X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: Good morning, ma'am. Before we begin today, can you confirm your age for me? 
Patient: Good morning, doctor. Sure, I'm seventy nine years old. 
Doctor: Great, thank you. What seems to be the problem today, ma'am? 
Patient: Well, I have this arthritis, as you know. 
Doctor: Yes, how would you describe your arthritis? 
Patient: Well, at this point I'd say it's debilitating. 
Doctor: I see, so the antiinflammatories and rest haven't helped at all? 
Patient: No, I haven't had any improvement, doctor. It's still so bad. 
Doctor: I see, I believe you'd be a good candidate for a knee replacement. 
Patient: Yes, I thought so. What are the risks of infection for the surgery? 
Doctor: Um, it's less than one percent, we use prophylactic antibiotics to control for infection the entire time. 
Patient: That's great, what about anesthesia, will I be asleep for this? 
Doctor: Yes, you won't feel a thing.
Patient: Great, yes, I'd like to do the surgery, doctor.

Clinical note:
Symptoms: N/A
Diagnosis: bilateral knee degenerative arthritis
History of Patient: Patient is a 79-year-old female with disabling bilateral knee degenerative arthritis unresponsive to conservative measures. Agreed to proceed with surgery.
Plan of Action: Knee replacement surgery discussed and agreed upon. Risks, complications, anticipated benefits, and postoperative course were discussed with patient.
Doctor: Welcome to the clinic. 
Patient: Thank you. 
Doctor: Are you from the area? 
Patient: I was born and raised in Iowa. My husband and I moved here twenty years ago, and we have been here ever since. 
Doctor: It is a wonderful city. Do you have kids? 
Patient: Yes! We have two kids. 
Doctor: Do you have any history or present use of tobacco, alcohol and recreational drugs or substances? 
Patient: I have a glass of wine every once and a while but no to the rest.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any history of Tobacco/Alcohol/illicit drug use.
Plan of Action: N/A
Doctor: Any of your family members have issues like seizures?
Patient: None on my father's side, but, yeah, on my mom's side some of the family members had seizures. Like, my mom had them during her childhood. I know that my great grandmother had it and so does my great aunt.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  There is no other significant neurological history on the paternal side of the family.
Plan of Action: N/A
Doctor: Do you have a sore throat, cough or earache? 
Patient: No.

Clinical note:
Symptoms: Negative for sore throat, earache, cough
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Can you tell me what are the diseases you have been diagnosed with in the past? 
Patient: Sure, I have had hypertension, diabetes, asthma and cholesterol problem.
Doctor: Ok, is there anything else?
Patient: Nope.
Doctor: And it is type two diabetes, right?
Patient: Yes.
Doctor: Thank you!

Clinical note:
Symptoms: N/A
Diagnosis: hypertension, type 2 diabetes mellitus, asthma, high cholesterol
History of Patient: N/A
Plan of Action: N/A
Doctor: Good afternoon, sir. Do you remember the details of your surgery? 
Patient: No, can you remind me? 
Doctor: Well, um, we did a right orchiectomy due to your testicular cancer, when did you have that? 
Patient: Um, it was about eighteen years ago now, so that was about nineteen eighty nine. 
Doctor: Good, while you're here, do you have any other conditions that I should be aware of? 
Patient: Sure, I have G E R D, and um, I B S. 
Doctor: Thank you, what about allergies, do those bother you? 
Patient: Yeah, unfortunately I have those. 
Doctor: Do you have them in the spring, or in the fall? 
Patient: Actually, I have them in both. It's really annoying. 
Doctor: What allergy symptoms do you have usually? 
Patient: Um, another doctor called it a postnasal drip. 
Doctor: Okay, yes, I'm familiar with that. Have you ever had any other surgeries? 
Patient: Yeah, um, I had a hernia removed and repaired some time ago. 
Doctor: I see, what about any other major medical conditions? 
Patient: I've had carpal tunnel before.
Doctor: Which hands did you have it in? 
Patient: I've had it in both.

Clinical note:
Symptoms: N/A
Diagnosis: testicular cancer, GERD, irritable bowel syndrome, seasonal asthma triggered by postnasal drip, bilateral carpal tunnel syndrome, excision of abdominal teratoma and incisional hernia
History of Patient: Status post right orchiectomy due to testicular cancer approximately 18 years ago (around 1989), GERD, irritable bowel syndrome, seasonal asthma triggered by postnasal drip in both fall and spring, history of bilateral carpal tunnel syndrome, status post excision of abdominal teratoma and incisional hernia
Plan of Action: N/A
Doctor: How old are you? 
Patient: I'm eighty six years old. 
Doctor: What gender do you identify with? 
Patient: I identify as a female. 
Doctor: How long have you had this back and buttock pain? 
Patient: Its been a while, now. I know I have a fracture in my lower back. 
Doctor: How have you been managing this? 
Patient: Another doctor called this conservative treatment. I've been resting a lot, and using antiinflammatories. 
Doctor: Has there been any improvement?
Patient: Its been several months at this point, and honestly no, there's been no improvement. I'm still in a lot of pain.  
Doctor: This C T Scan you had recently shows sclerosis, with some healing of a L five compression fracture, but if you look here, the healing is not complete. 
Patient: What can we do about this? I'm in so much pain. 
Doctor: I believe you'd be a candidate for a bilateral L five kyphoplasty. 
Patient: What's that? 
Doctor: It's a small procedure on that L five vertebra. Its minimally invasive, and we can actually do it as an outpatient procedure. 
Patient: Oh, wow, that's good to hear. What are the risks of infection?
Doctor: Very low, historically, they're less than one percent. 
Patient: How is this possible? 
Doctor: We'll use antibiotics in order to control for infection. 
Patient: That's great, will I be under anesthesia?
Doctor: Yes, you'll be asleep for the whole thing. 
Patient: Great, yes, I'd like to have this done, I can't keep living in this pain. 
Doctor: Awesome, I agree. Do you have control over your bladder and bowel movements? 
Patient: Yes, thankfully, I have complete control over everything like that still. 
Doctor: Do you wear a brace or corset normally?
Patient: Yes, I usually wear both. 
Doctor: Okay, last question, can you notice any weakness in your body? 
Patient: No, I'm still very strong, even at my age.

