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PLAN

Symptoms: N/A Diagnosis: N/A History of Complaint: N/A Plan of Action: Daily application of Acticoat dressing, pressure relief by spending at least 8 hours out of the chair, follow-up appointment in one week

<s>[INST] That sounds doable. I'll try my best. No questions about the plan. [/INST] Okay, so let's go over the plan again. I'd like you to apply Acticoat dressing daily and make sure you're spending at least eight hours out of the chair for pressure relief. Any questions? </s><s>[INST] Can I make that appointment today? [/INST] I'd also like you to come back in a week for a reevaluation. </s><s>[INST] Great. [/INST] Yes, the receptionist will be able to get you on the schedule for next week. </s>

EXAM

Symptoms: N/A Diagnosis: N/A History of Patient: Alert, no distress, calm, cooperative, communicative Plan of Action: N/A.

<s>[INST] Guest_clinician: She was brought to emergency by her son. Apparently, she is doing fine, no distress. She is alert, and I was able to communicate with her and take her history, she was cooperative and calmy responded to all my questions. [/INST] What happened? </s><s>[INST] [/INST] Okay, that's good. </s>

CC

Symptoms: itchy rash Diagnosis: N/A History of Patient: N/A Plan of Action: N/A

<s>[INST] Not long. Less than a day if I had to guess. [/INST] How long have you had this rash? </s><s>[INST] No, it's just really itchy. I tried applying Cortisone to it, but it didn't help much. [/INST] Is it causing you any pain? </s><s>[INST] Yeah. I've only noticed it on my left arm. [/INST] Is the rash localized to the left arm? </s>

PASTMEDICALHX

Symptoms: pale appearance, fatigue Diagnosis: N/A History of Patient: N/A Plan of Action: N/A

<s>[INST] Yeah, yeah, I am fine. [/INST] Are you okay? </s><s>[INST] No I am okay. I have always been healthy my whole life. Just a little fatigued now. [/INST] I am asking this as you look a little pale. </s><s>[INST] Yeah, but I am okay. [/INST] Okay that won't be something we can't fix. </s><s>[INST] As I said, I am healthy. [/INST] Yes, I do not see any issues with your past history. </s>

ROS

Symptoms: Negative chest pain, negative dyspnea on exertion, negative palpitations, negative edema Diagnosis: N/A History of Patient: No history of heart attack, no history of arrhythmias, no history of hypertension Plan of Action: N/A

<s>[INST] No. [/INST] Any history of heart attack? </s><s>[INST] No. [/INST] Any chest pain, palpitations or shortness of breath on exertion? </s><s>[INST] It's normal. [/INST] How about your blood pressure? </s><s>[INST] No. [/INST] Any swelling? </s><s>[INST] No. [/INST] Any history of irregular heartbeats? </s>

GENHX

Symptoms: not feeling full, increased hunger at night Diagnosis: N/A History of Patient: status post lap band placement in 01/09, previous problems with adjustments, recent car accident Plan of Action: band adjustment

<s>[INST] Thank you, doctor. [/INST] Welcome back in, Miss A. </s><s>[INST] No, not really. Can you remind me? [/INST] Do you remember the information about your operation? </s><s>[INST] Thank you. [/INST] Sure, you had a lap band replacement in January of O nine, and you had a band adjustment. </s><s>[INST] Well, I've been under a lot of stress lately, and I had problems with my adjustments before. [/INST] How are you feeling today? </s><s>[INST] Actually, doctor, I was in a car accident a couple weeks ago, and I'm having problems. [/INST] Has anything changed since the operation? </s><s>[INST] I don't feel full. [/INST] What symptoms are you experiencing? </s><s>[INST] I'm not really hungry, but I also don't feel full. When I get hungry at night I can't wait until the morning to eat. I get so hungry. [/INST] How is your appetite? </s><s>[INST] Yeah, I usually have a candy bar, and that helps some. [/INST] Do you eat anything when you feel like this? </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: former heavy smoker (2 packs per day), quit 2 years ago, former heavy alcohol use (6 packs of beer plus 2 drinks per day), has been dry for 2 years, denies illicit drug use Plan of Action: N/A

<s>[INST] Yeah, I quit two years ago. But before that I used to smoke two packs per day. I first started smoking as a teenager. [/INST] Do you smoke, or have you smoked in the past? </s><s>[INST] I used to drink six packs of beer plus two additional drinks a day for many years. Good news is that I've been dry for two years now. [/INST] Do you drink at all? </s><s>[INST] No none of that. [/INST] Any illicit drug use, such as cocaine, marijuana or heroin? </s>

GENHX

Symptoms: cough (dry sounding), pain on the right side of abdomen, body aches, nausea, fever (chilled with warm forehead) Diagnosis: N/A History of Patient: Symptoms present for two days, abdominal pain occurs during coughing episodes Plan of Action: N/A

<s>[INST] I have high blood pressure and macular deterioration. Last year I caught pneumonia but that has cleared up. [/INST] Welcome into the clinic! I would like to start with your past medical history. </s><s>[INST] I have had this cough and pain on the right side of my abdomen. [/INST] Okay. What brings you in today? </s><s>[INST] Two days. I have had body aches and have been feeling nauseous too. [/INST] How long has this been going on? </s><s>[INST] I think so. I was chilled and my forehead was warm. The cough is a dry sounding cough. [/INST] Have you had a fever? </s><s>[INST] Yes. [/INST] Does the abdominal pain come during one of these coughing episodes? </s>

ASSESSMENT

Symptoms: Improved right arm Symptoms, subtle tremor. Diagnosis: Hypertension, depression (improved with Lexapro), osteoporosis, osteoarthritis. History of Patient: Right arm Symptoms resolved, depression possibly improved with Lexapro (full dosage started about a week ago), occasional non-daily intake of Lexapro, subtle tremor observed. Plan of Action: Monitor blood pressure, continue Lexapro at full dosage daily, monitor for worsening joint or bone pain related to osteoporosis and osteoarthritis.

<s>[INST] My arm is all better. It is not in pain at all anymore. [/INST] It is nice to see you again, miss. We are following up on a few things today. How is your arm feeling? </s><s>[INST] It's helping a little bit. [/INST] How has your mood been? Are you feeling any relief from your symptoms since you have been on the Lexapro? </s><s>[INST] I am taking ten M G. [/INST] How much Lexapro are you taking now? </s><s>[INST] About a week ago. I don't take it every day. I don't feel like I need it some days. [/INST] How long have you been taking the full dosage? </s><s>[INST] Okay. [/INST] I want you to take the full dosage every day. This might be why you have not had much relief with your symptoms yet. </s><s>[INST] I didn't even notice. [/INST] Your hands are a little shaky. Is this a normal occurrence for you? </s><s>[INST] No. [/INST] It is very subtle. We will keep an eye on it for now. Your blood pressure is a little better today. Have you experienced any worsening joint or bone pain? I want to check on your osteoporosis and osteoarthritis. </s>

PASTSURGICAL

Symptoms: N/A Diagnosis: N/A History of Patient: Vasectomy. Plan of Action: N/A

<s>[INST] Good morning, doctor. [/INST] Good morning, sir. </s><s>[INST] Yes, I had a vasectomy some time ago. [/INST] Before we begin, have you ever had surgery? </s>

PASTSURGICAL

Symptoms: N/A Diagnosis: N/A History of Patient: negative for any surgery Plan of Action: N/A

<s>[INST] No. [/INST] Did you ever have any surgery? </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: No known exposures. Married with 2 children. Patient is born and raised in Oklahoma. Plan of Action: N/A

<s>[INST] Not too bad, can't complain. [/INST] Hi, how's it going? </s><s>[INST] Yeah, I can't wait to spend some time with my kids this afternoon. [/INST] It looks like the weather's been warming up, which is nice. </s><s>[INST] Two. [/INST] Aw, how many kids do you have? </s><s>[INST] I've been married to my wife for about ten years now. [/INST] And are you single, dating, married? </s><s>[INST] Hah, it sure is. [/INST] Congratulations! That's a decade, my friend. </s><s>[INST] I was actually born in Oklahoma. [/INST] Are you from the area? </s><s>[INST] Moved up here in O seven. [/INST] How long- </s><s>[INST] No way! How funny. Where from? [/INST] Awesome. I moved here in O nine, so two years after you. </s><s>[INST] No to all of the above. [/INST] I'm originally from Kentucky. And I have to do the routine ask, but any drinking, smoking, or illicit drug use? </s><s>[INST] [/INST] Got it. </s>

PASTMEDICALHX

Symptoms: N/A Diagnosis: N/A History of Patient: significant history of alcohol abuse Plan of Action: N/A

<s>[INST] Doctor: I tried but was unsuccessful. She's very out of it. [/INST] Guest_clinician: Were you able to get a history from her? </s><s>[INST] Doctor: According to her records, she has a long history of alcohol abuse. [/INST] Guest_clinician: Does she have a history of alcohol abuse? </s>

PASTMEDICALHX

Symptoms: N/A. Diagnosis: N/A. History of Patient: Patient's medical history includes hypertension, dementia (diagnosed six months ago), urinary incontinence, chronic back pain (present for several years), and degenerative changes to the spine. Plan Of Action: N/A.

