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231 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within normal limits.
Plan of Action: N/A
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<s>[INST] Not really, no. [/INST] Do you drink? </s><s>[INST] No. [/INST] Any drugs? </s><s>[INST] I like to go on walks with my dog every day. I'm also eating a lot healthier these days. [/INST] Do you get a chance to exercise during the week? </s><s>[INST] I actually got promoted last month so it's been going well. I've had a lot more time to spend with my family as a result. [/INST] That's wonderful. How's work going for you? </s><s>[INST] Thank you so much. [/INST] That's great to hear. Congratulations! </s>
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22 |
EDCOURSE
|
Symptoms: Sensitivity to light, nausea
Diagnosis: Migraine
History of Complaint: Seen in urgent care, prescribed Tylenol with codeine for pain relief, advised to take a day off from school and rest until feeling better
Plan of Action: N/A
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<s>[INST] They didn't do much other than tell me to follow up with you. [/INST] I looked over your report from urgent care. </s><s>[INST] Can I take anything for it? [/INST] Given that you're sensitive to light and feel nauseated, I believe a migraine is highly likely. </s><s>[INST] Can I get a doctor's note, too? [/INST] I'm going to prescribe you Tylenol with codeine to help your pain. </s><s>[INST] Okay. Thank you. [/INST] Yes. In fact, I'd like you to take a day off from school and rest until you start to feel better. </s>
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1,040 |
PASTSURGICAL
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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
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<s>[INST] I have had a heart bypass surgery. [/INST] What kinds of surgeries have you had in the past? </s><s>[INST] Maybe. And I have had my tonsils and appendix taken out. [/INST] Is that C A B G? </s><s>[INST] [/INST] Sure. Okay. </s>
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350 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: former smoker (quit in 2007), past cocaine use (quit in 2005), history of alcohol abuse (quit more than 10 years ago)
Plan of Action: N/A
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<s>[INST] Uh yeah, but I quit in two thousand seven. [/INST] Any history of smoking? </s><s>[INST] Uh if I were to guess, I'd say one pack per day. [/INST] On average, how many packs per day did you smoke? </s><s>[INST] I used to do coke, but I quit that in two thousand five. [/INST] Any other drugs? </s><s>[INST] Um I used to drink one pint per day, but I quit drinking more than ten years ago. [/INST] And any history of drinking? </s>
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776 |
PASTSURGICAL
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: C-section, D&C
Plan of Action: N/A
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<s>[INST] I had a C section for my kiddo and one D and C. [/INST] What type of surgery have you had in past? Anything big or small? </s><s>[INST] [/INST] Okay. </s>
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82 |
PASTMEDICALHX
|
Symptoms: N/A.
Diagnosis: Type 2 diabetes, high cholesterol.
History of Patient: N/A.
Plan of Action: N/A.
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<s>[INST] I have type two diabetes. My numbers always come high. [/INST] Do you have any medical history that we should be aware of? </s><s>[INST] I also have high cholesterol. [/INST] Okay, anything else? </s><s>[INST] [/INST] Okay. </s>
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537 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] Nope. [/INST] Any known medical history in the family? </s><s>[INST] Nope. [/INST] How about anyone with high blood pressure or heart disease or diabetes in the family? </s>
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131 |
GENHX
|
Symptoms: Intense constant right frontal headache, pressure type discomfort with throbbing component, mild nausea.
Diagnosis: N/A.
History of Patient: Onset of headache early on Monday, persistent for more than 48 hours, denies similar discomfort in the past, denies trauma.
Plan of Action: N/A.
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<s>[INST] I am sixteen. [/INST] Hi miss. How old are you? </s><s>[INST] White. [/INST] What race do you identify as? </s><s>[INST] No I have a really bad migraine. [/INST] Are you okay? You have a headache? </s><s>[INST] Here, since Monday. [/INST] Okay can you point to where you are feeling it the most? </s><s>[INST] Yes, I am feeling a lot of pressure. [/INST] Okay so mostly on the right frontal side and it's been forty eight hours now? </s><s>[INST] It is throbbing. [/INST] I can understand the discomfort. Is it continuous or throbbing? </s><s>[INST] Nine or more. [/INST] On the scale of one to ten, ten being the worst, how would you rate it? </s><s>[INST] No I haven't. [/INST] Have you ever experienced similar symptoms in the past? </s><s>[INST] No no. [/INST] Did you hit your head buy any chance? </s><s>[INST] No. [/INST] Okay can you tell me if you have any fever or chills, congestion, cough cold like symptoms? </s><s>[INST] No nothing like that. [/INST] Any nausea, vomiting, diarrhea or trauma anywhere? </s><s>[INST] No everything else is fine. [/INST] Anything from head to toe? </s>
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1,173 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Noncontributory.
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<s>[INST] No. [/INST] Do thyroid problems run in your family? </s>
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138 |
FAM/SOCHX
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Habit of Smoking and Cocaine Positive.
Plan of Action: N/A.
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<s>[INST] Doctor: He was a former smoker and tested positive for cocaine during his last visit in January O eight. [/INST] Guest_clinician: Any history of drug or alcohol use? </s>
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283 |
CC
|
Symptoms: abdominal pain, nausea, vomiting
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] Doctor: Hm, any nausea or vomiting? [/INST] Patient: I am having stomach pain. </s><s>[INST] [/INST] Patient: Yes, both. </s>
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479 |
FAM/SOCHX
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Divorced, lacks support at home, denies tobacco, alcohol, and illicit drug use.
Plan Of Action: N/A.
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<s>[INST] No, I'm divorced. [/INST] Are you married, ma'am? </s><s>[INST] Yes, so I have no support at home, it's difficult. [/INST] Do you live alone? </s><s>[INST] No, I never have. [/INST] Do you drink or smoke? </s><s>[INST] No, absolutely not. [/INST] What about more illicit substances? </s>
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130 |
PASTMEDICALHX
|
1. Liver cirrhosis caused by alcohol. This is per the patient. 2. He thinks he is diabetic. 3. History of intracranial hemorrhage. He said it was subdural hematoma. This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis. 4. He said he had a seizure back then, but he does not have seizures now.
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<s>[INST] Thank you. [/INST] Welcome to the clinic, sir. </s><s>[INST] I used to have seizures, but they have stopped now. [/INST] Let us start with your medical history. </s><s>[INST] About seven years ago I had a traumatic stroke. They told me I had bleeding in the brain. After the stroke I was left with this weakness on my right side. [/INST] Was there a cause of the seizures? </s><s>[INST] My arm, hand, and my face. [/INST] What part of your body is affected by the weakness? </s><s>[INST] My liver is falling. It is because of all the alcohol that I have consumed over the years. I am not drinking anymore. [/INST] Do you have any other health problems? </s><s>[INST] No. I just stopped drinking. I think I have diabetes. [/INST] Are you being treated for your liver disfunctions? </s><s>[INST] I have been really thirsty, and I have been having numbness and tingling in my feet. [/INST] What makes you feel like you have diabetes? </s><s>[INST] [/INST] Oh okay. We can definitely do some test today to find out if you are diabetic or not. </s>
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711 |
MEDICATIONS
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Using Triamcinolone 0.1% cream three times a day on left wrist rash, using Bactroban ointment three times a day as needed for bug bites on legs, using Nystatin ointment on lips once a day as needed (previously four times a day), Klonopin dose adjusted to 4 mg in the morning and 6 mg at night instead of 6 mg and 8 mg as previously recommended
Plan of Action: N/A
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<s>[INST] The one on my left wrist? [/INST] Have you been applying Triamcinolone zero point one percent three times a day to your rash? </s><s>[INST] Yep. [/INST] Yes. And Bactroban ointment is also three times a day as needed for your bug bites. </s><s>[INST] Uh yeah. I've been using it much less now. [/INST] Are you still using Nystatin on your lips once a day as needed? </s><s>[INST] Yeah, I mean I'm taking four M G in the morning and six M G at night instead of the six M G and eight M G that was recommended. I feel like I do better with the lower doses. [/INST] So let's see, your other medications are the same as of July thirtieth O four with the exception of Klonopin? </s>
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899 |
GENHX
|
Symptoms: pain in right knee, located on the inside (medial aspect), twisted knee at work
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] Sure, no problem, doctor. [/INST] I just need to confirm a few pieces of information from my nurse before we begin today, sir. </s><s>[INST] Yes, that's correct. [/INST] Great, so it says here that you are forty five years old, and you identify as Caucasian. Is that correct? </s><s>[INST] Well, I have this pain in my right knee, sir. [/INST] Thank you, so, what seems to be the problem today? </s><s>[INST] It's right here, on the inside of my right knee. [/INST] Where is your pain? </s><s>[INST] Actually, yeah. I twisted it while I was at work. [/INST] Is there an injury associated with this pain? </s>
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455 |
GENHX
|
Symptoms: Bad cough with phlegm, decreased appetite.
Diagnosis: N/A.
History of Patient: Two-and-a-half-year-old male has been sick for the past three to four days. Mother describes congested sounds with cough and decreased appetite. No fever or runny nose. Nobody else at home is currently ill. No cigarette smoke exposure. Brought to the emergency room after a bad coughing spell, with no apnea during the episode.
Plan Of Action: N/A.
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<s>[INST] Guest_family: I am doing well but my son is sick. He is two and a half years old. [/INST] Hi there! How are the both of you doing today? </s><s>[INST] Guest_family: He has a bad cough. He's been sick for the last three or four days. It sounds like there is phlegm rattling around in there when he coughs. He had a bad coughing fit this morning. I got nervous and decided to bring him in. [/INST] What are his symptoms? </s><s>[INST] Guest_family: No. [/INST] During his coughing episode this morning, did you notice any loss of breath or gasping for air? </s><s>[INST] Guest_family: No. [/INST] Has he had a runny nose? </s><s>[INST] Guest_family: No. He has not been eating much. [/INST] Any fever? </s><s>[INST] Guest_family: No. [/INST] Is anyone else in the household sick? </s><s>[INST] Guest_family: No. [/INST] Is anyone in the household a smoker? </s>
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237 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Works at ABC. Social alcohol drinker. Non-smoker.
