X7-qP2-mN9-v4/MTS_Dialogue-Clinical_Note huggingface dataset:
Doctor: So, tell me what's going on with you?
Patient: Well, yesterday evening between seven or eight I developed nausea and suddenly it started hurting on the right side of my chest? 
Doctor: Where exactly did it hurt? 
Patient: Ah, my upper chest part and it went all around my right side till my back.
Doctor: Okay, how do you feel now?
Patient: I feel very weak and tired, don't feel like doing anything but resting. 
Doctor: Any fever?
Patient: Yeah, nurse just took my temperature it was one hundred point three. 
Doctor: Okay. Did you have these symptoms before? 
Patient: No, first time. I never felt like this before.
Doctor: Okay. Any chills or shivering? 
Patient: No.
Doctor: When was your last bowel movement? 
Patient: It was yesterday. 
Doctor: Did you notice any blood in your stool or any rectum bleeding?
Patient: No.
Doctor: How old are you?
Patient: I am twenty eight.
Doctor: Okay, and you had a gastric bypass surgery, one year ago. 
Patient: Yes, almost one year ago. I lost about two hundred pounds after that.
Doctor: And you felt well after the surgery? 
Patient: Absolutely! Until yesterday when my nausea and pain started. 
Doctor: Okay.

Clinical note:
Symptoms: Nausea, right upper quadrant pain wrapping around to the right side and back, malaise, low-grade fever (100.3°F).
Diagnosis: N/A
History of Patient: Status post gastric bypass surgery nearly one year ago. Lost about 200 pounds after surgery. Developed nausea and right upper quadrant pain yesterday evening. Denies prior similar Symptoms. Last normal bowel movement was yesterday. Denies chills or blood per rectum.
Plan of Action: N/A
Doctor: Okay, so it looks like your blood work shows that your sodium levels are very low. This could explain some of the symptoms you've been having lately. 
Patient: What does that mean? Why are my sodium levels so low? 
Doctor: It could be due to a number of- 
Patient: Should I start eating more salt? 
Doctor: Not necessarily. But I believe it's partly due to the diuretic that you've been taking these past few weeks. Your blood work also shows anemia. I'd like to start you on some iron supplements for now and get you back in for another eval. The front desk has access to your orders and they can print you out a lab slip. 
Patient: Do you think the iron will help with my tiredness? I've been so exhausted and caffeine hasn't been helping one bit.

Clinical note:
Symptoms: Acute tiredness
Diagnosis: Anemia of unknown etiology, acute hyponatremia
History of Patient: Symptoms: Acute tiredness
Diagnosis: Anemia of unknown etiology, acute hyponatremia
History of Patient: N/A
Plan of Action: Doctor suggests starting iron supplements for the anemia and reevaluation, attributes low sodium levels partially to diuretic use.

Plan of Action: Doctor suggests starting iron supplements for the anemia and reevaluation, attributes low sodium levels partially to diuretic use.
Doctor: So, you are a cigarette smoker? 
Patient: Yeah. 
Doctor: How much do you some? 
Patient: Not as much as some people. 
Doctor: How much is that exactly? 
Patient: Well, I probably buy a new pack once a week. 
Doctor: Okay. So that is about four packs a month and fifty packs a year. 
Patient: Yeah, I guess so.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: 50+ pack-year cigarette use.
Plan of Action: N/A
Doctor: Are you married, sir? 
Patient: Yes, to my wonderful wife.
Doctor: Great, can I assume you support each other at home? 
Patient: Yes, doctor, that's correct. 
Doctor: Do you smoke or drink, sir? 
Patient: Well, I don't smoke, and I don't do anything harder, either. But I drink just about every day. 
Doctor: How much do you drink a day? 
Patient: I drink maybe two or three drinks a day, so maybe four or nine a week.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Married with support at home. Denies tobacco and illicit drug use. Drinks two to three alcoholic beverages a day and up to four to nine per week.
Plan of Action: N/A
Doctor: Do you know if anyone in your family has history of heart disease, stroke anything of that sort?
Patient: Let me think. You mean only blood relatives?
Doctor: Yes.
Patient: Yes. We have some of those diseases in our family.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Remarkable for coronary artery disease, stroke, and congestive heart failure in the family.
Plan of Action: N/A
Doctor: What kinds of surgeries have you had in the past?
Patient: I have had a heart bypass surgery.
Doctor: Is that C A B G?
Patient: Maybe. And I have had my tonsils and appendix taken out.
Doctor: Sure. Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: History of CABG (possibly Coronary Artery Bypass Graft), appendectomy, and tonsillectomy surgeries.
Plan of Action: N/A
Doctor: Good morning, ma'am. Can you tell me more about this low back pain? 
Patient: Well, I'm not as young as I used to be, I'm fifty nine. 
Doctor: What set this pain off? Is there any injury? 
Patient: Yes, I had a fall in the beginning of two thousand six. I slipped on a freshly waxed floor. 
Doctor: What part of your lower back did you fall onto? 
Patient: I fell onto my tailbone and just general lower back. 
Doctor: Is this the only fall you've had?
Patient: No, I had another one in March of two thousand six. 
Doctor: What happened when you fell that time? 
Patient: I was trying to qualify on the gun range with a handgun, when I lost my footing. 
Doctor: What made you lose your footing?
Patient: I think it was more weakness than a loss of balance. 
Doctor: What treatments have you had for this?
Patient: Well, I've been to P T, and I had, um, cauterization of some of the nerves in my lower back.
Doctor: How many times have you had this cauterization done? 
Patient: I've had it twice, once in October and the other in November. 
Doctor: This was in two thousand eight, right? 
Patient: Correct. The P T said I have low back pain and degenerative disc disease.