<s>[INST] Guest_family: Sure. It's a bit long, sadly. [/INST] Can you give me a quick run down of her medical history? </s><s>[INST] Guest_family: She was recently diagnosed with dementia. She's also suffered from high blood pressure for some time now. [/INST] I'm sorry to hear that. </s><s>[INST] Guest_family: Six months ago. [/INST] When was she diagnosed with dementia? </s><s>[INST] Guest_family: No, but she's not able to control her bladder well which leads to her having frequent accidents. Oh and she's had back pain for several years along with degenerative changes to her spine. Poor thing. I can't help but feel so bad for her situation. It definitely hasn't been easy. [/INST] Any history of heart disease, diabetes, or stroke? </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: father passed away at 81, mother had multiple myeloma and passed away at 83 Plan of Action: N/A

<s>[INST] My mother had cancer. She had multiple myeloma. She passed away at age eighty three. My dad died when he was eighty one. [/INST] What is your family medical history? </s>

GENHX

Symptoms: severe headaches, worsening with coughing, straining, sneezing, standing up, relieved when lying down, constant pain with intensity in forehead, ringing in ears, blurry vision, dimming lights Diagnosis: history of Codman-Hakim shunt set at 90 mmH2O, chronic headaches, depression History of Patient: acute onset of headaches after shunt adjustment following MRI on April 18th, 2008, poor sleep due to headaches, tried Imitrex and Motrin 800 mg twice a day without relief, scheduled follow-up with Dr. Y for headache management Plan of Action: N/A

<s>[INST] Guest_clinician: Patient has been cared by Doctor X since two thousand and two. She had a Codman Hakim shunt set at ninety M M H two O. She last came to our clinic in January two thousand and eight. At that time, she was recommended to follow up with Doctor Y for the medical management of her chronic headaches. She was also recommended to see a psychiatrist for her depression. [/INST] Hello today I have my assistant with me, and she will be representing your case. Tell me who do we have today? </s><s>[INST] I did. It was okay. [/INST] Did you go and see a psychiatrist? </s><s>[INST] My headaches are back. They are very severe this time. It all happened that, after that scan. [/INST] What brings you here today? </s><s>[INST] Guest_clinician: She had her stunt adjusted which was after the M R I on April eighteenth. [/INST] When did she have her scan? </s><s>[INST] Doctor: Are you able to sleep in the night properly? [/INST] Patient: Yes, and after that I'm having these very bad headaches. </s><s>[INST] Doctor: Is there anything that elevates this pain? Or decreases it? [/INST] Patient: No, these headaches wake me up in the night. I haven't had a proper sleep in like ages. </s><s>[INST] Doctor: Is it like specific to any particular area of your head? [/INST] Patient: Everything seems like increasing it. It just gets worse with coughing, straining, sneezing, even when I'm trying to stand. I tried all the medications, but nothing is helpful. There was Imitrex and I also tried Motrin eight hundred M G twice a day, but nothing seems to be like effective. Actually, it helps a bit when I lie down. </s><s>[INST] Doctor: Is there any nausea associated with the headaches? [/INST] Patient: It is like all over but, uh, very much intense in the forehead. </s><s>[INST] Doctor: Anything else that happens along with these headaches? [/INST] Patient: No. </s><s>[INST] Doctor: Any changes in your vision? [/INST] Patient: Yeah, I get that ringing sound in my ears, and I just don't feel well. </s><s>[INST] Doctor: Any other thing you want to add? [/INST] Patient: Yeah, it gets blurry, and I feel like lights are dimming. I will be meeting Doctor Y tomorrow. </s><s>[INST] [/INST] Patient: No, that's it. </s>

MEDICATIONS

Symptoms: N/A Diagnosis: N/A History of Patient: N/A Plan of Action: Tylenol for pain.

<s>[INST] Just Tylenol for my pain. [/INST] Are you taking any medicines? </s><s>[INST] [/INST] Okay. </s>

GENHX

Symptoms: Swelling in the left leg, swelling in the right leg to a lesser extent, pain and loss of mobility in the left shoulder, low back pain, increased frequency of urination, nocturia, weight gain, shortness of breath. Diagnosis: Elevated white count, leukocytosis. History of Patient: The patient, a 44-year-old white female, presents with swelling in her left leg for the past three years, worsening over the past two to three months. The swelling improves in the morning but worsens throughout the day, causing discomfort. Her right leg also swells, though not as severely. She also complains of pain and decreased mobility in her left shoulder, with associated low back pain. She denies any history of shoulder injury but has experienced gradual loss of strength and mobility over the past year. She reports increased frequency of urination and nocturia, along with weight gain of approximately 12 pounds since March, currently weighing 284 pounds. She notes stable blood pressure, takes Atenolol 12.5 mg daily, and Lasix as needed but dislikes it due to increased urination. She denies chest pain but reports gradually increasing shortness of breath. She works as a bus dispatcher for the city of Wichita, involving prolonged sitting, which exacerbates leg swelling towards the end of the day. Laboratory findings show an elevated white count, with previous consultations regarding leukocytosis deemed non-problematic. The patient requests a cholesterol check. Plan of Action: Further evaluation and management of leg swelling, left shoulder pain, leukocytosis, increased urinary frequency, and weight gain. Cholesterol check warranted.

<s>[INST] Yes sure. I got this swelling for almost three years now, and it has been worse for the past two to three months. Sometimes it gets better in the morning when I get up, but then throughout the day it begins to swell again. Lately it is staying bigger, and it feel uncomfortable with it being so large. The right leg also swells, but not nearly like the left leg. [/INST] Okay I am looking at you for multiple issues today. One of the biggest being swelling on your left leg. Can you tell me more about that? </s><s>[INST] I am forty four. My biggest problem is this pain in my left shoulder. I feel as if this low back pain is due to a poor mattress. [/INST] How old are you, miss? </s><s>[INST] No, I don't remember hurting shoulder, but gradually I am losing some mobility. It is hard for me to get my hands behind my back or behind my head. I am losing strength in the left shoulder gradually for the last year. [/INST] Did you hurt your shoulder? </s><s>[INST] So far white counts are high. In April two thousand five Doctor X Y Z was asked to look at my high white count, but she thought it wasn't a problem and asked me to come for follow up. [/INST] Ok let's look at your labs. </s><s>[INST] I have a lot of frequency with urination, and I get up to pee at night at least two to three times. Also, I have gained weight, I think about twelve pounds since March. Right now, I am two eighty four pounds. [/INST] Any other complaints? </s><s>[INST] Yes, that's correct. It makes me pee so much. I do not take it. [/INST] Okay. So, I can see that your blood pressure is staying stable. You do take Atenolol twelve point five M G per day and Lasix as needed. </s><s>[INST] No chest pain, but I am gradually feeling short of breath. [/INST] How about chest pain or shortness of breath? </s><s>[INST] I work for the city of Wichita as bus dispatcher. My work demands sitting a lot, and just really does not move around much. But towards the end of the day my leg swells up. [/INST] What work you do? </s><s>[INST] I need cholesterol check right? [/INST] Okay that's okay. </s><s>[INST] [/INST] Yes, you do, but all the other labs are normal. </s>

DISPOSITION

Symptoms: Patient reports feeling fair, with slow improvement. Diagnosis: N/A. History of Patient: Patient received treatment and is experiencing gradual improvement. Plan of Action: Continue monitoring patient's progress.

<s>[INST] I am feeling pretty fair, improving slowly. [/INST] How are feeling now after the treatment? </s><s>[INST] Okay. [/INST] Okay? </s>

GENHX

Symptoms: left knee pain, locking of knee, inability to fully extend knee, pain on attempted extension Diagnosis: N/A History of Patient: Symptoms started 2 years ago after MCL sprain during hockey, no instability reported Plan of Action: N/A

<s>[INST] Good morning, doctor. I'm forty one. [/INST] Good morning, sir. Before we begin, how old are you? </s><s>[INST] It's been about two years now. [/INST] Thank you, and how long have you had this left knee pain? </s><s>[INST] Yeah, I sprained my MCL while playing hockey back then. [/INST] Is there an injury? </s><s>[INST] Well, the knee locks up on me, I can't extend it all the way, and it just hurts really bad if I try to. [/INST] What kind of symptoms have you had in this knee since then? </s><s>[INST] No, not at all. [/INST] Do you feel any instability? </s>

ALLERGY

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

<s>[INST] Oh yes, I cannot take Sulfa drugs. [/INST] Any known allergies? </s><s>[INST] [/INST] Let me add that to your record. </s>

FAM/SOCHX

Symptoms: N/A. Diagnosis: N/A. History of Patient: Mother passed away from cancer (specific type unknown), father died from a heart attack. Patient moved from another country long ago and lacks medical records. Plan of Action: N/A.

<s>[INST] Hm, my mother passed away due to cancer. [/INST] So, tell me about your family's medical history. </s><s>[INST] Actually, I don't know that. [/INST] Oh, what type? </s><s>[INST] And my dad died due to heart attack. [/INST] Okay. </s><s>[INST] Yeah. [/INST] Oh. </s><s>[INST] No, I don't have it. I moved here from a different country a long time ago with barely anything. I don't have any medical records from my past. [/INST] Okay, I don't see your vaccination record here, do you have it? </s><s>[INST] [/INST] I see. </s>

ASSESSMENT

Symptoms: Coughing, shortness of breath, sleepiness, tiredness, confusion, weakness, muscle loss, instability. Diagnosis: COPD exacerbation, community-acquired pneumonia (both resolving), generalized weakness, deconditioning, fall secondary to instability. History of Patient: Long history of lung disease (COPD), recent exacerbation with Symptoms including coughing, shortness of breath, sleepiness, tiredness, confusion; diagnosed with pneumonia while on a trip, currently improving but still requiring oxygen therapy; experienced a fall due to instability and failure to use assistance despite being advised by family and nurses to do so. Plan of Action: Continue home oxygen therapy for a short period, address generalized weakness and deconditioning, emphasize the importance of calling for assistance when needed.

<s>[INST] I have a long history of lung disease. COPD to be exact. Recently, I was experiencing a lot of coughing and shortness of breath even on walking from one room to another. All the time I felt sleepy, tired, or confused. [/INST] How are you doing today? </s><s>[INST] It is getting better. [/INST] How is it now? </s><s>[INST] I was also diagnosed with pneumonia; I was on trip and there they found it. It is also getting a lot better now, but doctor said to continue taking oxygen for some more time. [/INST] What else? </s><s>[INST] With everything going on, I felt weak and tired and it looks like I have lost all my strength and muscle. [/INST] Oh wow! </s><s>[INST] Doctor: Did you use a wheelchair? [/INST] Patient: I also felt very instable and had a fall. I did not call for any assistance but now I think I should have called someone. Everyone including my family and nurses all tell me all the time to call for assistance. I was just being stubborn and hurt myself. </s><s>[INST] Doctor: You know I would agree with everyone else; you should call for assistance if you need help like getting out of bed or need to use the restroom. [/INST] Patient: No. </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: Positive for diabetes mellitus in the maternal grandmother. Plan of Action: N/A

<s>[INST] The only thing that I know about is that my grandma has diabetes. [/INST] Tell me about your family medical history. </s>

GENHX

Symptoms: Whole body hurts, feeling cold Diagnosis: N/A History of Complaint: 52-year-old gentleman with history of heroin abuse and recent use, history of cocaine use, history of alcohol abuse Plan of Action: N/A

<s>[INST] I am fifty two. Yes doc. I remember you. [/INST] Hi mister Jones. Do you remember me from the last time you were here? How old are you now? </s><s>[INST] I gotta kick the heroin. It's going to kill me this time. Please help me. My whole body hurts. I am so cold. [/INST] What have you been using most recently? I need to know what kind of drugs we are dealing with. </s><s>[INST] I did some coke. It's this heroin that is going to get me. I used to abuse alcohol, but now I have switched to drugs. [/INST] Okay. Is there anything else that you been using recently? Alcohol? Pills? </s>

FAM/SOCHX

Symptoms: N/A. Diagnosis: N/A. History of Patient: Father has systemic lupus erythematosus (SLE), uncle has Addison's disease. High blood pressure also runs in the family. Plan of Action: N/A.

