galgantar/MTS-Dialog-cleaned huggingface dataset:
Dialogue:
Doctor: Hello, how are you today?
Patient: Not good. 
Doctor: What happened? 
Patient: I have a lot of congestion. I also am coughing a lot. It feels like I am choking on something.

Clinical note section (CC):
Congestion and cough.
Dialogue:
Doctor: Are there any major medical conditions in your past that I should be aware of? 
Patient: No, but what do you mean by that?
Doctor: Well, anything from high blood pressure, to cancer, to depression. Do any of those sound familiar?
Patient: Oh, no I don't have any of those.

Clinical note section (PASTMEDICALHX):
None.
Dialogue:
Doctor: Do you feel any shortness of breath?
Patient: No.
Doctor: Any snoring or sleep disorder like interrupted breathing? 
Patient: Um, no.
Doctor: Any history of asthma or lung disease?
Patient: No.

Clinical note section (ROS):
RESPIRATORY: No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.
Dialogue:
Doctor: Have you ever had surgery, sir? 
Patient: Yeah, I had one of my testicles removed int he summer of eighty five. 
Doctor: Do you remember the reason it needed to be removed? 
Patient: They just told me it was enlarged, but I don't know much more. 
Doctor: Was it cancerous? 
Patient: No, they weren't sure what was the cause, but they told me it wasn't cancer.

Clinical note section (PASTSURGICAL):
In 1985, he had removal of a testicle due to enlarged testicle, he is not quite sure of the cause but he states it was not cancer. REVI
Dialogue:
Doctor: Hello, miss. Before we begin, I just want to confirm some information with you. 
Patient: Sounds good. 
Doctor: You had this injury on your left shoulder recently, right? 
Patient: Yeah, that's correct. 
Doctor: Are you still experiencing G E R D? 
Patient: Oh, yeah. I can't drink coffee anymore. 
Doctor: That's awful. Coffee is what keeps me alive. Are you still experiencing anxiety? 
Patient: Yeah, I am. 
Doctor: Two more questions. Is your blood sugar still high?
Patient: I think so. 
Doctor: You currently have osteoporosis, correct? 
Patient: That's correct.

Clinical note section (PASTMEDICALHX):
Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.
Dialogue:
Doctor: Please fill me in regarding your past medical history.  
Patient: I had a blood clot in my lung. This was back when I was living in Germany.  
Doctor: How long ago was that? 
Patient: Um, nineteen ninety seven. I think? 
Doctor: How did they treat you for the blood clot? 
Patient: I believe they used thrombolysis and I took Warfarin for six months. 
Doctor: Have you experienced any other blood clotting issues? 
Patient: Yes. I have had recurring clotting problems since nineteen ninety nine. They had to put a I V C filter in.  
Doctor: Are there any other health problems I should know about? 
Patient: I have Psoriasis. 
Doctor: Any history of miscarriage? 
Patient: No.

Clinical note section (PASTMEDICALHX):
Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis.  Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed.  Psoriasis.  She denied any history of miscarriage.
Dialogue:
Doctor: Let's go over your social history, shall we? 
Patient: Go for it. 
Doctor: Do you drink? 
Patient: Nope. 
Doctor: How about smoke? 
Patient: Nope. 
Doctor: And any illegal drug use? 
Patient: Definitely not.

Clinical note section (FAM/SOCHX):
The patient denies tobacco, alcohol or illicit drug usage.
Dialogue:
Doctor: So, as you mentioned, you live in adult care center?
Patient: Yes, Life Care Center.
Doctor: Okay.
Patient: It is a nice place.
Doctor: Okay. Do you drink or smoke?
Patient: No, I quit a long time back.
Doctor: Drugs?
Patient: No, I have never done that.
Doctor: Okay.
Patient: Yeah.

Clinical note section (FAM/SOCHX):
The patient lives at Life Care Center. She does not smoke, drink or use intravenous drugs.
Dialogue:
Doctor: Do you take any medication? 
Patient: You mean prescriptions?
Doctor: I mean anything at all?
Patient: No, I don't.

Clinical note section (MEDICATIONS):
None.
Dialogue:
Doctor: Good morning. 
Patient: Good morning, doctor. 
Doctor: I'm just going to need some background information before we begin. So, are you married?
Patient: Yes, to my lovely wife. 
Doctor: Great, do you smoke? 
Patient: Well, I used to smoke about a pack a day, but I quit five years ago. 
Doctor: Congratulations on quitting, that's great. How long did you smoke that pack a day?
Patient: I did for about fifteen years. 
Doctor: Well, its good that you quit. Do you drink?
Patient: I'd say I drink socially, like if I'm at a party or a football game, something like that.
Doctor: I understand. Is there any history of drug abuse?
Patient: No, absolutely not.

Clinical note section (FAM/SOCHX):
Marital status:   Married.   Smoking history: Smoked 1 PPD, quit 5 years ago and after smoking for 15 years.  Alcohol history: Drinks socially.   Denies any history of drug abuse.
Dialogue:
Doctor: Any history of pregnancies or miscarriages? 
Patient: I had a miscarriage about thirty years ago. 
Doctor: How far along were you when you miscarried? 
Patient: About twenty weeks.