Clinical note:
Symptoms: low back pain
Diagnosis: low back pain, degenerative disc disease
History of Patient: The patient, a 59-year-old female, has a history of low back pain secondary to a fall in 2006. She slipped on a freshly waxed floor, fell on her tailbone and low back region. She had another fall in March 2006 while qualifying on the gun range, attributing it to weakness in her lower extremities. The patient underwent cauterization of the nerves in her low back in October and November 2008 to alleviate painful Symptoms. Additionally, she has been referred to Physical Therapy.
Plan of Action: N/A
Doctor: Have you ever had surgery, ma'am? 
Patient: Yeah, doctor, I've had a whole lifetime worth of back surgeries.
Doctor: How many surgeries have you had? 
Patient: I've had four. 
Doctor: Do you know the surgeries you've had?
Patient: Actually, I have the op notes here. 
Doctor: I see, you've had an anterior cervical discectomy, and fusion of C three through C seven. 
Patient: Yes, I had all of those with Doctor L. 
Doctor: Do you have any children?
Patient: Yes doctor, I have seven, but I had three miscarriages. 
Doctor: Were any of your children born through C sections? 
Patient: No, none of them were.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Four back surgeries over her lifetime, anterior cervical discectomy and fusion of C3 through C7 in 2005 by Dr. L. G10, P7, no cesarean sections.
Plan of Action: N/A
Doctor: Have you ever had any major surgeries? 
Patient: I had a skin tag removed but no. No major surgeries. 
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No significant past surgical history except for the removal of a skin tag.
Plan of Action: N/A
Doctor: With ten being the worst pain imaginable, out of ten, how would you describe your pain today?
Patient: I'd say its about a six out of ten today. 
Doctor: What makes the pain worse? 
Patient: It's worse when I try to walk around on it. 
Doctor: Do you have any pain at night?
Patient: No, thankfully I don't. 
Doctor: How long have you been wearing that exterior knee brace?
Patient: Oh, for a little while now.

Clinical note:
Symptoms: pain rated at 6/10 on the Pain Analog Scale, primarily with ambulation
Diagnosis: N/A
History of Patient: Patient denies pain at night, wearing an exterior knee brace on the affected leg, appears to be on a backboard
Plan of Action: N/A
Doctor: I need to ask you a few questions.
Patient: Sure.
Doctor: Do you feel any weakness or tiredness?
Patient: No.
Doctor: Any uneasiness or illness? 
Patient: No, nothing of that sort.
Doctor: Any chills or high temperature? 
Patient: Nope.
Doctor: Any excessive sweating or night sweating? 
Patient: Um, no.
Doctor: How about allergies, are you allergic to anything? 
Patient: No, no allergies. 
Doctor: Alright.

Clinical note:
Symptoms: Negative weakness, negative fatigue, negative malaise, negative chills, negative fever, negative night sweats, negative allergies
Diagnosis: N/A
History of Patient: GENERAL: Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

Plan of Action: N/A
Doctor: Do you smoke or drink? 
Patient: No. 
Doctor: Any drug use? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No alcohol, drugs, or tobacco use reported.
Plan of Action: N/A
Doctor: Do you smoke?
Patient: Yes!
Doctor: How about alcohol, do you drink?
Patient: Yes, I do.
Doctor: And how much do you drink and is it occasional or on daily basis? 
Patient: Well, I love my wine, I drink about four to five glasses per day.
Doctor: Wow! That's a lot.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Patient is a smoker and drinks alcohol daily, consuming four to five glasses of wine per day.
Plan of Action: N/A
Doctor: Do you smoke cigarettes?
Patient: Yes.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: The patient is a smoker.

Plan of Action: N/A
Doctor: Any important family history, any medical issues in the family?
Patient: Well, my father died of a heart attack. I don't remember how old he was, but I do remember that he had some long run heart issues. 
Doctor: What about your mom? 
Patient: My mom's death was a mystery for all of us. She died of some complications because of the dental procedures. So never got to know what killed her. 
Doctor: Do you have kids? Are they all doing good health wise? 
Patient: I have a daughter, she's healthy.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Father died of a myocardial infarction (MI) at an unknown age with long-term heart issues. Mother died of complications of a dental procedure. Patient has one healthy daughter.
Plan of Action: N/A
Doctor: Hi there! How are you today? 
Patient: Hi. I am not doing so well. I have had this cough and a pain in my stomach. Right here by my belly button.
Doctor: How long has this been going on? 
Patient: Two days.  It has been very painful. 
Doctor: I would like to examine your abdomen. Is that okay? 
Patient: Yes.

Clinical note:
Symptoms: cough, abdominal pain
Diagnosis: N/A
History of Patient: Symptoms of cough and abdominal pain for two days.
Plan of Action: N/A
Doctor: Can you please confirm the medications that you have already taken?
Patient: Yeah, I just finished the course for Minocin. I also took Duraphen II D M.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Recently finished Minocin and Duraphen II DM.

Plan of Action: Recently finished Minocin and Duraphen II DM.
Doctor: Has anyone in your family had a history of heart disease or issues? 
Patient: Well, yeah. Actually, my dad passed away due heart disease.
Doctor: Oh, I am sorry to hear that. Do you know what kind of heart problem he had?
Patient: Yeah, it is called co-
Doctor: Oh, coronary heart disease? 
Patient: Yes, exactly!
Doctor: I see.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: His father died of coronary artery disease.