Plan of Action: N/A
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<s>[INST] I work at A B C store, doctor. [/INST] So, what do you do for a living, sir? </s><s>[INST] No, I don't smoke at all. [/INST] That's great, do you smoke? </s><s>[INST] I'd say I drink socially, like if I'm at a party, or something. [/INST] How about alcohol? Do you drink? </s>
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655 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years. Denies any alcohol use. Denies any IV drug use.
Plan of Action: N/A
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<s>[INST] Seventeen years back. [/INST] When was the last time you had a cigarette? </s><s>[INST] About one pack per day. I smoked for forty four years. [/INST] Okay, and how much did you used to smoke? </s><s>[INST] No I have not done that. [/INST] Okay, how about any I V drugs? </s>
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549 |
GENHX
|
Symptoms: tooth pain on left side (upper and lower), ongoing for three days
Diagnosis: N/A
History of Patient: extensive dental disease, multiple teeth pulled, missed dental appointments leading to standby appointments only, has OxyContin and Vicodin at home for knee pain
Plan of Action: N/A
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<s>[INST] Yes, yes, many, many problems. Firstly, they pulled out so many teeth and now I have this bad tooth problem. [/INST] What is up with your teeth man? It's been giving you problems huh? </s><s>[INST] Yes, it's a new pain. Right now it has been going on for three days on left side's upper and lower teeth. [/INST] Oh, so this is new? </s><s>[INST] I would have but I have missed so many appointments that they now do not allow me to schedule regular appointments. So they put me on a standby appointment now. [/INST] Then why didn't you go and visit your regular dentist? </s><s>[INST] It is okay. [/INST] Oh I am sorry. </s><s>[INST] No. [/INST] Okay any other problems or any other complaints? </s><s>[INST] No, no illness whatsoever. [/INST] How about any recent illnesses or injuries? </s><s>[INST] Yes I have OxyContin and Vicodin at home. I use it for my knee pain. But I want more pain medicines. I do not want to use up that medicine for my toothache. [/INST] Do you have any medicine at home for pain? </s><s>[INST] I am twenty nine. [/INST] Okay I understand. How old are you again? </s>
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388 |
PLAN
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: Advised to take it slow and do activities as tolerated after plaster removal from foot. No follow-up needed if no pain and doing fine.
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<s>[INST] Doctor: Um, I have taken the plaster off and your foot looks good. I don't want you to restrict your activities, but you are the best judge of the situation. So, I will advise you to take it slow and do as much as you can tolerate. [/INST] Patient: And do I have to restrict my movement or activities? </s><s>[INST] Doctor: As long as you are doing fine, having no pain, I think we are okay. [/INST] Patient: Got it. Thank you, Doctor. Do I need a follow-up? </s><s>[INST] Doctor: Bye. [/INST] Patient: Alright then bye. </s>
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213 |
PASTMEDICALHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: chickenbox and measles
Plan of Action: N/A
.
|
<s>[INST] Okay. [/INST] I want to talk to you about your reproductive history, okay? </s><s>[INST] Yes, I do. [/INST] Do you take birth control pills? </s><s>[INST] I had both chickenpox and measles when I was a kid. [/INST] Do you have any kind of medical history that I should be aware of? </s>
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705 |
MEDICATIONS
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Medication includes Insulin, metformin, Glucotrol, and Lipitor.
Plan of Action: N/A
|
<s>[INST] Yes. [/INST] Are you on insulin? </s><s>[INST] Yes. [/INST] Are you on metformin as well? </s><s>[INST] Yes I take that. [/INST] How about glucotrol? </s><s>[INST] Yes. [/INST] Are you on lipitor? </s>
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477 |
GENHX
|
Symptoms: Weakness in right leg, overall weakness, feeling tired, falls (4 times), improvement with sugar intake, odd fisted posture during episodes, mild pallor during episodes.
Diagnosis: N/A.
History of Patient: 51-year-old female experienced weakness in her right leg, requiring arm support for movement, falls occurred on 1/3/93 and again on 1/4/93, brought to UIHC hospital for evaluation on 1/5/93.
Plan Of Action: Patient presented to UIHC hospital for evaluation of weakness and falls.
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<s>[INST] I fell four times on third of this month because my leg suddenly gave out. [/INST] Hello, what brings you here today? </s><s>[INST] You don't ask age of a lady. She will never tell you the truth. [/INST] How old are you? </s><s>[INST] That's true. I'm just teasing you. I'm fifty one. [/INST] I know I'm in the wrong profession. I have to do that every time I meet someone. So how old are you? </s><s>[INST] I am right handed. [/INST] Are you right handed or left handed? </s><s>[INST] Oh, I noticed weakness in my right leg before as well and sometimes, like, I have to give the support of my arm to actually move it. Sometimes during these episodes I just turn pale and it's like overall weakness. I feel so tired. My husband, he gives me some sugar, three teaspoons, and then it helps a little bit but not completely. [/INST] So, you said that your legs suddenly gave out. What happened exactly? Was it sudden? Or were you noticing some weakness before as well? </s><s>[INST] It's overall. I remember in one of these episodes I was, like, in an odd fisted posture. [/INST] So, is your weakness like overall in your legs or it is at any single point? </s><s>[INST] No, nothing like that. [/INST] Is there any change in your sensations? Like if I touch you, is it like same before or was there any change? </s><s>[INST] Nope. [/INST] Is there change in vision? Are you seeing double? </s><s>[INST] Nope. [/INST] Any difficulty in swallowing or eating? Any loss of consciousness? </s><s>[INST] No. [/INST] Any difficulty in speech? Slurring, or anything like that? </s><s>[INST] Nope. It's just that I fall and then fell again last night. I was feeling so weak. Nothing was helping me. That's when, in the morning, my husband brought me to the U I H C hospital for the evaluation on the fifth. [/INST] You said that these episodes have been happening for some time, so did you see anyone for those before? </s>
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472 |
CC
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Symptoms started getting progressively worse over the past two days, no history of cellulitis reported.
Plan Of Action: Questionable need for antibiotic therapy for possible lower extremity cellulitis.
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<s>[INST] Doctor: According to the patient, his symptoms started getting progressively worse over the past two days. [/INST] Guest_clinician: I see here that he may need antibiotic therapy for possible cellulitis of his lower extremities. </s><s>[INST] Doctor: No. [/INST] Guest_clinician: Does he have a history of cellulitis? </s>
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1,074 |
GENHX
|
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
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<s>[INST] Guest_family: Thank you! It is nice to meet you. [/INST] Welcome in. I am Doctor Welch. </s><s>[INST] Guest_family: She is three years old now. [/INST] How old is your daughter? </s><s>[INST] Hi! [/INST] Hi there! </s><s>[INST] Guest_family: Okay. [/INST] Mom I would like to start off with some questions regarding pregnancy, childbirth, and prior children. </s><s>[INST] Guest_family: No. She is my only child. [/INST] Do you have any other children? </s><s>[INST] Guest_family: I had a very early miscarriage before getting pregnant again with her. [/INST] Have you ever had any miscarriages or abortions prior to having your daughter? </s><s>[INST] Guest_family: Thank you. I was difficult but when I got pregnant again with her, we were so overjoyed. [/INST] I am so sorry to hear that. </s><s>[INST] Guest_family: I had the flu in my seventh or eighth month of pregnancy. Other than that I had no problems. [/INST] Did you have any difficulties or problems during your pregnancy with her. </s><s>[INST] Guest_family: I was thirty six weeks. [/INST] How far along were you when you gave birth? </s><s>[INST] Guest_family: I had a regular birth. [/INST] Did you have a vaginal birth or a C section? </s><s>[INST] Guest_family: No. [/INST] Were any tools used during the birth to help with the birthing process? </s><s>[INST] Guest_family: I was in labor for eleven hours. [/INST] How long were you in labor for? </s><s>[INST] Guest_family: They gave me a little bit of laughing gas but not much. [/INST] Were you given any anesthesia during the birth? </s><s>[INST] Guest_family: Seven pounds and ten ounces. [/INST] What was her birth weight? </s><s>[INST] Guest_family: No. I am not sure. [/INST] Do you recall her Apgars score? </s><s>[INST] Guest_family: Five days. [/INST] How long did you stay in the hospital after the birth? </s><s>[INST] Guest_family: She did not walk until well after two years old. She only rolled from side to side at two. [/INST] Let us move to questions regarding your daughter. Has she had any development problems? </s><s>[INST] Guest_family: She was around one or two. [/INST] Okay. How old was she when she spoke her first words? </s><s>[INST] Guest_family: She was two. [/INST] When did she start to feed herself, using her hands? </s><s>[INST] Guest_family: No. She is not interested but I have been trying. [/INST] Has she been toilet trained yet? </s>
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1,049 |
FAM/SOCHX
|
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
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<s>[INST] 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. [/INST] Any important family history, any medical issues in the family? </s><s>[INST] 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. [/INST] What about your mom? </s><s>[INST] I have a daughter, she's healthy. [/INST] Do you have kids? Are they all doing good health wise? </s>
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550 |
CC
|
Symptoms: worsening jaw pain, specific spot of pain.