<s>[INST] My dad has lupus and his brother has Addison's disease. High blood pressure also runs in the family. [/INST] Any medical problems on your mom or dad's side? </s><s>[INST] Yes, he follows up with his rheumatologist pretty regularly. [/INST] Is your dad being treated for lupus? </s>

FAM/SOCHX

Symptoms: N/A. Diagnosis: N/A. History of Patient: Patient lives at home with her mother, brought to the Emergency Department by her mother due to feeling sick, no smoking in the home. Plan Of Action: N/A.

<s>[INST] Guest_family: Hi, Doctor. We're both doing fine. I brought my daughter in today because she's been feeling sick. [/INST] Hi, there. How are you both doing? What brings you two to the Emergency Department? </s><s>[INST] My mom can give you the address. I still live with her. [/INST] I see. Let me ask your daughter a few questions before we start. Hi, ma'am. I understand you feel sick. Before we begin I just want to confirm some information with you. Where is your primary residency? </s><s>[INST] Nope. My Mother has forbidden smoking in her home. [/INST] Thank you. One last question. Do you smoke? </s>

OTHER_HISTORY

Symptoms: N/A. Diagnosis: N/A. History of Patient: Completely unremarkable family medical history. Patient has boyfriend and is sexually active. Denied drug, alcohol, or tobacco use. Plan of Action: N/A.

<s>[INST] No, everyone in my family is quite healthy. I'm not aware of any medical problems. [/INST] Do you know about any medical traits in your family? </s><s>[INST] Yes, I am with my boyfriend. [/INST] Are you sexually active? </s><s>[INST] No, none of them. [/INST] Do you take any drugs or alcohol or smoke? </s>

EXAM

Symptoms: N/A. Diagnosis: VITAL SIGNS: Bloodpressure is 125/75. His weight is 197 with height 5 feet 4 inches History of Patient: N/A. Plan Of Action: N/A.

<s>[INST] Yes. [/INST] You are five feet four inches. </s><s>[INST] Okay. [/INST] Weight one ninety seven. </s><s>[INST] Okay. [/INST] Your blood pressure is one twenty five over seventy five. </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: Denied ETOH (alcohol), tobacco, or illicit drug use. Patient specifically denied methamphetamine use. Plan of Action: N/A

<s>[INST] No. [/INST] Do you smoke or drink? </s><s>[INST] You mean like meth? [/INST] Any drugs? </s><s>[INST] No, never did it. [/INST] Yeah. </s><s>[INST] [/INST] Okay. </s>

GENHX

Symptoms: progressive loss of color vision, gradual onset of blurry vision, blind spot in right eye, mild fluctuations in Symptoms Diagnosis: N/A History of Patient: Symptoms started one year ago, blurred vision developed two months ago, no other associated Symptoms such as weakness, dizziness, vertigo, nausea, vomiting, double vision, or headaches Plan of Action: N/A

<s>[INST] Oh, I am fifty eight now. [/INST] How old are you? </s><s>[INST] Yeah. Okay. It all started a year ago. It started with losing the color in my vision. [/INST] So, you are here today because you are having some vision difficulties? Tell me about what has been going on, ma'am. </s><s>[INST] Gradual. And now I am starting to have blurry vision. [/INST] Was the loss sudden or gradual? </s><s>[INST] I noticed it two months ago. [/INST] When did that start happening? </s><s>[INST] It is an all over vision blur and then I have on blind spot in my right eye. [/INST] Is the blurred vision an all blur or is there a blind spot of blurred vision. </s><s>[INST] Some days I feel like things are a little better but not much. I have basically been the same. [/INST] Have you had any fluctuations in your symptoms in the last year? Have you gained any vision back? </s><s>[INST] No. [/INST] Have you experienced any weakness, dizziness, vertigo, nausea or vomiting? </s><s>[INST] No. [/INST] Any double vision or headaches? </s><s>[INST] No. [/INST] Any pain in or behind the eye at all? </s><s>[INST] No. Just the vision problems. [/INST] Any other health concerns or complains? </s><s>[INST] [/INST] Alright! Let me take a look here. </s>

GENHX

Symptoms: N/A Diagnosis: N/A History of Patient: moderate to severe sleep apnea, follow-up for CPAP Plan of Action: N/A

<s>[INST] I am thirty. [/INST] Hi sir, how old are you? </s><s>[INST] Yes, that is correct, I still can't sleep. [/INST] We are following up today for your moderate to severe apnea, right? </s><s>[INST] Yes. [/INST] Okay and you did the CPAP? </s><s>[INST] Sure. [/INST] Okay, let's review it today. </s>

ROS

Symptoms: N/A Diagnosis: No fevers, chills, sweats, weight loss, weight gain, exertional chest pain, orthopnea, PND, palpitations, paresis, paresthesias, syncope, double vision, blurred vision, tinnitus, decreased auditory acuity, rhinorrhea, sneezing, indigestion, heartburn, diarrhea, blood in stools, black stools, change in bowel habits, dysuria, hematuria, pyuria, polyuria, nocturia, slow urinary stream, wheezing, cough, sputum production, skin lesions, nonhealing lesions, joint pain, bone pain, back pain, erythema at joints, heat intolerance, cold intolerance, polydipsia, easy bruising, easy bleeding, swollen lymph nodes. History of Patient: N/A Plan of Action: N/A

<s>[INST] Um no. [/INST] Let me examine you. Tell me, did you have any fever or chills, any sweating or that sort of thing? </s><s>[INST] No. [/INST] How about abnormal weight loss or weight gain? </s><s>[INST] No, no chest pain and shortness of breath. [/INST] Are you experiencing any chest pain on exertion or shortness of breath normally or when you try to sleep? </s><s>[INST] No. [/INST] Let me see your legs. They look good I don't see any pedal edema. Usually that happens due to excess water retention. Any palpitations? </s><s>[INST] No and no. [/INST] Any feeling of numbness or tingling? Did you faint or lose consciousness anytime? </s><s>[INST] Doctor: Any double and or blurred vision? [/INST] Okay, good! </s><s>[INST] Doctor: Any difficulty hearing or any wired continuous sound you may hear? [/INST] Patient: No. </s><s>[INST] Doctor: Okay, um tell me if you had any um, allergies, or sneezing, or runny nose? [/INST] Patient: No. </s><s>[INST] Doctor: Okay, got it. [/INST] Patient: No, no really. </s><s>[INST] No. [/INST] Any indigestion, or heart burn? Did you notice any blood in stool or black stool? </s><s>[INST] Nope. [/INST] Any diarrhea or vomiting? </s><s>[INST] No, just normal. [/INST] Are you feeling thirsty frequently? </s><s>[INST] Doctor: And I see you got a urine test, so no pus cells or blood present. [/INST] Okay. </s><s>[INST] Doctor: Any pain while passing urine though? Any blood? [/INST] Patient: Yes. </s><s>[INST] Doctor: And how is the urine frequency? Do you have to wake up at night to urinate? [/INST] Patient: No. </s><s>[INST] Doctor: How bout the stream while passing urine? You think it's normal or somewhat slow? [/INST] Patient: Well, my frequency is normal. I don't have to wake up at night for urinating. </s><s>[INST] Doctor: Okay, so any cough or cold like symptoms any sputum? [/INST] Patient: No, it's absolutely normal. </s><s>[INST] Doctor: No wheezing, right? [/INST] Patient: Nope. </s><s>[INST] Doctor: I don't see any lesions, that's good. Any mood swings, feeling depressed or have anxiety? [/INST] Patient: Yes, no wheezing. </s><s>[INST] Doctor: Any joint pain in the legs, back or anywhere? [/INST] Patient: No. </s><s>[INST] Doctor: Okay, so no erythema in the joints. Any heat or cold intolerance? [/INST] Patient: Um no. </s><s>[INST] Doctor: Okay, any difficulty swallowing? Let me check here, lymph nodes look fine. And do you bleed easily and does the bleeding stop normally? [/INST] Patient: No. </s><s>[INST] Doctor: Do you bruise easy? [/INST] Patient: Oh yes! </s><s>[INST] Doctor: Okay. Any abnormal skin lesions? [/INST] Patient: No, not really. </s><s>[INST] [/INST] Patient: No. </s>

ASSESSMENT

Symptoms: N/A. Diagnosis: Blood-borne pathogen exposure secondary to contaminated needlestick. History of Patient: N/A. Plan of Action: N/A.

<s>[INST] Doctor: We are looking at blood born pathogen exposure secondary to needlestick. [/INST] Patient: Doc what are you going to diagnose me as? </s><s>[INST] [/INST] Patient: Yes, I was also thinking around contamination. </s>

GENHX

Symptoms: no fever, no chills, no cough, no congestion, no nausea, no vomiting, no chest pain, no chest pressure. Diagnosis: hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis, kidney stones History of Patient: 76-year-old white female, presents to the clinic today originally for hypertension and a med check, followed by Dr. Kumar, issues stable Plan of Action: N/A

<s>[INST] I came in for a refill of my blood pressure medicine. [/INST] What brings you back into the clinic today, miss? </s><s>[INST] No. [/INST] It looks like Doctor Kumar followed up with you last time regarding your hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones. Have you noticed any changes or do you have any concerns regarding these issues? </s><s>[INST] No. [/INST] Have you had any fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure? </s><s>[INST] I am seventy six years old and identify as a white female. [/INST] Great. Also, for our records, how old are you and what race do you identify yourself as? </s>

FAM/SOCHX

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

<s>[INST] No. [/INST] Are you aware of any medical problems in your family? </s><s>[INST] No. [/INST] Anyone with any heart disease or diabetes? </s>

GENHX

Symptoms: Cough not improving, sore taste in mouth since last week, "trouble with eyes" feeling funny but vision is fine, worsening back pain, right shoulder and neck pain over the last week with no injury reported. Diagnosis: N/A History of Patient: The patient reports cough not improving, sore taste in mouth since last week, "trouble with eyes" feeling funny but vision is fine, worsening back pain, right shoulder and neck pain over the last week with no injury reported. Denies diarrhea, abdominal pain, nausea, vomiting, dysuria, or loss of appetite. Plan of Action: N/A

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

GENHX

Symptoms: The patient states she is feeling a bit better.. Diagnosis: N/A. History of Patient: N/A. Plan Of Action: N/A.