Plan of Action: N/A
Doctor: Good morning, ma'am. Just to confirm, you're thirty two years old, correct? 
Patient: Yes, doctor, that's correct. 
Doctor: Good, so, have you been able to get a P C P yet? 
Patient: No, I haven't gotten one just yet. 
Doctor: Are you in the process of getting one? 
Patient: Yeah, Project Access is trying to find me one. 
Doctor: Good, um, what seems to be the problem today, then? 
Patient: Well, I was at Doctor X Y Z's office today, I had an appointment, but they cancelled me because I don't have the Project Access insurance yet. 
Doctor: I see, what were you going to see Doctor X Y Z for? 
Patient: I'm having a lot of pain in my foot. 
Doctor: Okay, have you seen Doctor X Y Z before? 
Patient: Yeah, I saw him on May fourteenth two thousand four. 
Doctor: But you still don't have a P C P, correct? 
Patient: Yes, that's correct. 
Doctor: Okay, we've seen you quite a few times in here. You were in here last week and saw Doctor X Y Z for some back pain, how did they treat you? 
Patient: Um, I got some pain medicines and muscle relaxers. 
Doctor:  Okay, so, can you tell me more about your foot, please? 
Patient: Well, I have this pain in my foot, and I had surgery before so there's plates and screws in it.
Doctor: Have you ever talked to anyone about removing this hardware? 
Patient: Well, I was supposed to see Doctor X Y Z about it, but since that appointment was cancelled, I came here. 
Doctor: I see, how long have you had this foot pain? 
Patient: Um, it started hurting a lot yesterday. 
Doctor: Is there any injury here? 
Patient: No, it's just chronically painful, honestly. 
Doctor: Do any activities bother it? 
Patient: Yeah, I can't exercise without a lot of pain. 
Doctor: I see, well, we've x rayed this before, and I see the hardware in there, but there's no apparent abnormality or evidence of loosening, at least from what I can see.

Clinical note:
Symptoms: Chronic foot pain, exacerbated by exercise.
Diagnosis: N/A
History of Patient: Patient experiencing chronic foot pain with plates and screws from previous surgery. Appointment with Dr. XYZ for evaluation of hardware removal was cancelled. No recent injury to foot. Pain worsened significantly yesterday.
Plan of Action: N/A
Doctor: Do you smoke or drink? 
Patient: No.
Doctor: Any drugs? 
Patient: You mean like meth? 
Doctor: Yeah. 
Patient: No, never did it. 
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Denied ETOH (alcohol), tobacco, or illicit drug use. Patient specifically denied methamphetamine use.
Plan of Action: N/A
Doctor: Hello, miss. How are you? What brings you to my office today?
Patient: I am doing well. Just here for a refill on my medication.
Doctor:  Great. That should be easy. How has the stress management been going to control the acne?
Patient: It is going well. My husband has been on board with my meditations and yoga. He is very supportive. 
Doctor: Wonderful. Are will still clean from drinking and smoking? That can interact with your medications. 
Patient: Yeah I know. I don't drink or smoke.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: The patient is married.  She is a nonsmoker and nondrinker.

Plan of Action: Refill medication. Patient's stress management includes meditation and yoga, supported by her husband. Patient is nonsmoker and nondrinker.
Doctor: So I have here that you're taking three different medications. 
Patient: Yeah. I've been taking them every day just like they told me to. 
Doctor: I see. That's good. Did you refill your prescriptions with the newly revised doses? It looks like they changed the dosing of your medications at the hospital. 
Patient: Um I've just been taking what I have at home. 
Doctor: I advise that you take the doses that they prescribed. If you'd like me to put in a new order, please let me know. 
Patient: Okay, yeah that's fine. I can pick it up on my way home. I didn't think the dosing mattered much as long as I took the meds every day.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Patient was not taking the revised dose of medications as per discharge orders and prescription.
Plan of Action: Doctor advised patient to take the doses prescribed at discharge and offered to put in a new order.
Doctor: Any major surgeries in the past?
Patient: Not too many, but a catheter was put in my heart.
Doctor: Oh, so cardiac catherization, correct?
Patient: Yep.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No major surgeries except for prior cardiac catheterization.
Plan of Action: N/A
Doctor: Hello, sir. I see you're being seen for an evaluation for your allergy. Can you please confirm your age?
Patient: Yeah, that's right. Thirty four.
Doctor: Let me take a look at your medical records. I see you were treated at the A B C Medical Center for an allergic reaction, correct? 
Patient: Yeah. I was rushed to the hospital that day. After, they told me to get checked for a follow up. 
Doctor: Who told you to have a follow up? 
Patient: One of the E R doctors and the kidney doctor. 
Doctor: I see. Your records indicate you had some swelling around the eye on May third of two thousand and eight. The cause was unknown. I see you were transferred from A B C Medical Center to X Y Z Medical center that day. 
Patient: Yeah, that sounds about right. Were there more details about that? 
Doctor: Yeah, there is. It says here you have a history of renal failure, so you needed dialysis. They believe the allergic reaction was due to this medicine called, Keflex, which was used during your dialysis treatment. Does that name ring a bell? 
Patient: Yeah, it does. I forgot why they gave it to me.  
Doctor: Usually, Keflex is used to treat a skin cellulitis dialysis shunt infection. 
Patient: Oh, I see. 
Doctor: I would like to ask you more about your allergies. What would you say you're allergic to? 
Patient: I've had a lot of problems with grass and sometimes pollen. 
Doctor: I see. I'll put that down as grass allergies, and environmental and inhalant allergies. Do you have any life-threatening allergic reactions? 
Patient: Nope. Never had that. 
Doctor: Have you ever had any swelling under the skin due to something you ate or touched? 
Patient: Nope. Never had that either. 
Doctor: That's great. I'm taking a look at your medications. I see you aren't taking anything for your allergies, but you are taking Atenolol. Do you have high blood pressure? 
Patient: Yeah, I do. 
Doctor: I see. All that's left from your report are the treatments they gave you before you were discharged from the hospital. 
Patient: What were the treatments they gave me? 
Doctor: Looks like they monitored you the whole time and gave you some corticosteroid therapy and antihistamine therapy. You didn't have any additional problems as well.