Clinical note section (GYNHX):
Spontaneous miscarriage at 3 months approximately 30 years ago.
Dialogue:
Doctor: Hello, how are you doing? How old are you?
Patient: I am an eighty three year old woman, how do you expect me to do?
Doctor: Tell me, what is happening with you, what bought you here today?
Patient: I feel a lot of weakness in my both hands. 
Doctor: Is it something new or old?
Patient: I had difficulty in swallowing and some problems with speech too in the past. I used to have cramps in my legs and weakness only in my right arm but now it is continuously increasing in both arms.

Clinical note section (GENHX):
Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.
Dialogue:
Doctor: How are you feeling today?
Patient: Good.
Doctor: Is there any issue that I should be worried of?
Patient: No.
Doctor: Are you feeling condifent of your health? 
Patient: Yes.

Clinical note section (DISPOSITION):
Stable.
Dialogue:
Doctor: Any surgical history? 
Patient: I had a I V C filter placed for a blood clot and a tubal ligation. 
Doctor: When was your I V C filter placed? 
Patient: Nineteen ninety nine.

Clinical note section (PASTSURGICAL):
IVC filter placement 1999.   Tubal ligation.
Dialogue:
Doctor: Your lymph node is swollen. There are many reasons why a lymph node can become swollen. Since it has only been swollen for two days, I would like to monitor it.  
Patient: Okay. So, is it not a spider bite? 
Doctor: It is possible. Let's monitor it for now.

Clinical note section (ASSESSMENT):
Possible insect bite with lymphangitis.
Dialogue:
Doctor: Did you have any heart issues in the past? 
Patient: Ah yes, I had a heart attack. 
Doctor: Anything else? 
Patient: My heart doctor said that I have something like a irregular or fast heartbeat. 
Doctor: Who is your heart doctor? Whom did you see last?
Patient: It is Doctor X.
Doctor: So, did he put anything inside your heart or something?
Patient: Yeah, I think I have one stent put in but I don't remember properly.
Doctor: Okay, and who is your primary doctor? 
Patient: My primary doctors name is Doctor Y?

Clinical note section (PASTMEDICALHX):
MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure.  The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y.
Dialogue:
Doctor: Hi there! What brings you into see me today? 
Patient: I have been having this bad cough. My joints started hurting really bad. I have never felt this kind of joint pain before. This morning I coughed up some blood. 
Doctor: Okey. I would like to start with a sputum culture, bloodwork and then a C T scan. 
Patient: Okay.

Clinical note section (CC):
coughing up blood and severe joint pain.
Dialogue:
Doctor: How are you doing today?
Patient: I am good, thank you.
Doctor: Are you married?
Patient: No, I'm single.
Doctor: Do you live alone or with family?
Patient: I live with my sister.
Doctor: Have you ever taken any kind of illegal drugs?
Patient: Nope.
Doctor: What about alcohol or smoking?
Patient: No.

Clinical note section (FAM/SOCHX):
Single, lives with sister, and denies Tobacco/ETOH/illicit drug use.
Dialogue:
Doctor: We are planning laparoscopic surgery to take out your gall stones. 
Patient: Okay. Will that be covered by my insurance?
Doctor: Let me ask the staff.
Patient: Okay.

Clinical note section (PROCEDURES):
Laparoscopic cholecystectomy.
Dialogue:
Doctor: Are you married?
Patient: Yes. I have a caring wife.
Doctor: At any point did you have more than one sexual partner?
Patient: I love my wife. So no, to answer your question. 
Doctor: Did you travel anywhere in the recent past?
Patient: Nope. 
Doctor: Any changes in your living status? 
Patient: No, I'm still in my sweet Casa.
Doctor: Have you had any contact with anyone sick recently?
Patient: Not that I am aware of.

Clinical note section (FAM/SOCHX):
No ill contacts.  No travel or changes in living condition.
Dialogue:
Doctor: Do you live alone?
Patient: No. I have a whole family with me. 
Doctor: Who all lives with you? 
Patient: My grandparents, mom, and my sister.

Clinical note section (FAM/SOCHX):
She lives with mom, sister, and her grandparent.
Dialogue:
Doctor: Have you had any acne flare ups? 
Patient: No. 
Doctor: Do you have any left over medication? 
Patient: No. I took all of my pills and didn't miss any days.

Clinical note section (MEDICATIONS):
The patient is 100% compliant with her meds.  She reports she does not miss any doses.
Dialogue:
Doctor: So, I asked you to follow-up on your cerebrovascular accident, right?
Patient: Hm, yeah. 
Doctor: Okay, how are you feeling?
Patient: I am bit better but still don't feel one hundred percent. 
Doctor: Yeah, I understand. I am looking at your blood sugar report and-
Patient: And is it okay?
Doctor: Well, you have diabetes and that explains your nerve pain. Basically, high blood sugar can cause the neuropathy.

Clinical note section (ASSESSMENT):
1.  Diabetes mellitus. 2.  Neuropathy. 3.  Status post cerebrovascular accident.
Dialogue:
Doctor: Do you have any conditions that I should know about? 
Patient: Yes, um, I had an acoustic neuroma in two thousand five. 
Doctor: Did you have surgery on this? 
Patient: Yes, it was benign, but they still wanted to take it out. 
Doctor: Yeah, that happens. What other treatments have you had? 
Patient: Um, in February of two thousand four, and August of two thousand nine I had treatments for recurrence. 
Doctor: Do you have skull markers in place? 
Patient: Yeah, they're planning on doing radiation. 
Doctor: Aside from the acoustic neuroma removal, have you had any other surgeries? 
Patient: Yeah, I had a mastoidectomy in the past.  
Doctor: What medications are you taking?
Patient: Um, I just take Tylenol and Aleve occasionally for pain. 
Doctor: Do you smoke?
Patient: No, I don't. 
Doctor: How about alcohol, do you drink?
Patient: Yes, um, I'd say about five beers a week.