<s>[INST] Good morning, doctor. [/INST] Good morning, ma'am. </s><s>[INST] Honestly, I'm feeling a little bit better. [/INST] How are you feeling today? </s><s>[INST] [/INST] That's good to hear, ma'am. </s>

GENHX

Symptoms: pain and injury to the back of left thigh, knee injury from a boat accident, hypergranulation tissue around graft site, drainage from areas with hypergranulation tissue. Diagnosis: N/A. History of Patient: traumatic injury to left posterior thigh, surgery for large defect in left posterior thigh, ongoing external fixation for healing fractures in leg, grafting and full thickness skin grafting for closure of defect, nearly healed in gluteal fold area. Plan of Action: referred to clinic for management of hypergranulation tissue and drainage from graft site.

<s>[INST] I'm forty nine years old, and I identify as white. [/INST] Hello, sir. Before we begin your visit, could you verify your age and ethnicity for me, please? </s><s>[INST] I was referred to you so that I could get whatever's wrong with me under control. [/INST] Thank you. What brought you in today? </s><s>[INST] I hurt the back of my leg pretty bad this past year when I was in A B C D. [/INST] I see. What seems to be happening? </s><s>[INST] The back of my left thigh. [/INST] What part of your leg? </s><s>[INST] I also hurt my kneecap from a boat when I was out in the water fishing. [/INST] I see. So just the leg? </s><s>[INST] It was a whole show. A helicopter came down and swooped me to X Y Z Hospital, where I got surgery. [/INST] Was that severe? </s><s>[INST] Yeah, they did. Here you go. [/INST] I can see you still have an external fixation on your knee so that the fracture heals. Did the hospital give you a report on the surgery? </s><s>[INST] Yeah. Whatever that means. [/INST] Thank you. Let me take a look. So, it looks like you underwent grafting and full thickness skin grafting for closure for a large defect in your left posterior thigh. That seems to be healed in the gluteal fold on the left area. </s><s>[INST] Go for it. [/INST] Let me examine the area. </s><s>[INST] Is that bad? [/INST] I can see several areas that have hypergranulation tissues around the graft site and low in the leg. </s><s>[INST] No, I'm not. [/INST] I don't think so. Are you feeling any symptoms of a fever or anything? </s><s>[INST] [/INST] That's good. You don't have any infections then. </s>

GENHX

Symptoms: Left hemibody numbness, stiffness and clumsiness in right hand, listing to the right when walking. Diagnosis: N/A. History of Patient: Symptoms started on 7/29/93 with left hemibody numbness, followed by stiffness and clumsiness in right hand on 7/7/93, and listing to the right when walking. Denied recent colds/flu-like illness, history of multiple sclerosis, Symptoms of Lhermitte's or Uhthoff's phenomena. Plan of Action: N/A.

<s>[INST] I am forty four. [/INST] How old are you? </s><s>[INST] I'm right handed. [/INST] Are you right handed or left handed? </s><s>[INST] I don't know. I woke up over this numbness on my left side of the body. I remember it was on July twenty nineth. [/INST] Tell me what happened. </s><s>[INST] I was able to walk and there was no weakness or any other thing you mentioned. [/INST] Was there any sensation like having pins and needles? Was there any weakness? Is there any change in your visual or mental status? Were you able to walk? </s><s>[INST] There was nothing around Independence Day. It all started after that. At first, I felt that my right hand is very clumsy, and it is kind of stiff. Then I noticed leaning towards the right when walking. It was strange. Happened around July seventh. [/INST] When did you first start noticing these symptoms? </s><s>[INST] No. [/INST] Did you recently have any cold or flu like symptoms? </s><s>[INST] No. [/INST] Were diagnosed with a thing called multiple sclerosis? </s><s>[INST] No. [/INST] Did you ever have a feeling where you felt like there's an electric is going up or down your spine? </s><s>[INST] No. [/INST] How about any fatigue or pain? Any frequency in your urination? Any urgency in that? </s>

DISPOSITION

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

<s>[INST] I am good. [/INST] How are you? </s><s>[INST] Can I go home now? [/INST] That's great. You are stable. </s><s>[INST] Thank you! [/INST] Yes, you can. </s>

PROCEDURES

Symptoms: N/A Diagnosis: N/A History of Complaint: Permanent pacemaker placement after removal of temporary internal pacemaker Plan of Action: N/A

<s>[INST] I am well. [/INST] How are you feeling? </s><s>[INST] Yes. [/INST] So, we have placed a permanent pacemaker and removed your temporary internal pacemaker. </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Complaint: Not obtainable Plan of Action: N/A

<s>[INST] No I don't know. [/INST] Can you tell me some illness that might run in your family? </s><s>[INST] Yes. [/INST] Are you sure? </s>

PASTSURGICAL

Symptoms: N/A. Diagnosis: N/A. History of Patient: Patient expresses fear and reluctance regarding surgery, stating it is their first surgery and expressing concern about potential complications. Plan of Action: Surgery scheduled, reassurance provided by the doctor.

<s>[INST] Can we reschedule? I'm too scared to do it. [/INST] Hello. Are you ready for your surgery today? </s><s>[INST] Never. What if something goes wrong? [/INST] It'll be fine. Don't worry too much about it. Have you ever had a surgery before? </s><s>[INST] Thank you, Doctor. Let's get started then. [/INST] You have nothing to worry about. I've done this procedure multiple times, and everyone was fine after. </s>

FAM/SOCHX

Symptoms: N/A. Diagnosis: N/A. History of Patient: Patient is married and lives with his wife. Nursing notes were reviewed and agreed upon by the doctor. Plan Of Action: N/A.

<s>[INST] Yes, I'm lucky to have, and live with my lovely wife. [/INST] Are you married, sir? </s><s>[INST] Yes, she was lovely as well, I hope you're paying them well. [/INST] That's very nice. Did you speak with the nurse before I came in here? </s><s>[INST] Thank you, Doctor. [/INST] We take good care of them. They'll be happy to hear that. Let me look, she should have left me some notes, um, yep, these look good, I agree with all of this. This looks good. </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: Occasionally drinks alcohol, nonsmoker, works as a nurse aid on the second shift at a nursing home, decided not to enroll in Wichita State for the current semester due to feeling tired, in a relationship with one partner, denies specific stress in the relationship Plan of Action: N/A

<s>[INST] I'd say I have the occasional drink, but I don't smoke. [/INST] So, do you drink or smoke, sir? </s><s>[INST] I'm a nursing aid in a nursing home right now. [/INST] What do you do for a living? </s><s>[INST] No, I work the second shift, so I work some late nights and early mornings. [/INST] Do you work the normal day shift? </s><s>[INST] No, I decided to take some time off. [/INST] Are you back at Wichita State this semester? </s><s>[INST] Yeah, I'm just really tired, so I decided to step away for a little. [/INST] Is everything okay? </s><s>[INST] Yes, I've been dating my boyfriend for a while now. [/INST] That's understandable. Are you dating right now? </s><s>[INST] No, everything is going really well. [/INST] Is there any significant stress in your relationship? </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Complaint: Family history includes son with glaucoma, high cholesterol, high blood pressure, and rheumatoid arthritis at age 58, eldest brother died at age 92 from old age, two younger brothers died in their seventies from Parkinson's disease, father died at age 85 and mother at age 89, both from "old age" Plan of Action: N/A

<s>[INST] Buckle up. This is a long one. My son is fifty eight and he suffers from glaucoma, high cholesterol, high blood pressure, and R A. My eldest brother passed away at ninety two due to old age and my two younger brothers followed in their seventies after a long battle with Parkinson disease. [/INST] I'd like to know more about your family's medical history. </s><s>[INST] It's alright. Both my mom and dad died in their mid eighties from old age. I think my dad was eighty five and my mom eighty nine. [/INST] I'm incredibly sorry to hear that. </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: No tobacco use, occasional alcohol use, no illicit drug use, two grown children, married, works as a social worker dealing with adult abuse and neglect issues, husband is a high school chemistry teacher Plan of Action: N/A

<s>[INST] Good morning, doctor. Absolutely, that's not a problem at all. [/INST] Good morning, ma'am. I just need a few pieces of information before we get started today. </s><s>[INST] I don't smoke, and I drink, um, I'd say on occasionally. [/INST] Do you smoke or drink, ma'am? </s><s>[INST] No, I don't. [/INST] What about harder drugs, do you use any of those? </s><s>[INST] Yes, to my wonderful husband. [/INST] Are you married? </s><s>[INST] I'm a social worker, and my husband is a high school chemistry teacher. [/INST] That's great, what do you two do for a living? </s><s>[INST] I love it, I work with adult abuse and neglect issues. [/INST] What great work both of you are doing. What kinds of people do you work with as a social worker? </s><s>[INST] Yes, we have two sons. [/INST] Yes, that's great. Do you have any children? </s><s>[INST] No, they're both grown and on their own now. [/INST] Do they live at home? </s>

GENHX

Symptoms: N/A Diagnosis: bilateral knee degenerative arthritis History of Patient: Patient is a 79-year-old female with disabling bilateral knee degenerative arthritis unresponsive to conservative measures. Agreed to proceed with surgery. Plan of Action: Knee replacement surgery discussed and agreed upon. Risks, complications, anticipated benefits, and postoperative course were discussed with patient.

