morning, ma'am. You're eighty two years old, is that correct? 
Patient: Good morning, doctor. Yes, that's correct. 
Doctor: Good, and just one more piece of background information, which hand do you write with?
Patient: I use my right hand for everything. 
Doctor: Good, so what seems to be the problem today?
Patient: Doctor, I've had years of pain in this shoulder. 
Doctor: What kind of treatments have you had?
Patient: Well, um, I've had antiinflammatories, and rested, and none of it has helped so far. 
Doctor: Can I assume the pain is impacting your daily life? 
Patient: Yes, it certainly is. The pain is unbearable now.

Clinical note:
Symptoms: Chronic shoulder pain.
Diagnosis: N/A.
History of Patient: Patient reports years of pain in the shoulder, unresponsive to anti-inflammatories and rest, impacting daily life.
Plan of Action: N/A.
Doctor: Have you ever had surgery? 
Patient: What, like a joint replacement?
Doctor: Well, anything from joint replacements, to appendix removal, or C sections?
Patient: Yeah, I've had an appendectomy and hysterectomy, actually.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Previous surgeries include appendectomy and hysterectomy.
Plan of Action: N/A.
Doctor: Can you confirm your age for me, ma'am?
Patient: Absolutely, I'm sixty six now. 
Doctor: Good, so it's been about five months since you last evaluation for type two diabetes and high blood pressure. 
Patient: Yes, and I have a few other problems today, too. 
Doctor: Sure, we can treat all of them. What seems to be the problem today? 
Patient: I'm having some right shoulder pain. 
Doctor: Can you remember an injury to this shoulder? 
Patient: No, not that I can remember. 
Doctor: What aggravates your symptoms? 
Patient: It hurts when I move the shoulder. 
Doctor: Do you have any weakness, numbness, or tingling? 
Patient: No, I don't have any of that. 
Doctor: Okay, back to diabetes, how has that been progressing? 
Patient: Well, I can only check it in the morning, and it's usually less than one hundred. 
Doctor: Have you been checking your blood sugar two hours after meals? 
Patient: No, doctor, I haven't been. When I check them, it's normal though. 
Doctor: Do you have any records to prove that? 
Patient: No, I don't have that with me today. 
Doctor: That's important, do you have any other issues or concerns today? 
Patient: No, I can't think of anything. 
Doctor: Okay. I'm looking at your charts, and I see you had a benign breast biopsy done on June eleventh two thousand four. Did you have a repeat done after six months like they asked? 
Patient: No, I never had that done, I need to.

Clinical note:
Symptoms: Right shoulder pain, Main Complaint: Right shoulder pain, Aggravating Factors: Movement of the shoulder, Associated Symptoms: No weakness, numbness, or tingling reported
Diagnosis: Type 2 diabetes (controlled in the morning), High blood pressure, History of benign breast biopsy (follow-up needed)
History of Patient: 66-year-old female presenting for a five-month recheck on type II diabetes mellitus and hypertension. Denies injury to shoulder but experiences pain with certain movements, no weakness, numbness, or tingling. Only checks blood sugar in the morning, which has been below 100, hasn't checked two hours after meals, no records available. No other issues or concerns mentioned. Benign breast biopsy done on 06/11/04, advised to have a repeat mammogram after six months, which hasn't been done.
Plan of Action: Assessment and management of right shoulder pain, Review of blood sugar monitoring technique and scheduling a follow-up for comprehensive blood sugar monitoring, Evaluation and management of high blood pressure, Arrange follow-up for overdue breast biopsy repeat.
Doctor: What is your family medical history?  
Patient: None, that I know of.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Do you mind giving me a run down of his past medical history? I want to make sure it's all in his chart. 
Guest_family: Sure. I'll start with his surgeries. If I remember correctly, he had back surgery, a couple knee surgeries, and coronary artery bypass surgery with angioplasty. 
Doctor: I see. When did he have these done? 
Guest_family: I'd have to check, but I know he had back surgery in O nine. He has a history of high blood pressure and high cholesterol. He was recently diagnosed with B P H potentially linked to cancer. It's B P H, right? Or is it B H P? 
Doctor: If it's his prostate, then B P H is correct. 
Guest_family: Oh, he has high P S A levels, too. I think that's related to the prostate. 
Doctor: Is he currently experiencing any symptoms? 
Guest_family: He was complaining of pain earlier. He does have a history of fatigue, tiredness, and shortness of breath though. So far, he hasn't complained about the usual.

