X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: Hello Miss Long, I see that you have been referred today by A B C, D O, for a reevaluation. Are you having issues with your hand eczema again? 
Patient: Yes, it has been flaring. 
Doctor: Can you confirm your age for the records please? 
Patient: Sure, I'm twenty nine. 
Doctor: If I'm not wrong, you are from Vietnam, right? 
Patient: That's right.
Doctor: Are you married? Single or with a partner? 
Patient: I'm single. 
Doctor: Are you working somewhere? 
Patient: No, currently I'm unemployed.
Doctor: Okay, since you are an established patient here in our dermatology department, let me just update all your information into the records. 
Doctor: Okay according to my records we have last seen you here in our office on July thirteenth of two thousand and four.
Patient: Yeah, I think so.
Doctor: I have previously treated you with Aristocort cream and Cetaphil cream. I also ask you to increase your moisturizing cream and lotion and asked you to wash your hands in Cetaphil cleansing lotion.
Patient: I've been doing all that, but now it looks like my eczema is flaring. I have these cracks in my hands and they feel very dry. 
Doctor: Have you been washing your hands with Cetaphil cleansing lotion? 
Patient: No, I was using soap. The Cetaphil cleansing lotion was not working.  I had a lot of pain and burning sensation whenever I tried to use that. 
Doctor: It may be because of the fissures. I mean those cracks in your hands. 
Patient: I have been wearing gloves as much as I can. 
Doctor: Okay.

Clinical note:
Symptoms: Hand eczema flaring, dry and cracked hands, pain and burning sensation
Diagnosis: N/A
History of Patient: Established patient of dermatology, last seen on 07/13/04, previously treated with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, instructed to wash hands with Cetaphil cleansing lotion; currently experiencing flare despite compliance with treatment, attributed to use of soap instead of Cetaphil cleansing lotion causing pain and burning due to fissures, wearing gloves as much as possible
Plan of Action: N/A
Doctor: Have you been applying Triamcinolone zero point one percent three times a day to your rash? 
Patient: The one on my left wrist? 
Doctor: Yes. And Bactroban ointment is also three times a day as needed for your bug bites. 
Patient: Yep. 
Doctor: Are you still using Nystatin on your lips once a day as needed? 
Patient: Uh yeah. I've been using it much less now. 
Doctor: So let's see, your other medications are the same as of July thirtieth O four with the exception of Klonopin?  
Patient: Yeah, I mean I'm taking four M G in the morning and six M G at night instead of the six M G and eight M G that was recommended. I feel like I do better with the lower doses.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Using Triamcinolone 0.1% cream three times a day on left wrist rash, using Bactroban ointment three times a day as needed for bug bites on legs, using Nystatin ointment on lips once a day as needed (previously four times a day), Klonopin dose adjusted to 4 mg in the morning and 6 mg at night instead of 6 mg and 8 mg as previously recommended
Plan of Action: N/A
Doctor: So, I am looking at your reports, you don't have anemia or any other blood disorders. 
Patient: Well, that's a relief!
Doctor: Yeah. 
Doctor: Let me check your lymph nodes. They are nonpalpable. I don't see any swollen glands or anything. 
Patient: Great!