Clinical note:
Symptoms: back and buttock pain
Diagnosis: L5 compression fracture with sclerosis, incomplete healing
History of Patient: 86-year-old female with history of back and buttock pain, conservative treatment unsuccessful, CT scan shows incomplete healing of L5 compression fracture
Plan of Action: bilateral L5 kyphoplasty scheduled, patient denies bowel or bladder incontinence, wears back brace and corset, no weakness reported
Doctor: Good afternoon, sir, and who's the patient today? You, or your daughter?
Guest_family: Not me today, its my daughter.
Doctor: And how old are you, dear?
Patient: I'm eighteen. 
Doctor: What seems to be the problem today?
Patient: I hurt my right knee while playing tennis, um, it was about three days ago now. It really hurts. 
Doctor: I see, tennis, huh? Was there any contact involved?
Patient: No, I took a step wrong when I went for an awkward shot. 
Doctor: Are you able to stand on this knee?
Patient: Not well, it feels unstable, like I'm going to fall over.  
Doctor: Have you ever hurt this knee before?
Patient: Yeah, tore my ACL in two thousand eight. 
Doctor: I assume you had surgery for that?
Patient: Yeah I did, um, with Doctor X. He called it an, um, A C L reconstruction.
Doctor: How did you recover from this?
Guest_family: She didn't do well, she didn't do what we or the others doctors suggested, and the knee never really got the same tightness back.
Doctor: What did they do about that?
Guest_family: I have it in my notes here, they did an, um, A C L revision. That was done by Doctor Y.
Doctor: When was that done?
Guest_family: Looks like it was at the end of two thousand eight. 
Doctor: Following the revision, how did you cover?
Patient: I did everything they said, I did it exactly as they wanted, and I did fine until this last injury.  
Doctor: Good, was there any instability following the revision?
Patient: Nope, I was really stable.

Clinical note:
Symptoms: pain, instability in right knee
Diagnosis: ACL injury, previous ACL reconstruction, ACL revision reconstruction
History of Patient: 18-year-old female with recent non-contact injury to right knee while playing tennis, past history of ACL injury in 2008, underwent ACL reconstruction followed by ACL revision reconstruction in the same year due to laxity of the graft
Plan of Action: N/A
Doctor: How're you feeling today? 
Patient: Much better. The antibiotics seemed to really help. 
Doctor: Are you still experiencing any symptoms? 
Patient: Um no, thankfully. I had some wheezing when I first started the antibiotics, but it's improved a ton. I don't think the wheeze is even there anymore. 
Doctor: Good, good.

Clinical note:
Symptoms: wheezing (improved)
Diagnosis: N/A
History of Patient: previous history of wheezing, improved with antibiotics
Plan of Action: N/A
Doctor: Any medical problems that run in the family? 
Patient: No, nothing that comes to mind.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
.
Doctor: Hi Mister B, nurse tells me you had a fall?
Patient: Yes, a pretty bad one. 
Doctor: Okay, tell me what happened? 
Patient: Well, I was running to catch a taxi and stumbled upon a piece of rock, lost my balance and fell. 
Patient: I fell face down and my head hit the sidewalk. The next thing I remember is I am all dazed and people trying to help me. 
Doctor: I see, did you lose consciousness after the fall? 
Patient: No. 
Doctor: So, is your head hurting?
Patient: Only the right forehead where I have the scrape and my chin. 
Doctor: Okay, any neck or back pain? 
Patient: No. 
Doctor: Any stomach pain? 
Patient: No.
Doctor: Pain anywhere else, in extremities, hand or leg? 
Patient: No.
Doctor: Okay, and how old are you? 
Patient: I am forty two.
Doctor: Okay.