Diagnosis: N/A
History of Patient: N/A
Plan of Action: refer to TMJ specialist.
|
<s>[INST] The pain seems to have gotten worse. [/INST] How's your jaw doing? </s><s>[INST] Sure. Ow, ow, ow. That's the spot that hurts the most. What's causing it? [/INST] Do you mind if I take a look? </s><s>[INST] [/INST] It's hard to say, but I'm thinking it could be T M J. I'd like to get you in to see a T M J specialist. </s>
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1,104 |
GENHX
|
Symptoms: hip pain, difficulty with activities, groin pain
Diagnosis: severe degenerative changes of left hip joint, avascular necrosis (AVN) of left femoral head
History of Patient: 32-year-old male with eight to ten year history of left hip pain, initially thought to have low back pain with radiculopathy, previous evaluation by multiple specialists, previous antibiotic steroid use, heavy drinking history
Plan of Action: discussion of hip resurfacing versus conventional total hip replacement, seeking second opinion
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<s>[INST] It's been about eight or ten years now. It began while I was working in construction. [/INST] So, how are long have you had pain in this hip? </s><s>[INST] I'm thirty two now, so I've been in pain since I was in my twenties. [/INST] How old are you now? </s><s>[INST] Yeah, um, I've actually seen several doctors before, the last I saw was Doctor A B C a few weeks ago. [/INST] Have you seen another doctor for this, or am I the first? </s><s>[INST] They thought it was low back pain, and something called, um, radiculopathy. [/INST] What did those doctors tell you? </s><s>[INST] Yes. [/INST] Does your pain radiate into your legs? </s><s>[INST] It's been persistent, and I've had difficulties on and off since then. [/INST] Has your pain been present for the eight years, or did it come and go? </s><s>[INST] He gave me some pain medicine, and we talked about going to another specialist for surgery. [/INST] Okay. The x rays from Doctor A B C show severe degenerative changes as well as avascular necrosis of the femoral head. What else did the Doctor do for you? </s><s>[INST] Something about resurfacing the hip, or a hip replacement. I'm here for another opinion on that. [/INST] Do you remember the names of the procedures suggested? </s><s>[INST] Yes, and I can't do any of the activities I used to. [/INST] I saw you come in with a cane, do you have groin pain as well? </s><s>[INST] I've taken antibiotic steroids before. [/INST] Besides the pain medication, have you had anything else? </s><s>[INST] Yes, a lot. [/INST] Okay. Do you drink? </s>
|
810 |
GENHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Pregnancy and delivery without complications, no history of hospitalizations or surgeries
Plan of Action: N/A
|
<s>[INST] Yes, I have a wonderful baby girl at home. [/INST] Do you have any children, ma'am? </s><s>[INST] Nope, everything went very smooth. I'm thankful. [/INST] Wonderful, were there any complications with your pregnancy or delivery? </s><s>[INST] No, thankfully. [/INST] Good, have you ever been hospitalized for any issue? </s><s>[INST] Correct, I never have. [/INST] Good, so I can assume you've never had surgery? </s>
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547 |
PASTMEDICALHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] Doctor: We don't have any record of P M H for this patient. [/INST] Guest_clinician: I don't see any past medical history here in this report. </s><s>[INST] [/INST] Guest_clinician: Okay. </s>
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21 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Complaint: Non-cigarette smoker, non-alcohol user, single with no children, works as a payroll representative, previously worked in jewelry business involving chemicals
Plan of Action: N/A
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<s>[INST] No, I do not. [/INST] Do you smoke? </s><s>[INST] No, I don't drink alcohol as well. [/INST] How about alcohol. </s><s>[INST] No, I am single, thus no kids. [/INST] Okay let me ask you, do you have any children or are you married? </s><s>[INST] I work as a payroll representative. I used to do a lot of work in jewelry business, with chemical. [/INST] Okay, where do you work? </s><s>[INST] Yeah. [/INST] interesting. </s>
|
984 |
CC
|
Symptoms: Abdominal pain (all over the belly), gnawing sensation
Diagnosis: N/A
History of Patient: Pain has been ongoing for two to three weeks, described as a gnawing sensation which is new to the patient, no past abdominal surgeries
Plan of Action: N/A
|
<s>[INST] All over my belly. [/INST] Where are you experiencing the most pain? </s><s>[INST] Two to three weeks. [/INST] How long has this been going on? </s><s>[INST] It does. [/INST] Does the pain come and go? </s><s>[INST] The pain? [/INST] And how would you describe- </s><s>[INST] Hm I'd describe it as a gnawing sensation. [/INST] Yes. </s><s>[INST] I believe so. I don't ever remember feeling this way before. [/INST] Is this sensation new? </s><s>[INST] None. [/INST] Any past abdominal surgeries? </s>
|
598 |
PASTSURGICAL
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Underwent circumcision; date not remembered, to be found in medical chart.
Plan of Action: N/A.
|
<s>[INST] Yes. [/INST] He had circumcision? </s><s>[INST] No I do not. But it should be in the chart. [/INST] Do you remember the date? </s>
|
57 |
MEDICATIONS
|
Symptoms: N/A
Diagnosis: N/A
History of Complaint: N/A
Plan of Action: N/A
|
<s>[INST] No. [/INST] Are you taking any medications? </s><s>[INST] None. [/INST] Any over the counter drugs or anything? </s><s>[INST] [/INST] Okay. </s>
|
1,108 |
CC
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Two-month follow-up
Plan of Action: N/A
|
<s>[INST] I know right? [/INST] Hello, it's been two months already? </s><s>[INST] [/INST] Just feels like yesterday. </s>
|
783 |
PASTMEDICALHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Left temporal lobe seizures, hypertension
Plan of Action: N/A
|
<s>[INST] Thank you. [/INST] Welcome in! </s><s>[INST] I have some memory loss problems. [/INST] Let us get a little background. What is your medical history? </s><s>[INST] Well, I have seizures. [/INST] What kind of memory problems? </s><s>[INST] I have temporal lobe seizures. [/INST] Do you know what kind of seizures that you have? </s><s>[INST] I also have high blood pressure. [/INST] Do you have any other health conditions? </s><s>[INST] [/INST] Okay. </s>
|
474 |
GENHX
|
Symptoms: Persistent left knee pain.
Diagnosis: Unstable OCD (osteochondritis dissecans) lesion of the left knee.
History of Patient: 13-year-old male initially seen at Sierra Pacific Orthopedic Group, MRI demonstrated unstable OCD lesion of the left knee, presented for a second opinion, surgery recommended due to instability of the fragment, risks and benefits of surgery discussed, risks include anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure to relieve pain or restore articular cartilage, possible need for other surgical procedures, and possible early arthritis, parents agreed to the plan.
Plan Of Action: Surgery recommended to address the unstable OCD lesion in the left knee.
|
<s>[INST] Good afternoon, doctor. [/INST] Good afternoon, young man. </s><s>[INST] I'm thirteen. [/INST] How old are you, sir? </s><s>[INST] Guest_family: Well, at first, we went to Sierra Pacific Orthopedic Group, and he had an M R I that showed, um, O C D in the left knee. [/INST] So, what brings you in today? </s><s>[INST] Guest_family: So, we're here for a second opinion on that. [/INST] Yes, I see that from the report. </s><s>[INST] Guest_family: Okay, that's about what we've heard so far. What are the risks of infection of the procedure? [/INST] Yes, we should do surgery on this knee. There's gross instability of the fragment, and we don't want that get worse. </s><s>[INST] Guest_family: Okay, will he be asleep the entire time? [/INST] It's less than one percent. We use antibiotics to control for infection. Other risks include bleeding, changes in sensation of the limb, changes in motion, failure to relieve pain or restore the articular cartilage, the possible need for another procedure, and possible early arthritis. I would not worry, though. These things are rare. </s><s>[INST] Guest_family: Okay, my husband agrees. We want to do the surgery. [/INST] Yes, he won't feel a thing. </s>
|
142 |
ALLERGY
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: She has no known drug allergies.
Plan of Action: N/A.
|
<s>[INST] No. [/INST] Any known allergies? </s><s>[INST] No. [/INST] Any allergy to any drug? </s>
|
135 |
FAM/SOCHX
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Consume Alcohol.
Plan of Action: N/A.
|
<s>[INST] I have a drink every once and a while. [/INST] Do you use tobacco products, alcohol, or recreational drugs, miss? </s><s>[INST] I don't even drink that often. I probably have one drink per month. [/INST] How many drinks do you consume in a week? </s><s>[INST] I was engaged but that is not happening anymore. It is a long story. [/INST] Are you married? </s><s>[INST] I am a metal grinder. [/INST] I am sorry the hear that. What do you do for work? </s>
|
230 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Family history of prostate cancer in the patient's father and paternal uncle. Paternal uncle also had Hodgkin's disease and melanoma.
Plan of Action: N/A
|
<s>[INST] Um, yeah, my dad had prostate cancer. [/INST] Do you have any medical conditions that run in your family that I should know about, ma'am? </s><s>[INST] Um, my mom's brother had Hodgkin's disease, melanoma, and prostate cancer. [/INST] What about your mother, or the rest of your family? </s>
|
619 |
GENHX
|
Symptoms: feet and hand cramps, muscle contractions in toes and feet, calf pain, thumb flexion cramps
Diagnosis: N/A
History of Patient: experiencing cramps in feet and hands for the past six months, foot cramps more notable than hand cramps, cramps occur exclusively at night, occur about three times per week, standing relieves discomfort, toes in extended position during cramps, calf pain follows foot cramps, hand cramps less severe and frequent, occur randomly, thumb flexion cramps, started taking Bactrim nine months ago, history of HIV for 21 years, stopped antiretroviral medications six or seven years ago due to stomach upset, CD4 count of 326, never developed AIDS, considering resuming antiretroviral treatment
Plan of Action: N/A
|
<s>[INST] Doctor: Tell me what brings you here, sir? [/INST] Patient: I'm right handed. </s><s>[INST] Doctor: How frequent is it? [/INST] Patient: I'm having these cramps in my feet, in my hand and I just wanted to get checked. It has been happening for like six months. I develop muscle contractions in my toes and both feet. It only happens in night. </s><s>[INST] Doctor: What do you do when you have these cramps? [/INST] Patient: Around three times a week. </s><s>[INST] Doctor: Did you ever have this symptom before? [/INST] Patient: I try to stand and it helps me relieve some of the discomfort. I noticed my toes are kind of extended. Whenever I step on the ground, it seems to pop into place. With all these cramps, I've started having pain in my calf. Sometimes because of that I could not sleep, or it wakes me up in the night. Similar to my toes, these cramps have also started coming up in my hands. They are not that strong or frequent. They're completely random and not in the nighttime. Sometimes my thumb gets so flexed that I have to move it to bring it to the right position and to relieve the cramp. </s><s>[INST] Doctor: Are you taking any medications? [/INST] Patient: No, not like this. </s><s>[INST] Doctor: Do you have any other medical condition? [/INST] Patient: Yeah, I took an antibacterial called Bactrim around nine months ago. I was taking it briefly before, but now I'm taking it consistently. I cannot think of anything that is causing it. </s><s>[INST] Doctor: Why did you stop the medications? [/INST] Patient: I have H I V for the last twenty one years and I was taking antiretroviral medications for it. I stopped those medications around six or seven years ago. </s><s>[INST] Doctor: Do you know your C D four count? [/INST] Patient: I could not tolerate them. They were making my stomach weak. </s><s>[INST] [/INST] Patient: It was three hundred and twenty six. I never developed autoimmune deficiency syndrome. I think I should restart my medicines. </s>
|
233 |
GENHX
|
Symptoms: accidentally jammed a needle into his right hand index finger.