Clinical note:
Symptoms: N/A
Diagnosis: HEMATOLOGIC/LYMPHATIC:: Normal; Negative for anemia, swollen glands, or blood disorders.
History of Patient: N/A
Plan of Action: N/A
Guest_family: Hi, how are you?
Doctor: I am well, how's the baby? I see that he is eight pounds and thirteen ounces, and he was born via…?
Guest_family: Yes, C section. Yeah, he is he has never been hospitalized. He was born a week early.
Doctor: Okay, I would like to ask you some questions about the pregnancy and other history. 
Guest_family: Yes, sure go ahead.
Doctor: Great, have you had any infections during pregnancy like G B S or S T D infections?
Guest_family: No, I haven't, I only had thumb and toenail infections and we treated that with rubbing alcohol. We have a history of boils in the family, so I am not afraid of minor infections like this. 
Doctor: Did you smoke during pregnancy? 
Guest_family: Yes, I did, but stopped after five months.
Doctor: Sir, have you had any S T D while she was pregnant?
Guest_family_2: No, I was not diagnosed with anything unusual.
Doctor: Great, so looks like you were discharged in forty eight hours and no more hospital stays for you.
Guest_family: That is correct.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: 8 pounds 13 ounces term baby born 1 week early via planned repeat C-section, mom denies infections during pregnancy except for thumb and toenail infections treated with rubbing alcohol, negative GBS status, mom smoked up to last 5 months of pregnancy, both parents deny sexually transmitted diseases or genital herpetic lesions, mom and baby discharged from hospital within 48 hours, no hospitalizations for patient so far
Plan of Action: N/A
Doctor: Welcome to the clinic, sir. I am Doctor Jones. 
Patient: Thank you. It is nice to meet you. 
Doctor: Do you use tobacco products? 
Patient: Yes. I smoke cigarettes. I am working on quitting. 
Doctor: I am glad you are attempting to quit. We have a lot of tools now to help with cravings. How much do you smoke per day now? 
Patient: I smoke about a pack a day. 
Doctor: Do you drink alcohol or use recreational drugs? 
Patient: I drink but I don't do any drugs. 
Doctor: How many alcoholic drinks do you consume per week? 
Patient: I drink about four drinks per night. I used to drink a lot more than that. I have cut back on my drinking.  
Doctor: Are you physically active? Do you exercise?
Patient: I was very athletic when I was growing up. Now I don't exercise on a regular basis.
Doctor: What do you do for employment? 
Patient: I am a network engineer. I work for Shepherd Pratt.
Doctor: Are you married? 
Patient: Yes. I have been married to my wife for five years now. 
Doctor: Do you live at home with your wife and or is there anyone else living in your home?
Patient: No. Just me and the wife.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Smokes one pack of cigarettes per day, working on quitting; drinks four alcoholic beverages per night, previously drank more; denies illicit drug use; was athletic growing up; works as a network engineer at Shepherd Pratt; married for five years, lives with wife
Plan of Action: N/A
Doctor: Are you married? 
Patient: I'm divorced. 
Doctor: So, do you live alone? Or do you have kids? 
Patient: I live with my girlfriend, and we have a kid together. I also have three other kids from my former wife. 
Doctor: Do you smoke? 
Patient: I used to smoke. But I, I've quit like fifteen years ago. 
Doctor: What about alcohol? 
Patient: Yeah, I drink beer. Around one to two beers a day. 
Doctor: Are you working? 
Patient: I'm retired right now, but I used to work in an iron company.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Divorced, lives with girlfriend and one child from current relationship, three children from former marriage, former smoker (quit over 15 years ago), drinks 1-2 beers per day, retired from work, former ironworker
Plan of Action: N/A
Doctor: Do you want to go home?
Patient: Yes, I do. Can I?
Doctor: Yes, you sure can.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Discharge to home
Doctor: Are you studying? 
Patient: Yes. I'm doing my major in computer science. 
Doctor: Do you live alone? 
Patient: No, I live in my family. Mainly my parents and my sisters.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Have you ever had surgery before?
Patient: No, not that I know of. 
Doctor: So, no gallbladder removal, or joint replacements?
Patient: Unless they did it while I was sleeping, but none that I can remember.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No previous surgeries
Plan of Action: N/A
Doctor: I remember you had mentioned that one of your family members had bone cancer. Are there any other medical problems that run in your family? 
Patient: Sadly, yes. Stroke and dementia are the other two big ones. 
Doctor: I'm sorry to hear that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Family history of stroke, bone cancer, and dementia
Plan of Action: N/A
Doctor: Are you allergic to any meds?
Patient: Me?
Doctor: Yes.
Patient: No, I am not.
Doctor: Are you sure?
Patient: Yes, I am damn sure. 
Doctor: Okay great!

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: What's bringing her in today? 
Guest_family: Oh, doctor. She hasn't been doing well at all. 
Guest_family: I think she's actually gotten worse. 
Doctor: I understand. I'm sorry to hear that she hasn't been feeling well. Let me see what we can do for her today. 
Guest_family: I haven't taken her temperature since this morning. It was one hundred and three degrees when she woke up. 
Doctor: What time did she wake up today? 
Guest_family: Um, around eight I believe. She also suffers from apnea.
Doctor: It looks like she has an upper respiratory infection. 
Guest_family: Is she going to get better? 
Doctor: Yes, she should feel better once we start treating the infection. But I'm worried it may be pertussis.

Clinical note:
Symptoms: Upper respiratory illness, fever (103°F), apnea
Diagnosis: Possible pertussis
History of Patient: N/A
Plan of Action: N/A
Doctor: And you've had recurring abscesses for the past two years, correct? 
Patient: Unfortunately, yes. 
Doctor: Where have they been located? 
Patient: Um in the public area and my thighs. 
Doctor: Have you ever needed to get an abscess drained? 
Patient: Yeah. I've gotten about four I and D's.

Clinical note:
Symptoms: Recurring abscesses
Diagnosis: N/A
History of Patient: Recurrent abscesses in the pubic area and thighs for the past two years, undergone about four incision and drainage (I&D) procedures
Plan of Action: N/A
Doctor: How's your overall health? 
Patient: Fine, I guess. I'm being treated for I B S by my G I. Last time I was in, they told me that my white blood cell levels aren't where they were supposed to be.