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

GENHX

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

<s>[INST] I'm doing much better today, doctor. [/INST] How are you feeling today, sir? </s><s>[INST] They're both improving. [/INST] How is your strength and muscular pain? </s><s>[INST] No, I'm doing quite well, honestly. [/INST] Do you have any other complaints today? </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: positive family history of asthma and diabetes, positive family history of renal disease on father's side Plan of Action: N/A

<s>[INST] My uncle on my dad's side of the family had kidney failure. I lot of my family members have diabetes and asthma. [/INST] What is your family medical history? </s>

FAM/SOCHX

Symptoms: N/A. Diagnosis: N/A. History of Patient: No recent STDs, not currently sexually active, last PPD was negative, will be placed again today, 100% compliant with medication adherence, last dental exam was in 11/07 where 2 teeth were extracted, last Pap smear was negative 1 year ago, has not had a mammogram yet as not of screening age, no family history of breast cancer. Plan Of Action: Treatment adherence counseling performed, PPD to be placed again today.

<s>[INST] Good afternoon, doctor. [/INST] Good afternoon, young lady. </s><s>[INST] Sure. [/INST] Let's get the personal questions out of the way to begin, shall we? </s><s>[INST] No, not that I know of. [/INST] Have you had any S T D s recently? </s><s>[INST] No, I'm not. [/INST] Are you sexually active? </s><s>[INST] Okay, that's fine, doctor. [/INST] I'm looking here, and your last P P D was negative, but we'll do another one today. </s><s>[INST] Yes, I've taken everything exactly as you told me to. [/INST] Have you been compliant with all of the medicine you've been prescribed? </s><s>[INST] Yeah, it was in November of two thousand seven. [/INST] Good, do you remember when your last dentist appointment was? </s><s>[INST] They pulled two teeth for me. [/INST] What did they do for you at your last visit? </s><s>[INST] It was about a year ago. [/INST] Good, and when was your last pap smear? </s><s>[INST] Yes, thankfully. [/INST] I assume it was negative? </s><s>[INST] No, not yet. I'm not old enough. [/INST] Have you had a mammogram yet? </s><s>[INST] No, I don't, at least not that I know of. [/INST] Do you have a family history of breast cancer? </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: Noncontributory. No specific family medical history provided. Plan of Action: N/A

<s>[INST] No. [/INST] Any specific family medical history that I should be aware of? </s><s>[INST] No. [/INST] Anyone in your family, even grandparents, if you know them, did they have diabetes or high blood pressure? </s><s>[INST] No. [/INST] Anyone else sick at home? </s>

FAM/SOCHX

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

<s>[INST] I have or had two sons both born normally without any complications. [/INST] Can you tell me about your family? </s><s>[INST] One of my sons was a heavy smoker, he uses to smoke a whole packet or more in a day. We tried everything possible, but he just couldn't quit. He died of clots. [/INST] Why did you say had? </s><s>[INST] Yes, my father had heart related issues, he died in his sixties, my mother died of colon cancer. I also have a sister but I don't think she has any issues.c [/INST] Does anyone in your family like parents or siblings had any medical issues? </s>

FAM/SOCHX

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

<s>[INST] Yes. I'm doing my major in computer science. [/INST] Are you studying? </s><s>[INST] No, I live in my family. Mainly my parents and my sisters. [/INST] Do you live alone? </s>

ROS

Symptoms: N/A Diagnosis: N/A History of Patient: Noncontributory Plan of Action: N/A

<s>[INST] No, everything is fine. [/INST] Any issues from head to toe? </s>

EDCOURSE

Symptoms: Pain Diagnosis: N/A History of Complaint: N/A Plan of Action: Patient received Dilaudid 4 mg IM for pain without adverse reaction

<s>[INST] Yes, I want something strong for this. [/INST] Are you in pain? </s><s>[INST] Yes please. [/INST] We can give you a shot. </s><s>[INST] Thank you. [/INST] Okay nurse, give her Dilaudid of 4 M G I M. </s><s>[INST] No I feel much better. [/INST] How are you now? Any bad side effects? </s>

ROS

Symptoms: N/A Diagnosis: N/A History of Patient: Eating fairly well, sleeping well, experiencing a little difficulty with stools being hard Plan of Action: Continue high fiber diet, inform doctor or nurses if condition does not improve or worsens

<s>[INST] I am doing good, considering. [/INST] How are you feeling today? </s><s>[INST] Yes. I was able to get some good sleep last night. [/INST] Are you sleeping well? </s><s>[INST] Yes. I ate a little bit of breakfast this morning. [/INST] Have you been able to eat without any trouble? </s><s>[INST] Yes, I did this morning. [/INST] Have you been able to have a bowel movement yet? </s><s>[INST] It was still a little difficult and hard. [/INST] Did you experience any difficulties with your movement? </s><s>[INST] [/INST] Okay. Continue the high fiber diet that we discussed, and it should improve. Please let me or one of the nurses know if it has not improved or becomes worse. </s>

EXAM

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

<s>[INST] No pain. [/INST] Let's check your throat. Okay, I don't see any swelling or any mass. Is there any pain when I touch you? </s><s>[INST] [/INST] I don't feel any kind of lump in your throat. That is a good sign. It looks very flexible and symmetric. </s>

MEDICATIONS

Symptoms: N/A. Diagnosis: N/A. History of Patient: N/A. Plan of Action: N/A.

<s>[INST] None whatsoever. [/INST] Are you on any medications at this time? </s><s>[INST] [/INST] Got it. </s>

MEDICATIONS

Symptoms: N/A. Diagnosis: N/A. History of Patient: Patient takes Allegra for seasonal allergies and Proventil for exercise-induced asthma. Plan Of Action: N/A.

<s>[INST] Meds? [/INST] Do you take any- </s><s>[INST] I do. I take Allegra for seasonal allergies. I also take something that starts with a P. I'm blanking on the name. My other doctor prescribed it to me for exercise induced asthma. [/INST] Yes. </s><s>[INST] Yes, that's it! I keep that on hand in case my asthma gets outta control. [/INST] Oh, do you mean Proventil? </s><s>[INST] You mean is it expired? No, I don't think so. It hasn't been long since I visited the pharmacy. [/INST] Is it up to date? </s><s>[INST] [/INST] Good. I always like to advise my patients to check expiration dates. </s>

ALLERGY

Symptoms: N/A Diagnosis: N/A History of Patient: No known drug allergies. Plan of Action: N/A

<s>[INST] No, I do not have any allergies. [/INST] Are you allergic to anything? </s><s>[INST] [/INST] Great. </s>

ASSESSMENT

Symptoms: dizziness Diagnosis: atrial fibrillation History of Patient: N/A Plan of Action: N/A

<s>[INST] Yes, rhythm problem is bad. [/INST] You have atrial fibrillation from the past? </s><s>[INST] Yes. I do. [/INST] And no dizziness? </s><s>[INST] [/INST] Okay well... </s>

ROS

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

<s>[INST] I am feeling well. [/INST] So how are you feeling? </s><s>[INST] No, nothing like that. [/INST] Any illness or fever? </s><s>[INST] No. [/INST] Any headache or nausea? </s><s>[INST] No. [/INST] Any vomiting or stomach upset? </s><s>[INST] No, not at all. [/INST] Okay, any numbness tingling or loss of sensation in the hand? </s><s>[INST] Yeah. [/INST] Otherwise feeling well? </s>

FAM/SOCHX

Symptoms: N/A. Diagnosis: N/A. History of Patient: Family history includes sister with breast carcinoma diagnosed in her 50s and father with gastric carcinoma diagnosed in his 70s. Denies family history of ovarian, uterine, or colon cancer. Plan of Action: N/A.

<s>[INST] My dad had stomach cancer. [/INST] What is your family medical history? </s><s>[INST] I think he was seventy something. My sister has breast cancer. She is in her fifty's. [/INST] How old was he when he was diagnosed? </s><s>[INST] No. Not that I am aware of. [/INST] Any family history of uterine, ovarian or colon cancer? </s>

DIAGNOSIS

Symptoms: N/A. Diagnosis: Complex open wound right lower extremity complicated by methicillin-resistant Staphylococcus aureus cellulitis. History of Patient: N/A. Plan of Action: Aggressive treatment for the wound.

<s>[INST] Is there a treatment for my right leg? [/INST] Alright. So this is going to be a complex case. Your wound is complicated by methicillin-resistant staphylococcus aureus cellulitis. </s><s>[INST] [/INST] There is. It will be more aggressive, but we can do it. </s>

ROS

Symptoms: Congestion, cough Diagnosis: N/A History of Patient: Congestion for three weeks, coughing, no fevers, no vomiting Plan of Action: N/A

<s>[INST] Doctor: Oh, how long? [/INST] Guest_family: Congestion and cough. </s><s>[INST] Doctor: Okay. [/INST] Guest_family: It's been three weeks now. </s><s>[INST] Doctor: How about fever nausea vomiting diarrhea? [/INST] Guest_family: He has been like this for so long, but nothing else. </s><s>[INST] Doctor: Okay great. [/INST] Guest_family: No fever, no vomiting, nothing else. </s>

ASSESSMENT

Symptoms: Pain on the left side, nausea, vomiting. Diagnosis: Kidney stones in the ureter close to the bladder. History of Patient: Experiencing pain on the left side, nausea, and vomiting. Plan of Action: Consultation with a surgeon recommended.