Diagnosis: patient tested negative for HIV but positive for Hepatitis C.
History of Patient: The patient, a 54-year-old right-handed male, accidentally jammed a needle into his right hand index finger while working as a phlebotomist and respiratory therapist. He was wearing gloves and protective clothing at the time of the incident. The source patient tested negative for HIV but positive for Hepatitis C.
Plan of Action: N/A
|
<s>[INST] I work as a phlebotomist and respiratory therapist. [/INST] What do you do in the hospital? </s><s>[INST] I am fifty four. [/INST] Ok, how old are you? </s><s>[INST] Thank you! [/INST] You are very young. </s><s>[INST] I am coming for regular screening. [/INST] Patient: So, as you remember I was trying to measure blood gas as I was working with a patient and I accidently jammed that needle inside my right hand index finger. </s><s>[INST] Yes, I had gloves and protective clothing. [/INST] Were you wearing gloves? </s><s>[INST] Yes, he got negative HIV but positive Hep C. [/INST] Yes, thank you for that. Did they screen patient? </s><s>[INST] I am scared. [/INST] Ok. </s>
|
62 |
GENHX
|
Symptoms: Right greater than left upper extremity pain, weakness, paresthesias, sharp shooting radicular pain and weakness down left upper extremity
Diagnosis: Cervical spinal stenosis
History of Complaint: Incident on 06/04/07 exacerbating symptoms, ongoing right upper extremity pain, paresthesias, weakness believed to radiate from neck, physical therapy helping with neck pain but not hand weakness, difficulty opening jars and doors, often drops items from right upper extremity, nonoperative management by Dr. X for neck pain but not upper extremity symptoms, no bowel or bladder dysfunction, no lower back pain, no lower extremity pain, no instability with ambulation
Plan of Action: N/A
|
<s>[INST] Guest_clinician: This is Miss A B C. She's here for her follow up regarding her cervical spinal stenosis. She was seen by you on nineteenth June. She had an incident on fourth of June, when she lifted many objects and experienced exacerbated symptoms. She is experiencing paresthesia, weakness, and pain in her upper extremities on the right side more than the left since then. She was referred for a cervical spine M R I. [/INST] Hello, this is my assistant, and she will be working with me today for your care. Can you please represent the patients case? </s><s>[INST] I'm still having all those things like pain and weakness, and I believe that everything is coming down from my neck. [/INST] So, how are you feeling today? </s><s>[INST] I did some. It was helping me with my neck pain. But this right hand is still feeling weak. I feel it is difficult at times to open jars and open doors. Many times, I drop items. [/INST] Did you get some physical therapy? Did it help? </s><s>[INST] Right side is giving me more problems than the left. [/INST] Is it happening with both hands or one is more than the other? </s><s>[INST] Yeah, one more thing I noticed is that sometimes when I am sleeping in the night, I feel this sharp shooting pain and weakness. It goes down my left side of upper, I mean, whole hand and I feel scared after that. [/INST] Anything else that you noticed? </s><s>[INST] Yeah, Doctor X is trying to help me, uh, with that without surgery. His methods are good it and it is helping me with my neck pain, but not hand. [/INST] Are you seeing anyone for that? </s><s>[INST] Nope. [/INST] Are you having any issues with your bowel movements? </s><s>[INST] Nope. [/INST] Any pain in the lower side of your back or in your legs? </s><s>[INST] Nope. [/INST] Any problem with walking or stability? </s>
|
77 |
FAM/SOCHX
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
|
<s>[INST] No one comes to mind. [/INST] Does anyone in your family suffer from any health problems? </s><s>[INST] [/INST] Great. </s>
|
292 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: cancer and heart disease
Plan of Action: N/A
|
<s>[INST] Actually, yes, I know a few family members have, but I can't remember who had what kind. [/INST] Now, let's talk about your family history. Have any of them had cancer? </s><s>[INST] Yes, that rings some bells. [/INST] That's okay. What about heart disease? Can you remember anyone having that? </s><s>[INST] I know that a lot of my family has had arthritis in the past, but I can't remember whether or not they had joint replacements, honestly. [/INST] Thank you, has anyone in your family had a joint replacement? </s>
|
73 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Complaint: Lives with husband, nonsmoker, no history of drug abuse, drinks two to three drinks daily, completed 12th grade
Plan of Action: N/A
|
<s>[INST] Okay. [/INST] Hello, I will ask you a few basic questions, okay? </s><s>[INST] I am with my husband. [/INST] What is your living status? Do you live alone or with family? </s><s>[INST] I cleared my twelfth grade but never joined college after that. [/INST] What is your education level? </s><s>[INST] Nope. [/INST] Um, did you ever take any kind of illicit drugs? </s><s>[INST] No, I never smoked, and I do take two or three drinks daily but nothing like being alcoholic. [/INST] Any chronic drinking habit or smoking? </s>
|
832 |
GENHX
|
Symptoms: shoulder pain, difficulty working
Diagnosis: right shoulder injury
History of Patient: injured right shoulder on January 1, 2002, work-related injury as a CNA, tried physical therapy and subacromion decompression without much improvement, evaluated by Dr. X who suspected brachial plexopathy and superficial radial neuritis, EMG testing showed right suprascapular neuropathy with possible C5 radiculopathy, negative MRI for disk herniation, underwent suprascapular nerve decompression, received nerve blocks for ongoing pain
Plan of Action: N/A
|
<s>[INST] Thank you. [/INST] Welcome back to the clinic. </s><s>[INST] Yes, that's correct. [/INST] I understand that we are doing an impairment rating exam today. </s><s>[INST] Yes. [/INST] And we are evaluating your right shoulder injury. Correct? </s><s>[INST] Yes. I was working as a C N A at the Veteran's House. [/INST] Was this a workrelated injury? </s><s>[INST] I was transferring a patient from a wheal chair to a bed, and I hurt my shoulder. [/INST] How did the work injury happen? </s><s>[INST] January first, two thousand and two. [/INST] What is the date of the incident? </s><s>[INST] No. I have not been able to go back to work yet. [/INST] Are you currently working? </s><s>[INST] I am a thirty one year old, white, female. [/INST] I am required to ask some specific questions for the L and I paperwork. What is your ago, ethnicity and gender? </s><s>[INST] No. [/INST] Have you ever had a prior injury to your right shoulder? </s><s>[INST] Right. [/INST] Are right or left hand dominant? </s><s>[INST] No. [/INST] Other then your shoulder injury, do you have any other chronic health problems? </s><s>[INST] No. [/INST] Are you experiencing any fever, chills or illnesses? </s><s>[INST] Okey. I have done a lot of different treatments. [/INST] Let discuss some of the previous treatments and test that you have been done for your shoulder. </s><s>[INST] I tried physical therapy. They did a subacromion decompression treatment in November, two thousand and two. [/INST] What treatments have you done? </s><s>[INST] Not much. I went and saw Doctor Lin and he said that I might have a nerve fiber injury. I forget what he called it. [/INST] Did either of those treatments help? </s><s>[INST] Yes. That sounds right. [/INST] Brachial plexopathy? </s><s>[INST] Okey. They should be in my chart. I had Doctor Lin send over all my records. [/INST] Oh, I see his notes in your chart. It says that he felt like you had a right superficial radial neuritis and blocked this with resolution of your symptoms. Then it looks like he sent you to get E M G testing at Valley Medical. Let me look for those results. </s><s>[INST] Whatever that means? I ended up getting a nerve block because I was still in pain. Doctor Lin did one in the frount of my shoulder and then another in the back. [/INST] Here it is. It says that the right suprascapular neuropathy although a C5 radiculopathy could not be ruled out. MRI testing on the cervical spine was then done which was negative for disk herniation and underwent suprascapular nerve decompression of the scapular notch on December eighteenth, two thousand and three. </s><s>[INST] Yes, it has been. [/INST] This has been a long drawn out course of treatments for you. </s>
|
49 |
ROS
|
Symptoms: N/A
Diagnosis: N/A
History of Complaint: N/A
Plan of Action: N/A
|
<s>[INST] Doctor: Okay, thanks for your help. [/INST] Guest_clinician: I did a review of her systems, and everything looks normal other than what was mentioned earlier. </s><s>[INST] [/INST] Guest_clinician: No problem. </s>
|
797 |
ROS
|
Symptoms: Exertional shortness of breath, frequent urination
Diagnosis: N/A
History of Patient: Denies chest pain, GI problems, bleeding disorders or bleeding history
Plan of Action: N/A
|
<s>[INST] No, I don't. [/INST] Do you have any chest pain? </s><s>[INST] Yes, I do get breathless only when I have to do some form of exertion like walking a long time or running. [/INST] Any breathlessness? </s><s>[INST] No, I don't have any stomach problems except I have to go frequently to use a bathroom. [/INST] Okay. How about any bowel issues? </s><s>[INST] No nothing like that. [/INST] Okay frequency. How about any prolonged bleeding issues or anything like that sort? </s>
|
43 |
PLAN
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: Advised patient to continue normal activities as long as feeling fine.
|
<s>[INST] Guest_clinician: Patient was good. I have advised him to continue with his normal activities as long as he is feeling fine. [/INST] How did the patient do on the activity test? </s>
|
583 |
GENHX
|
Symptoms: Chest pain.