Clinical note:
Symptoms: N/A
Diagnosis: Episodic leukopenia, mild irritable bowel syndrome
History of Patient: Being treated for irritable bowel syndrome (IBS) by gastroenterologist, last visit revealed white blood cell levels not within normal range
Plan of Action: N/A
Doctor: Do you have any family history of chronic illnesses that I should know about? 
Patient: What do you mean by that?
Doctor: Well, it could be anything from depression, to arthritis, to cancer. 
Patient: Oh yeah, my mom has arthritis.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Family history of arthritis (mother)
Plan of Action: N/A
Doctor: How are you moving around? Are you able to perform your day to day activities?
Patient: Little bit, not so much.
Doctor: So just listen to your body and go around as much as you can.
Patient: Okay.
Doctor: Do not overstress yourself.
Patient: Okay I can do that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Activity advised "as tolerated," caution against overexertion
Doctor: Are you allergic to anything?
Patient: No, I am not allergic.
Doctor: Okay.
Patient: Yeah.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Remind me, how did he hurt himself?
Guest_family_1: He was riding quads on October tenth two thousand seven when he got thrown off. 
Doctor: Yes, and we did O R I F on his fracture dislocation of the left elbow. 
Guest_family_1: Yes, he also fractured the neck of his right glenoid, um, if I remember correctly. 
Doctor: Which hand does he write with? 
Guest_family_1: He writes with his right hand. 
Doctor: Okay. That fracture appears to have healed very well; kids generally heal pretty well. How does it feel today? 
Guest_family_1: Yes, he's only ten. He's been pretty stiff, so he's been going to P T, and using his Dynasplint.
Doctor: That's good that he is already in P T. His left elbow fracture is healed, so we should do another surgery in order to remove that hardware. That may help decrease some of the irritation with elbow extension. He looks neurologically intact in terms of movement and reflexed in his wrist and hand. 
Guest_family_1: Yes, I agree. What is the risk of infection of this surgery? 
Doctor: Historically, the risk of infection is less than one percent. 
Guest_family_1: Oh, wow, that's low, how is that possible? 
Doctor: We'll use prophylactic antibiotics, this controls for infection, and helps keep everything clean. Other Risks include bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, and continued postoperative stiffness.
Guest_family_1: Wow, that's great, will be he asleep the entire time? 
Doctor: Yes, we'll use anesthesia, he won't feel a thing. 
Guest_family_1: Will this fix his pain, for sure?
Doctor: I can't guarantee it, he may still be in some pain. 
Guest_family_1: Okay, what about you, dear? What do you think?
Guest_family_2: Yeah, I think we should do it, boys should be playing sports with their friends.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: 10-year-old right-hand dominant male threw himself off a quad on 10/10/2007, underwent open reduction and internal fixation of left elbow fracture dislocation, sustained nondisplaced right glenoid neck fracture, experiencing postoperative stiffness treated with physical therapy and Dynasplint, neurologically intact distally
Plan of Action: Surgery recommended for hardware removal from left elbow to decrease irritation with elbow extension, risks discussed include anesthesia, infection, bleeding, changes in sensation and motion of extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness; parents agreed to the plan
Doctor: Since you have a family history of coronary heart disease, let me check you for its risk factors.
Patient: Yeah, my father had it.
Doctor: Any history of high blood pressure or diabetes? 
Patient: No.
Doctor: How about smoking, do you smoke? 
Patient: No, I don't smoke.
Doctor: And in the past, did any other Doctor mention that you might have sign or symptom indicating that you may have coronary artery disease?
Patient: No.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: CORONARY RISK FACTORS: No history of hypertension or diabetes mellitus.  Active smoker.  Cholesterol status, borderline elevated.  No history of established coronary artery disease.  Family history positive.
Plan of Action: N/A
Doctor: Who all are there in your family?
Guest_family: It's me, my husband, my two older kids and this little baby.
Doctor: Everyone living together?
Guest_family: Yes
Doctor: Is she going to any daycare?
Guest_family: No, she's at home all the time.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Currently lives with mom, dad, two siblings, at home full time, does not attend daycare
Plan of Action: N/A
.
Doctor: Do you drink?
Patient: Oh, I do but occasionally. Who doesn't like a nice cocktail! 
Doctor: Okay. How about cigarettes, do you smoke?
Patient: No, I don't smoke.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No smoking, occasional alcohol consumption
Plan of Action: N/A
Doctor: I am okay.
Patient: I have bad nausea.
Doctor: Oh, so sorry.
Patient: And I feel very dizzy like I am going to faint.
Doctor: Okay let me see what is going on.
Patient: Okay.

Clinical note:
Symptoms: Nausea, feeling faint
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: What brings you into the office today?   
Patient: I had a stroke about a month ago. The right side of my face is still not moving. 
Doctor: Is it only the right side of the face that is affected by paralysis? 
Patient: Yes. It has improved a little bit since I was in the hospital.  
Doctor: That is a good sign. It can take up to six months see how much movement you will regain.

Clinical note:
Symptoms: Right-sided weakness
Diagnosis: N/A
History of Patient: Had a stroke about a month ago, right side of face affected by paralysis, some improvement since hospitalization
Plan of Action: N/A
Doctor: Do you use tobacco? 
Patient: What, like smoke cigarettes? 
Doctor: Yes ma'am, do you? 
Patient: Oh, no. I don't do anything like that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Nonsmoker
Plan of Action: N/A
Doctor: Have you ever had surgery, ma'am? 
Patient: Yes, I had it for melanoma some time ago. 
Doctor: I see here that you had a hysterectomy as well, is that correct? 
Patient: Oh, yes, that's true. I had that done too.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Surgery for melanoma, hysterectomy
Plan of Action: N/A
Doctor: So, let's see here. You don't recall anyone in your family having a history of neuromuscular diseases, correct?
Patient: No, no one I can think of. 
Doctor: Do you know of anyone who has had foot deformities or neuropathy in their arms or legs?
Patient: No, not one person comes to mind.
Doctor: Great. Does anyone in your immediate family have a high arch?
Patient: No, at least no one that I know of.
Doctor: And you said that your aunt or sister has type two diabetes?
Patient: My aunt. She's had it for some time now.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No family history of neuropathy, pes cavus, foot deformities, or neuromuscular diseases; aunt has history of type II diabetes
Plan of Action: N/A
Doctor: So, what I feel is you might have short term memory loss due to high stress, but I also feel it's probably due to your current situation. The other impression I have is that you have anxiety issues and again it's stress related. 
Patient: Yeah, I do have anxiety issues.

