X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: Good morning, young lady. Is this your mother? 
Patient: Yes, this is my mommy. 
Doctor: Good morning, mom. Can you tell me more about your daughter, please?
Guest_family: Good morning, doctor. Well, she's thirteen now, but she's had feet problems all her life. 
Doctor: What's been the problem with her feet?
Guest_family: Well, she had bilateral feet corrections when she was a year old. 
Doctor: Okay, how has she been since that procedure?
Guest_family: Well, just look at her heel, doctor. 
Doctor: Yes, I see. She has pretty significant calcaneal valgus deformity. 
Patient: What does that mean, doctor? 
Doctor: Your heel is out of alignment, sweetie. Do you have pain?
Patient: Yes, I have a lot of pain, doctor. 
Guest_family: What can we do about this, doctor? 
Doctor: Well, given all of her symptoms, I think we should do a calcaneal osteotomy and Achilles lengthening procedure. 
Guest_family: What does that procedure entail? 
Doctor: Well, in short, we'll go in there and straighten everything out, and get everything lined back up. 
Guest_family: What's the risk of infection with the surgery, sir? 
Doctor: Actually, it's less than one percent, so it's extremely low.
Guest_family: How is this possible, doctor?
Doctor: We use antibiotics to control for infection the entire time. 
Guest_family: That's great. Will she be asleep for this procedure? 
Doctor: Yes, we'll use anesthesia the entire time. She won't feel a thing. 
Guest_family: Okay, that's good too. What about after the procedure? What's the protocol?
Doctor: Well, I'll need your help. We have to be strict about her being nonweightbearing for six weeks at minimum. 
Guest_family: Will she need a brace too?
Doctor: Yes, at least for six months, but if she does everything I ask of her, it will be only six months. 
Guest_family: Okay, yes, I think we should do the procedure. What do you think, honey?
Patient: Yes, I want to get back to playing sports with my friends.
Doctor: The other risks include bleeding; changes in sensation in most of extremity; hardware failure; need for later hardware removal; possible nonunion; possible failure to correct all the deformity; and need for other surgical procedures.  I would not worry about these issues, though. It is quite rare. So, looking at her radiographs, the spinal arch is definitely collapsed. I think you guys are making the right decision.

Clinical note:
Symptoms: significant pain in feet
Diagnosis: calcaneal valgus deformity
History of Patient: bilateral feet corrections at 1 year of age, significant calcaneal valgus deformity since then
Plan of Action: calcaneal osteotomy and Achilles lengthening procedure, strict nonweightbearing for at least 6 weeks, wearing a brace for up to 6 months
Doctor: Good morning, young man. Are these your parents?
Patient: Yes. 
Doctor: Good, can you tell me more about your son, please? 
Guest_family_1: Well, he's five now, and he fell onto his right arm on December fifth two thousand seven.
Doctor: After he fell, how was he treated? 
Guest_family_1: We went to the E D right after he fell, and they said he had complete fractures of both bones in the arm. 
Doctor: Yes, I see that here, he also has shortening bayonet apposition. 
Guest_family_1: What can we do for this? 
Doctor: There's actually a few options here. First we can cast it and see how he heals, generally, children heal up very well from fractures. 
Guest_family_1: That's good, we like that option more than any kind of surgery. 
Doctor: However, surgery is also an option here as well. 
Guest_family_1: Yeah, to be completely sure we fix this, I think we should opt for the surgery, what do you think, honey?
Guest_family_2: Yes, I agree. What are the risks of infection for this surgery?
Doctor: The risk of infection is very low, generally less than one percent. We use antibiotics to control for infection. 
Guest_family_1: Will he be asleep for the surgery?
Doctor: Absolutely, he won't feel a thing. Other risks include bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, and cast tightness. I would not worry about these risks. We have great results with these surgeries. 
Guest_family_1: Then yes, we'd like to do the surgery.

Clinical note:
Symptoms: refracture of right forearm
Diagnosis: complete fractures of both bones in right arm, shortening bayonet apposition
History of Patient: fell onto right arm on December 5, 2007
Plan of Action: surgery for closed reduction and pinning, with risks including anesthesia, infection, bleeding, changes in sensation and motion of extremity, hardware failure, need for later hardware removal, cast tightness
Doctor: Hello. Are you a new patient? 
Patient: I am. I've been traveling a lot, so I don't have a local doctor I usually see. 
Doctor: That's fine. What is the reason for your visit? 
Patient: I've had this dark spot on my leg for a long time. 
Doctor: I see. Do you know if your family has any chronic medical problems? 
Patient: Not that I know of. 
Doctor: That's good. I think I'll be able to remove it surgically. Before I go over the procedures, have you had a surgery before? 
Patient: Yeah, I have. I had surgery on my back and to remove my appendix. 
Doctor: Sounds good. Other than that dark spot, you seem to be very healthy.