Diagnosis: N/A.
History of Patient: He was stung by a Yellow Jacket Wasp, experiencing localized swelling in his right hand and arm.
Plan of Action: N/A.
|
<s>[INST] Yes sir, that's right. I've seen him for years. [/INST] Good morning, young man. You're a patient of Doctor X Y Z, correct? </s><s>[INST] Yes, doctor. That's all right. [/INST] I just need to confirm some demographic information before we get started today. So, you're a twenty nine year old white male, correct? </s><s>[INST] Well, I got stung by a Yellow Jacket Wasp yesterday. [/INST] Great, thank you. So, what seems to be the problem today? </s><s>[INST] Yes, it's in my right hand and right arm. [/INST] Do you have a lot of swelling? </s><s>[INST] Yeah, this wouldn't be the first time. [/INST] Have you every been stung by wasps before? </s><s>[INST] Yeah, I have. I have had one severe reaction. I came because I wanted to make sure it didn't get to that point again. I've never had, um, anaphylaxis, nothing super serious to date. [/INST] Have you had similar reactions before? </s><s>[INST] No, it's never felt like it was going to close up or anything like that. [/INST] Okay, that's good. Do you have any shortness of breath or difficulty with your throat? </s><s>[INST] No, I don't have anything like that either. [/INST] Do you have any rapid heartbeat or anxiety? </s><s>[INST] Yes, that's really all, doctor. [/INST] So, it's just the localized swelling where you got stung? </s>
|
448 |
IMMUNIZATIONS
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan Of Action: N/A.
|
<s>[INST] Yeah. [/INST] Did you have your vaccines? </s><s>[INST] No, I had all of them and am up to date with my immunizations. [/INST] Did you skip any? </s>
|
582 |
CC
|
Symptoms: Chest pain.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: He is maintained on Flonase and denies much in the way of nasal Symptoms.
|
<s>[INST] Guest_family: He is complaining of chest pain. [/INST] What is going on with him? </s>
|
8 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Complaint: History of inhalation and intravenous drug abuse, currently on methadone maintenance, followed for depression and substance abuse in Psychiatry, lives with a roommate
Plan of Action: N/A
|
<s>[INST] I am on treatment now. They are following me up for depression issues too. [/INST] When are you planning to quit your I V and inhalation drugs Mister X Y Z? </s><s>[INST] Yes. [/INST] Okay yes, you are on methadone maintenance. </s><s>[INST] I have a roommate. [/INST] Who lives with you? </s>
|
931 |
GENHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: patient had cardioversion for atrial fibrillation, taking Coumadin, history of smoking but quit several years ago, denies COPD or emphysema, no family members are sick
Plan of Action: N/A
|
<s>[INST] Guest_family: We're doing fine. I'm the mother of my four year old boy. [/INST] Hello. How are you all doing today? </s><s>[INST] Gest_family: We just wanted to follow up after my son's E R visit. [/INST] Hello, ma'am. What seems to be the problem? </s><s>[INST] Guest_family: He was playing at the park and thought it was a good idea to jump off the swing. Crazy kid, right? [/INST] Oh, no. What happened? </s><s>[INST] Guest_family: I gave it to the nurse. Did you not get it? [/INST] It happens. Live and you learn, as they say. Do you have any information from the E R visit. </s><s>[INST] Doctor: Could you read it to me, please? [/INST] Guest_clinician: Sorry. I got really busy, but here is the report. </s><s>[INST] Doctor: Are there any exams on the report? [/INST] Guest_clinician: Of course. So, their son severely injured his left distal humerus. No problems were claimed before the injury. The E R saw him for his deformed elbow. </s><s>[INST] Doctor: Thank you, nurse. Mom, were you there before his surgery? [/INST] Guest_clinician: There is an x ray and physical exam. They both confirmed a closed type three supracondylar fracture of his left distal humerus with severe puckering of the skin anteriorly with major ecchymosis in the same region. He did have a radial pulse palpable </s><s>[INST] Doctor: I see. What do you all identify as? [/INST] Guest_family: My husband and I were. My husband rushed from this cultural event he had planned. </s><s>[INST] Doctor: I see. I'm going to perform a neurological exam on your son now. Hi buddy. Is it fine if I do a quick exam? [/INST] Guest_family: We identify as white. </s><s>[INST] Doctor: Thanks. It'll be quick. [/INST] Patient: Sure. </s><s>[INST] Doctor: After doing the exam I see his ulnar, median, and radial nerves are intact. I couldn't do the entire exam because the pain might be too much for him. [/INST] Patient: Okay. </s><s>[INST] [/INST] Guest_family: Thank you so much for your help. </s>
|
116 |
ROS
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: Denies continuous ringing or thumping noises in ears, hearing problems, dizziness, or spinning sensation.
Plan of Action: N/A.
|
<s>[INST] No, nothing like that. [/INST] Lets talk about your ears. Any continuous ringing or thumping noises you may hear? </s><s>[INST] Um, no. [/INST] Any hearing problems? </s><s>[INST] Nope. [/INST] Any dizziness or spinning sensation? </s>
|
223 |
GENHX
|
Symptoms: numbness in right upper arm
Diagnosis: uterine papillary serous carcinoma
History of Patient: completed 6 cycles of carboplatin and Taxol, last chemo treatment on January 18th, 2008
Plan of Action: N/A
|
<s>[INST] Good morning, doctor. Sure, that's no problem. [/INST] Good morning, ma'am. I just need to confirm some information about you before we begin today. </s><s>[INST] Yes, that's right doctor. [/INST] Great, so you're sixty seven years old, and White, correct? </s><s>[INST] Um, I've had six, I'm here for a follow up today. [/INST] Thank you. Do you remember how many cycles of carboplatin and Taxol you've had for your cancer, ma'am? </s><s>[INST] Yes, I remember that. Can you remind me the full name of my cancer? [/INST] Yes, I see here that your last chemo treatment on January eighteenth two thousand eight. </s><s>[INST] Thank you, doctor. [/INST] It's a uterine papillary serous carcinoma. </s><s>[INST] Well, I just have some numbness in my right upper arm today. [/INST] Sure, do you have any problems today? </s><s>[INST] Well, no, not really. [/INST] Has this gotten worse recently? </s><s>[INST] No, there's no numbness there. [/INST] That's good. Do you feel this in your toes at all? </s><s>[INST] No, thankfully no. [/INST] Good, do you have any tingling or burning to speak of? </s>
|
380 |
ASSESSMENT
|
Symptoms: N/A.
Diagnosis: Refractory hypertension.
History of Patient: Patient has a history of refractory hypertension, with recent improvement in blood pressure readings. Missed appointment with internist at senior center, GFR below sixty percent.
Plan of Action: Reschedule appointment with internist at senior center.
|
<s>[INST] Yeah, I feel much better, I read about my condition and it is called something as um refraction or-- [/INST] I mean, I am so happy to see your report today, your blood pressure looks much better. That's amazing given your past few visits your B P was out of control and even with changing your medications we were having tough time bringing it down. </s><s>[INST] Oh yeah that! [/INST] Refractory hypertension. </s><s>[INST] Yes. [/INST] But the good news is that it is getting better. </s><s>[INST] Yes, I made an appointment last week, um, no week before that, but I completely forgot about it. [/INST] Last time we talked about seeing the internal medicine doctor there at your senior center, right? </s><s>[INST] Yes, I will do it today. [/INST] Hm, okay we need to reschedule that. </s><s>[INST] Okay, I will do that. Thank you! [/INST] Okay, your reports look fine. G F R is below sixty percent, that's a good sign. Overall, Miss K, you look better, but we need to reschedule your appointment with the Internist. That's kind of important. </s><s>[INST] [/INST] You are welcome. </s>
|
143 |
FAM/SOCHX
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
|
<s>[INST] I don't think so. My family has been pretty healthy. Both my parents died of old age. [/INST] Let's talk about your family history. Did anyone in your family have any medical issues that you were aware of? </s><s>[INST] I have one older brother. He's into weightlifting and all. I would say he's pretty healthy. [/INST] What about your siblings? Any kind of thyroid issue or diabetes or blood pressure issue there? </s>
|
1,057 |
PASTSURGICAL
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: No major surgeries except for prior cardiac catheterization.
Plan of Action: N/A
|
<s>[INST] Not too many, but a catheter was put in my heart. [/INST] Any major surgeries in the past? </s><s>[INST] Yep. [/INST] Oh, so cardiac catherization, correct? </s>
|
100 |
PASTMEDICALHX
|
Symptoms: N/A,
Diagnosis: N/A,
History of Patient: Hypertension, kidney problems, frequent urinary infections, severe aortic stenosis.,
Plan of Action: N/A.
|
<s>[INST] You mean my heart problem and things? [/INST] Can you tell me what problems you have had in the past. Or what medical issues are currently going on? </s><s>[INST] Okay, I have hypertension and kidney problems since many years. [/INST] Yes. </s><s>[INST] I get frequent urinary infections. [/INST] Okay. </s><s>[INST] Okay. I also have severe aortic stenosis. [/INST] Your urine creatinine is normal. </s>
|
684 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her.