Clinical note section (PASTMEDICALHX):
Illnesses:  The patient had a diagnosis in 2005 of an acoustic neuroma.  It was benign, but treated neurosurgically.  In February 2004 and again in August 2009 he has had additional treatments for recurrence and he currently has some skull markers in place because radiation is planned as a followup, although the tumor was still indicated to be benign. Operations: He has a history of an old mastoidectomy.  He has a past history of removal of an acoustic neuroma in 2005 as noted. Medications:  The patient takes occasional Tylenol and occasional Aleve. Substance Use: Tobacco:  He does not smoke cigarettes. Alcohol:  He drinks about five beers a week.
Dialogue:
Doctor: Is there any medically related disease in the family? 
Patient: Nope. 
Doctor: What about things like depression or Alzheimer's or other nerves related disorders?
Patient: Nothing that I'm aware of.

Clinical note section (FAM/SOCHX):
No neurologic disease in family.
Dialogue:
Doctor: Do you have any major health conditions I should be aware of? 
Patient: Yes, I actually have the sugar. 
Doctor: What about anything to do with the heart? 
Patient: Yes, I forgot about that, um, I have high blood pressure too.

Clinical note section (PASTMEDICALHX):
Diabetes and high blood pressure.
Dialogue:
Doctor: Do you live alone?
Patient: I live with my husband. Forty four years and counting.
Doctor: That's incredible. Do you have any children?
Patient: We have three kids. 
Doctor: Do you work currently?
Patient: I worked as a L and D nurse before I retired in early two thousand and one. 
Doctor: How's retirement been?
Patient: Wonderful. I get to spend quality time with my grandkids.
Doctor: Great to hear. And do you smoke or drink?
Patient: No smoking or drinking for me. Happy as a clam.

Clinical note section (FAM/SOCHX):
Denies any smoking or alcohol.  She is married since 44 years, has 3 children.  She used to work as a labor and delivery nurse up until early 2001 when she retired.
Dialogue:
Doctor: Welcome to the clinic, sir. I am Doctor Frank. 
Patient: Thank you. It is nice to meet you. 
Doctor: Let's start with your medical history. 
Patient: I have high blood pressure and high cholesterol. I have heart disease. I have had five stents put in. I also was told that I have diabetes. My other doctor did an oral glucose tolerance test and the results were not normal. 
Doctor: Do you know what the results from the glucose test was? 
Patient: I believe my sugar shot up to over three hundred with the test they gave me. 
Doctor: Do you take any medications for your blood glucose levels? 
Patient: No. My glucoses are generally normal when I check it.
Doctor: Have you had any surgeries other than the stents? 
Patient: I had plastic surgery on my face from an injury near my eye. I also had an ear graft from when I developed an ear infection during my honeymoon.

Clinical note section (PASTMEDICALHX):
He has coronary artery disease and has received five stents.  He has hypertension and hypercholesterolemia.  He states that he was diagnosed with diabetes based on the results of an abnormal oral glucose tolerance test.  He believes that his glucose shot up to over 300 with this testing.  He does not take any medications for this and his blood glucoses are generally normal when he checks it.  He has had plastic surgery on his face from an orbital injury.  He also had an ear graft when he developed an ear infection during his honeymoon.
Dialogue:
Doctor: Good afternoon, sir. My chart here says that you're seventy two years old, is that correct? 
Patient: Yes, that's correct sir. 
Doctor: Great, can you tell me about your medical history? 
Patient: Well, I was diagnosed with chronic lymphocytic leukemia in May of two thousand eight. 
Doctor: Do you have any doctor's notes about this diagnosis?
Patient: Yes, here you go doctor. 
Doctor: Thank you, so this shows that you had autoimmune hemolytic anemia at the time of your diagnosis. 
Patient: Yes, that rings some bells. 
Doctor: What medications have you been taking for your hemolysis? 
Patient: Um, I've been taking five M G of prednisone every other day. 
Doctor: Great, so we'll follow up on everything today, and do a complete blood count. 
Patient: That sounds good, doctor. 
Doctor: We discontinued your prophylactic antivirals and antibacterial at your last visit, correct?  
Patient: Yes, I haven't taken them for a while now.

Clinical note section (GENHX):
The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008.  He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.  He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day.  He comes in to clinic today for follow-up and complete blood count.  At his last office visit we discontinued this prophylactic antivirals and antibacterial.
Dialogue:
Doctor: How's it going? Are you ready for your physical today, sir? 
Patient: I am, but can we hurry? I have to get to work soon.
Doctor: Oh, what do you do for work?
Patient: I work in sales. I walk quite a bit from house to house to sell some products. They won't sell on their own. That's why I'm in a hurry. 
Doctor: Oh, wow. Do you have to lift any heavy products?
Patient: Nope. I just walk around with my tablet. Could we start the physical, please?
Doctor: Yeah, let's get started. I'll ask some basic background questions to get the physical started?
Patient: Sounds good. 
Doctor: Do you smoke?
Patient: I do. I'll smoke like one and a half pack of cigarettes every day. I get stressed at work.
Doctor: I see. Do you also drink alcohol?
Patient: Oh, yeah. I'll drink several days out of the week. 
Doctor: Are you currently active?
Patient: No, not really. I used to golf in the past, but work has been busy. I miss golfing. I could get away from my wife for a bit and drink with the boys.