Clinical note:
Symptoms: dark spot on leg
Diagnosis: N/A
History of Patient: No local physician, previous back surgery and appendectomy, otherwise generally healthy
Plan of Action: N/A
Doctor: It's surgery day! How are you feeling? 
Patient: Not as excited as you. 
Doctor: Have you had a surgery before? 
Patient: Yeah. It was something with my chest. 
Guest_family: Hi Doctor. I'm the mother. He had a chest port placement. 
Doctor: I see. Thank you for letting me know.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Chest Port placement surgery
Plan of Action: N/A
Doctor: What is your living status? Do you live alone or with family? 
Patient: I live with my boyfriend. 
Doctor: Do you smoke? 
Patient: Yes. 
Doctor: For how long you are smoking? 
Patient: Around ten years. 
Doctor: How many cigarettes do you take? 
Patient: Well, one pack of cigarettes lasts for around three days. 
Doctor: Do you drink? 
Patient: I do take beer. 
Doctor: How many do you drink a day? 
Patient: I take around six bottles once a week. 
Doctor: Are you working somewhere? 
Patient: I was working in a herbicide plant. There were so many layoffs because of this pandemic. I lost my job too.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: unemployed, formerly worked at herbicide plant
Plan of Action: N/A
Doctor: I want to talk to you about your reproductive history, okay?
Patient: Okay. 
Doctor: Do you take birth control pills? 
Patient: Yes, I do. 
Doctor: Do you have any kind of medical history that I should be aware of? 
Patient: I had both chickenpox and measles when I was a kid.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: chickenbox and measles
Plan of Action: N/A
.
Doctor: Just want to ask you few questions.
Patient: Okay shoot.
Doctor: Do you have any nausea, vomiting?
Patient: Yes to both. 
Doctor: How about fever?
Patient: Yes, I do. 
Doctor: Any blood in sputum or chest pain?
Patient: Yes, I do.

Clinical note:
Symptoms: nausea, vomiting, fever, hemoptysis, pleuritic chest pain
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Well, this is a case of hypothermia. 
Guest_family: Will he survive?
Doctor: Don't worry, we will take care of him.

Clinical note:
Symptoms: N/A
Diagnosis: hypothermia
History of Patient: N/A
Plan of Action: N/A
Doctor: Do you take any tobacco related products? 
Patient: I used to chew tobacco, but I quit when I was thirty seven. 
Doctor: What about alcohol consumption? Do you drink? 
Patient: I take one glass of wine every day. 
Doctor: Are you married? 
Patient: Yes, sir. I'm married to a wonderful woman for last thirty five years. 
Doctor: Are you still working? 
Patient: I used to. Now I'm retired, I was a lab manager before.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: He has a history of tobacco use, which he quit at the age of 37.  He has one alcoholic drink per day.  He is married.  He is a retired lab manager. 
Plan of Action: N/A
Doctor: Hello! What brings you back into the clinic today? 
Patient: I came back because I increased my methothrexate as we discussed the last time I was here. A few days later I started getting multiple canker sores in my mouth. They hurt. 
Doctor: I am sorry. It is likely that the increased dosage of your methothrexate is the cause of the mouth sores. Have you experienced a decreased appetite, nausea, abdominal discomfort or diarrhea?
Patient: No. It is painful to eat with the sores, but I still have an appetite. 
Doctor: Have you had any new rashes, or hair loss? 
Patient: No. 
Doctor: I would like to get some bloodwork done. I would also recommend we decrease your dosage back to your previous amount. I would also like to see you back in two weeks to see how you are doing. 
Patient: Okay.

Clinical note:
Symptoms: multiple canker sores in mouth, pain while eating
Diagnosis: stomatitis, possibly methotrexate related
History of Patient: increased methotrexate dosage, resulting in mouth sores
Plan of Action: decrease methotrexate dosage back to previous amount, bloodwork, follow-up appointment in two weeks
Doctor: Are you aware of any medical issues in your family? 
Patient: No. 
Doctor: How about any known heart disorder or diabetes in the family.
Patient: No, I'm not aware of anything like that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: So, I am looking at his x ray and it does not show any open fracture or any kind of bone abnormality.
Guest_family: Okay, I was really worried about my son. 
Doctor: I understand, but like I said, I didn't see any open fracture in his x ray report nor any abnormality. 
Guest_family: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
.
Doctor: Do you drink? 
Patient: Yes, I do take two or four beers in a day. 
Doctor: Do you smoke? 
Patient: Oh yeah, I'm a smoker. I take around one to two packs of cigarettes each day.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: drink and smoke
Plan of Action: N/A
Doctor: Do you live alone? 
Patient: I wouldn't say I live alone. I have three cats and they always keep me company.  
Doctor: Aw, what kind of cats? 
Patient: Two Persian cats and one Chartreux. 
Doctor: Are you currently working? 
Patient: I retired a few months ago. I used to work as a psych aide for the State of Pennsylvania. 
Doctor: Congratulations on your retirement. 
Patient: Thank you. 
Doctor: How long did you work as a psych aide? 
Patient: Thirty two years. 
Doctor: Incredible. One more question. Do you smoke, drink, or use drugs recreationally?  
Patient: I drink wine every now and then. I used to smoke back in the day, but I'm five years smoke free. I do not do drugs.  
Doctor: Always great to hear.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: drink and smoke
Plan of Action: N/A
.
Doctor: Hi there! What brings you in today? 
Guest_family: I think my baby got into the ant bait. I am not sure if he consumed any of it but he was under the counter and it was in his hands.
Doctor: What kind ant bait did he get into?
Guest_family: It was the one with Borax in it. 
Doctor: Do you have a picture of it? 
Guest_family: Yes. It is in my phone.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Possible exposure to ant bait with Borax, further assessment needed
Doctor: Good morning, ma'am. I just need to confirm some information about you before we begin today. 
Patient: Good morning, doctor. Sure, that's no problem. 
Doctor: Great, so you're sixty seven years old, and White, correct? 
Patient: Yes, that's right doctor. 
Doctor: Thank you. Do you remember how many cycles of carboplatin and Taxol you've had for your cancer, ma'am? 
Patient: Um, I've had six, I'm here for a follow up today. 
Doctor: Yes, I see here that your last chemo treatment on January eighteenth two thousand eight. 
Patient: Yes, I remember that. Can you remind me the full name of my cancer? 
Doctor: It's a uterine papillary serous carcinoma. 
Patient: Thank you, doctor. 
Doctor: Sure, do you have any problems today? 
Patient: Well, I just have some numbness in my right upper arm today. 
Doctor: Has this gotten worse recently? 
Patient: Well, no, not really. 
Doctor: That's good. Do you feel this in your toes at all? 
Patient: No, there's no numbness there. 
Doctor: Good, do you have any tingling or burning to speak of? 
Patient: No, thankfully no.