Clinical note:
Symptoms: Short-term memory loss (probable situational), anxiety
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Who's my patient today?
Guest_family: Today, it's my brother.
Doctor: What seems to be the problem today?
Guest_family: Well, he's a vegetarian but he has high cholesterol and he's on a medication to control it.
Doctor: Has he changed his diet?
Guest_family: Yes, he did when he got a letter saying that his fat levels were high in the blood.
Doctor: What kinds of foods did he eliminate?
Patient: Oh, you know, all of the fun ones. Like cappuccino, quiche, crescents, candy, vending machines, all of that stuff.
Doctor: Do you take your lunch to work?
Patient: Yes, I do about three or four times a week instead of eating out so much.
Doctor: Are you exercising right now?
Patient: Yes, I do about six or seven days a week.
Doctor: What kind do you like to do?
Patient: Well, I do just about everything. I swim, I bike, run and then I lift weights.
Doctor: How long do you workout per day?
Patient: Usually, it's about one and a half to two and a half hours every day.
Doctor: Good, are you training for anything specific?
Patient: Actually, yes I'm going to do a triathlon.
Doctor: Can I assume you're losing weight?
Patient: Yes, I am.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Brother is a vegetarian with elevated cholesterol, on medication to control it; improved diet after receiving letter about elevated lipids, eliminating foods like cappuccino, quiche, crescents, candy from vending machines; packing lunch 3-4 times per week instead of eating out; exercising 6-7 days per week (swimming, biking, running, weightlifting) for 1.5-2.5 hours each session; training for a triathlon; losing weight
Plan of Action: N/A
Doctor: The patient has possible free air in their diaphragm. 
Guest_clinician: How old is the patient?
Doctor: Seventy six. 
Guest_clinician: Past medical history? 
Doctor: Unknown as of now.

Clinical note:
Symptoms: N/A
Diagnosis: Possible free air under the diaphragm
History of Patient: N/A
Plan of Action: N/A
Doctor: Out of ten, ten being the worst pain imaginable, how would you rate your pain today? 
Patient: Today it's about a six or seven, and it's usually pretty constant there. 
Doctor: Does the pain change with the weather? 
Patient: Yes, when it's cold out it turns to ten out of ten. It's better when it's warm out. 
Doctor: Does the pain change throughout the course of the day? 
Patient: Yes, it progressively gets worse and worse as the day goes on, but I also have a pretty hard time getting out of bed in the morning, too. 
Doctor: Out of ten, how would you rate your pain at night? 
Patient: Oh, it's ten out of ten. 
Doctor: Does the pain wake you up at night? 
Patient: If I sleep at all. I'm not sleeping well at all, and when I do it's for less than an hour at a time. 
Doctor: Are there any activities that really aggravate the pain? 
Patient: Yes, if I sit for more than about twenty minutes, or if I lay flat on my back. 
Doctor: Does anything alleviate the pain?
Patient: Laying on my side helps a little.

Clinical note:
Symptoms: Constant pain (baseline 6-7/10), worsening to 10/10 at night or in cold weather, less severe in warmer weather, worsens throughout the day, difficulty getting out of bed in the morning, poor sleep (less than one hour at a time), aggravated by sitting for more than 20 minutes or lying supine, eased by side lying position
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Guest_family: For as long as I have been taking care of her, she has had this tracheal tube and she barely speaks. She mostly signals if she needs anything.
Doctor: Okay. It's mentioned in her report that she has a history of smoking.
Guest_family: She is nodding yes. 
Doctor: Well, it's alright. I think it's going to be difficult taking any past medical information from her.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Previously a smoker; currently has a tracheostomy and communicates mainly through signals
Plan of Action: N/A
Doctor: Have you been taking anything for high blood pressure? 
Patient: Yeah, I started taking Toprol and uh the one that starts with an A. I forget what it's called. 
Doctor: Hm are you talking about Avalide? 
Patient: Oh right, yeah that's the one.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Taking Toprol and Avalide for hypertension and anxiety
Plan of Action: N/A
Doctor: Good afternoon, ma'am. Before we begin, may I ask how old you are? 
Patient: Good afternoon, doctor. I'm fifty six years old, now. 
Doctor: Great, thank you. What seems to be the problem today, ma'am? 
Patient: Well, I need some support for dietary recommendations for healthy eating for my husband and me. 
Doctor: Why would that be, ma'am? 
Patient: Um, I have a lot going on, high cholesterol, high blood pressure, acid reflux, and I just want to lose some weight. My husband has high cholesterol too. 
Doctor: Tell me more about your eating habits, please. 
Patient: Well, we live by ourselves now that our children are gone, but I'm used to cooking really large portions. 
Doctor: Are you struggling to make food for just two people? 
Patient: Yes, that's a good way to put it. I'd like to just make less food, that way we're not so tempted to eat so much. 
Doctor: I understand, are you busy, do you work? 
Patient: Well, I start a new job this week.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: 56-year-old female seeking dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease, and weight reduction; husband also diagnosed with high blood cholesterol; struggling with adjusting to preparing food for two people after cooking for larger portions; starting a new job
Plan of Action: N/A
Doctor: Hello! What brings you into the office today?
Patient: Hi! I have not been able to go pee, and I have had this sharp pain in my left side. 
Doctor: Have you recently had any surgical procedures?
Patient: No. 
Doctor: Do you have a history of an enlarged prostate or kidney stones? 
Patient: No. 
Doctor: I would like to get some imaging done. 
Patient: Okay.