Clinical note section (FAM/SOCHX):
He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.
Dialogue:
Doctor: Hm do you normally have high blood pressure? 
Patient: This is the first time in my life that I've been told to see a doctor for my blood pressure. 
Doctor: And when did you notice it reading higher than normal? 
Patient: Around the time of my surgery. Not sure if that has anything to do with it. Do I need to start taking blood pressure medicine?

Clinical note section (CC):
Perioperative elevated blood pressure.
Dialogue:
Doctor: Hello. Looks like you're here for your physical today. I'll start by asking you some basic questions. 
Patient: Sounds good to me.
Doctor: Do you currently smoke?
Patient: I stopped two years ago. 
Doctor: How much would you say you smoked before?
Patient: Maybe like ten packs a year. Who knows? I lost track.
Doctor: Do you drink alcohol?
Patient: Oh, yeah. I kill a six pack of beer every week. 
Doctor: Do you use any illegal substances?
Patient: No. I don't go that hard.

Clinical note section (FAM/SOCHX):
10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.
Dialogue:
Doctor: You have a lung problem called bronchitis.
Patient: What does that mean?
Doctor: Bronchitis is an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs.
Patient: Okay.
Doctor: But don't worry with proper medication we can fix it.
Patient: Okay.

Clinical note section (DIAGNOSIS):
Bronchitis.
Dialogue:
Doctor: Have you been able to move around at all? 
Patient: I do what I can. Most of the time I lay on the couch, but I'll sometimes find it in me to get up and do things.
Doctor: What type of activities are you able to do without pain? 
Patient: Knitting and folding laundry for the most part.

Clinical note section (PLAN):
As tolerated.
Dialogue:
Doctor: Did the nurse give you the handout for a cardiac diet? 
Patient: Yes. 
Doctor: It is important for you stick to the cardiac diet. The cardiac diet emphasizes low fat foods such as vegetables, whole grains, and fish. I would like for you limit processed foods that are high in sugar and sodium, as these increase the risk of heart disease. 
Patient: Okay.

Clinical note section (PLAN):
Low-fat, low-salt, cardiac diet.
Dialogue:
Doctor: Hello! I would like to get some background on what brings you in today. What symptoms have you been having? 
Patient: I am exhausted. I get lightheaded when I stand up. My family noticed that my skin and eyes are yellow. I have not been feeling well. I had a fever about a week ago. There has been a few nights where I woke up all sweaty with chills.  
Doctor: Have you had any trouble drinking or eating? 
Patient: Yeah. I have not been able to eat normally for that last three to four weeks. I lost twenty six pounds. 
Doctor: Have you experienced any nausea or vomiting? 
Patient: I have been nauseous, but I have not vomited.
Doctor: Any pain anywhere in the abdomen or low back area? 
Patient: Yes, there has been some pain.  
Doctor: Can you tell me or show me where the pain is coming from? 
Patient: It comes and goes. It hurts all around my stomach. Oh, my pee has been a vary dark color for about a week now. 
Doctor:  Do you have a history of liver disease? 
Patient: No but I did have a cholecystectomy a long time ago.

Clinical note section (GENHX):
40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed. He did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). He was nauseated but denied vomiting. He did admit to intermittent abdominal discomfort which he could not localize. In addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous.
Dialogue:
Doctor: So, what do you do for a living sir? 
Patient: Right now, I work in the finance department. 
Doctor: That's great. Do you smoke? 
Patient: No, I never do that. 
Doctor: What about alcohol, do you drink? 
Patient: Well, on the weekends I do, not during the week though. 
Doctor: How many drinks do you have on the weekends? 
Patient: Per day, I'll have three or four. 
Doctor: Okay, what about harder substances, do you do any harder drugs? 
Patient: No, absolutely not.

Clinical note section (FAM/SOCHX):
The patient is employed in the finance department.  He is a nonsmoker.  He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends.  He denies any IV drug use or abuse.
Dialogue:
Doctor: Do you have any history of high blood pressure or cardiac disease? 
Patient: No.  
Doctor: Any renal, lung, or liver disease history? 
Patient: No.

Clinical note section (PASTMEDICALHX):
None. No history of hypertension or of cardiac, renal, lung, or liver disease.
Dialogue:
Doctor: Does arthritis run in your family? 
Patient: No, not that I know of. 
Doctor: So, you can't remember anything with your grandparents, or parents? 
Patient: No, it doesn't ring any bells.

Clinical note section (FAM/SOCHX):
Noncontributory.
Dialogue:
Doctor: So, how long has your stomach been hurting?
Patient: It started two days back.
Doctor: Any nausea or vomiting?
Patient: No.
Doctor: Okay, any diarrhea?
Patient: Yes, I am having severe cramping with diarrhea. 
Doctor: Oh, okay. Any dizziness or weakness?
Patient: Yes, I am feeling very weak and tired all the time.
Doctor: Any cough with sputum? 
Patient: No cough at all.
Doctor: Okay. Are you having any pain or burning while passing urine?
Patient: No, I am fine.
Doctor: Hm, everything else looks fine. No problem there with your eyes, nose, throat, and other systems.
Patient: It's just my tummy which is hurting.
Doctor: Don't worry we will take care of it.