Clinical note:
Symptoms: numbness in right upper arm
Diagnosis: uterine papillary serous carcinoma
History of Patient: completed 6 cycles of carboplatin and Taxol, last chemo treatment on January 18th, 2008
Plan of Action: N/A
Doctor: How long has she had difficulty swallowing? 
Guest_family: A while now. We scheduled her to see an endocrinologist, but she's not able to get in until Monday. I wanted to see if we could get to the bottom of it now. 
Doctor: It does appear that her thyroids are fairly enlarged. I believe that's where most of her symptoms, if not all, are stemming from. 
Guest_family: Does that mean she'll need surgery? 
Doctor: We'll have to see, but chances are higher since she's experiencing symptoms due to her thyroid. 
Guest_family: When will we find out? 
Doctor: I'd like to get some imaging done and see if we can get a consult in first.

Clinical note:
Symptoms: difficulty swallowing
Diagnosis: symptomatic thyroid goiter
History of Patient: difficulty swallowing for a while, scheduled to see endocrinologist on Monday, enlarged thyroid
Plan of Action: imaging to be done, consult with specialist
Doctor: Do you have any significant medical conditions that run in your family that I should be aware of? 
Patient: Yes, um, I know some of my relatives have had coronary artery disease, and, um, high blood pressure. 
Doctor: What about cancer? Does anyone in your family have a history of cancer? 
Patient: No, that doesn't ring any bells.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: coronary artery disease, high blood pressure
Plan of Action: N/A
Doctor: Any past medical problems or surgeries that I should know of? 
Patient: Nope, none that I can think of.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No significant past medical history reported.
Plan of Action: N/A
Doctor: So, I see here in your reports you have arthritis in you both knees. 
Patient: Yes.
Doctor: And you got a tear in your eye in the past, right? 
Patient: Ah yes, I got a tear in my retina. 
Doctor: Right. Also, it's mentioned here that you have atrial fibrillation.
Patient: That's correct.
Doctor: Are you taking any medications? 
Patient: Yes, I am on anticoagulants.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: Atrial fibrillation, osteoarthritis of the knees bilaterally, history of retinal tear.
History of Patient: Tear in Retina in the past, Medication in Anti Coagulants
Plan of Action: N/A
Doctor: Have you had any procedures in the past?
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: None
Plan of Action: N/A
.
Doctor: Do you have any medical conditions that run in your family that I should know about, ma'am? 
Patient: Um, yeah, my dad had prostate cancer. 
Doctor: What about your mother, or the rest of your family? 
Patient: Um, my mom's brother had Hodgkin's disease, melanoma, and prostate cancer.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Family history of prostate cancer in the patient's father and paternal uncle. Paternal uncle also had Hodgkin's disease and melanoma.
Plan of Action: N/A
Doctor: Do you drink? 
Patient: Not really, no. 
Doctor: Any drugs? 
Patient: No. 
Doctor: Do you get a chance to exercise during the week?  
Patient: I like to go on walks with my dog every day. I'm also eating a lot healthier these days.  
Doctor: That's wonderful. How's work going for you? 
Patient: I actually got promoted last month so it's been going well. I've had a lot more time to spend with my family as a result. 
Doctor: That's great to hear. Congratulations! 
Patient: Thank you so much.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.
Plan of Action: N/A
Doctor: Are you allergic to anything?
Patient: No, I do not have any allergies.
Doctor: Great.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No known drug allergies.
Plan of Action: N/A
Doctor: What do you do in the hospital?
Patient: I work as a phlebotomist and respiratory therapist. 
Doctor: Ok, how old are you?
Patient: I am fifty four.
Doctor: You are very young.
Patient: Thank you!
Patient: So, as you remember I was trying to measure blood gas as I was working with a patient and I accidently jammed that needle inside my right hand index finger.   
Patient: I am coming for regular screening.
Doctor: Were you wearing gloves?
Patient: Yes, I had gloves and protective clothing.
Doctor: Yes, thank you for that. Did they screen patient?
Patient: Yes, he got negative HIV but positive Hep C.
Doctor: Ok.
Patient: I am scared.

Clinical note:
Symptoms: accidentally jammed a needle into his right hand index finger.
Diagnosis: patient tested negative for HIV but positive for Hepatitis C.
History of Patient: The patient, a 54-year-old right-handed male, accidentally jammed a needle into his right hand index finger while working as a phlebotomist and respiratory therapist. He was wearing gloves and protective clothing at the time of the incident. The source patient tested negative for HIV but positive for Hepatitis C.
Plan of Action: N/A
Doctor: They took some fluid out of your back remember? 
Patient: Yes actually.
Doctor: We got the results back for that and it looks like it was clear then it turned bloody. 
Patient: They checked my urine and blood too.
Doctor: Yes, they did. I see the orders for urine culture, B M P, C B C, C R P, and blood culture as well.
Patient: I got albuterol nebulizer treatment too.
Doctor: That is good. but did that help you?
Patient: No, it did not.
Doctor: Oh I am sorry.
Patient: It is okay.
Doctor: I see that they gave you some antibiotics in E R?
Patient: Yes, Ampicillin and Cefotaxime.