Clinical note:
Symptoms: Left flank pain, unable to urinate
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Imaging ordered
Doctor: Has he ever had any mental retardation problems in the past? 
Guest_family: No. 
Doctor: Did he go through mainstream education? 
Guest_family: Yes, he graduated high school last year. He had an I E P. He has a job now. 
Doctor: Oh really. That's great. 
Guest_family: We went through a program for the disabled to find him the job. He is doing well. 
Doctor: What is the job? 
Guest_family: He works at cardboard shop. 
Doctor: So, he is ambulatory. No issues with performing the work. 
Guest_family: No! His boss said he is doing very well.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: And you are-
Guest_family: Hi, I am her nurse. 
Doctor: So, do you know about her past medical history?
Guest_family: I have very limited information, as I very recently started working with her. She does have dementia and that's the main reason why I was hired. Her family wanted someone to look after her twenty four seven. 
Doctor: Oh, I see. 
Guest_family: But I do have her medical records. You can have a look.
Doctor: Yeah, that will be nice. Let me check her reports quickly. She has a history schizophrenia, chronic anemia and hypothyroidism and she also suffers from asthma. 
Guest_family: Yes. 
Doctor: Oh, I also see here she tested positive for P P D, was she diagnosed with tuberculosis? 
Guest_family: I honestly don't know, but I wasn't told that.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: Dementia, asthma, chronic anemia, hypothyroidism, schizophrenia, positive PPD in the past
History of Patient: N/A
Plan of Action: N/A
Doctor: Your last visit was on April seventh two thousand five, correct. 
Patient: Ah no, it was on April eighth two thousand five, doctor. 
Doctor: That's right. So, has anything changed since then?
Patient: No, everything is the same really.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Unchanged from last visit of 04/08/2005.
Plan of Action: N/A
Doctor: Any nausea, vomiting or diarrhea?
Patient: Nope.

Clinical note:
Symptoms: No nausea, vomiting, diarrhea
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Guest_family: What do you think doctor, what does she have?
Doctor: Well, I think she has hay fever. Otherwise she looks like a healthy two year old.
Guest_family: Hm, okay.

Clinical note:
Symptoms: N/A
Diagnosis: hay fever
History of Patient: Otherwise healthy 2-year-old young lady
Plan of Action: N/A
Doctor: Hello, sir. I'll be your doctor today. How are you feeling? 
Patient: Um uh who? Where am I? 
Doctor: You're in the emergency room. 
Patient: I'm where? 
Doctor: The police found you outside of the local bar. Do you remember what happened prior to your arrival here? 
Patient: I'm no longer at the bar? 
Doctor: No, you're here because someone was worried you may need medical attention.  
Patient: I don't know what's going on. Can you call my girlfriend? She was there with me before we got into a fight.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Not obtainable as the patient is drowsy and confused
Plan of Action: N/A
Doctor: How's your husband doing? 
Patient: He's good. He usually comes with me to my appointments, but he had to run some errands this morning. 
Doctor: Happy to hear that he's also doing well.  
Patient: Me too.  
Doctor: I just have one more question for you regarding your social history. Do you smoke? 
Patient: No, never. 
Doctor: Okay, so no changes.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Married, nonsmoker
Plan of Action: N/A
Doctor: How are you feeling today?  
Patient: I am doing good, considering.  
Doctor: Are you sleeping well?  
Patient: Yes.  I was able to get some good sleep last night.   
Doctor: Have you been able to eat without any trouble?  
Patient: Yes. I ate a little bit of breakfast this morning.  
Doctor: Have you been able to have a bowel movement yet?  
Patient: Yes, I did this morning.  
Doctor: Did you experience any difficulties with your movement?  
Patient: It was still a little difficult and hard.  
Doctor: Okay. Continue the high fiber diet that we discussed, and it should improve. Please let me or one of the nurses know if it has not improved or becomes worse.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Eating fairly well, sleeping well, experiencing a little difficulty with stools being hard
Plan of Action: Continue high fiber diet, inform doctor or nurses if condition does not improve or worsens
Doctor: Our records show that he is up to date with his vaccinations.
Guest_family: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Up-to-date with vaccinations
Plan of Action: N/A
Doctor: Are you allergic to any medications? 
Patient: No

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: None
Doctor: So, do you remember when your last pap smear was? 
Patient: I have it written down right here in my notes. It was in October of two thousand one. 
Doctor: Great, do you have any children?
Patient: Yes, I have a beautiful daughter. 
Doctor: That's wonderful. Have you only been pregnant once? 
Patient: Yes, I've just pregnant once and it was with my daughter.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Last pap smear in October 2001. Pregnant once
Plan of Action: N/A
Doctor: Have you undergone any surgeries? 
Patient: I had both my tubes tied in O one and I had a polyp removed when I was fourteen. 
Doctor: And that was a- 
Patient: Oh, sorry I didn't mean to interrupt. 
Doctor: It's alright. I just wanted to know if that polyp was found in your colon? 
Patient: Yes, it was.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Bilateral tubal ligation in 2001, colon polyp removed at 14 years old
Plan of Action: N/A
Guest_family: Doctor can you check my baby boy?
Doctor: Yes for sure.
Guest_family: He has a fever.