Clinical note section (ROS):
Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness.  She denies any cough, sputum production, or dysuria at this time.  Otherwise, a 10-system review is essentially negative.
Dialogue:
Doctor: My nurse wrote on your chart that you're seventy nine years old, is that correct, ma'am? 
Patient: Yes, doctor, that's right. 
Doctor: Your surgery was eight days ago, right? 
Patient: Yeah, I'm recovering now. 
Doctor: Are you aware of the details behind your surgery? 
Patient: Honestly, all the details are pretty foggy. 
Doctor: Okay, well you had acute cholecystitis, so we tried a laparoscopic cholecystectomy. 
Patient: Did everything go well, doctor? 
Doctor: Well, we had to do an open procedure due to some difficult anatomy. You were a tough case. How are you doing today?
Patient: I'm improving, I guess.
Doctor: How is your strength? 
Patient: It's getting better. 
Doctor: Are you eating well?
Patient: Yeah, I'm back to having my regular diet now. 
Doctor: Are you going to the bathroom regularly? What medicines are you taking for this prolonged ileus?
Patient: Well, I wasn't, but it's gotten with the tetracycline and Reglan.

Clinical note section (GENHX):
She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago.  The patient has required conversion to an open procedure due to difficult anatomy.  Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan.  The patient is starting to improve, gain more strength.  She is tolerating her regular diet.
Dialogue:
Doctor: After going over your most recent test results from this morning and the progress in your mobility, I would like to send you home today. 
Patient: That's great news. I would love to go home. 
Doctor: How are you feeling right now? 
Patient: I feel good!
Doctor: Do you have any questions before we let you go home today? 
Patient: Where can I get the medications that we discussed? 
Doctor: I will send them to your pharmacy. 
Patient: Okay.

Clinical note section (DISPOSITION):
The patient was discharged in good and stable condition.
Dialogue:
Doctor: Good afternoon, ma'am, how are you today, my dear?
Patient: It's good to see you too, doctor. I'm in some pain today. 
Doctor: Before we begin, refresh my memory, how old are you? 
Patient: Doctor, I'm fifty eight years young. 
Doctor: Yes, what seems to be the problem today?
Patient: Well, about two years ago I had a fall, and then I had blood clots in my left knee. 
Doctor: How were you treated for this? 
Patient: I went to the hospital, and then to a nursing home. I had to live there for a year.
Doctor: Did you have any problems before your fall? 
Patient: Nope, not at all, I was mostly doing everything by myself. I used a pickup walker around the house, but that's it. 
Doctor: Have you been to P T for this?
Patient: Yes, they referred me to P T because of the arthritis in this knee.  
Doctor: Since the injury, have you been able to walk?
Patient: Not really, I spend most of my time laying down or seated. My knee is in so much pain, I just want to be able to walk around my house again.

Clinical note section (GENHX):
The patient is a 58-year-old female, referred to therapy due to left knee osteoarthritis.  The patient states that approximately 2 years ago, she fell to the ground and thereafter had blood clots in the knee area.  The patient was transferred from the hospital to a nursing home and lived there for 1 year.  Prior to this incident, the patient was ambulating independently with a pickup walker throughout her home.  Since that time, the patient has only been performing transverse and has been unable to ambulate.  The patient states that her primary concern is her left knee pain and they desire to walk short distances again in her home.
Dialogue:
Doctor: I have your reports.
Patient: Okay.
Doctor: Your E K G is normal, with normal sinus rhythm. This means your heart is beating normal.
Patient: Okay!
Doctor: And your chest x ray, too, looks normal.
Patient: Nice.

Clinical note section (IMAGING):
EKG, normal sinus rhythm.  Chest x-ray unremarkable.
Dialogue:
Doctor: Hi, how are you, miss?
Patient: I am well, how about you?
Doctor: Good. Are you married and do you have kids?
Patient: Sure. I am married. I have two kids and we all live together with my husband.
Doctor: That's great. Do you smoke cigarettes?
Patient: No, I don't smoke or drink alcohol.
Doctor: How about any drugs?
Patient: No, I have never done that.
Doctor: Okay. What do you do for a living?
Patient: I work in a business office.
Doctor: Okay that is good. Okay, have you ever been diagnosed with any type of sexually transmitted diseases?
Patient: Oh, you mean syphilis and stuff? No, I haven't.
Doctor: Okay. Have you ever got exposed to asbestos, chemicals, or industrial gases. Maybe you could have been exposed at work or elsewhere? Not sure if your business office has anything like that.
Patient: Um, not that I am aware of. 
Doctor: Have you travelled anywhere recently?
Patient: Oh no, nor I am planning to.
Doctor:  Great. Any sick contacts at home or outside?
Patient: Oh, no.