Clinical note:
Symptoms: N/A
Diagnosis: patient received a lumbar puncture with CSF fluid sent off for culture and cell count. This tap was reported as clear, then turning bloody in nature. The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture. 
History of Patient: N/A
Plan of Action: The patient also received 1 albuterol nebulizer treatment, which did not help his respiratory status. Finally, the patient received 1 dose of ampicillin and cefotaxime respectively.
Doctor: Tell me about your medical history. Did you have any surgeries? Any medical issues in the past? 
Patient: I had my tonsils removed when I was a kid, maybe around eight. I was hospitalized for the heart attack in ninety six. They did some surgery to check how my heart is functioning and then they did a bypass I guess. 
Doctor: Do you have some record of those surgeries? 
Patient: Oh yes, I got it with me. Here it is. 
Doctor: That is awesome. Let me have a look. So, according to this you had L I M A to L A D coronary bypass graft. You also had had three saphenous vein grafts performed. 
Patient: Yes I had so many surgeries, it's hard to keep a track of all those complex names. That's why I keep those papers with me all the time if I go to any new doctor. 
Doctor: I will add all these surgeries into my record. Thank you.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: He had tonsillectomy at the age of 8. He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure. He had LIMA to the LAD and had three saphenous vein grafts performed.
Plan of Action: N/A
Doctor: How's everyone in your family?
Patient:  My mom, dad and siblings are good.
Doctor: They are well, that is good. That's what we want.
Patient: Yes.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Mother, father, and siblings were alive and well.
Plan of Action: N/A
Doctor: So, what do you do for a living, sir? 
Patient: I work at A B C store, doctor. 
Doctor: That's great, do you smoke? 
Patient: No, I don't smoke at all. 
Doctor: How about alcohol? Do you drink? 
Patient: I'd say I drink socially, like if I'm at a party, or something.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Works at ABC. Social alcohol drinker. Non-smoker.
Plan of Action: N/A
Doctor: Do you take any daily medications or supplements? 
Patient: Nope.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: None
Plan of Action: N/A
Doctor: Good afternoon, sir, how are you today? 
Patient: Good afternoon, Doctor, my knees are in a lot of pain today.
Doctor: Is the pain equal? Or is one knee worse than the other?
Patient: Um, the left knee hurts more than the right, but there's pretty significant pain with both. 
Doctor: Is it interfering with your ability to walk? 
Patient: Yes, I can walk like, maybe a half a mile a day, then the pain gets too bad. 
Doctor: Are you able to go up and down stairs?
Patient: I have to take them one at a time. 
Doctor: I see you have degenerative joint disease of both knees, does that ring any bells?
Patient: Yes, but what does that mean?
Doctor: You have arthritis in both of your knees, sir.
Patient: Ah, yes.
Doctor: Have you had surgery on these knees? 
Patient: Um, I had surgery on both of these knees, let me check my notes. It was an, um, arthroscopy. 
Doctor: When were these surgeries?
Patient: They were in the nineteen ninety one nineteen ninety two time frame, somewhere in there.
Doctor: How have you managed this since the surgeries?
Patient: I've taken antiinflammatories, had injections, and I've even used narcotics. 
Doctor: I see. If those haven't helped, I think you'd be a good candidate for knee replacements. 
Patient: Can we do both at the same time?
Doctor: No, let's do the left since that one hurts more. Do you have any other conditions I should know about?
Patient: I've had a lot of back surgeries, I have spinal stenosis. 
Doctor: Do you know what surgeries you've had?
Patient: Let me check my notes, um, I've had a spinal decompression and epidural steroids injection. 
Doctor: Who has prescribed you narcotics for this pain?
Patient: The pain is so bad, but Doctor X has handled those.

Clinical note:
Symptoms: Left knee pain worse than right, significant pain in both knees, limitation in walking (approximately 1/2 mile a day), difficulty going up and down stairs (one at a time).
Diagnosis: Severe bilateral knee degenerative joint disease (DJD), left greater than right. Arthritis in both knees.
History of Patient: The patient had arthroscopy on both knees in the 1991/1992 timeframe. He has been on a conservative treatment course including nonsteroidal anti-inflammatory drugs (NSAIDs), narcotics, and injections. Due to progressive limitations, he has opted for total joint surgery on the left knee. Additionally, he has had multiple back surgeries for spinal stenosis, including decompression and epidural steroid injections. Significant pain is managed with narcotic medication prescribed by Dr. X.
Plan of Action: Total joint surgery planned for the left knee due to persistent limitations. Management of back pain with narcotic medication.
Doctor: Do you smoke?
Patient: Yes.
Doctor: How much?
Patient: Two cigarettes per day.
Doctor: Okay that is not bad, but try quitting.
Patient: Okay.
Doctor: Alcohol?
Patient: No, I don't drink.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Tobacco use, averages two cigarettes per day. Alcohol use, denies.
Plan of Action: N/A
Doctor: Hi Ryan, what brings you here today?
Patient: Well, you told me to follow up if my cough doesn't get better. Also, I started having several other issues. 
Doctor: Oh really!
Patient: Yeah.
Doctor: Okay, so tell me about your cough, is it getting worse than before? 
Patient: It's about the same but not getting better.
Doctor: Hm. And what about your diarrhea and stomach pain?
Patient: No more diarrhea and no pian. 
Doctor: Bowel movement?
Patient: Normal.
Doctor: Any pain while peeing? Are you able to empty your bladder completely?
Patient: No pain and no problem emptying my bladder.
Doctor: Okay good. Any nausea or vomiting?
Patient: Nope, but I have developed this weird sore taste in my mouth.
Doctor: Oh okay. How long?
Patient: Since last week.
Doctor: I see. Any loss of appetite?
Patient: No, not really. 
Doctor: Okay and what other issues were you talking about? 
Patient: Yeah, I am also having some trouble with my eyes, I am able see fine, but it feels kind of funny. 
Doctor: Okay. 
Patient: And then my back is hurting so much, and last week my right shoulder and neck started to hurt. 
Doctor: Did you injure it or had a fall or anything?
Patient: No. 
Doctor: Okay.