Plan of Action: N/A
|
<s>[INST] Guest_family: We've been together for twenty seven years now. [/INST] So how long have you two been married? </s><s>[INST] Guest_family: We actually met in high school. We dated for some time and then we took a break, but we ultimately got back together. [/INST] Oh wow, that's so wonderful to hear. How did you guys meet? </s><s>[INST] Guest_family: Shoot. [/INST] Aw, high school sweethearts. I have a few more questions to ask. </s><s>[INST] Guest_family: She doesn't do any of that. [/INST] Any tobacco, hard drugs, or alcohol? </s><s>[INST] Guest_family: Nothing major. [/INST] Great. And do you know of any medical problems that run on her side of the family? </s><s>[INST] [/INST] I see. </s>
|
123 |
PASTMEDICALHX
|
Symptoms: Intense burning in throat after eating, especially junk food.
Diagnosis: Reflux disease, depression.
History of Patient: N/A.
Plan of Action: N/A.
|
<s>[INST] I feel an intense burning in my throat. [/INST] So, what stomach symptoms are you experiencing? </s><s>[INST] It really hurts after eating food, especially junk food. [/INST] When do you feel this? </s><s>[INST] Ah, yes. [/INST] That's pretty consistent with reflux disease. </s><s>[INST] Absolutely, please, what does it show. [/INST] I got your survey results back as well, let's discuss them. </s><s>[INST] [/INST] According to your answers, it looks like you have depression as well. </s>
|
755 |
PASTSURGICAL
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Bilateral tubal ligation in 2001, colon polyp removed at 14 years old
Plan of Action: N/A
|
<s>[INST] I had both my tubes tied in O one and I had a polyp removed when I was fourteen. [/INST] Have you undergone any surgeries? </s><s>[INST] Oh, sorry I didn't mean to interrupt. [/INST] And that was a- </s><s>[INST] Yes, it was. [/INST] It's alright. I just wanted to know if that polyp was found in your colon? </s>
|
110 |
GENHX
|
Symptoms: Fatigue, easy tiredness, blood in stool.
Diagnosis: Mild chronic graft-versus-host disease (GvHD), mild iron deficiency.
History of Patient: Received transplant approximately four and a half years ago, experienced rectal bleeding issues, underwent complete endoscopy revealing benign polyps which were removed.
Plan of Action: Addressing iron deficiency with patient.
|
<s>[INST] I've been better. Thank you. [/INST] Hi, how are you doing today? </s><s>[INST] That's right. I'm coming around between a month or two. [/INST] So, you are here for your follow up right? Remind me how often are you coming here? </s><s>[INST] I'm not taking any medicine now. I just wanted to let you know. [/INST] Yeah, it's every four to eight weeks. </s><s>[INST] I think it was around four and a half years ago. I'm feeling much better after that. I do have complaints of blood in my stool. But after you sent me to that doctor, that gastro doctor, I feel good. I know they said that they removed something, but I'm not sure, but after that it has been improved a lot. [/INST] Yeah, I can see it in your record. It says that you are off of all the immunosuppression. So, just let me check. It says here that you do have mild chronic G V H D. It is not that bad that I should be worried about any therapy or anything else. How long ago did you get that transplant? </s><s>[INST] Yeah, I agree. That was a relief. [/INST] Okay, let me see in my chart. You had some rectal bleeding issues because of which I referred you to the gastroenterologist. A complete endoscopy was performed, which was both on the upper and the lower side. There was no evidence of ulcers or any other abnormality. That's good news, right? </s><s>[INST] Yeah, I remember this said they removed something, but I forgot the name. [/INST] They did find some polyps and they removed it. They turned out to be benign, so nothing to worry about there. </s><s>[INST] I don't know. I feel a lot of fatigue and like I'm not able to do things like I used to do before. I get tired very easily. I don't know if it is related to something or not, but things have been weird. I'm not able to do even the minor things like I lift two boxes and I'm done for the day. Is it something that I should be worried about? [/INST] Is there any other issue that I can help you with? </s><s>[INST] [/INST] It looks like you have a mild iron deficiency. I will work on that with you, don't worry. </s>
|
1,127 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] What do you mean by that? [/INST] Any specific medical traits in the family? </s><s>[INST] I'm not aware of any such thing in my family. [/INST] I meant does anyone in your family or extended family have any medical problems that they were treated for? </s>
|
967 |
ROS
|
Symptoms: trouble breathing, dyspnea on exertion
Diagnosis: N/A
History of Patient: started experiencing trouble breathing two weeks ago, no other associated Symptoms
Plan of Action: N/A
|
<s>[INST] Doctor: I'm sorry to hear that. We'll get to the bottom of it. [/INST] Patient: Oh doc, I've had a lot of trouble breathing lately. </s><s>[INST] Doctor: When did you first start noticing this? [/INST] Patient: Yeah, I lose my breath so quickly with just one to two flights of stairs. </s><s>[INST] Doctor: Any chest pain or tightness with the shortness of breath? [/INST] Patient: I believe two weeks ago. </s><s>[INST] Doctor: Any fever, chills, or sweats? [/INST] Patient: No, thankfully. </s><s>[INST] Doctor: Any cough or coughing up blood? [/INST] Patient: No. </s><s>[INST] Doctor: How about wheezing or swelling in your legs? [/INST] Patient: No. </s><s>[INST] [/INST] Patient: No. </s>
|
36 |
GENHX
|
Symptoms: Increased shortness of breath, difficulty breathing, orthopnea (especially over the past few nights), mild increase in peripheral edema, active wheezing with dyspnea.
Diagnosis: N/A.
History of Patient: No chest discomfort, acute chest pain, dizziness, fainting, or lightheadedness reported. No signs of cardiovascular accident or heart attack.
Plan of Action: Treatment for mild peripheral edema needed.
|
<s>[INST] I am okay. [/INST] Hi there, how are you? </s><s>[INST] Thank you! [/INST] So, I see you turned eighty-eight yesterday, happy birthday! </s><s>[INST] Correct! I am also seeing Doctor Y for my leukemia. [/INST] And you are referred by Doctor X, he is your primary physician, right? </s><s>[INST] Yes. [/INST] Hm he mentioned that it's chronic lymphocytic leukemia. </s><s>[INST] Doctor: And you are also seeing Doctor Z for your heart related problems. [/INST] Okay. </s><s>[INST] Doctor: So, tell me what is happening with you? [/INST] Patient: That is correct. </s><s>[INST] Doctor: Okay. [/INST] Patient: For the past one week I am having this increased shortness of breath and having difficulty breathing from past few nights while sleeping. </s><s>[INST] Doctor: Let me examine you, can you come forward and sit-up here? Any chest discomfort or acute chest pain or anything of that sort? Any pain of the left arm? [/INST] Patient: And this morning I was having difficulty catching my breath. I am also having wheezing since morning. </s><s>[INST] Doctor: Any dizziness, feeling like fainting or light headedness or losing control? [/INST] Patient: No. </s><s>[INST] Doctor: Well, I don't think there is any sign of cardiovascular accident or heart attack, so that's that. You do have mild peripheral edema. We need to treat that. [/INST] Patient: No. </s><s>[INST] [/INST] Patient: Okay. </s>
|
16 |
ROS
|
Symptoms: Left hip pain, shoulder pain, leg swelling, vision problems, hearing problems, chronic depression
Diagnosis: N/A
History of Complaint: Denies urinary problems, abdominal pain, chest pain, shortness of breath, headache syndrome, thyroid dysfunction; presents with swelling in lower extremities
Plan of Action: N/A
|
<s>[INST] Currently I just have left hip pain and shoulder pain. [/INST] Just to go over few things let me ask, any aches and pains? </s><s>[INST] Pretty bad. [/INST] Oh, how bad is it? </s><s>[INST] I have this leg swelling from last couple weeks. [/INST] What else is going on? </s><s>[INST] No. [/INST] Any new skin lesions on your legs from the swelling? </s><s>[INST] No problems with urination. [/INST] How about problems with urination and abdominal pain? </s><s>[INST] No I don't have any such problems, except I have vision and hearing problems. [/INST] How about chest pain or shortness of breath or hormonal imbalances? </s><s>[INST] Yes that is correct. [/INST] You have chronic depression right? </s><s>[INST] No. [/INST] Any sort of headaches? </s><s>[INST] [/INST] What about thyroid dysfunction? </s>
|
92 |
PASTMEDICALHX
|
Symptoms: N/A
Diagnosis: N/A
History of Complaint: History of migraine
Plan of Action: N/A
|
<s>[INST] Yes, that's correct. [/INST] And you mentioned that you have a history of migraine? </s>
|
2 |
PASTMEDICALHX
|
Symptoms: N/A
Diagnosis: N/A
History of Complaint: Essentially unchanged medical history from visit on April 15, 2005
Plan of Action: N/A
|
<s>[INST] What do you mean by that? [/INST] Has anything changed in your medical history since you last visit on April fifteenth two thousand five? </s><s>[INST] Oh, no, nothing like that. [/INST] Have you been diagnosed with any new medical conditions, or are you experiencing any new symptoms? </s>
|
548 |
CC
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] Guest_family: Hi Doctor, I am his mom. [/INST] Oh, dear God! What happened? </s><s>[INST] Guest_family: He was trying to climb a tree, slipped from there and got a deep cut on his thigh. [/INST] Hello, so what happened? </s><s>[INST] Yes. [/INST] So, you fell from the tree? </s>
|
858 |
FAM/SOCHX
|
Symptoms: N/A,
Diagnosis: N/A,
History of Patient: heavy tobacco and alcohol abuse for many years, lives with boyfriend,
Plan of Action: N/A
|
<s>[INST] I stay nearby in my apartment. [/INST] So where do you stay? </s><s>[INST] No, I stay with my boyfriend. [/INST] Alone? </s><s>[INST] Both. [/INST] Okay, and do you smoke and drink? </s><s>[INST] Well, I smoke a lot. Seven to eight packs per day. [/INST] And how much would say you smoke per day? </s><s>[INST] I don't remember exactly but for many, many years, I have a long history of chain smoking. [/INST] Oh! And for how many years? </s><s>[INST] Same, I drink heavily. I have been drinking for many years. [/INST] Hm. And alcohol? </s><s>[INST] [/INST] Hm. </s>
|
917 |
GENHX
|
Symptoms: foreign body sensation in left eye, pain in left eye (progressively worsened), no blurred vision, no photophobia
Diagnosis: N/A
History of Patient: Symptoms started during work, attempted flushing with water but pain persisted and worsened
Plan of Action: N/A
|
<s>[INST] Yeah, my left eye. Never had this happen to me in my forty one years. [/INST] So it looks like you're here today for a noticeable foreign body sensation in your eye. </s><s>[INST] Um when I was at work this morning. It felt like something was in my eye. I went to the bathroom mirror to check it out, but didn't see anything. I flushed my eyes with water in hopes of it helping with the weird feeling. [/INST] First time for everything I guess! When did you first notice the sensation? </s><s>[INST] The pain has definitely gotten worse since this morning. My vision is fine and bright lights don't seem to be a problem. [/INST] Okay. Hm, are you experiencing any eye pain, blurred vision, or sensitivity to light? </s>
|
903 |
MEDICATIONS
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] Augmentin, Detroal LA and lisinopril. [/INST] What medications are you currently taking? </s>