Clinical note:
Symptoms: perioral swelling
Diagnosis: N/A
History of Patient: Patient had an acute event of perioral swelling on 05/03/2008, believed to be due to an allergic reaction to Keflex, used to treat a skin cellulitis dialysis shunt infection. Grass allergies, environmental, and inhalant allergies occasionally noted. No history of anaphylactic or angioedema reactions. Currently not taking any medication for allergies. Taking atenolol for blood pressure control.
Plan of Action: N/A
Guest_family: Doctor, you must tell her. She has stopped taking her medications. And her blood pressure is out of control, she is angry all the time and not looking after herself at all. 
Patient: That is not true!
Doctor: Miss Tara, you need to take your medications on time. You are hypertensive and your readings don't look good.
Patient: I don't want to take anymore medications. I want to try some natural remedies to treat my high blood pressure. I am not going to take any prescription meds that's it.
Doctor: If that's the case then I will make note in your file that you are not complying.

Clinical note:
Symptoms: N/A
Diagnosis: hypertension
History of Patient: Patient is noncompliant with hypertension medications. Guest_family expresses concern about patient's uncontrolled blood pressure, anger, and lack of self-care.
Plan of Action: N/A
Patient: I think I got some allergy, my lips are swollen and its causing me difficulty in swallowing. 
Doctor: Oh, let me take a look.

Clinical note:
Symptoms: swelling of lips, difficulty swallowing
Diagnosis: N/A
History of Patient: Swelling of lips causing difficulty swallowing.

Plan of Action: N/A
Doctor: Any medical history? 
Patient: Um I suffer from depression and high blood pressure. 
Doctor: Are you taking anything for either? 
Patient: Only for high blood pressure. 
Doctor: Have you had surgeries in the past? 
Patient: I had surgery to get a few hemorrhoids removed back in two thousand and ten.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Significant for hemorrhoidectomy in 2010. History of depression and hypertension.
Plan of Action: N/A
Doctor: Do you have a family history of any medical conditions, such as diabetes or heart disease? 
Patient: No, nothing.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Noncontributory
Plan of Action: N/A
Doctor: How's your family? 
Patient: They're doing well, thank you. My three boys are all grown up. Hard to believe they're living their own as young professionals. One of them is actually a G I doctor in San Diego, California. 
Doctor: You must be so proud of your boys. 
Patient: My wife and I always say how lucky we are. 
Doctor: I'm sure. And I have a few more questions before we wrap up. 
Patient: Go for it. 
Doctor: Do you drink or smoke? 
Patient: I smoke about a third of a pack a day and I drink every now and again, but nothing crazy.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Patient smokes about a third of a pack a day, drinks occasional alcoholic drinks. Married with three grown successful sons, one of whom is a gastroenterologist in San Diego, California.
Plan of Action: N/A
Doctor: How's it going, buddy? I haven't seen you in a long time 
Patient: Hey, Doctor. It's been a while. I've been doing well. Just here for my check up. 
Doctor: Nice. How's the family doing? Are they all well? 
Patient: Yeah, they're doing great. Nobody has been sick for a while.
Doctor: That's great to hear. Nobody has new medical conditions either, right? 
Patient: Not that I know of. They're all doing good.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Reviewed and unchanged.

Plan of Action: N/A
Doctor: So, you and your husband live together, correct?
Patient: Yes. It's a miracle we've lasted this long.
Guest_family: Can't argue that. 
Doctor: Are you able to walk any distance without assistance?
Guest_family: She's most comfortable in her wheelchair, but she usually walks with a walker if she's at home.
Patient: Yeah, he's right.
Doctor: And how often do you walk with your walker?
Patient: If I were to guess, I'd say half the time.
Doctor: Great. 
Guest_family: If I'm nearby, I like to keep any eye on her incase she feels unstable and needs help sitting back down.
Doctor: It's good that you're both looking out for each other. Now moving onto the last few questions. Do you smoke or drink?
Patient: No and no.
Doctor: Did you smoke or drink in the past?
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Patient lives with her husband, usually walks with a walker and is wheelchair-bound, does not walk much. No history of alcohol abuse or smoking.
Plan of Action: N/A
Doctor: You do not look so well today. What seems to be the problem? 
Patient: Well‚ I am having a hard time. My whole body aches and I am in pain.  
Doctor: Do you have a history of drug use? 
Patient: Well yes. I am detoxing. 
Doctor: What kind of drugs have you been using? 
Patient: Heroin. 
Doctor: Okay. How long have you been using? 
Patient: I don't feel well. Maybe a year. I can't sleep or eat. 
Doctor: Have you had a fever, chills, vomiting or diarrhea? 
Patient: I think I have a fever. I feel chilled. I have had some diarrhea.