<s>[INST] Oh no. [/INST] Hi there! I have the results from your ultrasound. You have kidney stones in the ureter close to the bladder. </s><s>[INST] Yes, I have been. [/INST] This explains the pain you have been having on your left side. Are you still experiencing nausea and vomiting? </s><s>[INST] Okay. [/INST] I would like to set you up with a consult with a consult with a surgeon. </s>

GENHX

Symptoms: N/A Diagnosis: N/A History of Patient: regular diet, eating three meals a day Plan of Action: N/A

<s>[INST] Yes. [/INST] Do you eat three meals a day? </s><s>[INST] I would say yes. [/INST] Do you think those meals add up to about two thousand calories a day? </s>

CC

Symptoms: Chronic abscesses, open wounds on bilateral thighs Diagnosis: Chronic abscesses with open wounds, likely resulting from injection drug use History of Patient: Patient has a history of drug use, specifically injecting heroin into bilateral thighs, resulting in chronic abscesses and open wounds, worse on the right thigh Plan of Action: Radical excision followed by reconstruction surgery recommended due to non-healing wounds and worsening condition

<s>[INST] Guest_family: Hi doctor, I am his son Ethan. [/INST] Hi there, how is it going? </s><s>[INST] Doctor: So, I see your father has a history of drug abuse, right? [/INST] Nice to meet you. </s><s>[INST] Not abuse, I just used to do drugs. The last time I really made a big mistake I injected the heroine directly into both of my thighs and unfortunately, I got these ulcers which are not going away. [/INST] Guest_family: Yes. </s><s>[INST] Guest_family: The right thigh looks worse than the left one. [/INST] Yeah, this is really unfortunate. I can see these open wounds, it's because of the chronic abscesses. </s><s>[INST] Guest_family: He is sixty two. [/INST] Yeah, I see that. How old is your father? </s><s>[INST] Guest_family: No. [/INST] Does he have any other medical issues like sugar or blood pressure? </s><s>[INST] Guest_family: And is that the only way? [/INST] Okay, I think we need to surgically remove this whole area and then do a reconstruction. </s><s>[INST] Guest_family: Okay then we will follow whatever you suggest. [/INST] According to me, yes! I mean the wounds are not healing and it is only getting worst. </s><s>[INST] [/INST] Okay. </s>

ALLERGY

Symptoms: Hay fever, eczema, sinus problems, hives Diagnosis: N/A History of Complaint: No melanoma or skin cancers or psoriasis, family history of oral cancer (mother), nonsmoker, had sunburn in the past, on benzoyl peroxide and Daypro Plan of Action: N/A

<s>[INST] My skin has been going crazy. [/INST] Hello, miss. How are you doing today? </s><s>[INST] I can't really describe it, but I can show you. Here's a report from my local doctor. [/INST] Could you describe to me what's happening? </s><s>[INST] Yeah, I guess so. [/INST] I see. It says you have hay fever, eczema, sinus problems, and hives, correct? </s><s>[INST] Uhm. I don't think so. I know my mom has some type of cancer in her mouth. [/INST] Does this run in your family? </s><s>[INST] Oh, yeah. Here's the report with all that information. [/INST] I see. Have you been screened for cancer before? </s><s>[INST] Sounds good to me. So, what's all this stuff on my skin? [/INST] This looks good. It says you don't have melanoma or skin cancers or psoriasis. </s><s>[INST] Oh, yeah. I had some and it burned a lot. [/INST] Hm. Let me take a look. Have you been sunburned before? </s><s>[INST] It's on the report from my local doctor. [/INST] I see. Are you currently taking any medications? </s><s>[INST] Do I look like I smoke? I've never smoked in my life. [/INST] Looks like you're taking benzoyl peroxide and Daypro. You're not smoking with these medications, right? </s>

GENHX

Symptoms: N/A Diagnosis: N/A History of Patient: history of high blood pressure well under control, history of high triglycerides, otherwise generally healthy, nonsmoker Plan of Action: N/A

<s>[INST] Oh, I have high blood pressure but it's well under control. I make sure to keep it under normal range. [/INST] Do you have sugar or blood pressure problems? </s><s>[INST] Yeah, I have history of high triglycerides. But otherwise, I am pretty healthy. [/INST] Good. Any other health issues? </s><s>[INST] No. [/INST] Okay. Do you smoke? </s>

EXAM

Symptoms: N/A Diagnosis: CHEST: Normal AP diameter and normal contour without any kyphoscoliosis. History of Patient: N/A Plan of Action: N/A

<s>[INST] I'm good. Thank you. [/INST] How are you doing young man? </s><s>[INST] Okay. [/INST] Let's see how your chest is doing. </s><s>[INST] [/INST] Chest measurements look nice. No issue there. The outline also looks great. Also, there is no hunchback? </s>

ASSESSMENT

Symptoms: N/A Diagnosis: allergic rhinitis History of Patient: N/A Plan of Action: N/A

<s>[INST] I am not sure, maybe on and off. [/INST] Have you had sinus issues before? </s><s>[INST] Okay. [/INST] Because this is more allergic. </s><s>[INST] Is it different than sinus infection? [/INST] So, we call it allergic rhinitis. </s><s>[INST] Okay. [/INST] Yes, it's it is different. </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: tobacco abuse, illicit drug abuse History of Patient: lives with boyfriend Plan of Action: N/A

<s>[INST] I live with my boyfriend. [/INST] Who lives with you, miss? </s><s>[INST] Yes, I do. [/INST] Do you smoke cigarettes? </s><s>[INST] Sometimes, but I don't want to talk about it. [/INST] How about drugs? </s><s>[INST] Pardon? [/INST] Okay. Anything else you want to talk about? </s>

ROS

Symptoms: N/A Diagnosis: N/A History of Patient: NEUROLOGIC: Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness. Plan of Action: N/A

<s>[INST] No. [/INST] Have you experienced any headaches or blackouts recently? </s><s>[INST] Nope. [/INST] Dizziness or seizure? </s><s>[INST] No. [/INST] Any history of stroke? </s><s>[INST] [/INST] Okay, good. </s>

GENHX

Symptoms: shortness of breath with activities, occasional cough, small amount of sputum production Diagnosis: COPD, emphysema History of Patient: hospitalized for psychiatric problems, currently living in a nursing facility but wants to return to her apartment Plan of Action: N/A

<s>[INST] Yes, the last time I was seen in Pulmonary Medicine Clinic was March two thousand and four. [/INST] Hello, miss. How are you doing today? It looks like we are evaluating C O P D and emphysema. </s><s>[INST] I have actually been hospitalized for psychiatric problems and now live in a nursing facility. Things have not been too great. I don't like living there. [/INST] It has been quite some time. How are you feeling? </s><s>[INST] I want to live back in my apartment, but I know I am too ill to care for myself. [/INST] I understand the frustration. When you live in a nursing facility you lose a lot of your freedom. </s><s>[INST] I feel pretty stable. I still have shortness of breath when I do activities, but with my condition I feel like that is something I will have to live with. [/INST] In spite of all of that how are your respiratory issues? </s><s>[INST] The only thing that seems to have changed is that I have a small cough and produce some mucus. [/INST] Unfortunately, that is the nature of the disease. I am happy to see that the pulmonary disease has not changed significantly since your last visit. </s><s>[INST] No, none of that. [/INST] Okay. Do you have any fever or chills? </s><s>[INST] No, I luckily do not have any chest pains. [/INST] Do you experience any chest pains? I want to check especially since you have been coughing up some mucus. </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: She rarely drinks socially. She denies any illicit substance usage. Her husband reportedly gives her medication daily. Has been proactive in terms of seeking mental health care and medical care. The patient and husband report that from March 2009, she has been relatively independent, more socially active Plan of Action: N/A

<s>[INST] Hi. [/INST] Hi, there. </s><s>[INST] Doctor: It is nice to meet you as well. You are the husband, correct? [/INST] Guest_family: Hi! It is nice to meet you. </s><s>[INST] Doctor: How long have you two been married? [/INST] Guest_family: Yes. I am the husband. </s><s>[INST] Doctor: Do you live in the same household? [/INST] Guest_family: We have been married for forty eight years. </s><s>[INST] Doctor: Do you have a primary care physician? [/INST] Patient: Yes. </s><s>[INST] Doctor: I have a few recommendations I can give to you if you would like. [/INST] Patient: No, I am currently looking for someone. I have also been looking for someone to see for my mental health issues. </s><s>[INST] Doctor: Are you working currently? [/INST] Patient: I would like your recommendations for both. </s><s>[INST] Doctor: Do you drink alcohol or use any recreational drugs? [/INST] Patient: No, I am not. I used to work as a registered nurse. It has become too much for me right now. </s><s>[INST] Doctor: Have you ever taken any prescription drugs, muscle relaxants or sedative medications? [/INST] Patient: I don't do any drugs. I drink very rarely. I only drink is social situations. </s><s>[INST] Doctor: Oh, okay. [/INST] Guest_family: I don't think that she has ever taken muscle relaxants or sedative medications without prescriptions. I give her, her medications every day so she doesn't forget. </s><s>[INST] Doctor: Okay. How have you been feeling lately? Have you been participating in social activities? [/INST] Guest_family: She does have a pattern of self-prescribing for minor illness. She loves WebMD. </s><s>[INST] Guest_family: She used to never leave the house unless I go with her. She has defiantly been more independent lately. She even went and met a friend for coffee the other day. [/INST] Patient: Since this last March I have been feeling more social and have been doing things on my own more. </s><s>[INST] [/INST] That is great to hear. </s>

GENHX

Symptoms: acute onset of abdominal pain, dilated bladder with thick wall suggesting outlet obstruction, bilateral hydronephrosis, hydroureter, painful urination, nausea, vomiting, accidents with urination Diagnosis: N/A History of Patient: patient is a demented 80-year-old male living in board and care, son confirms acute onset of abdominal pain, CT scan findings, IV antibiotics and hydration given in ER Plan of Action: N/A

<s>[INST] What? [/INST] Hello, how are you? </s><s>[INST] Guest_family: Hello doctor, I am his son. [/INST] How are you related to the patient? </s><s>[INST] Guest_family: He is eighty years old. He is suffering from dementia. [/INST] Hello. How old is he? </s><s>[INST] Guest_family: I don't think so. Sometimes he even forgets his name. [/INST] I see. Do you think he will be able to provide me with his medical history? </s><s>[INST] Doctor: I don't blame you. I forget my things at my age. [/INST] Patient: He's kidding. I know my name. I also know his kids' names. I do agree that sometimes I forget my things or feel lost. </s><s>[INST] Doctor: What is his living status? [/INST] Guest_family: Yeah, it is something like episodic that he forgets everything and sometimes he's absolutely normal. On good days, he's very nice to talk to. </s><s>[INST] Doctor: That's good. So what brings you here in the emergency today? [/INST] Guest_family: He lives at a board and care. It is a cozier homelike place. </s><s>[INST] Doctor: Do you have any previous reports? [/INST] Guest_family: He started complaining of stomach aches. Luckily, I was there. It was very sudden at one moment he was talking to me nicely and then all of a sudden he started complaining of severe pain in his stomach area. That's when I decided to bring him here in the emergency room. </s><s>[INST] Doctor: Do you remember when was this scan done? [/INST] Patient: I have these reports. </s><s>[INST] Doctor: Do you remember of any medical issues before? [/INST] Patient: I have no idea. I just had these reports with me. </s><s>[INST] Doctor: Okay, let me see what your scan says. I am reading the C T Scan report provided by the patient. It states that patient has dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter. [/INST] Patient: Huh uh. </s><s>[INST] Doctor: I see that you have already been given some I V fluid along with antibiotics by the emergency room doctor. [/INST] Patient: Hm. </s><s>[INST] Doctor: Did he ever complain of pain during urination or nausea and vomiting? [/INST] Guest_family: Yeah. </s><s>[INST] Doctor: Thank you for providing me with all his history. It will be very helpful for me to treat him now. [/INST] Guest_family: Yes, he had fever a few days back. When we asked him about other symptoms, he said, it's hard to urinate and it is painful. Nausea and vomiting are something that I am not sure about. He was normally rushing to the restroom and every time used to say he didn't want to pee as it hurt him. He also had a few accidents in the last few days where he wet himself. </s>