Clinical note:
Symptoms: Fever
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Where's your rash? 
Patient: All over my torso and arms. 
Doctor: When did you first notice it? 
Patient: Well, it started on my back and then it made its way to my torso and arms. 
Doctor: Have you found yourself itching it? 
Patient: Yes.  
Doctor: Any potential triggers for the rash, such as dietary changes, new medications, or unfamiliar exposures? 
Patient: Nope. I mean I did remove some insulation in my basement a few days ago, but I didn't feel itchy that day. 
Doctor: Any shortness of breath, wheezing, facial swelling, tongue or lip swelling, or other associated symptoms? 
Patient: No.

Clinical note:
Symptoms: Itchy rash all over torso and arms
Diagnosis: No facial swelling, no tongue or lip swelling, no shortness of breath, wheezing, or other associated Symptoms, no identifiable triggers 
History of Patient: Possible exposure to insulation removal in basement a few days ago
Plan of Action: N/A
Doctor: Are you allergic to anything? 
Patient: As in drugs? 
Doctor: Yes, sorry. I was referring to drug allergies.
Patient: Oh yeah. I'm allergic to Sulfa drugs. 
Doctor: What happens when you take Sulfa drugs? 
Patient: Break out in a terrible rash. I remember I had to go to the E R the first and last time I took it. 
Doctor: Wow, I'm sorry. Rashes can be very uncomfortable and sometimes require immediate attention. 
Patient: Yeah, so no more Sulfa drugs for me. That's for sure.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Allergic to Sulfa drugs, breaks out in a terrible rash upon taking them, required ER visit after first and last exposure
Plan of Action: N/A
Doctor: Do you smoke? 
Patient: Yes. 
Doctor: How much do you smoke? 
Patient: Honestly, I smoke every day.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Current smoker, smokes every day
Plan of Action: N/A
Doctor: Does any of your family member have any major medical problems?
Patient: Yeah, my mother died of heart attack. She was seventy years old. My father died of cancer; it was prostate cancer. He was around eighty.
Doctor: Anything anyone else?
Patient: Hm, my brother had both heart disorder and prostate cancer and he died around seventy four.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Mother died of myocardial infarction (MI) at age 70, father died of prostate cancer at age 80, brother had coronary artery disease (CAD) and prostate cancer, died at age 74
Plan of Action: N/A
Doctor: Where's your pain? 
Patient: Right above my belly button. It's been bothering me for three weeks now.  
Doctor: Does the pain come and go? 
Patient: Um it's pretty constant, but it does seem to get worse at night. 
Doctor: Do you find that sitting or laying down in certain positions helps the pain? 
Patient: Eh not really. I can't seem to really get comfortable since it started. 
Doctor: Have you taken any medicine for the pain? 
Patient: I uh- 
Doctor: Yes? 
Patient: Um I took Pepto Bismol a few times, but that didn't do much. 
Doctor: Did they already take you back for your C T scan? 
Patient: Yeah. 
Doctor: We should be getting the results of your scan fairly soon then. In the meantime, I'm going to put in some additional orders.

Clinical note:
Symptoms: Abdominal pain and discomfort for 3 weeks
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Patient: Good morning, doctor. 
Doctor: So, I've reviewed your past notes, are there any other diagnoses I should know about?
Patient: Well, I've had depression for a while now. 
Doctor: Thank you for sharing that with me.

Clinical note:
Symptoms: N/A
Diagnosis: Depression
History of Patient: N/A
Plan of Action: N/A
Doctor: Good afternoon, ma'am. 
Patient: Good afternoon, doctor. 
Doctor: So, what do you do for a living? 
Patient: Right now, actually, I'm not working. 
Doctor: That's okay, I'm not here to judge. Are you married? 
Patient: No, I'm happily single right now. 
Doctor: Good for you, do you have any kids? 
Patient: No, I don't have any, its just me. 
Doctor: Do you drink or smoke? 
Patient: No, I don't do any of that. 
Doctor: Good, and do you use anything harder? Like illicit drugs? 
Patient: No, I absolutely do not. 
Doctor: Good, and with ten being the most stressful day every, how would you rate your stress level out of ten?
Patient: Today, I'd say its about an eight out of ten.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Not working, stress level rated at 8/10, single with no children, does not smoke, drink, or use illicit substances
Plan of Action: N/A
Doctor: Hello. How are you doing today?
Patient: My head has been hurting a lot. 
Doctor: I see. Did the nurse come in and ask you questions about past medical history?
Guest_clinician: Sorry, Doctor. I was looking for you. I reviewed his history with him, and nothing has changed. 
Doctor: Perfect. Let's do some tests to see why your head has been hurting.
Patient: I'm ready for less pain. Let's go.