Clinical note:
Symptoms: pain in right forehead and chin
Diagnosis: N/A
History of Patient: 42-year-old male, fell while running, struck face on sidewalk, denies loss of consciousness, complains of pain in right forehead and chin, no neck pain, back pain, extremity pain, or abdominal pain
Plan of Action: N/A
Doctor: Let's talk about your family history. 
Patient: Okay. 
Doctor: Can you tell me about any kind of medical traits that run in your family? 
Patient: I think my family has been blessed or I don't know if any. 
Doctor: What about any heart disease? 
Patient: Nope. No heart disease or diabetes or any other kind of issues that I'm aware of.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Hello, Nurse. Could you give me a run down on the eleven month old patient? 
Guest_clinician: The patient was presented with stage two neuroblastoma on the left when he was six weeks old. It was completely resected. It was shown not to be N Myc amplified and had some favorable Shimada histology. 
Doctor: Great. Did he have a follow up after?
Guest_clinician: He did. There was a second primary in his right adrenal gland. They performed a biopsy, which was consistent with neuroblastoma with favorable Shimada histology. 
Doctor: Did he receive any chemotherapy?
Guest_clinician: He is now being treated with it per protocol P nine six four one and not on study. His last chemotherapy appointment was on May twenty first two thousand and seven. They used carboplatin, cyclophosphamide, and doxorubicin.
Doctor: What did they do after chemotherapy? 
Guest_clinician: He received G C S F daily because he had neutropenia that delayed his second cycle. 
Doctor: Thank you, Nurse. I'll go talk to the mother. 
Guest_clinican: No problem, Doctor. 
Doctor: Hello, ma'am. It's nice to see you again. How is your little boy doing?
Guest_family: Not so well. Since out last visit, he had a stuffy nose for a couple of days. 
Doctor: Is it getting worse?
Guest_family: I think it's getting better now. It isn't as stuffy. 
Doctor: That's good to hear. Has he been sick or had any fevers?
Guest_family: Nope. Just the stuffy nose.
Doctor: Has he been able to eat anything?
Guest_family: At times, he didn't want to eat. It seemed like he wasn't hungry. 
Doctor: Does he still have a reduced appetite?
Guest_family: Not anymore. He's starting to eat again.
Doctor: Did he have any nausea or vomiting after he ate?
Guest_family: Thankfully, no. I would have made my husband clean up the vomit. 
Doctor: That's great. Is he able to pee and poop fine? No diarrhea, right?
Guest_family: His poop has been solid. I haven't seen anything bad about his pee either. 
Doctor: Great. Would you be able to open his mouth for me? I just want to check if everything's fine inside. 
Guest_family: Of course. Say ah. 
Patient: Ah. 
Doctor: Thank you. Oh, wow. It looks like he's showing some symptoms of thrush again. 
Guest_family: Oh, no. Should we restart fluconazole?
Doctor: It's just a fungal infection inside the mouth. I'll prescribe him fluconazole. It should get rid of it. 
Guest_family: Thank you so much. You all have been so helpful. My little boy is slowly getting better.

Clinical note:
Symptoms: nasal congestion (improving), diminished appetite (improving), thrush
Diagnosis: stage 2 neuroblastoma (initially left, then right adrenal gland), not N-Myc amplified, favorable Shimada histology, receiving chemotherapy per protocol P9641 (carboplatin, cyclophosphamide, doxorubicin)
History of Patient: nasal congestion improving, diminished appetite improving, normal urination and bowel movements, no diarrhea, no nausea or vomiting reported, recently restarted fluconazole for thrush
Plan of Action: continue chemotherapy per protocol, prescribe fluconazole for thrush
Doctor: So, how are long have you had pain in this hip? 
Patient: It's been about eight or ten years now. It began while I was working in construction. 
Doctor: How old are you now? 
Patient: I'm thirty two now, so I've been in pain since I was in my twenties. 
Doctor: Have you seen another doctor for this, or am I the first? 
Patient: Yeah, um, I've actually seen several doctors before, the last I saw was Doctor A B C a few weeks ago.
Doctor: What did those doctors tell you?
Patient: They thought it was low back pain, and something called, um, radiculopathy. 
Doctor: Does your pain radiate into your legs? 
Patient: Yes. 
Doctor:  Has your pain been present for the eight years, or did it come and go? 
Patient: It's been persistent, and I've had difficulties on and off since then. 
Doctor: Okay. The x rays from Doctor A B C show severe degenerative changes as well as avascular necrosis of the femoral head. What else did the Doctor do for you? 
Patient: He gave me some pain medicine, and we talked about going to another specialist for surgery.
Doctor: Do you remember the names of the procedures suggested? 
Patient: Something about resurfacing the hip, or a hip replacement. I'm here for another opinion on that. 
Doctor: I saw you come in with a cane, do you have groin pain as well?    
Patient: Yes, and I can't do any of the activities I used to. 
Doctor: Besides the pain medication, have you had anything else? 
Patient: I've taken antibiotic steroids before. 
Doctor: Okay. Do you drink? 
Patient: Yes, a lot.

Clinical note:
Symptoms: hip pain, difficulty with activities, groin pain
Diagnosis: severe degenerative changes of left hip joint, avascular necrosis (AVN) of left femoral head
History of Patient: 32-year-old male with eight to ten year history of left hip pain, initially thought to have low back pain with radiculopathy, previous evaluation by multiple specialists, previous antibiotic steroid use, heavy drinking history
Plan of Action: discussion of hip resurfacing versus conventional total hip replacement, seeking second opinion
Doctor: Let me examine your skin.
Patient: Sure.
Doctor: It looks normal and well hydrated. Any excessive sweating? 
Patient: No, not really.
Doctor: I don't see any injury or wounds. 
Patient: Yeah. 
Doctor: Its just a normal protocol to ask these questions for every new patient.
Patient: I understand.
Doctor: Thank you for your cooperation.

Clinical note:
Symptoms: N/A
Diagnosis: SKIN: Inspection within normal limits.  Well hydrated.  No diaphoresis.  No obvious wound.
History of Patient: N/A
Plan of Action: N/A
Doctor: Hi there! I am Doctor Kirkland.
Patient: Hi. 
Doctor: How are you feeling? 
Patient: I feel weird. Like I feel confused. I don't know how I got here. 
Doctor: That's okay. Do you remember what happened to you before you came here? 
Patient: No. 
Doctor: Can you tell me about your past medical history? 
Patient: Um.
Doctor: Take your time. 
Patient: I can't think of what it is called. It's something to do with my brain. 
Doctor: Okay. 
Patient: My doctor knows what it is. 
Doctor: What is the name of your doctor? 
Patient: Doctor Frank. 
Doctor: Doctor X? Across the street? 
Patient: Yes, that is his name. I don't know if that is across the street or not. 
Doctor: I will have your nurse give him a call and get some background information from him. 
Patient: Okay. 
Doctor: Can you please give Doctor X a call and get mister Jones' medical history? 
Guest_clinician: Yes, of course. 
Doctor: Thank you.