PASTMEDICALHX

Symptoms: chest wall cysts Diagnosis: N/A History of Patient: recent PPD negative in August 1994 Plan of Action: N/A

<s>[INST] Doctor: Hey, how's it going? It's been a while. [/INST] Patient: Hey, man. </s><s>[INST] Doctor: So anything new I should know of? [/INST] Patient: Yeah, it's been a while that's for sure. </s><s>[INST] Doctor: What type of stuff? [/INST] Patient: Uh I had some stuff on my chest that I saw a dermatologist for. </s><s>[INST] Doctor: Any cause for concern? [/INST] Patient: I think they were cysts. </s><s>[INST] Doctor: Glad to hear that. [/INST] Patient: Nah, the dermatologist said everything came back alright. </s><s>[INST] Doctor: Is this for a job? [/INST] Patient: Me too. I'm actually here to see if you can write me up a P P D slip. </s><s>[INST] [/INST] Patient: Yeah, my last one was negative, but I need to get another one. Last one I did was in nineteen ninety four. </s>

FAM/SOCHX

Symptoms: N/A. Diagnosis: N/A. History of Patient: Family medical history is unknown as patient's parents never shared their medical history, nor did their parents with them. Plan Of Action: N/A.

<s>[INST] I have no idea to be quite honest with you. My parents never shared their medical history with me and neither did their parents with them. I don't think they want any of us to worry. [/INST] Do you know of any medical problems that run in your family? </s><s>[INST] Will do. Thanks for understanding. [/INST] Oh wow, I understand. It can be hard for many people to share intimate details about their health to others, even when it comes to disclosing medical info to their own children. For now, I'll put unknown but please let me know if anything changes. </s><s>[INST] [/INST] Of course. It's not totally uncommon for people to not know their family history. </s>

DISPOSITION

Symptoms: N/A Diagnosis: N/A History of Patient: N/A Plan of Action: Stable disposition to home with her mother.

<s>[INST] Guest_family: We are good. [/INST] How have you both been doing? </s><s>[INST] Guest_family: Yes. It has been helping. [/INST] I see she has been gaining weight since she has been home. Have you been following the meal plan that we discussed? </s><s>[INST] [/INST] Great! </s>

GENHX

Symptoms: Elevated blood pressure, resolved right arm Symptoms (attributed to muscle problem in right shoulder blade), vague stomach problems, mouth sores, tremor (possibly due to Lexapro). Diagnosis: N/A. History of Patient: 89-year-old lady with elevated blood pressure, resolved right arm Symptoms, improved stomach problems after stopping Aleve, mouth sores, tremor possibly related to Lexapro. Plan of Action: Continuing previous blood pressure regimen, monitoring blood pressure, managing stomach Symptoms with Tylenol, Tums, and Mylanta, monitoring mouth sores, assessing tremor possibly related to Lexapro.

<s>[INST] I'll be ninety later this month, doctor. [/INST] I hear someone has a birthday coming up, how old are you turning, ma'am? </s><s>[INST] Well, actually, my high blood pressure and right arm symptoms are basically gone. [/INST] You're here for a follow up not very long after your first visit. What seems to be the problem today? </s><s>[INST] No, I'm not taking that right now. [/INST] Great, I saw your blood pressure reading for today, and it's much better. Are you taking the higher dose of Mavik we recommended? </s><s>[INST] I didn't feel well at all, so I just went back to the old dose. [/INST] How did you tolerate the higher dose? </s><s>[INST] Yes, doctor. I do think I could have some white coat high blood pressure. Doctors' offices make me nervous. [/INST] That was one M G per day, correct? </s><s>[INST] What is this for, doctor? [/INST] That does happen. Here, try this sample of Tarka, please. </s><s>[INST] I can't take these, doctor. They're too big. [/INST] Well, since you're taking the Mavik plus verapamil, you can switch over to Tarka, which is the combined version of the two drugs. </s><s>[INST] Doctor: Good, so back to that right arm, how is that doing today? [/INST] Guest_family: Hello doctor, I'm her daughter. Just so you know, we check her blood pressure at home periodically and it's always similar to that reading. </s><s>[INST] Doctor: Did you have x rays taken today? [/INST] Patient: Well, that pain is basically gone now, I think it had to do with that muscle problem back in my right shoulder blade. </s><s>[INST] Doctor: Good, I have the images right here. [/INST] Patient: Yes, the tech brought me back right before you came in. </s><s>[INST] Doctor: Well, these x rays of the neck and right shoulder show some degenerative changes, and possibly some kind of rotator cuff injury. [/INST] Patient: What do they show, doctor? </s><s>[INST] Doctor: Well, look right here. The humeral head is pretty high in the glenoid in the right shoulder, but do you have any pain here? [/INST] Patient: What makes you think there's an injury? </s><s>[INST] Doctor: Then we won't worry about it. [/INST] Patient: No, none. </s><s>[INST] Doctor: How has this pain developed and progressed recently? [/INST] Patient: I am having this stomach pain though, doctor. </s><s>[INST] Doctor: What medicines are you taking right now, then? [/INST] Patient: Well, it's improved somewhat with me not taking Aleve anymore. </s><s>[INST] Doctor: Do you think this could be acid reflux, or heartburn? [/INST] Patient: Right know, I'm just taking Tylenol as needed. That seems to be enough for me. </s><s>[INST] Doctor: I see. How long have you worn dentures? [/INST] Patient: No, but I take Tums, um, three times a day, and Mylanta at night. Oh yeah, I have these sores in my mouth, can you take a look? </s><s>[INST] Doctor: Do they come and go, the sores? [/INST] Patient: Oh I couldn't even tell you, it's been many, many years. </s><s>[INST] Doctor: Okay, we'll keep an eye on it. [/INST] Patient: Yes, one will come, then it'll heal up, then another. </s><s>[INST] Doctor: It's hard to tell if you have a tremor today, ma'am, but do you think the Lexapro is helping otherwise? [/INST] Patient: And doctor, since I've been taking the Lexapro, I have some tremors on basically my whole body, at least the upper body, like my torso and arms. </s><s>[INST] [/INST] Patient: Yes, we think so. </s>

PASTMEDICALHX

Symptoms: N/A Diagnosis: testicular cancer, GERD, irritable bowel syndrome, seasonal asthma triggered by postnasal drip, bilateral carpal tunnel syndrome, excision of abdominal teratoma and incisional hernia History of Patient: Status post right orchiectomy due to testicular cancer approximately 18 years ago (around 1989), GERD, irritable bowel syndrome, seasonal asthma triggered by postnasal drip in both fall and spring, history of bilateral carpal tunnel syndrome, status post excision of abdominal teratoma and incisional hernia Plan of Action: N/A

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

CC

Symptoms: Pain in tooth. Diagnosis: N/A. History of Patient: N/A. Plan of Action: N/A.

<s>[INST] Ah! Have pain in my tooth. [/INST] Why are you holding your face? </s><s>[INST] Oh, awfully bad. [/INST] Oh, how bad is it? </s><s>[INST] [/INST] I am so sorry. </s>

ALLERGY

Symptoms: N/A. Diagnosis: N/A. History of Patient: No Known drug allergies. Plan of Action: N/A.

<s>[INST] No, I am not allergic to anything. [/INST] Are you allergic to anything? </s><s>[INST] Yeah. [/INST] Okay so no drug allergies. </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: Patient is still a smoker, consuming approximately one pack of cigarettes per day. Plan of Action: Advised patient to consider quitting smoking.

<s>[INST] Yes, I do. [/INST] Do you smoke cigarettes? </s><s>[INST] Maybe one a day. [/INST] How many packs a day. </s><s>[INST] [/INST] Okay, you should think about quitting. </s>

CC

Symptoms: headache Diagnosis: N/A History of Patient: N/A Plan of Action: N/A

<s>[INST] Hello Doctor. [/INST] Hi, I am Doctor Chandler. </s><s>[INST] I am having a headache. [/INST] So, tell me what's going on? </s>

CC

Symptoms: fever Diagnosis: fever of unknown origin History of Patient: Patient has had a fever on and off for the past few days, no other cold-like Symptoms reported, Tylenol has provided some relief, denies recent sick contacts Plan of Action: N/A

<s>[INST] Ugh. [/INST] So what brings you in today? </s><s>[INST] You got that right. I've had a fever on and off for the past few days. [/INST] I'm guessing you're not feeling too great. </s><s>[INST] Right before I drove here. [/INST] When was the last time you took your temperature? </s><s>[INST] Yes, she did. [/INST] I see. Did the nurse take your temperature when you came in? </s><s>[INST] Um no not really. [/INST] Have you been experiencing cold like symptoms, such as cough, nasal congestion, headache, or nausea? </s><s>[INST] Yeah. I've taken Tylenol and that's helped a bit. [/INST] Have you tried taking any medicine to help with the fever? </s><s>[INST] I don't think so. I live with three other roommates and they seem fine. [/INST] Have you had recent sick contacts? </s>

GENHX

Symptoms: weakness, partial weakness on one side, inability to stand or care for oneself Diagnosis: multiple seizures, hemiparesis, C. diff infection History of Patient: moved to nursing home after hospitalization, had two surgeries on July 6th followed by radiation treatment on August 7th, developed C. diff infection likely due to surgeries or antibiotic use Plan of Action: N/A