Clinical note:
Symptoms: whole body aches, pain, difficulty sleeping, loss of appetite, fever, chills, diarrhea
Diagnosis: detox from heroin
History of Patient: Patient has been using heroin for approximately a year and is currently detoxing, experiencing Symptoms such as whole body aches, pain, difficulty sleeping, loss of appetite, fever, chills, and diarrhea.
Plan of Action: N/A
Doctor: How would you rate your general health?
Patient: I've been in reasonably good health at least physically. I try to go on frequent walks and eat a clean diet. However, there was one instance where I was not well mentally. After my husband died in nineteen seventy five, I had what I believe was a nervous breakdown. As a result of this, I was hospitalized for several weeks and treated with E C T. 
Doctor: I'm so sorry to hear about the loss of your husband. I can't imagine how difficult that must've been. I'm glad that you sought the care that you needed to feel better at that time. Did this happen when you were living in the United States or Korea?
Patient: This all happened when I was living in Korea. I'm grateful that I had my family and friends to support me.
Doctor: Social support is very important, especially when you are processing the loss of a loved one. 
Patient: Absolutely. 
Doctor: I have a few more questions before we move on. Any past medical problems?
Patient: I used to have high blood pressure.
Doctor: When you say used to, do you mean it's been resolved now?
Patient: Yes.
Doctor: Great news. How about surgeries? Have you had any in the past?
Patient: None whatsoever.
Doctor: Any alcohol or tobacco?
Patient: No, I stay away from things like that.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: The patient had a "nervous breakdown" in 1975 after the death of her husband, was hospitalized for several weeks, and treated with ECT. She does not smoke or drink alcoholic beverages. No prior surgeries. Past history of hypertension, but no longer present.
Plan of Action: N/A
Doctor: Are you experiencing any headaches, or do you have any history of migraine?
Patient: No. 
Doctor: Any temporary loss of consciousness? 
Patient: No.
Doctor: Any feeling of being off balance or fainting?
Patient: No.
Doctor: Any continuous sound you may hear? 
Patient: No.
Doctor: Okay so no tinnitus. Any mouth sores or ulcers? 
Patient: Um, no.
Doctor: Do you notice any change in your voice, any hoarseness? 
Patient: No, nothing like that. 
Doctor: Did you notice any swelling in and around your mouth? 
Patient: No, I did not.
Doctor: Any history of goiter or swelling of your thyroid gland? 
Patient: Nope.
Doctor: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling, or goiter
Plan of Action: N/A
Doctor: Hello, miss. How can I help?
Patient: Well, I just turned fifty seven this year and I would like to get rid of these wrinkles on my face. I don't like them one bit. 
Doctor: You look beautiful and actually have a lot of fullness in the face.  It is great that you do not smoke and do not have history of skin disease. We can definitely help you with these minor issues.

Clinical note:
Symptoms: facial rhytids (wrinkles)
Diagnosis: N/A
History of Patient: 57-year-old female presenting with facial rhytids, predominant fullness in submandibular and midface regions, prominent nasolabial folds, otherwise healthy, nonsmoker, no history of skin disease
Plan of Action: Discussion of treatment options for facial rhytids recommended
Doctor: Good afternoon, ma'am. 
Patient: Good afternoon, doctor. 
Doctor: Remind me, how young are you?
Patient: Oh doctor, you flatter me. I'm sixty two years old. 
Doctor: Great, and you've had a rotator cuff repair before, correct? 
Patient: Yes, that's correct. 
Doctor: Good, well, what seems to be the problem today?
Patient: I'm still having a lot of pain in this shoulder. 
Doctor: Oh no, have you had any recent imaging done on this shoulder? 
Patient: Yes, I had an M R I not too long ago, can you take a look? I have it right here. 
Doctor: Thank you, yes, um, this M R I shows that you've torn that rotator cuff again. 
Patient: Oh no, can we do another surgery to repair it again?
Doctor: Yes, we'll have to. 
Patient: What's the risk of infection of the surgery?
Doctor: Its less than one percent. We'll use antibiotics to control for infection the entire time. 
Patient: Will I be asleep again?
Doctor: Yes, you won't feel a thing. 
Patient: Great, yes, I'd like to go forward with the surgery. I need to get back to playing tennis.