|
302 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] No, no, and no. [/INST] How about any drugs, alcohol, or tobacco? </s>
|
289 |
PASTMEDICALHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Recurrent urinary tract infections, chronic incontinence, bladder atony, right-sided cerebrovascular accident (CVA), atrial fibrillation status post pacemaker, type 2 diabetes with neuropathy, pain on the right side from stroke, hypothyroidism
Plan of Action: N/A
|
<s>[INST] Sure. I just came into the hospital I think about three weeks back for recurrent urine infections. [/INST] Tell me about your past problems. </s><s>[INST] Yes that is why they put catheter in me. [/INST] Yes it says here that you have bladder problems from a long time, mostly related to tone and capacity. </s><s>[INST] Yes, because of my heart problems they had to put pacemaker in. [/INST] Okay and you have recently had right side C V A? </s><s>[INST] I have hereditary diabetes. [/INST] Okay. Good. </s><s>[INST] That's right. [/INST] Okay and your neural problem is associated to that as well. </s><s>[INST] Yes, because of my stroke. [/INST] You have pain on the right side now? </s><s>[INST] Yes, for my hypothyroidism. [/INST] And you take thyroid medications too? </s><s>[INST] Yeah. [/INST] Okay. </s><s>[INST] I have had many surgeries. They took out my gall bladder, then colon cancer surgery was in nineteen ninety eight. [/INST] What surgeries have you had in the past? </s><s>[INST] Yes, that is correct. [/INST] And now pacemaker placement, right? </s>
|
947 |
CC
|
Symptoms: tiredness, weakness, dark urine
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] I have not been feeling well. I am tired and feel weak. [/INST] Hi there! What brings you in today? </s><s>[INST] I noticed after I went to the bathroom this morning, that my urine was dark. [/INST] Have you had any other symptoms? </s><s>[INST] Yes. [/INST] Have you been staying hydrated? </s><s>[INST] Okay. [/INST] Lets get a urine sample. I will have the nurse come in with a sample cup. </s>
|
767 |
ASSESSMENT
|
Symptoms: N/A
Diagnosis: Diabetes type II uncontrolled, acute cystitis
History of Patient: N/A
Plan of Action: Change diabetes medication, start antibiotic for acute cystitis, advise patient to watch diet, stay hydrated, and take medications
|
<s>[INST] I kind of knew it was a U T I. I have had it before, but nothing this painful and severe. I feel like I am going to die! [/INST] Alright, I am looking at your urine report and it confirms what I was suspecting. You have a urinary tract infection. </s><s>[INST] Well, is it because of my diabetes? [/INST] Oh yes, it is because you got something called as acute cystitis and its usually very painful and can cause some serious complications. </s><s>[INST] Yes! [/INST] I am afraid I don't have better news for you, but your diabetes is out of control. It's way too high and you must be really careful. Are you taking your medicines? </s><s>[INST] Yeah, sometimes I don't care about my diet. [/INST] How bout diet? </s><s>[INST] Alright, thank you! [/INST] Well, you must watch your diet, you can't just be careless. I am going to change your diabetes medication. And let's start you on the antibiotic that should give you relief. Also stay hydrated drink plenty of fluids it will help you flush the infection out. </s><s>[INST] [/INST] Take care. </s>
|
879 |
ALLERGY
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] No, thankfully. [/INST] Have you had any adverse reactions to medications you've taken in the past? </s>
|
10 |
GENHX
|
Symptoms: Worsening bunion deformity.
Diagnosis: N/A.
History of Patient: History of Charcot-Marie-Tooth disease. Desires surgical treatment for bunion deformity.
Plan of Action: N/A.
|
<s>[INST] Good afternoon, doctor. Absolutely, that's no problem. [/INST] Good afternoon, ma'am. Welcome to A B C D General Hospital. Before we begin, I just need to confirm some background information on you. </s><s>[INST] I'm nineteen, sir. [/INST] First, how old are you? </s><s>[INST] Yes, sir, that's correct. [/INST] Good, and your chart says you identify as Caucasian. Is that correct? </s><s>[INST] I've had this bunion on my foot for such a long time. [/INST] Great, what seems to be problem today, ma'am? </s><s>[INST] At this point, um, I don't even remember how long it's been. [/INST] How long has this bunion been present? </s><s>[INST] Actually, yes. I have a history of, um, Charcot Marie tooth disease. [/INST] Do you have any other conditions that I should be aware of? </s><s>[INST] I would like to have surgery to cut this bunion off, I can't take it anymore. [/INST] That's good to know, thank you. </s>
|
511 |
PASTMEDICALHX
|
Symptoms: N/A.
Diagnosis: N/A.
History of Patient: N/A.
Plan of Action: N/A.
|
<s>[INST] No, not that I can think of. [/INST] Do you have any chronic conditions I should know about, sir? </s><s>[INST] Yes, I have. I've broken my hand and tibia before. [/INST] What about injuries, have you ever broken a bone? </s>
|
636 |
GENHX
|
Symptoms: headache, lower back pain, neck pain
Diagnosis: N/A
History of Patient: Motor vehicle accident on January fifteenth, 2001, patient was driving a small sports car, collision occurred when another car hit patient's car from the left side, patient was wearing a seatbelt, impact forced patient's car off the road into a utility pole, other driver was drunk and ran a traffic signal, estimated impact speed was 80 miles per hour, patient briefly lost consciousness at the scene, patient was able to exit the vehicle and was transported to St. Thomas Memorial Hospital by Rescue Squad, evaluated in the emergency room and later discharged
Plan of Action: N/A
|
<s>[INST] Doctor: What kind of car were you driving that night? [/INST] Patient: Man, what a night. </s><s>[INST] Doctor: I'm so sorry to hear that. I'm glad that you are here in one piece. Were you wearing your seatbelt? [/INST] Patient: I was driving my small sports car through an intersection when another car hit me from the left side. The impact forced my car off the road and into a utility pole. </s><s>[INST] Doctor: Good. [/INST] Patient: Yeah, I had my belt on and everything. </s><s>[INST] Doctor: That's such a shame. Do you remember how fast the car was going when it collided into you? [/INST] Patient: Unfortunately, the driver was drunk and ran a traffic signal. </s><s>[INST] Doctor: Did you lose consciousness at all? [/INST] Patient: If I had to guess maybe eighty miles per hour. It looks like the driver who hit me was already cited by police. </s><s>[INST] Doctor: Did you get out of the car by yourself? [/INST] Patient: Yeah, I briefly lost consciousness when help arrived at the scene. I felt an immediate headache when I regained consciousness. I also had lower back and neck pain. </s><s>[INST] Doctor: This was on January fifteenth, correct? [/INST] Patient: Yeah, I got out by myself. Once I made it out, the Rescue Squad drove me to Saint Thomas Memorial Hospital. I was seen in the emergency room and later discharged. </s><s>[INST] [/INST] Patient: Yessir. </s>
|
796 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Retired on disability due to knee replacements, no history of smoking, alcohol consumption, or illegal drug use
Plan of Action: N/A
|
<s>[INST] I'm doing just fine. [/INST] How are you doing today, ma'am? </s><s>[INST] Nope. [/INST] Any kind of alcohol consumption? </s><s>[INST] Nope. [/INST] Have you ever taken any kind of illegal drugs? </s><s>[INST] No. [/INST] What about smoking? </s><s>[INST] No, sir. I had issues with my knees, and they had to put in the new ones. I was kind of disabled and that's why I retired. [/INST] Are you still working? </s>
|
969 |
GENHX
|
Symptoms: fell off a swing, pain in left elbow, burning or tingling feelings in left arm
Diagnosis: incarcerated medial epicondyle fracture, mildly angulated radial shaft break
History of Patient: fell off swing at school, initially seen at Urgent Care with attempted closed reduction, increased ulnar paresthesias post-procedure
Plan of Action: urgent open reduction and internal fixation to relieve pressure on ulnar nerve, reduce radial shaft fracture, explained risks of surgery including anesthesia, infection, bleeding, changes in sensation and motion, hardware failure, need for later hardware removal, and possible continuous nerve Symptoms, father agreed to surgery
|
<s>[INST] Guest_family: Good afternoon, doctor. It's my daughter today. [/INST] Good afternoon, who's the victim today, sir? Is it you, or your daughter? </s><s>[INST] I'm thirteen, sir. [/INST] Remind me, how old is she? </s><s>[INST] Yeah, I fell off the swing at school earlier this afternoon at about one thirty. [/INST] So, what happened? My nurses tell me she fell today. </s><s>[INST] It's really bad here on my left elbow. [/INST] Where does it hurt, young lady? </s><s>[INST] I use my right hand for everything, thank goodness for that. [/INST] Which hand do you write with? </s><s>[INST] Guest_family: Yeah, we went to an Urgent Care and she had an x ray there. [/INST] Before seeing me, have you seen anyone else? </s><s>[INST] Guest_family: They said her arm was broken, and they tried to do a reduction. [/INST] What else did they do? </s><s>[INST] Guest_family: Yeah, I have them right here, take a look, please. [/INST] Do you have those x rays with you right now? </s><s>[INST] What does that mean? [/INST] Well, these x rays show an incarcerated medial epicondyle fracture, as well as a mildly angulated radial shaft break. </s><s>[INST] Yes, I do. [/INST] Well, in short, you broke the inside part of your elbow. In addition to the pain, do you have any burning or tingling feelings in that arm? </s><s>[INST] No, I didn't, this is new. [/INST] Did you have this before they tried to do a reduction? </s><s>[INST] Yes, it is. [/INST] Is this feeling getting worse? </s><s>[INST] Guest_family: What should we do? [/INST] Okay, guys, there is a lot of pressure on that ulnar nerve because of the break and the attempted reduction. </s><s>[INST] Guest_family: O R I F? What's that [/INST] We need to do an O R I F procedure A S A P. I'll reduce that radial shaft fracture at the same time. </s><s>[INST] Guest_family: Will this not heal on its own? [/INST] I'll put some pins in the elbow, in order to stabilize the break, and we can start the healing process. </s><s>[INST] Guest_family: Okay, what are the risks of infection with the surgery? [/INST] No, we need to do the surgery. </s><s>[INST] Guest_family: How is this possible? [/INST] Historically, its less than one percent. </s><s>[INST] Guest_family: Will she be asleep for this? [/INST] We use prophylactic antibiotics, this helps us control for infection the entire time. </s><s>[INST] Guest_family: Will she need this hardware taken out in the future? [/INST] Yes, she won't feel a thing. </s><s>[INST] Guest_family: Okay, yes, we'd like to do the surgery. [/INST] Yes, in about a year or two, after everything is healed up nicely. The other risks include bleeding, changes in sensation and motion of the extremity, and hardware failure. I see good results from my surgeries so I would not worry about these things, but I must disclose. </s>
|
1,185 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Positive for heart disease, hypertension, and cerebrovascular accidents. Family history is positive for colon cancer affecting her father and a brother. The patient has a daughter who was diagnosed with breast cancer at age 40.