<s>[INST] I feel pretty weak right now, but I am doing okay at the moment. [/INST] How are you feeling today, sir? </s><s>[INST] Yes, I have. They moved me into the nursing home after I was released from the hospital. I hope that it is just temporary. [/INST] I reviewed the chart notes that was sent to me by the nursing home. They also sent me your medical history. You have been going through a lot recently. </s><s>[INST] I had multiple seizures. After I was stabilized from the last seizure this side of my body in not working right. [/INST] I understand that you had a seizer and that is why you were taken to the hospital. </s><s>[INST] Yes. That is why they moved me to the nursing home. I can't stand up. I am too weak. I can't take care of myself. The nurses have to help me do everything. [/INST] Okay so you are having some partial weakness on this side? </s><s>[INST] After being in the hospital I got an infection in my intestines. They put me on some antibiotic that I have never heard of and a probiotic. [/INST] I am going to try to help you get back to doing things on your own. </s><s>[INST] Yes, and then I had a radiation treatment too. [/INST] Okay. I see here in the chart that you had two surgeries on July sixth. </s><s>[INST] That sounds right. [/INST] Oh yes. On August seventh. </s><s>[INST] What is C diff? [/INST] Your surgeries may have been the reason for the C diff. </s><s>[INST] That make since. [/INST] It is an infection in the large intestine. It is often caused by overuse of antibiotics, and you have been on them for a while due to the surgeries that you have had. Or it could be from the surgery itself. </s>

FAM/SOCHX

Symptoms: N/A Diagnosis: N/A History of Patient: Mother, father, and siblings were alive and well. Plan of Action: N/A

<s>[INST] My mom, dad and siblings are good. [/INST] How's everyone in your family? </s><s>[INST] Yes. [/INST] They are well, that is good. That's what we want. </s>

GENHX

Symptoms: Falls, lightheadedness prior to falls, confusion, numbness in fingers, muscle weakness in hands, muscle twitching (fasciculations) in legs, constipation alternating with diarrhea, blood pressure drops upon standing, loss of feeling in feet, loss of joint position sense in feet. Diagnosis: N/A History of Patient: The patient is a 79-year-old right-handed man who has experienced multiple falls over the past few years, with associated lightheadedness and confusion. He has a history of pneumonia and shingles. He currently resides in a Chronic Rehabilitation Unit and relies on a wheelchair due to inability to use a walker. He experiences numbness and muscle weakness in his hands, muscle twitching in his legs, constipation alternating with diarrhea, blood pressure drops upon standing, loss of feeling in feet, and loss of joint position sense in feet. Plan of Action: N/A

<s>[INST] Okay. [/INST] So let's start from the beginning. </s><s>[INST] Yes. [/INST] You're seventy nine years old, correct? </s><s>[INST] Right. [/INST] Right or left handed? </s><s>[INST] Hm about a year and a half ago I fell while trying to walk from my bed to the living room. [/INST] Do you remember when you had your first fall? </s><s>[INST] Uh yeah I did have some lightheadedness and I was a bit confused. I was aware of my surroundings though. My legs just gave out and the next thing I knew I was on the floor. [/INST] Did you feel lightheaded prior? </s><s>[INST] No, thank goodness. [/INST] I see. Did you lose consciousness? </s><s>[INST] Yeah. I was good until my legs gave out on me July third of O eight. [/INST] Guest_family: He got up by himself and felt fine afterwards. The strangest thing. </s><s>[INST] Not this time. [/INST] Did you experience the same lightheadedness as before? </s><s>[INST] I was later diagnosed with pneumonia. The fall was blamed on the pneumonia. [/INST] Guest_family: We had to rush him to the hospital after that. </s><s>[INST] To be on the safe side, I started using a walker from then on. [/INST] Got it. </s><s>[INST] Nope. I used to walk about two miles a day before all of this stuff started happening to me. This isn't even the end of it. My legs gave out on me again August O eight. No lightheadedness beforehand, but they did find that I had pneumonia again. [/INST] Did you need any type of walking assistance prior to your falls? </s><s>[INST] Doctor: Did rehab help? [/INST] Guest_family: They admitted him to the hospital and later sent him for rehab. </s><s>[INST] Doctor: Did you return to your previous health? [/INST] Patient: Yeah. I was able to use my walker after that. </s><s>[INST] Doctor: Did they diagnose you with pneumonia again? [/INST] Patient: Uh not really, no. I had another fall in October O eight. </s><s>[INST] Doctor: Are you currently living at home? [/INST] Patient: Yeah. I also had shingles. </s><s>[INST] Doctor: I'm sorry to hear that. [/INST] Patient: I'm living in a Chronic Rehab Unit. I can't use my walker anymore. I'm confined to a wheelchair. </s><s>[INST] Doctor: Is it all of your fingers or only some? [/INST] Patient: On top of that, I've noticed that my hands have been numb for the past three weeks. </s><s>[INST] Doctor: Are you noticing any other symptoms along with the numbness in your fingers? [/INST] Patient: All. </s><s>[INST] Doctor: I see. [/INST] Patient: Yes. I feel like I've lost quite a bit of muscle in my hands. They're also much weaker than before. My strength hasn't been the same since July O eight. It's definitely getting worse. </s><s>[INST] Doctor: Fasciculations? [/INST] Patient: I've had muscle twitching in my legs since August O eight. </s><s>[INST] Doctor: Any cramping or problems swallowing? [/INST] Patient: Yes. In my lower legs and thighs. </s><s>[INST] Doctor: Any difficulty breathing? [/INST] Patient: No. </s><s>[INST] Doctor: Any constipation or diarrhea? [/INST] Patient: No. </s><s>[INST] Doctor: But no loss of bowel or bladder control? [/INST] Patient: Both actually. It tends to alternate. </s><s>[INST] Doctor: Okay. [/INST] Patient: No. I've noticed that my blood pressure has been out of whack. I also feel like I'm about to faint anytime I stand. </s><s>[INST] Doctor: How long has that been going on? [/INST] Patient: I don't think I have much feeling in my feet. They feel like sponges. </s><s>[INST] [/INST] Patient: Uh nine months or so. I lost joint position sense in my feet around that time, too. </s>

ALLERGY

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

<s>[INST] No I do not. [/INST] Do you have any allergies? </s><s>[INST] Okay. [/INST] Okay. </s><s>[INST] Doctor: No, I want to know about all allergies. [/INST] Patient: Are you only asking for medical allergies? </s>

GENHX

Symptoms: Itchy rash all over torso and arms Diagnosis: No facial swelling, no tongue or lip swelling, no shortness of breath, wheezing, or other associated Symptoms, no identifiable triggers History of Patient: Possible exposure to insulation removal in basement a few days ago Plan of Action: N/A

<s>[INST] All over my torso and arms. [/INST] Where's your rash? </s><s>[INST] Well, it started on my back and then it made its way to my torso and arms. [/INST] When did you first notice it? </s><s>[INST] Yes. [/INST] Have you found yourself itching it? </s><s>[INST] Nope. I mean I did remove some insulation in my basement a few days ago, but I didn't feel itchy that day. [/INST] Any potential triggers for the rash, such as dietary changes, new medications, or unfamiliar exposures? </s><s>[INST] No. [/INST] Any shortness of breath, wheezing, facial swelling, tongue or lip swelling, or other associated symptoms? </s>

FAM/SOCHX

Symptoms: N/A. Diagnosis: N/A. History of Patient: Patient reports being in a monogamous relationship with an HIV-positive male partner for three years. Plan of Action: Offer counseling on safe sexual practices and regular testing for sexually transmitted infections.

<s>[INST] Yes. [/INST] Are you sexually active? </s><s>[INST] Just one. [/INST] How many partners do you have? </s><s>[INST] Yes. [/INST] Is this a monogamous relationship? </s><s>[INST] He is a male. We have been together for three years. He is H I V positive. [/INST] What gender is you partner? </s>

PASTMEDICALHX

Symptoms: N/A Diagnosis: hypertension, anxiety History of Patient: N/A Plan of Action: N/A

<s>[INST] Maybe, I might. What exactly do you mean by that, doctor? [/INST] Do you have any major medical conditions that I should know about, sir? </s><s>[INST] Okay, that's what I thought. I have high blood pressure. [/INST] Well, it's broad, but it could be anything from depression to high blood pressure, to cancer. </s><s>[INST] Um, yeah, I have anxiety, too. [/INST] What about your mental health, is there anything of note there? </s>

GENHX

Symptoms: Back and neck pain. Diagnosis: N/A History of Patient: Patient reports a history of chronic neck pain following a car accident. Additionally, occasional back pain is experienced. Plan of Action: N/A

<s>[INST] I got into a car accident a long time ago and I have always had neck pain. [/INST] Do you have any history of chronic pain? </s><s>[INST] Sometimes I have back pain. [/INST] Okay. Any other pain throughout the body? </s><s>[INST] [/INST] Okay. </s>

ALLERGY

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

<s>[INST] No. None that I know of. [/INST] Do you have any drug allergies? </s>

CC

Symptoms: nausea Diagnosis: N/A History of Patient: N/A Plan of Action: N/A

<s>[INST] Hi Doctor, I am good. [/INST] Hello, how are you? </s><s>[INST] Well, I am having nausea and I just want to get it checked. [/INST] So, what is going on with you? </s><s>[INST] [/INST] Okay. </s>

GENHX

Symptoms: She has been having some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM. She has some loss of feeling in her big toe and calf. Diagnosis: Denies any new bowel or bladder dysfunction or increased sensory loss. She had some patchy sensory loss from L4 to S1. History of Patient: She is a 14-year-old right-handed female who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age. The last surgery was in 03/95. She did well. Plan of Action: N/A

<s>[INST] Guest_family: Sure, well she's fourteen now, um, she's right handed, and she just started high school. [/INST] Can you tell me more about your daughter, ma'am? </s><s>[INST] Guest_family: Yeah, she had an, um, lipomyomeningocele repair when she was about three days old, and then again when she was three and a half years old. [/INST] Has she ever had surgery? </s><s>[INST] Guest_family: Um, it was in March of nineteen ninety five. [/INST] When was her last surgery? </s><s>[INST] Guest_family: She did well, honestly. [/INST] How did she do following the second surgery? </s><s>[INST] Well, I've been having some leg pain on the side of my legs. [/INST] So, what brings you in for a visit today? </s><s>[INST] It's been several months at this point. [/INST] How long have you had this pain? </s><s>[INST] Um, it's the worst at night, I have to take medicine for the pain. [/INST] When is your pain the worst? </s><s>[INST] Guest_family: She takes Advil, Motrin, and Tylenol P M. [/INST] What do you take? </s><s>[INST] Yeah, there's no problems there. I do have some loss of feeling in my big toe and calf though. [/INST] Wow, that's a lot. Looks like you have some patch sensory loss in the L four to S one region. Are you going to the bathroom regularly? </s>