Clinical note:
Symptoms: Cough not improving, sore taste in mouth since last week, "trouble with eyes" feeling funny but vision is fine, worsening back pain, right shoulder and neck pain over the last week with no injury reported.
Diagnosis: N/A
History of Patient: The patient reports cough not improving, sore taste in mouth since last week, "trouble with eyes" feeling funny but vision is fine, worsening back pain, right shoulder and neck pain over the last week with no injury reported. Denies diarrhea, abdominal pain, nausea, vomiting, dysuria, or loss of appetite.
Plan of Action: N/A
Doctor: So, sir, what do you do for a living? 
Patient: Right now, I'm working with Chevron as a petroleum engineer. 
Doctor: That's fantastic. So, do you drink?
Patient: Um, I'd say I drink socially, like if I'm at a party or something. 
Doctor: Sure, me too. Do you smoke?
Patient: No sir, I don't do that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: He is a petroleum engineer for Chevron. Drinks socially. Does not use tobacco.
Plan of Action: N/A
Doctor: Is anyone else at home sick? 
Patient: No. My husband and daughter seem to be doing okay. They haven't complained of anything yet.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Noncontributory. No one else at home is sick.
Plan of Action: N/A
Doctor: Hi, how are you doing, ma'am? What brings you here today?
Patient: I'm good, thank you. I'm having this weakness on my left side after the brain, I mean, after they removed my tumor from the brain. 
Doctor: Remind me when did you have your surgery for brain tumor? 
Patient: It was on October twenty fourth last year. 
Doctor: How old are you now? 
Patient: I'm sixty four. 
Patient: He is my husband, Al. 
Doctor:  Hi, nice to meet you. 
Doctor:  Tell me what happened. 
Patient: They asked me to go to the physical therapy for all the problems I was having after my brain surgery. I went from November fifth to the fourteenth of last year. I did therapy for around two weeks starting on November fifth. My problems were not solved so I went to the hospital and then they did some tests and they found out something was wrong. They said there is swelling in my brain so they admitted me there and then I had my second surgery. 
Doctor: When was the second surgery? When did you get admitted? 
Patient: It was on December fifth. I was there in the rehab the whole time and then I was discharged for home one month after my second surgery. 
Doctor: Was there any other issue? 
Guest_family: Yeah. When she was in the rehab she developed something which they called D V T in her left calf. She did not have any such problem again after that.

Clinical note:
Symptoms: weakness on left side after brain tumor removal
Diagnosis: N/A
History of Patient: brain tumor removal surgery on October 24th last year, left-sided weakness following surgery, physical therapy from November 5th to November 14th, complications leading to second surgery on December 5th due to swelling in brain, discharged from acute rehab to home on January 5th, DVT in left calf during rehabilitation
Plan of Action: N/A
Doctor: What medication have you tried?
Patient: I took Nexium.
Doctor: Pain?
Patient: Yes.

Clinical note:
Symptoms: pain
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Nexium
Doctor: Well, I am looking at your test reports and your blood sugars have been running up and down but nothing to be worried about but yeah, we need to keep monitoring. This morning it was perhaps a bit high at one hundred eighty-eight. Last time it was one hundred fifty and in one report it's around one hundred twenty and in lower teens too which is good. So, tell me how are you feeling?
Patient: Well, I am doing okay. I am getting treated for hemorrhoids. I am also having some constipation from the past few weeks and I have recently developed this cough which is okay as I kind of get it often.
Doctor: Oh boy, that's a lot going on!
Patient: Yeah. 
Doctor: So, tell me are your hemorrhoids painful?
Patient: No, it's fine.
Doctor: And are you taking anything for constipation? 
Patient: Well, just prune juice.
Doctor: Okay, let me write you an order for a laxative that should help. How bout cough? Any pain in the ribs while coughing?
Patient: Nah, I am not bothered by it.
Doctor: Any headache or nerve pain or body pain?
Patient: Um, no I am fine.
Doctor: Any fall or imbalance problem?
Patient: No.
Doctor: Any agitation or any other issues? 
Patient: Well, I am doing okay! Sometimes if I have pain, I take Tylenol and usually it works for me.
Doctor: That's good!
Patient: Yeah.
Doctor: So, you have been seeking psychiatric help from Doctor Hudyncia right?
Patient: Yes.
Doctor: She mentioned in her report that you are responding well to her treatment and that your depression is under control and the medicine is working for you. That's good news. Oh, what medicine has she prescribed? Um let me see here in the report, oh okay, got it! It's Cymbalta. 
Patient: Right.
Doctor: And no side effects, right?
Patient: No.
Doctor: And looks like the plan is to treat you for a minimum one year. 
Patient: Yeah.
Doctor: Lastly, any breathing issues?
Patient: No.