Clinical note:
Symptoms: confusion
Diagnosis: N/A
History of Patient: confusion, difficulty recalling medical history
Plan of Action: nurse to call Doctor X to obtain patient's medical history
Doctor: Any issues from head to toe?
Patient: No, everything is fine.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Noncontributory
Plan of Action: N/A
Doctor: Hello, it's been two months already?
Patient: I know right?
Doctor: Just feels like yesterday.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Two-month follow-up
Plan of Action: N/A
Doctor: Tell me about your family medical history. 
Patient: No one in my family has any health problems.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Noncontributory
Plan of Action: N/A
Doctor: And are you working? What do you do?
Patient: Oh, I am a catholic priest!
Doctor: Oh wow! 
Patient: Yes. 
Doctor: And if you don't mind me asking, do you drink alcohol?
Patient: Maybe that is something for my confession box but jokes apart I don't drink.
Doctor: Sorry I need to ask these questions it's a protocol.
Patient: I understand. 
Doctor: And can I put down here that you don't smoke or use any kinds of drugs?
Patient: Yes, I don't do those either. 
Doctor: Cool.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Catholic priest, denied tobacco, alcohol, or illicit drug use
Plan of Action: N/A
Doctor: Okay, so where do you live?
Patient: I live at an old age nursing home.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: So, he is Arjun, and he is thirty seven years old and was complaining of chest pain.
Patient: Hi Doctors, how are you?
Doctor: We are good thanks for asking. 
Guest_clinician: Hi there Arjun, I am doctor J and I am assisting Doctor Wilson today. So, chest pain huh? 
Patient: Yep.
Guest_clinician: And I see here no cardiac excretion was mentioned. 
Doctor: Yeah. I am suspecting coronary spasm but that's questionable. 
Guest_clinician: Okay.
Doctor: I did run a cardiac enzyme profile and it was negative. 
Guest_clinician: Alright. And he also has hyperlipidemia?
Doctor: Yes, he does.
Guest_clinician: Okay and did you order an E K G?
Doctor: I did, it is normal too. 
Guest_clinician: Don't worry Arjun, we will take of you. 
Patient: Thank you.

Clinical note:
Symptoms: chest pain
Diagnosis: questionable right coronary spasm, hyperlipidemia
History of Patient: 37-year-old gentleman with negative cardiac workup, negative EKG and cardiac enzyme profile
Plan of Action: N/A
Doctor: So, do you live in the area? 
Patient: Yes, my husband and I have lived here for a long time. He died a few years back. 
Doctor: I'm sorry to hear that. 
Patient: It's alright. 
Doctor: Do you smoke or drink? 
Patient: No, I don't. 
Doctor: Do you use any illicit drugs or substances? 
Patient: No, I don't do anything like that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: widow, local resident, no smoking or illicit drug use
Plan of Action: N/A
Patient: Um, I take the generic for Ultracet. Sometimes I take as many as four times a day. 
Doctor: Does this help the pain?
Patient: No, I'm still in pretty significant pain, doctor.

Doctor: Good morning, sir. My nurse's chart says that you're thirty four years old. Is that correct? 
Patient: Yes, doctor, that's correct. 
Doctor: How long have you had this back pain?
Patient: Well, it's been a while now. 
Doctor: Does the pain go into your legs?
Patient: Yes, into the left leg, more towards the outside of my leg. 
Doctor: Is there any injury that started this pain?
Patient: Yeah, I was lifting at work on August twenty seventh two thousand three when I lifted something and felt a pretty sharp pain from my back down into my left leg. 
Doctor: Have you had back pain or surgeries before this injury? 
Patient: No, I haven't. 
Doctor: Are you having weakness in the legs?
Patient: Yes, I am. 
Doctor: Okay, I believe you are a good candidate for surgery, sir. It seems like you have a lot of weakness and pain in the S one nerve root distribution.
Patient: Okay. What are the risks of infection for this surgery?
Doctor: Overall, the risk of infection is very low, less than one percent. We use antibiotics to control for infection the entire time. 
Patient: Will I be asleep for the surgery?
Doctor: Yes, you'll be under anesthesia. You won't feel a thing. 
Patient: Okay, yes. I'd like to do the surgery.

Clinical note:
Symptoms: back pain, pain radiating into left leg, weakness in legs
Diagnosis: N/A
History of Patient: lifting injury on August 27, 2003, sharp pain from back down to left leg, no previous history of back pain or surgeries, severe weakness in S1 nerve root distribution
Plan of Action: surgery recommended due to weakness and pain in S1 nerve root distribution, risks of infection discussed (less than one percent), patient consented to surgery after informed consent
Doctor: Anyone sick in your family? 
Patient: Nope.
Doctor: So, everyone is healthy?
Patient: That's right.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Mister Sunil, your blood pressure is high, and I am noticing this from past two-three times you have been here. It's been constantly high, you are not taking it seriously. 
Patient: No, nothing like that Doctor! It's been well under control. I have been monitoring at home.
Doctor: Are you noting your readings? Did you bring it with you?
Patient: No. I did not get the readings with me but I assure you I am taking care and my B P is normal.
Doctor: Well, it's up and I am little bothered by it.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: high blood pressure noted during last two to three visits, patient claims blood pressure is under control at home but did not bring readings, doctor is concerned about elevated blood pressure
Plan of Action: N/A
Doctor: What is your family medical history?
Patient: My dad had colon cancer. 
Doctor: Did your dad pass from colon cancer?
Patient: No. They caught it early. He passed away from old age. My mom passed away when she was in her nineties from a stroke. 
Doctor: I am sorry. Do you have any family history of any neurological disorders like, M S, Alzheimer's, Parkinson's or epilepsy? 
Patient: Other then my mom having a stroke, I know of nothing else.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: father had colon cancer, caught early, mother died in her nineties from a stroke, no known family history of neurological disorders
Plan of Action: N/A
Doctor: Hello. I see you're here for a follow up. Did you get your blood work done? 
Patient: I did. Here are the results.
Doctor: Let me take a look. Oh, wow. It looks like your blood sugar is high. Are you exercising every day?
Patient: Not really. Is that bad? 
Doctor: You are at risk of developing type two diabetes.