Clinical note:
Symptoms: Headache
Diagnosis: N/A
History of Patient: Otherwise unchanged
Plan of Action: N/A
Doctor: We're going to check around your knee now. 
Patient: Okay, sounds good. 
Doctor: Looks like your deep tendon reflexes are the same on both legs. Sensation seems great and intact.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: NEUROLOGIC: Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.
Plan of Action: N/A
Doctor: Can you tell me something about your family? Any illnesses in family? 
Patient: My dad's mom has diabetes and hypertension and my dad's dad had emphysema and he was a smoker.
Doctor: Okay.
Patient: Yeah.
Doctor: Is there any history of death of child who was less than a year maybe? 
Patient:  No, there isn't.
Doctor: Okay. That's great. No illnesses for small children?
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Paternal grandmother has diabetes and hypertension, paternal grandfather had emphysema and was a smoker, no children needing pediatric subspecialist or any childhood deaths less than 1 year of age
Plan of Action: N/A
Doctor: Alright, I am looking at your urine report and it confirms what I was suspecting. You have a urinary tract infection.
Patient: I kind of knew it was a U T I. I have had it before, but nothing this painful and severe. I feel like I am going to die!
Doctor: Oh yes, it is because you got something called as acute cystitis and its usually very painful and can cause some serious complications. 
Patient: Well, is it because of my diabetes?
Doctor: I am afraid I don't have better news for you, but your diabetes is out of control. It's way too high and you must be really careful. Are you taking your medicines?
Patient: Yes!
Doctor: How bout diet?
Patient: Yeah, sometimes I don't care about my diet.
Doctor: Well, you must watch your diet, you can't just be careless. I am going to change your diabetes medication. And let's start you on the antibiotic that should give you relief. Also stay hydrated drink plenty of fluids it will help you flush the infection out.
Patient: Alright, thank you!
Doctor: Take care.

Clinical note:
Symptoms: N/A
Diagnosis: Diabetes type II uncontrolled, acute cystitis
History of Patient: N/A
Plan of Action: Change diabetes medication, start antibiotic for acute cystitis, advise patient to watch diet, stay hydrated, and take medications
Doctor: Good morning, ma'am. 
Patient: Good morning, doctor.
Doctor: Before we begin, I just have a few questions. Do you remember what illnesses you had as a child?
Patient: Yes, I got a few. I had strep throat, mumps, and, um, chickenpox growing up.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Childhood illnesses include strep throat, mumps, and chickenpox
Plan of Action: N/A
Doctor: Hi there! I am Doctor Sherman. 
Patient: Hello! It is nice to meet you. 
Doctor: It looks like your P C P sent you to us for a possible prostate problem. 
Patient: Yes. I am nervous. 
Doctor: Do not be nervous. We will start with discussing the symptoms you have been experiencing, a physical exam and then we will get a urine sample if you are able. 
Patient: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Urology evaluation for possible prostate problem, including discussion of Symptoms, physical exam, and urine sample
Doctor:  What are you taking for allergies?
Patient: Claritin.
Doctor: Okay. 
Patient: For my allergic rhinitis.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Claritin for allergic rhinitis
Doctor: Do you have any known allergies to medication? 
Patient: Nope. None that I know of.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: None
Doctor: What is your family medical history? 
Patient: My dad had a heart attack and passed away at sixty one. 
Doctor: I am so sorry to hear that. 
Patient: Thank you. 
Doctor: Do you know of any other major health conditions in your family? 
Patient: No. None that I know of. Everyone is relatively healthy. 
Doctor: That's good.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Father died of myocardial infarction (MI) at age 61
Plan of Action: N/A
Doctor: Hello, sir how are you feeling today? 
Patient: I feel terrible. Very sick and I can barely move. I feel so weak.

Clinical note:
Symptoms: Feeling sick, weakness
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: So, we looked at your previous blood work results, now let me see what these reports say from today's C B C exam.
Patient: Sure.
Doctor: Okay so your hemoglobin levels look within range, white counts are thirteen point three, then seven point six lymphocytes and twenty six thousand platelets.
Doctor: Okay?
Patient: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: The patient's CBC results from before were reviewed.  Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.
History of Patient: N/A
Plan of Action: N/A
Doctor: Welcome back. 
Patient: Thank you. 
Doctor: You are back for a follow up on your right arm pain, right? 
Patient: Yes. It has been almost a year since the pain first started. 
Doctor: How has your arm been feeling? 
Patient: I still have this dull pain in my upper outer area of my arm. 
Doctor: How long does the pain last? 
Patient: It was coming and going, but now the pain is more persistent since I last saw you. It is still happening every day. 
Doctor: Remind me again. You are right handed. Right? 
Patient: Yeah. It makes is hard to do things with the persistent pain. 
Doctor: I bet it does. Are you experiencing any numbness or tingling sensation in your arm or hand? 
Patient: No, but I have had this achy sensation in my hand radiating down to my fingers. 
Doctor: Do you have a history of any other neck or shoulder injuries? 
Patient: It is not from a specific injury but I have had this neck pain for thirty years. 
Doctor: Did you see anyone for the neck pain? 
Patient: Yes. I saw someone for it in two thousand and six, and then I developed this ear pain. They could not figure out what was going on so eventually I was sent to have an M R I of my neck and upper spine, which showed some degenerative changes. Then I was referred to Doctor X who was treating me for neck pain.  He gave me steroid injections. 
Doctor: Are you still seeing Doctor X for the epidural injections? 
Patient: Yes. I have been seeing him since two thousand and seven. 
Doctor: How old are you?
Patient: I am fifty eight. 
Doctor: Are you experiencing any symptoms from receiving the injections? 
Patient: Those are for neck pain. My arm pain recent. I have been having the injections for a while now, without any trouble. 
Doctor: What medications have you been taking for the pain? 
Patient: There are a few of them that I take. I gave the list to the nurse. 
Doctor: Okay. 
Patient: I also have taken several Medrol packs. They make my blood sugars to increase so I try not to take it. 
Doctor: Okay. Does the pain prevent you from doing your daily activities or decrease your quality of life? 
Patient: No. I can do everything like normal, but constant nagging pain does get to me at times.