Clinical note:
Symptoms: Pain, fatigue, tiredness, shortness of breath.
Diagnosis: High blood pressure, high cholesterol, BPH (benign prostatic hyperplasia), potentially linked to cancer, elevated PSA levels.
History of Patient: Had back surgery in 2009. Also had knee surgeries and coronary artery bypass surgery with angioplasty. Recently complained of pain, history of fatigue, tiredness, and shortness of breath.
Plan of Action: N/A.
Doctor: How long have you been living with diabetes, sir? 
Patient: Oh, it's been about thirty five years now. 
Doctor: How long have you been taking insulin for this? 
Patient: Well, um, I've been taking insulin for about twenty years now. 
Doctor: Do you have any major medical conditions that I should know about? 
Patient: Yeah, um, prostate cancer. 
Doctor: How were you treated for this? 
Patient: I've had radiation. Oh, my P S A is zero point zero one, by the way.

Clinical note:
Symptoms: N/A.
Diagnosis: Diabetes (35 years), prostate cancer.
History of Patient: Taking insulin for 20 years. Treated for prostate cancer with radiation, PSA level is 0.01.
Plan of Action: N/A.
Doctor: So, what stomach symptoms are you experiencing?
Patient: I feel an intense burning in my throat. 
Doctor: When do you feel this?
Patient: It really hurts after eating food, especially junk food. 
Doctor: That's pretty consistent with reflux disease. 
Patient: Ah, yes. 
Doctor: I got your survey results back as well, let's discuss them.
Patient: Absolutely, please, what does it show.
Doctor: According to your answers, it looks like you have depression as well.

Clinical note:
Symptoms: Intense burning in throat after eating, especially junk food.
Diagnosis: Reflux disease, depression.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Any difficulty in swallowing?
Patient: No.
Doctor: Any nausea, vomiting or blood in your vomit?
Patient: No, no vomit at all. No problem there.
Doctor: Okay, any stomach pain?
Patient: No. 
Doctor: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Hello, ma'am. How are you feeling today? 
Patient: I'm sad and depressed. 
Doctor: I'm sorry to hear that. Why do you feel that way?
Patient: My cancer came back.

Clinical note:
Symptoms: Sadness, depression.
Diagnosis: Cancer recurrence.
History of Patient: N/A.
Plan of Action: N/A.
Doctor:  What's going on with you? What brings you here today? 
Patient: I am having loose watery stools for more than two weeks now. I feel very lethargic. I also have pain in my tummy.

Clinical note:
Symptoms: Loose watery stools for more than two weeks, lethargy, pain in tummy.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Are you allergic to anything? 
Patient: No.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: No allergies
Plan of Action: N/A.
Doctor: Are you a smoker? 
Patient: I used to smoke. I quit in nineteen sixty eight. 
Doctor: Excellent! Have you weighed your self recently? 
Patient: I weighed myself this morning. I am at one hundred and eighty three pounds. 
Doctor:  And how tall are you? 
Patient: I used to be five foot ten but I think I have been shrinking. 
Doctor: That is definitely a possibility. We do shrink as we go through life. I can have the nurse get your height after we do your exam. 
Patient: Okay.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Quit smoking in 1968.He quit smoking in 1968.  His current weight is 183 pounds.  His tallest height is 5 feet 10 inches
Plan of Action: N/A.
Doctor: Do you smoke?
Patient: No, I have never smoked in my entire life.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Welcome to the clinic, sir. 
Patient: Thank you. 
Doctor: Let us start with your medical history. 
Patient: I used to have seizures, but they have stopped now. 
Doctor: Was there a cause of the seizures? 
Patient: About seven years ago I had a traumatic stroke. They told me I had bleeding in the brain. After the stroke I was left with this weakness on my right side. 
Doctor: What part of your body is affected by the weakness? 
Patient: My arm, hand, and my face. 
Doctor: Do you have any other health problems? 
Patient: My liver is falling. It is because of all the alcohol that I have consumed over the years. I am not drinking anymore. 
Doctor: Are you being treated for your liver disfunctions? 
Patient: No. I just stopped drinking. I think I have diabetes. 
Doctor: What makes you feel like you have diabetes? 
Patient: I have been really thirsty, and I have been having numbness and tingling in my feet. 
Doctor: Oh okay. We can definitely do some test today to find out if you are diabetic or not.