Clinical note:
Symptoms: constipation, cough
Diagnosis: hemorrhoids
History of Patient: constipation for the past few weeks, recent development of cough
Plan of Action: prescribed laxative for constipation, treated with Tylenol for pain, responding well to psychiatric treatment with Cymbalta for depression, plan to continue Cymbalta for minimum one year
Doctor: So, you saw Doctor X?
Patient: Yes, seven days back. I went to get my blood work done and then I followed up with Doctor Y.
Doctor: Yes, I will look at C B C diff and C M P profile.
Patient: I will follow up with my oncologist, Doctor Z, for my swellings. 
Doctor: Yeah, I couldn't get hold of Doctor Z but here is the phone number. You should book the appointment.
Patient: Okay I will do that.
Doctor: Also, I would like to follow up with your endocrinologist that is Doctor A for adjustments that is needed in your insulin pump. 
Patient: And you want me to see my gastro doc too?
Doctor: Yes, please follow up with Doctor B for issues with your J tube.
Patient: Sure thing.
Doctor: Lastly, I want you to see Doctor Y if your condition changes regarding colon cancer.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: positive lymph nodes, issues with J-tube
Plan of Action: follow up with Dr. X for blood work (CBC with diff and CMP), follow up with oncologist Dr. Z for lymph node swellings, follow up with endocrinologist Dr. A for insulin pump adjustments, follow up with gastroenterologist Dr. B for J-tube issues, follow up with Dr. Y if condition changes regarding colon cancer
Doctor: I see here that you were in for afib last month. 
Patient: Yep. 
Doctor: How're you doing? 
Patient: It's all under control for now. 
Doctor: That's good to hear. Are you still taking Metoprolol and Premarin? 
Patient: Yeah.

Clinical note:
Symptoms: N/A
Diagnosis: atrial fibrillation
History of Patient: under good control, now in normal sinus rhythm, on metoprolol and Premarin hormone replacement
Plan of Action: N/A
Doctor: Any health problems I should note? 
Patient: Diabetes. 
Doctor: Type one or two? 
Patient: Type two. 
Doctor: Are you on insulin? 
Patient: Yeah. I'm also trying to manage it with exercise.

Clinical note:
Symptoms: N/A
Diagnosis: Type 2 diabetes
History of Patient: N/A
Plan of Action: N/A
Doctor: Let me examine your leg. Well your x ray looks fine. No defect there, I don't see any mass or swelling. Are you able to walk or use that leg at all?
Patient: Oh yes, I am using it. I have also started going back on my regular walk. 
Doctor: Good, so your muscle strength is good, no loss of muscle tone there.
Patient: Yeah.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Hello, how are you?
Patient: Hi Doctor, I am good.
Doctor: So, what is going on with you? 
Patient: Well, I am having nausea and I just want to get it checked.
Doctor: Okay.

Clinical note:
Symptoms: nausea
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: How long have you had this cough? 
Patient: Past three weeks, doc. 
Doctor: Are you bringing anything up when you cough? 
Patient: Nah. 
Doctor: Any shortness of breath or chest pain? 
Patient: Nah. 
Doctor: How about fevers or chills? 
Patient: None of that.

Clinical note:
Symptoms: cough
Diagnosis: N/A
History of Patient: cough for the past three weeks, otherwise negative for fevers, chills, chest pain, or shortness of breath
Plan of Action: N/A
Doctor: Let's go over your history.
Patient: Okay.
Doctor: I see that you had an appendectomy.
Patient: Back in the nineteen forties. I also had an ankle resection in nineteen seventy five.
Doctor: Any complications with either surgery?
Patient: Uh nope.
Doctor: I also see that you have a recurring history of pneumonia.
Patient: Yeah. Started around age twenty and stuck with me ever since.
Doctor: How often have you had pneumonia?
Patient: Once every five years or so.
Doctor: Have you ever been hospitalized due to pneumonia?
Patient: Uh I'm usually given antibiotics and then discharged. 
Doctor: I see.
Patient: Unfortunately, I've had more episodes in the past year than ever before.
Doctor: Any history of inherited lung disease, bronchiectasis, or other chronic pulmonary cause for repeated pneumonia?
Patient: Not to my knowledge. 
Doctor: And you recently saw the urologist, correct?
Patient: Yes. I had a catheter placed for urinary retention. He told me he thinks it's due to an enlarged prostate.
Doctor: Do you have a history of diabetes or other medical problems?
Patient: Uh no. I've lost about eighteen pounds in the last month but other than that everything else seems to be fine.