Clinical note:
Symptoms: Dull pain in upper outer area of right arm, achy sensation in right hand radiating to fingers, constant nagging pain
Diagnosis: N/A
History of Patient: 58-year-old right-handed gentleman with right arm pain persisting for almost a year, 30-year history of neck pain, MRI of cervical spine showed degenerative changes, receiving epidural injections for neck and recent arm pain since 2007, history of taking Medrol dose packs causing increased blood sugars, taking multiple other pain medications
Plan of Action: N/A
Doctor:  What type of surgery have you had in past? Anything big or small?
Patient: I had a C section for my kiddo and one D and C.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: C-section, D&C
Plan of Action: N/A
Doctor: Are you currently taking any medications? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: So are you allergic- 
Patient: To any medications? No allergies here.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No known medical allergies
Plan of Action: N/A
Doctor: Hello again! 
Patient: Hi! 
Doctor: The results from you M R I showed nothing concerning.  The growth factors were normal with normal cell function and no signs of decreased blood supply to the brain. 
Patient: That's great news. 
Doctor: Yes it is.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Growth factors with coronary artery disease (CAD), otherwise unremarkable MRI results
Plan of Action: N/A
Doctor: So, I understand that you had a fall. 
Patient: Yes. I did fall. 
Doctor: What happened? 
Patient: I don't really know. I have balancing problems. I have been to my P C P for this issue a few days ago. I saw her about a week and a half ago because I had another fall. Maybe around late December since today is January seventh.  I have been having trouble with my right hand. It is like I am clumsy on my right side. I ended up falling because my right hand missed the railing when I grabbed it to head up the stairs. 
Doctor: Are you left or right handed? 
Patient: Right. 
Doctor: Can you tell me a little bit more about the trouble that you are having with the right hand? Is it localized to the right hand? 
Patient: Yes, it is only on my right side. It is like the right side of my body is weak and it has been getting worse. 
Doctor: How long has this issue been progressing for? 
Patient: About two years.
Doctor: Have you experienced any blurred vision or visual disturbances?
Patient: Yes. Every once and a while.  
Doctor: How old are you? 
Patient: I just turned fifty eight last week. 
Doctor: Happy belated birthday! 
Patient: Thank you!
Doctor: Did your P C P have any bloodwork or imaging done? 
Patient: Yes, she did. She did both. She said she would send my records over. 
Doctor: Oh. I see it here! Did Doctor Madison discuss the results of your H C T and the M R I yet? 
Patient: No. 
Doctor: Okay. The results showed clinoid masses. This explains that problems that you have been having with your right side, your balancing problems, and the visual disturbances. With only the M R I I cannot tell if the masses are malignant or not. 
Patient: So, are the masses cancer? 
Doctor: I don't know yet. I will have to run some more tests and potently have to do a biopsy. 
Patient: Okay.

Clinical note:
Symptoms: Gait difficulty, clumsiness of right hand, falling, occasional visual obscurations
Diagnosis: Bilateral posterior clinoid masses
History of Patient: 58-year-old right-handed female with 2-year history of increasing gait difficulty, clumsiness of right hand, falling, and occasional visual obscurations
Plan of Action: Further tests and potentially a biopsy to determine nature of masses
Doctor: Do you smoke? 
Patient: Yes, I do.
Doctor: How much? I mean can you tell me approximate amount?
Patient: Yes sure, I smoke half a pack a day.
Doctor: How about alcohol and drugs?
Patient: No, I do not drink or use. I have a five month old baby.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Gave birth to a baby five months ago, smokes half a pack of cigarettes per day, denies alcohol and drug use
Plan of Action: N/A
Doctor: With ten being the worst pain imaginable, how would you rate your pain today out of ten, ma'am? 
Patient: Well, out of ten, I'd say it's about a seven. 
Doctor: How would you describe your pain? 
Patient: Um, I'd say it's deep, and it really aches. 
Doctor: Where is your pain located? 
Patient: It's in my right lower back, and then into my butt. 
Doctor: What activities make your surgery worse? 
Patient: I can't go up and down stairs without a lot of pain, and it hurts when I sit for a long time, like when I drive. 
Doctor: Before this pain, how would you describe your activity level? 
Patient: I was very active before all this started. 
Doctor: Are you able to do any of your prior activities? 
Patient: Not really, I'm having a lot of problems with stuff around the house, like all the chores and projects I used to be able to do.

Clinical note:
Symptoms: Pain rated at 7/10 on Pain Analog Scale, described as deep and aching, primarily in right lower back and gluteal region
Diagnosis: N/A
History of Patient: Aggravating factors include stairs and prolonged driving, limitations with home tasks and projects, previously very active
Plan of Action: N/A
Doctor: Welcome in! 
Patient: Thank you. 
Doctor: Let us get a little background. What is your medical history? 
Patient: I have some memory loss problems. 
Doctor: What kind of memory problems? 
Patient: Well, I have seizures. 
Doctor: Do you know what kind of seizures that you have? 
Patient: I have temporal lobe seizures. 
Doctor: Do you have any other health conditions? 
Patient: I also have high blood pressure. 
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Left temporal lobe seizures, hypertension
Plan of Action: N/A