Clinical note:
Symptoms: N/A
Diagnosis: adult-onset diabetes (type 2 diabetes)
History of Patient: N/A
Plan of Action: N/A
Doctor: Have you had ever had surgery?
Patient: Yeah, I had my gallbladder removed a few years ago. 
Doctor: Thank you, what about any other parts of the body, like your eyes, ears, or nose?
Patient: Oh yeah, I forgot. I had eye surgery too. 
Doctor: Thank you, think hard, any other surgeries you can remember?
Patient: Let me look at my notes, um, it looks like I had a dilation and curettage done some time back, too. 
Doctor: I see. Thank you for sharing that with me.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: cholecystectomy, eye surgery, dilation and curettage (D&C)
Plan of Action: N/A
Doctor: Hi there! How are you doing? 
Patient: Um. I am feeing really strange. 
Doctor: Strange how? 
Patient: I took Ecstasy over the weekend and I feel weird still. My heart is racing. I feel agitated and have been having waves of sadness. I cannot shake this feeling.  
Doctor: When did you take the Ecstasy? 
Patient: On Saturday.

Clinical note:
Symptoms: heart racing, agitation, waves of sadness
Diagnosis: N/A
History of Patient: took Ecstasy over the weekend
Plan of Action: N/A
Doctor: Do you live alone? 
Patient: I do. I lost my husband to prostate cancer last year. 
Doctor: Oh wow. I'm so deeply sorry for your loss. Losing a loved one is incredibly difficult. I lost my sister to cervical cancer two years ago. It was one of the hardest experiences of my life. 
Patient: I'm sorry for your loss as well. It helps to remember the positive memories you had with them.  
Doctor: Yes, definitely. How have you been doing otherwise? 
Patient: Not bad. I've been keeping myself busy with gardening. 
Doctor: Gardening is a great hobby. 
Patient: Yes, I enjoy it very much. It brings me a lot of peace. 
Doctor: And as your doctor I have to ask, but any history of alcohol or drug use? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: widow, lives alone
Plan of Action: N/A
Doctor: Hello. How are you doing today?
Patient: I feel depressed. 
Doctor: I'm sorry to hear that. What's been happening?
Patient: My parents were fighting for a long time, and I think they're not together anymore. 
Doctor: That must be really hard. I'm sorry to hear that they're divorced. Who do you live with right now?
Patient: I usually hop houses. I'll go to my dad's house the first half of the week and spend time with his family. Then, I'll go to my mom's house during the last half of the week. 
Doctor: That's nice. Now you can ask for more gifts during Christmas. 
Patient: You know what? I never thought about that. That's a really good idea.

Clinical note:
Symptoms: depressed
Diagnosis: N/A
History of Patient: parents undergoing separation and divorce, patient spends time with father's family during first part of week and with mother during second part of week
Plan of Action: N/A
Doctor: What do you do for a living? 
Patient: I'm a real estate agent. 
Doctor: How long have you been working in the real estate business? 
Patient: Almost twenty years. 
Doctor: Wow. I know who to go to when I'm looking to buy a house.  
Patient: Happy to help. 
Doctor: So let's see here. Do you drink or smoke? 
Patient: I drink socially, but it's very infrequent. 
Doctor: And I have to ask, but any drug use? 
Patient: Nope. Not now, not ever.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No tobacco use, occasional EtOH, no known drug use, works as a real estate agent.
Plan of Action: N/A
Doctor: Welcome back in, Miss A. 
Patient: Thank you, doctor.
Doctor: Do you remember the information about your operation?
Patient: No, not really. Can you remind me?
Doctor: Sure, you had a lap band replacement in January of O nine, and you had a band adjustment. 
Patient: Thank you. 
Doctor: How are you feeling today? 
Patient: Well, I've been under a lot of stress lately, and I had problems with my adjustments before. 
Doctor: Has anything changed since the operation?
Patient: Actually, doctor, I was in a car accident a couple weeks ago, and I'm having problems. 
Doctor: What symptoms are you experiencing? 
Patient: I don't feel full. 
Doctor: How is your appetite? 
Patient: I'm not really hungry, but I also don't feel full. When I get hungry at night I can't wait until the morning to eat. I get so hungry. 
Doctor: Do you eat anything when you feel like this? 
Patient: Yeah, I usually have a candy bar, and that helps some.

Clinical note:
Symptoms: not feeling full, increased hunger at night
Diagnosis: N/A
History of Patient: status post lap band placement in 01/09, previous problems with adjustments, recent car accident
Plan of Action: band adjustment
Doctor: So, where do you live?
Patient: Ah, I now live in an assisted nursing facility.
Doctor: Okay, and do you drink or smoke? 
Patient: No, neither.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.