Clinical note:
Symptoms: recurring episodes of pneumonia, recent weight loss of approximately 18 pounds
Diagnosis: N/A
History of Patient: pneumonia episodes started around age 20, occurring once every five years on average but more frequent in the past year, treated with antibiotics and discharged, no known history of bronchiectasis or inherited lung disease, catheter placed for urinary retention possibly due to prostate enlargement, no history of diabetes or other medical problems
Plan of Action: N/A
Doctor: Hi again! How are you feeling today?
Patient: I am feeling okay. 
Doctor: Are you still experiencing any nausea or vomiting? 
Patient: No. I feel better now. 
Doctor: Have you had any shortness of breath or chest pain? 
Patient: No. 
Doctor: Any painful or burning urination? 
Patient: No. 
Doctor: Do you have a history of any seizure disorder? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: history of nausea and vomiting, currently feeling better, denies seizure disorder, chest pain, shortness of breath, dysuria
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: N/A
Plan of Action: N/A
Doctor: Your son had his circumcision performed here at Children's Hospital, correct? 
Guest_family: Yes, doctor. 
Doctor: Do you remember the date of that procedure? 
Guest_family: Um, it was on September sixteenth two thousand seven. 
Doctor: Good, the procedure went well. He had some phimosis, but the operation was quite smooth otherwise. 
Guest_family: What's phimosis?
Doctor: That's tightness of the foreskin. It sometimes makes the procedure more difficult, but everything went smoothly. 
Guest_family: Oh, that's good to hear. 
Doctor: He also had a little bit of bleeding when he woke up in the recovery room, so we had to put in some additional sutures. 
Guest_family: Okay, thank you for taking care of him. 
Doctor: It's my pleasure. Has he been taking his pain medicine? 
Guest_family: He took them for a couple days, but he really seems back to normal now. He doesn't seem to be in any pain. 
Doctor: Great, does he have any difficulty urinating? 
Guest_family: No, that's normal.
Doctor: Bowel movements? How are they?
Guest_family: That's normal too, doctor.

Clinical note:
Symptoms: N/A
Diagnosis: phimosis (resolved)
History of Patient: circumcision performed on 09/16/2007 at Children's Hospital, minor bleeding post-operation requiring additional sutures, pain managed with oral analgesics for a couple of days, normal urination and bowel movements
Plan of Action: N/A
Doctor: Is this something new? Or have you had it before?
Patient: No doctor, this is new.
Doctor: What exactly are you feeling?
Patient: I feel like my tongue is swollen.
Doctor: Okay. How old are you?
Patient: I am fifty four years old.
Doctor: Okay let me see how we can evaluate that.

Clinical note:
Symptoms: swelling of the tongue (new onset)
Diagnosis: N/A
History of Patient: new-onset swelling of the tongue in a 54-year-old patient
Plan of Action: N/A
Doctor: So, I think we need to start you on antibiotics for that ulcer on your right foot and possible osteomyelitis. I will send a prescription to your pharmacy. 
Patient: Sure.

Clinical note:
Symptoms: ulcer on right foot
Diagnosis: possible osteomyelitis
History of Patient: N/A
Plan of Action: start antibiotics, prescription sent to pharmacy
Doctor: Your condition is improved, and you look pretty stable. 
Patient: Yeah, I feel much better.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Do you have any allergies to medications?
Patient: Yes. Penicillin.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Looks like you have a U T I and I need to give you some antibiotics to treat it.
Patient: Okay.
Doctor: I will write you a prescription for Macrobid. Are you still using the Walgreens pharmacy at Thrashers Corner?
Patient: Yes.   
Doctor: Are you taking any other medications? 
Patient: Yes, I am taking quite a few. I always carry the list of my medications, let me tell you the names.  Yeah, so I take Dilantin for my seizures, Toprol for my high blood pressure and Pravachol for my cholesterol.
Doctor: Pravachol for my cholesterol. Wow, thank you for that, it helps a lot. Let me make a note of it.
Patient: Sure.

Clinical note:
Symptoms: N/A
Diagnosis: urinary tract infection (UTI)
History of Patient: patient taking Pravachol for cholesterol, Dilantin for seizures, and Toprol for high blood pressure; prescribed Macrobid for UTI
Plan of Action: N/A
Doctor: Have you had any operations in the- 
Patient: Nope. No surgeries. 
Doctor: How about any past injuries or illnesses? 
Patient: Nope.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: What is going on?
Patient: I have pain in my jaw since the morning.
Doctor: How bad is it?
Patient: Not that bad.

Clinical note:
Symptoms: jaw pain (since morning)
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Have you taken any medications in the past?
Patient: Do you mean prescription, or over the counter? 
Doctor: Either of those. 
Patient: Oh, I haven't taken anything in the past.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Any changes to your diet? 
Patient: I've been following the A D A diet online and maxing out at around eighteen hundred calories per day. 
Doctor: How're you feeling since starting this diet? 
Patient: A lot better actually. My blood sugar isn't as high as it used to be.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: following ADA 1800-calorie diet, patient reports feeling better with improved blood sugar levels
Doctor: Hello! How are you doing? 
Patient: I am doing okay. 
Doctor: Tell me about your past medical history.  
Patient: I was diagnosed with stage three ovarian cancer two years ago. They found a tumor in my upper abdomen. I had surgery and they removed everything. Doctor King is my oncologist.
Doctor: Are you still undergoing treatment? 
Patient: Yes. 
Doctor: Do you have any other medical conditions? 
Patient: Have a heart murmur. It has not been an issue. I also have acid reflux.  
Doctor: Do you take medication for the G E R D? 
Patient: Yes. I take omeprazole.