Plan of Action: N/A
|
<s>[INST] Hm, well both my father and my brother had colon cancer. My daughter was detected with breast cancer. [/INST] Let's talk about your family's medical history. </s><s>[INST] Yeah, she was forty. [/INST] Do you remember what her age was? </s><s>[INST] Well, I have a heart condition and high blood pressure. I also had a stroke. [/INST] I see. Anything else? </s><s>[INST] [/INST] Okay. </s>
|
731 |
CC
|
Symptoms: Nausea, feeling faint
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] I have bad nausea. [/INST] I am okay. </s><s>[INST] And I feel very dizzy like I am going to faint. [/INST] Oh, so sorry. </s><s>[INST] Okay. [/INST] Okay let me see what is going on. </s>
|
737 |
GENHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Brother is a vegetarian with elevated cholesterol, on medication to control it; improved diet after receiving letter about elevated lipids, eliminating foods like cappuccino, quiche, crescents, candy from vending machines; packing lunch 3-4 times per week instead of eating out; exercising 6-7 days per week (swimming, biking, running, weightlifting) for 1.5-2.5 hours each session; training for a triathlon; losing weight
Plan of Action: N/A
|
<s>[INST] Guest_family: Today, it's my brother. [/INST] Who's my patient today? </s><s>[INST] Guest_family: Well, he's a vegetarian but he has high cholesterol and he's on a medication to control it. [/INST] What seems to be the problem today? </s><s>[INST] Guest_family: Yes, he did when he got a letter saying that his fat levels were high in the blood. [/INST] Has he changed his diet? </s><s>[INST] Oh, you know, all of the fun ones. Like cappuccino, quiche, crescents, candy, vending machines, all of that stuff. [/INST] What kinds of foods did he eliminate? </s><s>[INST] Yes, I do about three or four times a week instead of eating out so much. [/INST] Do you take your lunch to work? </s><s>[INST] Yes, I do about six or seven days a week. [/INST] Are you exercising right now? </s><s>[INST] Well, I do just about everything. I swim, I bike, run and then I lift weights. [/INST] What kind do you like to do? </s><s>[INST] Usually, it's about one and a half to two and a half hours every day. [/INST] How long do you workout per day? </s><s>[INST] Actually, yes I'm going to do a triathlon. [/INST] Good, are you training for anything specific? </s><s>[INST] Yes, I am. [/INST] Can I assume you're losing weight? </s>
|
222 |
CC
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Possible exposure to ant bait with Borax, further assessment needed
|
<s>[INST] Guest_family: I think my baby got into the ant bait. I am not sure if he consumed any of it but he was under the counter and it was in his hands. [/INST] Hi there! What brings you in today? </s><s>[INST] Guest_family: It was the one with Borax in it. [/INST] What kind ant bait did he get into? </s><s>[INST] Guest_family: Yes. It is in my phone. [/INST] Do you have a picture of it? </s>
|
659 |
PASTSURGICAL
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] No, none. [/INST] Do you have any history of surgical procedures? </s>
|
331 |
CC
|
Symptoms: swelling in legs
Diagnosis: N/A
History of Patient: N/A
Plan of Action: N/A
|
<s>[INST] I am not so good. [/INST] Hello, how are you? </s><s>[INST] Well, I have lot of swelling in my legs. [/INST] Oh, what is going on with you? </s><s>[INST] [/INST] Hm, okay. </s>
|
1,192 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: The patient works at a local Christmas tree farm. He smokes cigarettes approximately one pack per day.
Plan of Action: N/A
|
<s>[INST] Yes I do smoke. Do you? [/INST] Hey, do you smoke cigarettes? </s><s>[INST] No, I just smoke one pack per day, it's not bad. [/INST] Nope. Are you planning on quitting? </s><s>[INST] Okay I will think about it. [/INST] Oh my God. No. It is bad. You should think about quitting. </s><s>[INST] I work at local christmas tree farm. [/INST] Where do you work? </s>
|
1,012 |
PASTMEDICALHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Significant for hypertension, asthma, and cervical cancer diagnosed at 15 years old. Patient describes the cervical cancer as "dormant."
Plan of Action: N/A
|
<s>[INST] Um, I have high blood pressure, and asthma. [/INST] Do you have any medical conditions that I should know about? </s><s>[INST] Yeah, I got diagnosed at fifteen years old. [/INST] I also see here that you have cervical cancer, can you tell me more about that? </s><s>[INST] Now, um, I'd say it's dormant. [/INST] How would you describe the progression of your cancer? </s>
|
179 |
CC
|
Symptoms: pain in the left side
Diagnosis: kidney stone stuck in the left ureter
History of Patient: N/A
Plan of Action: discuss treatment options
|
<s>[INST] Thank you. [/INST] Hi there! Welcome to the clinic. </s><s>[INST] I am in a great deal of pain. It is coming from my left side right here. [/INST] Doctor Murphy sent your records over. I reviewed the ultrasound, and we did find a kidney stone that has become stuck in the ureter on the left side. The stone is large enough to block the flow of urine from the kidney to the bladder. How much pain are you having and where is the pain located? </s><s>[INST] Okay. [/INST] Okay. Let use discuss your treatment options. </s>
|
1,010 |
ASSESSMENT
|
Symptoms: N/A
Diagnosis: Infected foreign body, right naris, Mild constipation
History of Patient: 1. Infected foreign body, right naris. 2. Mild constipation.
Plan of Action: N/A
|
<s>[INST] Doctor: Yeah so, we call it foreign body impaction. It is mostly affecting his right nostril and as you said there is constipation. [/INST] Guest_family: So apart from constipation what is his problem? What is up with his lungs? </s>
|
15 |
CC
|
Symptoms: N/A
Diagnosis: N/A
History of Complaint: N/A
Plan of Action: N/A
|
<s>[INST] No, I just came in for follow up. [/INST] Hi, how can I help? </s><s>[INST] Nope. Nothing. [/INST] Okay so just a follow up today. No complaints? </s><s>[INST] [/INST] That's great. </s>
|
185 |
ROS
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: N/A
Plan of Action: Negative rash, negative jaundice
|
<s>[INST] Um, no. [/INST] Have you ever had jaundice? </s><s>[INST] Nope. [/INST] Any rash or anything? </s>
|
1,047 |
FAM/SOCHX
|
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
|
<s>[INST] Yes! [/INST] Do you smoke? </s><s>[INST] Yes, I do. [/INST] How about alcohol, do you drink? </s><s>[INST] Well, I love my wine, I drink about four to five glasses per day. [/INST] And how much do you drink and is it occasional or on daily basis? </s><s>[INST] [/INST] Wow! That's a lot. </s>
|
928 |
FAM/SOCHX
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Denies tobacco, alcohol, or illicit drug use
Plan of Action: N/A
|
<s>[INST] No, sir, I don't. [/INST] Hi, do you smoke? </s><s>[INST] No. [/INST] Do you take any drugs? </s><s>[INST] No, none of those. [/INST] What about drinks? Do you take alcohol in any form? </s>
|
741 |
MEDICATIONS
|
Symptoms: N/A
Diagnosis: N/A
History of Patient: Taking Toprol and Avalide for hypertension and anxiety
Plan of Action: N/A
|
<s>[INST] Yeah, I started taking Toprol and uh the one that starts with an A. I forget what it's called. [/INST] Have you been taking anything for high blood pressure? </s><s>[INST] Oh right, yeah that's the one. [/INST] Hm are you talking about Avalide? </s>
|
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