Clinical note section (FAM/SOCHX):
Patient is married and lives with her husband and 2 children. Works in a business office. Denies any tobacco, alcohol, or illicit drug use of any kind. No history of sexually transmitted diseases. Denies exposures to asbestos, chemicals, or industrial gases. No recent travel. No recent sick contacts.
Dialogue:
Doctor: How old are you? 
Patient: I'm seventy. 
Doctor: When did you get diagnosed with diabetes? 
Patient: It was last fall. 
Doctor: Are you keeping a tab of your sugar? 
Patient: Yeah, I'm checking with Accu Cheks. Mostly, once a day. 
Doctor: How are your numbers coming? 
Patient: They are ranging from eighties to as high as one hundred and thirty two. 
Doctor: How are you feeling overall?
Patient: It's good. I go for a walk, almost daily. 
Doctor: How far do you go? 
Patient: Normally, we go like one to two miles. Sometimes the weather, when the weather is not favorable, we just go to the local mall, but mostly it's like I'm walking outside. 
Doctor: Any other issues? 
Patient: For the last several days, I do have this feeling of congestion. Looks like everything is congested and sometimes it's like something is coming out. 
Doctor: Where did you have your last mammogram? 
Patient: I had it in the Baylis Building. It was, it was last month, I think. 
Doctor: Who is the gynecologist?
Patient: I go to Doctor Cheng. 
Doctor: Do you smoke? 
Patient: Nope. Never in my life. 
Doctor: Any pain in your tummy, nausea, or vomiting, diarrhea or constipation? Any changes with the bowel movements? 
Patient: Nope. 
Doctor: Did you ever notice any blood in your urine or in your stools? 
Patient: Nope. 
Doctor: Do you check ankles for swelling? Have you ever noticed any swelling there? 
Patient: Yeah, I check my feet regularly and no swelling as such. I do wake up at night at least one time to go to the bathroom.

Clinical note section (GENHX):
A 70-year-old female who was diagnosed with diabetes mellitus last fall.  She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132.  She feels well.  She walks 1-2 miles most days.  If the weather is bad, they go to a local mall.  Otherwise they walk outside.  She does complain of some sinus congestion and drainage for the last several days.  She is up-to-date on her mammogram that she had at the Baylis Building.  She sees Dr. Cheng for her gynecological care.  She is a nonsmoker.  Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools.  She has nocturia x 1.  Denies swelling in her ankles.  She checks her feet regularly.
Dialogue:
Doctor: Hello, ma'am. How are you doing today? 
Patient: Not well. My allergies have been acting up again. 
Doctor: I see. Have you ever seen a doctor for your allergies? 
Patient: I have. My main doctor provided me with a report so that I could give it to you. Here is the report. 
Doctor: Thank you. Let me take a look at it.  I see you have a history of weight change. What is your current weight? 
Patient: I think I weigh in at one hundred and eighty pounds. 
Doctor: Thank you. I see your report says you have high blood pressure, correct? 
Patient: Yeah, that's correct. 
Doctor: I also see you have chronic issues with nasal inflammation, correct? 
Patient: Yeah, I do. It's really annoying when it comes back. 
Doctor: I can provide you with some medications to alleviate the chronic issues, but before I can, do you have any food allergies? 
Patient: I have some food allergies, but I'm not completely sure what foods I'm allergic too.

Clinical note section (PASTMEDICALHX):
Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change.  She is currently 180 pounds.
Dialogue:
Doctor: How old are you, sir? 
Patient: I am twenty eight years old. 
Doctor: I understand that you are having some difficulties that brings you in today.
Patient: Yes, I have lost some feeling on my right side. 
Doctor:  Numbness? How long have you been experiencing the loss of feeling? 
Patient: It has been about three months now. It's strange I have had pain and numbness at the same time. 
Doctor: Have you had any other symptoms associated with this? 
Patient: I have been having some balancing problems. It has been getting worse. I don't know if this is related but I have been having trouble breathing while eating. I feel like I am choking on my food, but I am not, and I gasp for air. It is scary.

Clinical note section (GENHX):
28 y/o male presented with a 3 month history of progressive right sided numbness; now anesthetic to pain. In addition, he experienced worsening balance, and episodes of aspiration while eating.
Dialogue:
Doctor: Good afternoon, ma'am. Before we begin, I just need a few pieces of information. 
Patient: Sure, no problem, doctor.
Doctor: First, how old are you?
Patient: I'm fifty six, doctor. 
Doctor: Good, did the nurses talk to you about the weight they took today?
Patient: No, they did not. 
Doctor: Well, ma'am, you're obese. That's posing a serious danger to your health. 
Patient: Yes, I know. I've been trying to lose weight. 
Doctor: Good, so, what seems to be troubling you today?
Patient: Well, I have a history of degenerative arthritis in my hips, so my other doctors have said.
Doctor: How have you been treated for this?
Patient: I had a right hip replacement with Doctor X in two thousand. 
Doctor: Did this help the pain?
Patient: Yes, on the right, but over the last three years or so the pain on the left hip has been getting worse. 
Doctor: Has it gotten worse faster recently?
Patient: Yeah, over the last few months it's gotten really bad. 
Doctor: What kind of medications are you taking for this?
Patient: Honestly, it's gotten so bad, its uncontrollable pain at this point. I'm taking narcotics now because it's so bad. 
Doctor: Are you able to do any activities?
Patient: No, the pain is messing with my daily living, activities are out of the question. 
Doctor: I think we should do another hip replacement on the left, ma'am. 
Patient: Me too, can you remind me the risk of infection from this surgery?
Doctor: Well, historically it's less than one percent. We use antibiotics to control for infection. 
Patient: Good, and will I be asleep for this?
Doctor: Yes, the whole time. You won't feel a thing. 
Patient: Good, yes, I want to do this procedure.
Doctor: The other risks include scar, dislocation, need for further surgery, deep vein thrombosis, and implant failure. I would not worry about any of these things since you have had a replacement before with no issues.