Clinical note:
1.  Liver cirrhosis caused by alcohol.  This is per the patient. 2.  He thinks he is diabetic. 3.  History of intracranial hemorrhage.  He said it was subdural hematoma.  This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis. 4.  He said he had a seizure back then, but he does not have seizures now.
Doctor: Hi miss. How old are you?
Patient: I am sixteen. 
Doctor: What race do you identify as?
Patient: White. 
Doctor: Are you okay? You have a headache?
Patient: No I have a really bad migraine.
Doctor: Okay can you point to where you are feeling it the most?
Patient: Here, since Monday.
Doctor: Okay so mostly on the right frontal side and it's been forty eight hours now?
Patient: Yes, I am feeling a lot of pressure.
Doctor: I can understand the discomfort. Is it continuous or throbbing?
Patient: It is throbbing.
Doctor: On the scale of one to ten, ten being the worst, how would you rate it?
Patient: Nine or more.
Doctor: Have you ever experienced similar symptoms in the past?
Patient: No I haven't.
Doctor: Did you hit your head buy any chance?
Patient: No no. 
Doctor: Okay can you tell me if you have any fever or chills, congestion, cough cold like symptoms?
Patient: No. 
Doctor: Any nausea, vomiting, diarrhea or trauma anywhere?
Patient: No nothing like that.
Doctor: Anything from head to toe?
Patient: No everything else is fine.

Clinical note:
Symptoms: Intense constant right frontal headache, pressure type discomfort with throbbing component, mild nausea.
Diagnosis: N/A.
History of Patient: Onset of headache early on Monday, persistent for more than 48 hours, denies similar discomfort in the past, denies trauma.
Plan of Action: N/A.
Doctor: Has the patient signed a do not resuscitate order? 
Guest_family: Yes, she has. 
Doctor: Does she have a healthcare proxy or durable power of attorney? 
Guest_family: Yes, she has both.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: How are you doing today?
Patient: I have a long history of lung disease. COPD to be exact. Recently, I was experiencing a lot of coughing and shortness of breath even on walking from one room to another. All the time I felt sleepy, tired, or confused. 
Doctor: How is it now?
Patient: It is getting better. 
Doctor: What else?
Patient: I was also diagnosed with pneumonia; I was on trip and there they found it. It is also getting a lot better now, but doctor said to continue taking oxygen for some more time. 
Doctor: Oh wow!
Patient: With everything going on, I felt weak and tired and it looks like I have lost all my strength and muscle. 
Patient: I also felt very instable and had a fall. I did not call for any assistance but now I think I should have called someone. Everyone including my family and nurses all tell me all the time to call for assistance. I was just being stubborn and hurt myself.
Doctor: Did you use a wheelchair?
Patient: No. 
Doctor: You know I would agree with everyone else; you should call for assistance if you need help like getting out of bed or need to use the restroom.