Plan of Action: N/A
Doctor: Any specific medical traits in the family? 
Patient: What do you mean by that? 
Doctor: I meant does anyone in your family or extended family have any medical problems that they were treated for?
Patient: I'm not aware of any such thing in my family.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Welcome in! I am Doctor Madison. 
Patient: Thank you. It's nice to meet you. 
Doctor: Are you married? 
Patient: Yes. We just got hitched last year. 
Doctor: Congratulations! 
Patient: Thank you. 
Doctor: Do you drink alcohol? 
Patient: No, I don't drink. 
Doctor: Do you smoke cigarettes? 
Patient: Yes. I know it's bad for me. 
Doctor: How much do you smoke per day? 
Patient: About a pack a day. 
Doctor: Okay. I have a lot of tools to help you quit smoking that we can discuss. 
Patient: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: discuss tools to help quit smoking
Doctor: We have you scheduled for a follow up and to have the staples removed in one week with Doctor X Y Z. Do you have your wound care instructions? 
Patient: Yes. 
Doctor: Do you have any questions? 
Patient: No. 
Doctor: If you do have questions or concerns that may come up, please don't hesitate to call the office. 
Patient: Okay. 
Doctor: If you develop a fever greater than one hundred and one point four, chills, nausea, vomiting, or continuing diarrhea please call the office. Also if your incision site becomes red, warm to the touch or has any drainage, call the office. 
Patient: Okay.

Clinical note:
Symptoms: fever, chills, nausea, vomiting, continuing diarrhea, redness, drainage, warmth around incision site
Diagnosis: N/A
History of Patient: N/A
Plan of Action: contact with questions or concerns, contact if fever > 101.4, chills, nausea or vomiting, continuing diarrhea, redness, drainage, or warmth around incision site, follow-up appointment in one week to have staples removed
Doctor: Have you had sinus issues before?
Patient: I am not sure, maybe on and off.
Doctor: Because this is more allergic.
Patient: Okay.
Doctor: So, we call it allergic rhinitis.
Patient: Is it different than sinus infection?
Doctor: Yes, it's it is different.
Patient: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: allergic rhinitis
History of Patient: N/A
Plan of Action: N/A
Doctor: She has a rare case of thrombocytopenia. I'd like her to come in for a consult. 
Guest_clinician: Any other medical history? 
Doctor: No, just the thrombocytopenia.

Clinical note:
Symptoms: N/A
Diagnosis: Thrombocytopenia
History of Patient: N/A
Plan of Action: N/A
Doctor: Hi there how are you?
Patient: I am good no problem at all other than the usual.
Doctor: And what is that?
Patient: You know, some discomfort I have on my right side. I have been feeling that since I had a stroke five years back.
Doctor: Right, right. We did an E M G right? 
Patient: Yes.
Doctor: And none of the medications we tried are helping?
Patient: No, I also saw a neurologist, but nothing is helping
Doctor: Okay, and are you monitoring your sugar regularly?
Patient: Oh yes, Everyday at least two to three times a day.
Doctor: And how bout insulin dose? 
Patient: Oh, that I kind of adjust myself. 
Doctor: Well, I have rechecked all the symptoms and everything looks fine. I don't see anything out of order, but we will keep monitoring. 
Patient: Okay. 
Doctor: And you are not smoking or drinking again are you? 
Patient: No, not since I had the stroke.
Doctor: In the past you had a history of heavy usage of both alcohol and smoking, you need to be careful. You are seventy years old. 
Patient: Yeah, I am taking care of it. 
Doctor: Alright take care then.

Clinical note:
Symptoms: Discomfort on the right side, persistent since stroke five years ago.
Diagnosis: N/A
History of Patient: EMG studies done, seen neurologist, medications not effective, monitors blood sugar regularly (2-3 times/day), self-adjusts insulin dosage, past heavy tobacco and alcohol usage.
Plan of Action: Monitor Symptoms, advise caution regarding tobacco and alcohol usage.
Doctor: What is the strength of your Omeprazole?
Patient: It is forty M G and I take it just once a day.
Doctor: Any herbal medication?
Patient: No I do not take anything like that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Omeprazole 40 mg once a day. Denies herbal medications.
Plan of Action: N/A
Doctor: So, to double check, you have a history of hay fever and asthma, correct? 
Patient: Yes. I was also recently diagnosed with cervical dysplasia. I found out shortly after my last O B G Y N visit. 
Doctor: And are you planning to follow up with your O B G Y N in the upcoming months? 
Patient: Yeah, the next visit is scheduled and everything.

Clinical note:
Symptoms: N/A
Diagnosis: Significant for asthma, allergic rhinitis, and cervical dysplasia.
History of Patient: N/A
Plan of Action: N/A
Doctor: So, do you have any family history of arthritis? 
Patient: Fortunately, no, not that I know of. 
Doctor: So, as far as you know, no one has had a joint replacement? 
Patient: No, it doesn't ring any bells.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Noncontributory.
Plan of Action: N/A
Doctor: Please, tell me about your medical history.
Patient: I've been dealing with depression and anxiety for some time now.
Doctor: I'm sorry, that must be difficult. 
Patient: Thank you, it is, but I manage. 
Doctor: What about your joints? How do you move? 
Patient: Oh yes, I have arthritis as well. I also had sciatic pain a long time ago, and a herniated disk. 
Doctor: Have you ever had neurological symptoms, like headaches, blurry vision, or weakness? 
Patient: Actually yes, I have migraines when I'm having my period. 
Doctor: Thank you, and have you had any surgery in the past?
Patient: Yes, I had my appendix out.