Clinical note section (GENHX):
This is a 56-year-old obese female with a history of bilateral degenerative hip arthritis.  She underwent a right total hip arthroplasty by Dr. X in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months. Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the  procedure.  All risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure.  The patient understood all these risks and was willing to continue further on with the procedure.
Dialogue:
Doctor: With ten being the worst pain ever, out of ten, how would you rate your knee pain at rest? 
Patient: At rest, um, I'd have to say there's no pain. 
Doctor: Okay, what about when you move the left knee? We call this active motion, how would you rate it then?
Patient: When I move it, um, the front of the knee hurts. I'd say its about a five out of ten.

Clinical note section (GENHX):
The patient reports that when seated and at rest, her knee pain is 0/10.  The patient states that with active motion of the left knee, the pain in the anterior portion increases to 5/10.
Dialogue:
Doctor: Good afternoon, ma'am, I just need some information before we get started today. 
Patient: Absolutely, good afternoon, doctor. 
Doctor: My chart says here that you're fifty nine years old, is that correct? 
Patient: Yes, that's correct. 
Doctor: I also see that you have a history of breast cancer, is that correct as well?
Patient: Yes, that's also correct. 
Doctor: When were you diagnosed initially? 
Patient: Um, I was diagnosed in June of nineteen ninety four. 
Doctor: How has this been managed in the past, ma'am? 
Patient: Um, I've taken Zometa, Faslodex, and Aromasin. 
Doctor: How has the cancer progressed since you were diagnosed? 
Patient: The doctors said I had rising tumor markers. 
Doctor: What imaging have you done to evaluate the cancer? 
Patient: I've had a P E T C T Scan done. 
Doctor: What did that scan show?
Patient: It showed that the cancer was metastatic. 
Doctor: I see here that you were involved in a clinical trial for your breast cancer, can you tell me more about that, please? 
Patient: I was in the C T S U C four zero five zero two trial, and I was randomized into the ixabepilone plus Avastin group. 
Doctor: How did you respond to this treatment? 
Patient: Um, I had something called dose limiting toxicity with the fourth cycle. I skipped the Ixempra on the first and eighth days. 
Doctor: How did they respond once this happened? 
Patient: They just reduced the dose I was given. 
Doctor: How did you handle this reduced dose? 
Patient: Honestly, I've been tolerating the treatment pretty well. I only have some neuropathy. 
Doctor: Do you have any other concerns of note? 
Patient: Um, I thought that I had a perforated septum earlier this month, and I went to my E N T right away, but everything was okay. There was no perforation. 
Doctor: Okay, so, you're here for your eighth day of Ixempra, correct? 
Patient: Yes, doctor, that's correct.

Clinical note section (GENHX):
She is a very pleasant 59-year-old nurse with a history of breast cancer.  She was initially diagnosed in June 1994.  Her previous treatments included Zometa, Faslodex, and Aromasin.  She was found to have disease progression first noted by rising tumor markers.  PET/CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU/C40502.  She was randomized to the ixabepilone plus Avastin.  She experienced dose-limiting toxicity with the fourth cycle.  The Ixempra was skipped on day 1 and day 8.  She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy.  Early in the month she had concerned about possible perforated septum.  She was seen by ENT urgently.  She was found to have nasal septum intact.  She comes into clinic today for day eight Ixempra.
Dialogue:
Doctor: I have to check for any swollen lymph nodes. I will go through different areas like in your neck, in your armpit, and in your groin. 
Patient: Yeah, that's okay. 
Doctor: Your neck looks clear. I cannot find any kind of swelling or abnormality there. 
Patient: That's good, right? 
Doctor: Yeah, it's true. Other parts also look clear.

Clinical note section (EXAM):
LYMPH: No lymphadenopathy was appreciated in the neck, axillae or groin.
Dialogue:
Doctor: I will check your skin for anything abnormal, okay? 
Patient: I'm okay with that. 
Doctor: Hm, I don't see any rashes or any red spots.

Clinical note section (EXAM):
SKIN: Inspection of the skin reveals no rashes, ulcerations or petechiae.
Dialogue:
Doctor: Do you have any allergies?
Patient: Not that I know. 
Doctor: Any adverse reaction to any kind of medications?
Patient: No.

Clinical note section (ALLERGY):
None known.
Dialogue:
Doctor: Did anyone in your family have any medical issues? 
Patient: Well, you see, my father died of a brain tumor. Doctors tried their best, but no surgery was possible for him. 
Doctor: What about your mother? 
Patient: She's just a little obese, otherwise there is no medical issue.

Clinical note section (FAM/SOCHX):
Pertinent for father who died of an inoperable brain tumour.  Mother is obese, but otherwise negative history.
Dialogue:
Doctor: Have you ever had your glucose levels measured? 
Patient: No.  
Doctor: I would like to test your levels today. 
Patient: Okay.

Clinical note section (PASTMEDICALHX):
DM II-HbA1c unknown
Dialogue:
Doctor: Do you consume alcohol, tobacco, or recreational drugs? 
Patient: No. 
Doctor: Are you married? 
Patient: I am a widowed. 
Doctor: I am so sorry to hear that. Do you live on your own? 
Patient: Thank you. Yes. I live by my self now.