Clinical note:
Symptoms: N/A
Diagnosis: Gastroesophageal reflux disease (GERD), Mitral valve prolapse, Stage IIIC papillary serous adenocarcinoma of the ovaries
History of Patient: diagnosed with stage three ovarian cancer two years ago, underwent surgery for tumor removal, currently undergoing treatment under oncologist Doctor King, also has a heart murmur which has not been problematic
Plan of Action: N/A
Doctor: How are your parents doing, sir? 
Patient: Well, doctor, I've lost both of them now. 
Doctor: I'm so sorry to hear that, sir. How about your brothers? 
Patient: Thank you, doctor. Both of my brothers are doing very well. 
Doctor: Remind me, please, how old are they? 
Patient: One of them is sixty eight, and the other is seventy seven. I'm in the middle. 
Doctor: That's great. Do you have any medical conditions that run in your family? 
Patient: Well, I'm not sure if it counts, but I had a brother and sister, they were twins, they died at birth. 
Doctor: Oh no, thank you for telling me. 
Patient: Yes, I thought it would be important. 
Doctor: Do you have any children, sir? 
Patient: Yes, I have two sons, they're both doing very well. 
Doctor: How old are your sons? 
Patient: One of them is fifty four, and the other is fifty seven. 
Doctor: In addition to the neonatal deaths, do you have any other conditions that I should know about? 
Patient: Yeah, um, a lot of my family has diabetes, and a lot of them have had heart attacks as well.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: diabetes and heart attack
Plan of Action: N/A
Doctor: Is there anyone that lives with you at home? You are going to need someone to help you care for your wound. 
Patient: My wife lives at home with me.  She can help me change my bandages.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Hello. Looks like you're having surgery today. 
Patient: Yeah, I am. I forgot what the surgery was, but it says it in my report. 
Doctor: I'm looking at it right now. Looks like you had a PermCath inserted three times and received peritoneal dialysis

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: PermCath insertion (3 times), peritoneal dialysis
Doctor: So, what is happening with you?
Patient: I had knee replacement for both my knees three years ago and now I am having some pain. 
Doctor: Okay and in one or both knees?
Patient: Both.
Doctor: Okay.

Clinical note:
Symptoms: pain in both knees
Diagnosis: N/A
History of Patient: bilateral knee replacement three years ago, experiencing pain in both knees
Plan of Action: N/A
Doctor: Hi!
Patient: Hello!
Doctor: How are you feeling now?
Patient: I am feeling okay.
Doctor: Yeah, looks like your condition is improving.
Patient: Yes, I think so too.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: And who are we seeing today?
Guest_family: Hi Doctor, this my son J and that's my wife. 
Guest_family_2: Hi there 
Doctor: Well, hello young man how are you feeling today?
Guest_family_2: He has been complaining of severe tummy pain and was crying the whole time. We are worried as he is a special child. He has autism. 
Doctor: For how long now?
Guest_family_2: Autism?
Doctor: No, I mean when did he start complaining of stomach pain?
Guest_family_2: It started last night.
Doctor: Oh okay, let me check him. Did he have any nausea or vomiting?
Guest_family: Yes, he threw up a lot and is refusing to eat or drink anything.
Doctor: And then he is complaining of tummy pain?
Guest_family_2: Yes.
Doctor: Well, the good part is he is not dehydrated. 
Doctor: Any diarrhea?
Guest_family_2: Yes, he went three to four times.
Doctor: Hm, but no blood or anything in the stools or vomit?
Guest_family: No, nothing like that, we did not notice anything.
Doctor: Okay good. 
Doctor: Well, let me run some tests but the signs and symptoms sound like he might have a stomach flu, also called as gastroenteritis in medical terms. I will start him on some medicines and hopefully that should help.

Clinical note:
Symptoms: Severe abdominal pain
- Crying
- Nausea
- Vomiting
- Refusal to eat or drink
- Diarrhea

Diagnosis:
 Gastroenteritis
Autism

History of Patient:
The patient, a young boy with autism, has been experiencing severe abdominal pain since last night. He has been crying and exhibiting signs of distress. He has also been vomiting frequently and refusing to eat or drink. Additionally, he has had several episodes of diarrhea, although there is no blood present in the stools or vomit.

Plan of Action:
The doctor suspects gastroenteritis based on the Symptoms described by the family. Tests will be run to confirm the Diagnosis, and the patient will be started on appropriate medications to manage the Symptoms.
Doctor: Hello, nice to meet you, miss. I will be taking care of you today. Before we start, can I get to know you a bit? I like to know who I am treating. 
Patient: Hello, nice to meet you. Of course. Um, what can I say? I am a recent widow. My husband passed when we were married for only eight years. I am also retired and loving every minute of it. 
Doctor: I am sorry to hear that, but I am glad you are happy after retirement. Do you celebrate your infinite days off with a drink or a cigarette?
Patient: No, I do not smoke. I drink occasionally, but it is very rare. 
Doctor: Do you have any children that you spend your time with?
Patient: I have three wonderful children.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: widowhood after eight years of marriage, retirement
Plan of Action: N/A
Doctor: What do you use to treat your asthma? 
Patient: I use my Albuterol inhaler.

Clinical note:
Symptoms: N/A
Diagnosis: asthma
History of Patient: N/A
Plan of Action: Albuterol inhaler
Doctor: Do you eat three meals a day? 
Patient: Yes.  
Doctor: Do you think those meals add up to about two thousand calories a day? 
Patient: I would say yes.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: regular diet, eating three meals a day
Plan of Action: N/A
Doctor: Are you still taking Micronase every morning? 
Patient: Yes, I take um two point five M G once a day. 
Doctor: Great. Continue taking Micronase by mouth every day. As for your infection, I want you to start taking Bactrim twice daily. I'll be prescribing you thirty pills. It'll be Bactrim four hundred M G and eighty M G tablets.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30
Doctor: Do you consume any kind of tobacco?
Patient: No.
Doctor: What about smoking?
Patient: No, I've never done it.
Doctor: Any kind of alcohol consumption?
Patient: Nope.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A