Clinical note:
Symptoms: shoulder pain
Diagnosis: re-tear of rotator cuff
History of Patient: 62-year-old female with previous rotator cuff repair, continued shoulder pain, repeat MRI confirmed re-tear of rotator cuff, patient wishes to proceed with repair after discussion of risks and benefits
Plan of Action: Surgery discussed and agreed upon to repair re-tear of rotator cuff, risks including infection addressed with assurance of antibiotic use, patient consented to surgery
Doctor: What brings you in today? 
Patient: I dropped a glass and one of the broken pieces cut my foot pretty badly. There was a lot of blood. 
Doctor: Is the area still bleeding? 
Patient: I got it to stop bleeding while I was waiting for my ride.  
Doctor: Is there any pain in the area? 
Patient: No, it doesn't hurt. 
Doctor: Are you able to walk normally without pain or discomfort? 
Patient: Yes. 
Doctor: Are you experiencing any numbness or loss of strength in the area? 
Patient: No. 
Doctor: Do you have any other injuries on any other part of your body? 
Patient: No. 
Doctor: Have you had any recent illnesses? 
Patient: No. 
Doctor: Do you have any other concerns while you are here today? 
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: 32-year-old male with glass injury to right foot resulting in significant bleeding, bleeding stopped, no pain, normal use of foot without numbness or weakness, able to ambulate without discomfort, no injuries to other parts of body, no recent illness, no other complaints
Plan of Action: N/A
Doctor: What do you do for a living, sir? 
Patient: I'm actually retired, but I used to work as a dock hand. 
Doctor: That's great, congratulations on your retirement! 
Patient: Thank you so much, doctor. 
Doctor: I just need some background information on you, sir. Do you smoke? 
Patient: Sure, I smoke about a half a pack of cigarettes a day. 
Doctor: Do you drink, sir? 
Patient: Well, not anymore, but I used to be an alcoholic.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: 120 pack-years smoking history, past alcohol abuse, retired dock hand
Plan of Action: N/A
Doctor: Any surgical history? 
Patient: I had my thyroids taken out. 
Doctor: When did you have them taken out? 
Patient: Hm three years ago. Man, time flies. 
Doctor: Did you experience any complications post surgery? 
Patient: Nothing out of the ordinary. 
Doctor: Who was the surgeon who did your thyroidectomy? 
Patient: Doctor X. 
Doctor: What was the final diagnosis? 
Patient: I had a growth on my thyroids. 
Doctor: Was the growth cancerous? 
Patient: It was. I was initially reluctant to get them out, but I realized it was necessary. I didn't have much of a choice if I wanted to live ya know.  
Doctor: That's understandable. I'm sorry you had to go through that. Surgery is daunting, let alone surgery to remove cancer.

Clinical note:
Symptoms: N/A
Diagnosis: growth on thyroid, thyroid cancer
History of Patient: Total thyroidectomy performed approximately three years ago due to a growth on the thyroid, no complications post surgery
Plan of Action: N/A
Doctor: Welcome in. I am Doctor Welch. 
Guest_family: Thank you! It is nice to meet you. 
Doctor: How old is your daughter? 
Guest_family: She is three years old now. 
Doctor: Hi there! 
Patient: Hi! 
Doctor: Mom I would like to start off with some questions regarding pregnancy, childbirth, and prior children. 
Guest_family: Okay. 
Doctor: Do you have any other children?
Guest_family: No. She is my only child. 
Doctor: Have you ever had any miscarriages or abortions prior to having your daughter? 
Guest_family: I had a very early miscarriage before getting pregnant again with her. 
Doctor: I am so sorry to hear that.
Guest_family: Thank you. I was difficult but when I got pregnant again with her, we were so overjoyed. 
Doctor: Did you have any difficulties or problems during your pregnancy with her. 
Guest_family: I had the flu in my seventh or eighth month of pregnancy. Other than that I had no problems. 
Doctor: How far along were you when you gave birth? 
Guest_family: I was thirty six weeks. 
Doctor: Did you have a vaginal birth or a C section? 
Guest_family: I had a regular birth. 
Doctor: Were any tools used during the birth to help with the birthing process?
Guest_family: No. 
Doctor: How long were you in labor for? 
Guest_family: I was in labor for eleven hours. 
Doctor: Were you given any anesthesia during the birth? 
Guest_family: They gave me a little bit of laughing gas but not much. 
Doctor: What was her birth weight? 
Guest_family: Seven pounds and ten ounces.
Doctor: Do you recall her Apgars score? 
Guest_family: No. I am not sure. 
Doctor: How long did you stay in the hospital after the birth? 
Guest_family: Five days. 
Doctor: Let us move to questions regarding your daughter. Has she had any development problems? 
Guest_family: She did not walk until well after two years old. She only rolled from side to side at two. 
Doctor: Okay. How old was she when she spoke her first words?
Guest_family: She was around one or two. 
Doctor: When did she start to feed herself, using her hands? 
Guest_family: She was two. 
Doctor: Has she been toilet trained yet? 
Guest_family: No. She is not interested but I have been trying.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Spontaneous vaginal delivery at 36 weeks gestation, birth weight 7#10oz, labor lasted 11 hours, light gas anesthesia given, mother had the flu in the 7th or 8th month of gestation, patient discharged 5 days post-partum. Development: spoke first words between 1 and 2 years of age, rolled side to side at age 2 but did not walk, fed self with hands at age 2 years, never toilet trained.
Plan of Action: N/A
Doctor: Okay and are you working? 
Patient: Oh yes, I am a farmer. I have a farmland and my wife, and I do farming.
Doctor: Good, so you are one happy married couple working together. 
Patient: Ah, yes.
Doctor: And how about tobacco, do you smoke or eat? 
Patient: Absolutely not. 
Doctor: Any use of drugs or alcohol?
Patient: Drugs? 
Doctor: Yeah, like cocaine or anything like that. 
Patient: Oh that, no. No drugs.
Patient: And I don't drink either. 
Doctor: Alright.

Clinical note:
Farmer, Married, no Tobacco/ETOH/illicit drug use.
Doctor: Well, looking at your hand x ray, the bone looks in alignment, and I don't see any effusion.
Doctor: Any tenderness or pain?
Patient: Ah, not really!
Doctor: There is no asymmetry. Can you move your hand up and down? Now rotate it. Can you move your fingers? 
Patient: Yes, I can do all of that, no problem at all.
Doctor: Can you bend your hand?
Patient: Yes.
Doctor: Perfect.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: BONE: No misalignment, asymmetry, defect, tenderness or effusion.  Capable of from of joint above and below bone.