Clinical note section (FAM/SOCHX):
Widowed; lives alone. Denied ETOH/Tobacco/illicit drug use.
Dialogue:
Doctor: Good afternoon, Anna. 
Patient: Good afternoon, doctor. 
Doctor: We've been pretty aggressive with downwardly adjusting both your Lantus and your Humalog insulins, how is your blood sugar today?
Patient: Well, it's still pretty low. 
Doctor: You've been taking the Lantus at night? 
Patient: Yes, and the sliding scale Humalog before I have meals. 
Doctor: When is your blood sugar the lowest? 
Patient: Um, it's worst in the mornings. 
Doctor: Do you remember your levels at that time? 
Patient: It's in the seventies usually. 
Doctor: We decreased your Lantus from eighty four to sixty units, right? 
Patient: Yes, doctor. 
Doctor: That's a pretty considerable change in dosage. 
Patient: What do you think, doctor? 
Doctor: Well, I can't really explain why your glucose have not climbed despite the decrease in insulin. 
Patient: That's strange, doctor. 
Doctor: My staff tells me that your appetite is good, and you're eating as well as ever, is that correct? 
Patient: Yeah, I'm just a little fatigued, but otherwise, I'm doing well.

Clinical note section (GENHX):
I am asked to see the patient today with ongoing issues around her diabetic control.  We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals.  Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change.  What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin.  The staff reports to me that her appetite is good and that she is eating as well as ever.  I talked to Anna today.  She feels a little fatigued.  Otherwise, she is doing well.
Dialogue:
Doctor: All your labs are negative, and it's been six months from your injury, is that right, sir?
Patient: Yes, that is correct. What is your plan of action here?
Doctor: Okay so I do not see any physical findings that might suggest any type of contamination. Your labs were negative, but I would like you to take precautions going forward to keep yourself protected. Try to avoid these situations in future by being informed. Always wear gloves.
Patient: I will try to educate myself and be vigilant on that part. I will try to prevent any such transmission. I will not expose myself to any intimate contacts.

Clinical note section (PLAN):
The patient is now six months out from his injury. He had negative lab studies. There were no physical findings that were suggestive of disease transmission. He was counseled on ways to prevent exposure in the future including use of protective gear including gloves, which he states that he always does. He was counseled that ways to prevent transmission or exposure to intimate contacts.
Dialogue:
Doctor: Okay I would like to know if these illnesses are in your family? 
Patient: Okay shoot.
Doctor: Diabetes, hypertension, any heart diseases, cancers?
Patient: Yeah, my family have a few individuals with diabetes and hypertension. My dad underwent a heart surgery bypass at the age of thirty four.

Clinical note section (FAM/SOCHX):
Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.
Dialogue:
Doctor: Ma'am, you need to work on your diet. Specially avoid food and drinks with high sugar content and no extra salt. 
Patient: What do you suggest I eat?
Doctor: For now, you can start with clear thin fluids, like broth or clear soups. 
Patient: Okay!

Clinical note section (PLAN):
No added salt, no concentrated sweets, thin liquids.
Dialogue:
Doctor: Are you working? 
Patient: I'm retired now, I worked as a truck driver before. 
Doctor: Do you smoke? 
Patient: Yeah, I do. 
Doctor: How many do you take in a day? 
Patient: Around one to three packs. 
Doctor: Do you drink? 
Patient: Nope. 
Doctor: Are you married? How many kids do you have? 
Patient: I'm divorced, and I have two sons. They both are into sports. They are healthy.
Doctor: So, you live with the kids? 
Patient: No, they visit me on weekends. I live with my mother.

Clinical note section (FAM/SOCHX):
retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother.
Dialogue:
Doctor: Good afternoon, ma'am. Can you confirm your age for me, please? 
Patient: I'm thirty nine years old, doctor. 
Doctor: Good, and you identify as African American, correct?
Patient: Yes, that's correct. 
Doctor: Great, are you familiar with the details of your operation? 
Patient: Someone told me, but I don't really remember what happened. 
Doctor: Okay, well, we did a repair of septal deviation, but unfortunately, we ended up with a large septal perforation. 
Patient: Okay, that's what I remember, thank you.
Doctor: Have you been using your saline nasal wash? 
Patient: Yeah, I have. 
Doctor: How many times per day have you been using it? 
Patient: Um, usually two or three times a day. 
Doctor: Have you had any discomfort? 
Patient: Yeah, I feel a stretching kind of pressure in my nose. 
Doctor: Is your nose dry? 
Patient: Yeah, and it bleeds because of it. 
Doctor: Other than what you've mentioned, do you have any other complaints at this time?  
Patient: No, everything else is pretty good.

Clinical note section (GENHX):
The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation.  The patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a "stretching" like pressure.  She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose.  She has no other complaints at this time.
Dialogue:
Doctor: Any stomach pain? 
Patient: No. 
Doctor: Any pain while passing urine? 
Patient: No, no. 
Doctor: And no issues with bladder control, right?
Patient: Yeah, its fine. 
Doctor: Okay, good. And how about urine frequency, did you notice any increase or decrease?
Patient: No, seems normal to me. 
Doctor: Any blood in urine? 
Patient: Nothing like that.

Clinical note section (ROS):
GENITOURINARY: No dysuria, hematuria, frequency, incontinence or colic.
Dialogue:
Doctor: Do you suffer from any allergies? 
Patient: I do. I struggle with asthma and hay fever. 
Doctor: Do you carry an inhaler around with you? 
Patient: Always.

Clinical note section (PASTMEDICALHX):
Asthma Allergic Rhinitis