Clinical note:
Symptoms: Coughing, shortness of breath, sleepiness, tiredness, confusion, weakness, muscle loss, instability.
Diagnosis: COPD exacerbation, community-acquired pneumonia (both resolving), generalized weakness, deconditioning, fall secondary to instability.
History of Patient: Long history of lung disease (COPD), recent exacerbation with Symptoms including coughing, shortness of breath, sleepiness, tiredness, confusion; diagnosed with pneumonia while on a trip, currently improving but still requiring oxygen therapy; experienced a fall due to instability and failure to use assistance despite being advised by family and nurses to do so.
Plan of Action: Continue home oxygen therapy for a short period, address generalized weakness and deconditioning, emphasize the importance of calling for assistance when needed.
Doctor: Were there any medical issues in the past? 
Patient: Oh, I have a list. I have asthma and sinus issues. I also had hives at some point and psoriasis. 
Doctor: How about allergies? 
Patient: I don't know of any.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Asthma, sinus issues, hives, history of psoriasis.
Plan of Action: N/A.
Doctor: Do you use tobacco products, alcohol, or recreational drugs, miss? 
Patient: I have a drink every once and a while. 
Doctor: How many drinks do you consume in a week? 
Patient: I don't even drink that often. I probably have one drink per month. 
Doctor: Are you married? 
Patient: I was engaged but that is not happening anymore. It is a long story. 
Doctor: I am sorry the hear that. What do you do for work? 
Patient: I am a metal grinder.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Consume Alcohol.
Plan of Action: N/A.
Doctor: Now that you're eighteen, I have a big question to ask you. Do you smoke? 
Patient: Never have, never will. 
Doctor: That's what I like to hear. You have a good head on your shoulders, bud. 
Patient: Thanks. I'd like to think so, too. I have some friends who smoke weed, but stay clear of tobacco.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Doctor: Have you ever been diagnosed with any illnesses? 
Patient: No, I do not have any diseases.
Doctor: How about any issues with B P, thyroid, diabetes?
Patient: Nope none.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
Guest_clinician: Any history of drug or alcohol use? 
Doctor: He was a former smoker and tested positive for cocaine during his last visit in January O eight.

Clinical note:
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Habit of Smoking and Cocaine Positive.
Plan of Action: N/A.
Doctor: I just quickly wanted to check few things, let's go over them together? 
Patient: Sure.
Doctor: Any heart condition like heart failure or anything?
Patient: No.
Doctor: Any heart catheterization? 
Patient: Um, no.
Doctor: Any history of chest pain, palpitation, or irregular heartbeat? 
Patient: No.
Doctor: Do you have high blood pressure?
Patient: No.
Doctor: Any history of high cholesterol? 
Patient: No. 
Doctor: Any excessive or abnormal sweating?
Patient: Not really, no.
Doctor: Any stress test or heart tests done recently? 
Patient: No.
Doctor: Okay, thank you for answering these questions. 
Patient: No problem.

Clinical note:
Symptoms: No palpitations, irregular rhythm, chest pain, diaphoresis.
Diagnosis: N/A.
History of Patient: No history of hypertension, hyperlipidemia, congestive heart failure, heart catheterization, stress test, or recent cardiac tests.
Plan of Action: N/A.
Doctor: Hello Miss Sherry, how are you doing today?
Patient: I have seen worse days. 
Doctor: Ha, I will take that as a positive answer then. I have my resident here with me, Doctor Helm, she will be representing your case today.
Guest_clinician: Hello.
Patient: Hello Doctor Helm.
Doctor: Doctor Helm. 
Guest_clinician: The patient is a sixty one year old female. She was diagnosed with non small cell lung cancer stage one A in the upper right lobe. She was treated with CyberKnife and the treatment was completed one month ago. This is her first visit after the CyberKnife treatment.
Doctor: Thank you Doctor Helm. So, Miss Sherry, how are you doing after the treatment?
Patient: I feel nauseous. 
Doctor: How would you define it mild, moderate, or severe? 
Patient: I would say mild. 
Doctor: What about vomiting?
Patient: No, only nausea is there. If I try to take deep breaths, then I still have pain. 
Doctor: How is your dysphagia? Are you able to swallow and eat your food and drink now?
Patient: It has been better now. I won't say I am all good but as I said I have seen the worst days. 
Doctor: Is there any heartburn or rash?
Patient: No.
Doctor: Are you coughing up blood, or just cough?
Patient: No, none of them. 
Doctor: Let me exam for any rib pain, okay?
Patient: Okay. 
Doctor: Any pain if I touch you here or here?
Patient: No.

Clinical note:
Symptoms: Mild nausea, pain with deep inspiration, resolving dysphagia.
Diagnosis: Non-small cell lung cancer stage IA (treated with CyberKnife therapy).
History of Patient: Completed CyberKnife treatment one month ago, experiencing low-level nausea without vomiting, no heartburn, cough, hemoptysis, rash, or palpable rib pain.
Plan of Action: N/A.