Plan of Action: N/A
Doctor: How about any surgeries in the past?
Patient: Well, I had colon surgery in nineteen eighty nine or was it ninety, oh yeah in nineteen ninety. 
Doctor: Okay and anything else?
Patient: Ah yes, I had three surgeries for my sinus one was the same year as my colon surgery, one was before that. So, the first one was in nineteen eighty seven I believe then nineteen ninety and the last one was in two thousand five.
Doctor: Wow, you remember the years also. 
Patient: Yeah, surprisingly.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Colon resection surgery in 1990, sinus surgeries in 1987, 1990, and 2005
Plan of Action: N/A
Doctor: So, do you drink or smoke, sir? 
Patient: I'd say I have the occasional drink, but I don't smoke. 
Doctor: What do you do for a living? 
Patient: I'm a nursing aid in a nursing home right now. 
Doctor: Do you work the normal day shift? 
Patient: No, I work the second shift, so I work some late nights and early mornings. 
Doctor: Are you back at Wichita State this semester? 
Patient: No, I decided to take some time off. 
Doctor: Is everything okay? 
Patient: Yeah, I'm just really tired, so I decided to step away for a little. 
Doctor: That's understandable. Are you dating right now?
Patient: Yes, I've been dating my boyfriend for a while now. 
Doctor: Is there any significant stress in your relationship? 
Patient: No, everything is going really well.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: Occasionally drinks alcohol, nonsmoker, works as a nurse aid on the second shift at a nursing home, decided not to enroll in Wichita State for the current semester due to feeling tired, in a relationship with one partner, denies specific stress in the relationship
Plan of Action: N/A
Doctor: What brings you in today, miss? 
Patient: I haven't been feeling well since I went to the dentist. 
Doctor: When did you go to the dentist? 
Patient: It was in May last year. 
Doctor: What happened at the dentist? Also, sorry, but how old are you. 
Patient: It was after I left the dentist. I was driving home, and I got lightheaded. I was so lightheaded that I had to pull over. 
Doctor: How long did the episode last? 
Patient: About two to three minutes. 
Doctor: Is this the only time that this has happened? 
Patient: No. In November last year, I was in the middle of eating breakfast when I got dizzy. I was so dizzy that I was nauseous, and I threw up several times. I was so exhausted from the dizziness and throwing up that I went to my room and took a two hour nap. I felt better and back to normal after I woke up from my nap. 
Doctor: How long did the vertigo last? 
Patient: It lasted about two to three minutes. So, about the same amount of time.
Doctor: Have you had any other dizzy episodes? 
Patient: No I didn't but in January on the thirteenth my right arm went numb. It lasted for about four to five hours. 
Doctor: Are you left handed, or right? 
Patient: I am right handed. 
Doctor: Have you experienced any slurred speech or trouble swallowing? 
Patient: No. 
Doctor: Have you had any continuing weakness other than the time in January?
Patient: No. 
Doctor: Have you experienced any headaches or visual changes?
Patient: No. 
Doctor: Any continuing vertigo or lightheadedness? 
Patient: No.

Clinical note:
Symptoms: lightheadedness, vertigo, nausea, vomiting, right arm numbness
Diagnosis: N/A
History of Patient: Experienced a 2-3 minute episode of lightheadedness while driving home from the dentist in May 1992, sudden vertigo episode with nausea and vomiting while eating breakfast in November 1992 lasting 2-3 minutes followed by a 2-hour nap resolving Symptoms, episode of right arm numbness lasting 4-5 hours on January 13, 1993, no associated weakness, headache, dysarthria, dysphagia, visual change, continuing vertigo, or lightheadedness
Plan of Action: N/A
Doctor: Oh wow, you got stung quite a few times. 
Patient: Yeah, you're right about that.  In my seventy six years this i have never gotten stung. This is new. 
Guest_family: He got stung around noon while I was inside preparing lunch. 
Patient: Yeah, they got both my hands and right knee. Those little monsters. 
Doctor: Did you notice redness and swelling right away? 
Patient: Um not right away.  
Doctor: How long did it take for your body to react? 
Patient: Bout thirty minutes or so. 
Doctor: Did you experience any shortness of breath, itching, or hives? 
Patient: No, surprisingly. 
Doctor: And no tongue swelling or trouble swallowing? 
Patient: No. 
Doctor: Have you gotten stung in the past? Or is this your first time? 
Patient: I got stung about a month ago. No redness or swelling like I do now. I guess it could've been due to the Benadryl I took as soon as it happened. 
Doctor: Did you take Benadryl again today? 
Patient: No, I figured I'd be okay. 
Guest_family: He takes Metoprolol and Hydrochlorothiazide for his blood pressure. 
Patient: And a baby Aspirin in the mornings. 
Doctor: Did you take your daily medications today? 
Patient: Yeah."

Clinical note:
Symptoms: increasing redness and swelling to left hand
Diagnosis: bee sting
History of Patient: Patient was stung by a bee on his right hand, left hand, and right knee approximately at noon, noted increasing redness and swelling to left hand, no immediate reaction, denies generalized Symptoms such as itching, hives, or shortness of breath, denies sensation of tongue swelling or difficulty swallowing, previously stung approximately one month ago without serious reaction, took Benadryl at that time, not taken anything for current Symptoms today, on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin daily
Plan of Action: N/A
Doctor: What is your family medical history?  
Patient: I was adopted.  I don't know my family medical history.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Were you ever diagnosed with any blood or heart disease?
Patient: Uh no. 
Doctor: Any other past medical issues?
Patient: No.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: Any major or minor surgeries done in the past?
Guest_family: Sorry, I have no idea about it.
Guest_family: I just started working for him.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
Doctor: I can see your medication list here.
Doctor: Do you take Accutane and Ovcon?
Patient: Yes, I do.
Doctor: Okay.
Patient: Okay.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: He take Accutane and Ovcon

Plan of Action: N/A
Doctor: What are you taking?
Patient: I take Tylenol.
Doctor: Is that only for pain?
Patient: Yes it is.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: He take Tylenol.