Clinical note:
Symptoms: Anxiety, depression, migraine headaches associated with menstrual cycle, sciatic pain (in the past), neurological Symptoms (migraines), joint pain.
Diagnosis: Osteoarthritis, history of sciatic pain, history of herniated disc, status post appendectomy.
History of Patient: History of sciatic pain, history of herniated disc
Plan of Action: N/A
Doctor: Do you have any past history of psychiatric treatment of struggles? 
Patient: I had some extreme fatigue back in nineteen ninety one. I was in therapy for six years. They had me on Prozac. I took in for that whole six years while I was in therapy. When I started the Prozac, I had just started working again. The stress at work was overwhelming. 
Doctor: Was this the first time that you had feelings for fatigue and depression? 
Patient: No. I have always had a little sadness or depressed time in my life but it had been manageable before all the work stress started happening. 
Doctor: How are you feeling these days? 
Patient: I get somewhat sad from time to time but I don't dwell on things anymore. 
Doctor: Do you ever have thoughts of selfharm or suicidal thoughts? 
Patient: No.

Clinical note:
Symptoms: Current Mood is Sad
Diagnosis: N/A
History of Patient: The patient sought psychotherapy on and off between 1991 and 1997 due to extreme fatigue, during which she was prescribed Prozac. She resumed Prozac when she started working again due to overwhelming work stress. She has a chronic history of mild sadness or depression but describes her current mood as somewhat sad without dwelling on things. She denied any history of suicidal ideation or homicidal ideation.
Plan of Action: N/A
Doctor: How many other children do you have? 
Guest_family: My husband and I have three children, your patient today, and another boy, and girl. 
Doctor: How is everyone else doing?
Guest_family: They're all doing very well, thank you for asking. 
Doctor: Do you live here in Easton? 
Guest_family: Yes, born and raised. 
Doctor: Good, do you have any pets? 
Guest_family: We have four dogs, three cats, and three mules. 
Doctor: What, no deer? 
Guest_family: No, no deer, at least not anymore. 
Doctor: What grade are you in, young man?
Patient: I'm in the second grade, doctor. 
Doctor: Good, how do you like P E? Are you able to play no problem? 
Patient: Yes, I love P E. I don't have any problems there.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: He lives with mom, dad, brother, sister, and everybody is healthy. They live in Easton. They have 4 dogs, 3 cats, 3 mules and no deer. At school, he is in second grade and he is doing PE without any limitation.
Plan of Action: N/A
Doctor: Are you still doing water aerobics? 
Patient: Yeah, I've been hitting the pool five days outta the week. 
Doctor: How're you feeling? Have you noticed any changes in energy and strength? 
Patient: I feel a bit stronger now compared to when I first started. I'm also way, way more energized.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: As tolerated, continue water exercise five days a week.
Doctor: Do you have any history of chronic pain? 
Patient: I got into a car accident a long time ago and I have always had neck pain. 
Doctor: Okay. Any other pain throughout the body? 
Patient: Sometimes I have back pain. 
Doctor: Okay.

Clinical note:
Symptoms: Back and neck pain.
Diagnosis: N/A
History of Patient: Patient reports a history of chronic neck pain following a car accident. Additionally, occasional back pain is experienced.
Plan of Action: N/A
Doctor: How is your pain today? 
Patient: Eh it's been a rough few days that's for sure. The pain started almost instantly. 
Doctor: I'm sorry to hear that. Have you been taking anything for it? 
Patient: I actually saw a chiropractor the other day. My neck pain has been unbearable. 
Doctor: Is the pain localized to one area? 
Patient: Yeah. 
Doctor: And it hasn't radiated to any other part of your body? 
Patient: Nope.  
Doctor: Are you experiencing a pins and needles sensation at all? 
Patient: Not yet. 
Doctor: Any back pain?  
Patient: Oh yeah. I'd say it's even worse than my neck pain. The pain starts in my lower back and radiates down both legs. 
Doctor: Any pins and needles as a result of this back pain? 
Patient: No, no pins and needles. 
Doctor: Are you experiencing stiffness in your back? 
Patient: The stiffness seems to worsen when I exert myself during activities.  
Doctor: Has it impacted your sleep at all? 
Patient: Honestly, I haven't gotten much sleep since the accident. It's been so difficult to find a comfortable position to sleep in. I've never had back problems until now. 
Doctor: This accident sure did a number on you. 
Patient: No kidding. 
Doctor: You had mentioned experiencing stiffness during strenuous activity. Is it mostly during the day or does it progress into the night? 
Patient: Yeah, it's mostly during the day. 
Doctor: I see. 
Patient: The pain does improve a bit when I lay flat or sit up in a chair. 
Doctor: But despite this, your activity continues to be restricted, correct? 
Patient: Yeah, correct. 
Doctor: I meant to ask if you felt better after chiropractic treatment? 
Patient: A little bit, but not much. 
Doctor: And would you say your pain has overall gotten worse or remained the same? 
Patient: It's stayed more or less the same. 
Doctor: And to confirm, you didn't have neck or lower back problems prior to the accident? 
Patient: Yeah.