Plan of Action: N/A
Guest_clinician: Hello, doctor. Let me give you a run down as to what we are dealing with today. This patient was last seen in January two thousand and four. She is coming for a follow up on interstitial disease secondary to lupus pneumonitis. I will let her tell you more about what happened yesterday. 
Doctor: Thanks, nurse. How are you feeling today, miss? Welcome back to the Pulmonary Medicine Clinic. What happened yesterday?
Patient: Well, I was doing fine since last time. My respiratory issues have been great and I have had no major difficulties breathing. 
Doctor: That's good to hear. What happened yesterday that caused you to want to come in so urgently?
Patient: Yesterday I noticed that I have some back and joint pain.  When I breathe deep my back hurts. 
Doctor: Are you experiencing any coughing?
Patient: No, coughing at this moment. 
Doctor: Have you been producing any mucus the times that you do cough?
Patient: No, I already said I didn't cough. 
Doctor: Okay. Any fevers or chills?
Patient: Nothing so far. 
Doctor: Do you have any other symptoms currently? 
Patient: I do notice that I am more tired than usual. 
Doctor: During physical activity do you seem out of breath or more tired than usual? I want to see if your pulmonary system is inhibited. 
Patient: No. I don't have issues with breathing when I do daily activities.

Clinical note:
Symptoms: increasing back and joint pain, back discomfort with deep breath, fatigue
Diagnosis: interstitial disease secondary to lupus pneumonitis
History of Patient: Since last visit in January 2004, patient's respiratory status has been good with no major difficulties, recent onset of increasing back and joint pain, back discomfort with deep breath starting yesterday, no cough or sputum production, no fevers or chills, increased fatigue
Plan of Action: Follow-up evaluation for interstitial disease secondary to lupus pneumonitis, assess back and joint pain, evaluate respiratory status and pulmonary limitations to activity
Doctor: Hello sir, it's been a while since your last visit. How have you been?  
Patient: Hello doctor, yes, I have come a long way. I guess last time I was here was in two thousand and two if I am not wrong. Was does your system say?
Doctor: You are right! It was August second of two thousand and two to be very precise. 
Doctor: Please confirm for the records, you are a white married man and must be forty nine years old now. Am I right?
Patient: You got it all right doctor!
Doctor: Are you still working in that airplane company?
Patient: Yes sir, still with Alaska Airlines but I have been promoted and work as a plane mechanic. 
Doctor: That is so nice! Good for you man! So, tell me how can I help you today? What brought you to our dermatology department today?
Patient: I'm having pain in my stomach on the right side and down here. 
Doctor: Is it only on the right side or anywhere else? 
Patient: It is on both sides and now I can feel it on the middle part of my left thigh as well.
Doctor: Tell me more about it. How did it start? When did you first notice it? 
Patient: It's been going on and off. It was not there for a while, but now it is like back again mainly on my tummy, down here. It is painful when I touch it. At first, I thought maybe I'm having shingles.
Doctor: When did you notice it? 
Patient: It all started before the holidays, I think one and a half months before the holidays. It is still going on for the past eight days in my tummy and the hips mainly on the right side.
Doctor: Did you get any treatment for this? Any over the counter medicines?
Patient: No, as I told you I thought it was shingles, but then there was no change in the skin, no rashes, nothing. I was not sure what to take.
Doctor: Okay, do you bathe every day?
Patient: Yes, I do but I try to use as little soap as possible. 
Doctor: Okay, here is what I think, all your symptoms are pointing towards hyperesthesia. I would like to run some tests to find the underlying cause and then we will start the treatment. A nurse will come and take you to the lab. Does this sound good to you?
Patient: Yes.

Clinical note:
Symptoms: hyperesthesia on right abdomen, left abdomen, and left medial thigh, intermittent problem, more pronounced in the past eight days on abdomen and right hip area, painful when touched
Diagnosis: hyperesthesia
History of Patient: Symptoms started six weeks before the holidays, cleared for a while, then recurred mainly on right lower abdomen, no treatment received, no skin changes observed, bathes daily with minimal soap use, married, works as an airplane mechanic
Plan of Action: Further tests to find underlying cause of hyperesthesia, followed by treatment
Doctor: Are you finished with your cancer treatments? 
Patient: Yes.  I am in remission now.  
Doctor: That is great! When was your last radiation treatment?
Patient: It has been over two years since my last treatment.

Clinical note:
Symptoms: N/A
Diagnosis: N/A
History of Patient: She has had no recent radiological procedures.
Plan of Action: N/A
Doctor: Do you smoke? 
Patient: Yeah. I smoke about a pack a day.  
Doctor: Do you have any plans of quitting? 
Patient: Eh not really.  
Doctor: As your doctor, I'd advise that you consider nicotine patches and find ways to break your smoking habit. 
Patient: Okay. I'll see what I can do. 
Doctor: Do you drink? 
Patient: Socially. 
Doctor: Are you married? 
Patient: No, but I have two littles ones. 
Doctor: Aw, how old are they? 
Patient: I have a four year old and a six year old. 
Doctor: That's great. I'm sure they keep you busy. Any hobbies? 
Patient: They really do, especially the four year old. As for hobbies, I like fixing up computers. I also like fishing, hiking, and camping with the family.

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.