Clinical note:
Symptoms: Severe neck pain, localized and non-radiating. Back pain originating in the lumbar region, radiating down both lower extremities, worse than neck pain, no associated paresthesias. Stiffness exacerbated by strenuous activity. Difficulty sleeping due to discomfort, unable to find a comfortable position. Activity significantly restricted.
Diagnosis: N/A
History of Patient: The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Despite chiropractic treatment, neck and back pain persist. No prior history of neck or lower back problems.
Plan of Action: N/A
Doctor: I have reviewed your x rays from your emergency room visit. I agree with Doctor Jones that your lungs show no signs of infection or decreased lung capacity. 
Patient: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Chest x-ray ordered by ER physician is unremarkable, indicating no signs of infection or decreased lung capacity.
Plan of Action: N/A
Doctor: Hello, how are you doing? What brings you here? 
Patient: I think I have allergies. I used to live in Seattle. I had allergies there, but I think they're getting worse after moving here. You see, I'm twenty three and I am a white female. I was in Seattle, I thought that the weather there is not for me. That's why I plan to move on here, but my allergies are not leaving me here either. 
Doctor: What did you take for your allergies before? 
Patient: Claritin and Zyrtec. 
Doctor: How effective were they? 
Patient: They seemed to be working for some time, but now I feel like nothing is effective anymore. 
Doctor: Have you ever tried Allegra? 
Patient: Yes, I tried that last summer and I've started it again like two weeks ago. But again, the story is the same. They work for some time and now it doesn't seem to be working anymore. 
Doctor: Have you tried sprays? 
Patient: I did use some over the counter ones. But I never got any prescribed nasal spray. 
Doctor: Any other medically related history that I should be aware of? 
Patient: I do have asthma if that counts. 
Doctor: Are you taking any medications for your asthma? 
Patient: Nope, nothing on the regular basis. 
Doctor: Do you think it is your asthma that is flaring up? 
Patient: I don't think so. I think, I still think it is just some allergies. I want to get tested.

Clinical note:
Symptoms: Allergies worsening after moving to a new location, ineffective response to Claritin, Zyrtec, and Allegra, history of asthma.
Diagnosis: N/A
History of Patient: This 23-year-old white female presents with a complaint of allergies. She used to have allergies when she lived in Seattle, but she thinks they are worse in her current location. In the past, she has tried Claritin and Zyrtec, both of which worked for a short time but then seemed to lose effectiveness. She has also tried Allegra but found it ineffective. She has used over-the-counter nasal sprays but has not used any prescription nasal sprays. She has asthma but does not require daily medication for it and does not believe it is flaring up.
Plan of Action: Patient desires allergy testing.
Doctor: Good afternoon, ma'am. 
Patient: Good afternoon doctor. 
Doctor: So, do you have any medical conditions I should know about. 
Patient: Actually, yes. I have a few. I have hyperthyroidism, and I've had gallbladder issues for some time now. 
Doctor: I see. How's your blood pressure? 
Patient: Oh, um, I have high blood pressure too.

Clinical note:
The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.
Doctor: Are you a smoker, sir? 
Patient: Yes, I've been smoking about a pack, to about a pack and a half a day for more than forty years now. 
Doctor: What about alcohol, do you drink? 
Patient: Yeah, I drink a six pack of beer a day, doctor. 
Doctor: What about drugs? Do you use any illicit substances? 
Patient: No, I never used anything like that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: The patient smoked 1-1/2 packs of cigarettes for more than 40 years. He consumes 6 beers per day. He denies any drug use.
Plan of Action: N/A
Doctor: I'd like her to come see you for a consult tomorrow. 
Guest_clinician: How long has she been suffering from migraines with aura? 
Doctor: About five years now. 
Guest_clinician: Does she have a neurologist she sees regularly? 
Doctor: Not since moving here.

Clinical note:
Symptoms: Migraine with aura.
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: So, sir, are you married?
Patient: Yes, I'm married to my lovely wife. 
Doctor: That's great, so, what did you do for a living? 
Patient: I was a Pepsi Cola truck driver, but thankfully, I'm retired. 
Doctor: Congratulations on your retirement. What seems to be the problem today then?
Patient: Thank you, it's nice to be done with that. The years took their toll though, I have a lot of pain in my back and knees. 
Doctor: Ah, yes, those years of sitting and lifting eventually catch up to everyone.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Married. He is retired, having been a Pepsi-Cola truck driver, with pain in his back and knees.
Plan of Action: N/A
Doctor: Tell me about your family medical history. 
Patient: The only thing that I know about is that my grandma has diabetes.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Positive for diabetes mellitus in the maternal grandmother.
Plan of Action: N/A
Doctor: Hello, Mister G, how are you today?
Patient: I am good doctor thank you for asking. I am here to talk to you about my will.
Doctor: Yeah, nurse informed me. So, tell me how can I help you?
Patient: As you know I have terminal cancer. I have decided I do not want to be resuscitated. I have appointed my daughter as my legal healthcare proxy and she respects my wish.
Doctor: Tell me what I can do to make you comfortable? 
Patient: Honestly doctor you have done enough and I am so thankful for that. I just wish to spend my last days at home surrounded with loved ones. I have my nurse, she takes care of me. I think I am fine! 
Doctor: Alright my friend.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: CODE STATUS: Do not resuscitate, healthcare proxy, palliative care orders in place.
Plan of Action: N/A
Doctor: Do you smoke? 
Patient: Nope. 
Doctor: What about alcohol? Or any kind of drugs? 
Patient: Nope.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No smoking, drinking, or drug use reported.
Plan of Action: N/A
Doctor: History of any illnesses, surgeries, or hospitalizations? 
Patient: I dislocated my wrist when I was a kid but that's all.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Surgeries: None. Injuries: Dislocated wrist. Illnesses: None.
Plan of Action: N/A
Doctor: Any pain while peeing? 
Patient: No.
Doctor: Any change in frequency or feeling the urgency to pee?
Patient: No.
Doctor: And what about bladder control, any accidents?
Patient: No. 
Doctor:  Any history of syphilis or any other S T D?
Patient: No, never.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: GENITOURINARY: Negative frequency, negative urgency, negative dysuria, negative incontinence. No history of STDs.
Plan of Action: N/A