Dataset:v0
id
dataset
encounter_id
dialogue
note
aci
D2N040
[doctor] carolyn is a 34 -year-old female with a history of diabetes mellitus type two who is here today with a headache so hi there carolyn it's nice to see you again listen i'm sorry you're having headaches well let's talk about it but i would like to record this conversation with this app that's gon na help me focus on you more would that be okay with you
[patient] yes that's okay
[doctor] okay great thanks so carolyn tell me about your headache and headache or headaches when did when did the...
CHIEF COMPLAINT
Headache.
MEDICAL HISTORY
Patient reports history of diabetes mellitus type 2.
SOCIAL HISTORY
Patient reports she enjoys golfing.
MEDICATIONS
Patient reports taking metformin 500 mg twice a day.
REVIEW OF SYSTEMS
Constitutional: Denies fever.
Eyes: Denies vision changes.
HENT: Reports ear flushing.
Neurological: Reports headaches and dizziness.
PHYSICAL EXAM
Eyes
- Examination: No papilledema.
- Extraocular Muscles: Grossly Intact without pain.
Neck
- General Examinat...
aci
D2N036
[doctor] hey george how are you today i understand you're here for some numbness and tingling in your fingers and some pain in your wrist
[patient] right my right wrist and hand has been bothering me probably for a few months now with pain and numbness
[doctor] okay and you said that's been ongoing for several months do you know what caused this type of pain or is it just something that started slowly or
[patient] it just kinda started on it's own it i notice it mostly at night
[doctor] okay
[pa...
CHIEF COMPLAINT
Left wrist and hand pain.
HISTORY OF PRESENT ILLNESS
George Lewis is a pleasant 57-year-old male who presents to the clinic today for evaluation of left wrist and hand pain. He reports an onset of a few months ago but denies any specific injury. However, the patient notes he often engages in repetitive motions while performing his work duties. His symptoms are worse at night, and he wakes with numbness in the bilateral hands. He experiences numbness in all fingers, but states ...
aci
D2N053
[doctor] so barbara i i know you are here for some itchy scalp pain can you tell me a little bit about how you're doing
[patient] yeah it's still quite a problem you know something i've been suffering with for so long now it's still quite itchy and it's really embarrassing too because i'll have dandruff so much like all over me but but i just ca n't stop itching
[doctor] okay when did you first notice this
[patient] i wan na say it's been a while but probably worsening in the past like six month...
CHIEF COMPLAINT
Itchy scalp pain.
REVIEW OF SYSTEMS
Constitutional: Denies fever or weight loss.
HENT: Reports scalp pain Musculoskeletal: Denies joint pain.
Skin: Reports itchy scalp Denies any rashes.
VITALS
BP: 130/68.
HR: 98.
RR:18.
Temperature is 97.7 today.
PHYSICAL EXAM
Integumentary
- Examination: Scalp reveals demarcated scaly, erythematous plaques. They are patchy in format and diffusely present across the back of the skull.
ASSESSMENT AND PLAN
1. Scalp psoriasis.
- Medical Re...
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D2N024
[doctor] patient is pamela cook . medical record number is 123546 . she's a 36-year-old female post bilateral reduction mammoplasty on 10-10 20-20 .
[doctor] hey , how are you ?
[patient] good . how are you ?
[doctor] i'm doing well . it's good to see you . how have you been ?
[patient] i've been doing good .
[doctor] great . how about your breasts , are they doing all right ?
[patient] great .
[doctor] are you having any chills , fever , nausea , or vomiting ?
[patient] no .
[doctor] good . all...
CHIEF COMPLAINT
Follow up bilateral reduction mammoplasty.
HISTORY OF PRESENT ILLNESS
Pamela Cook is a 36-year-old female who is returning for a postoperative visit. Status post bilateral reduction mammaplasty 10/10/2020.
The patient was last seen in clinic by Ruth Sanchez, PA in 03/2021 at which time there was a lump along the left breast, and she was advised to perform massages.
Today, Ms. Cook reports she is doing well and that her breasts feel great. She is no longer suffering from back...
aci
D2N059
[doctor] okay
[patient] good morning
[doctor] good morning thanks doctor doctor cooper i'm i'm you know i'm a little i'm sad to be in here but you know thanks for taking me in i appreciate it
[patient] sure absolutely what can i help you with today
[doctor] so you know i've been dealing with my asthma and like i tried to join sports but it's really kind of it's getting hard you know and i i i just wonder if there's something that can be done because i really do like playing water polo
[patient] ...
CHIEF COMPLAINT
Asthma.
MEDICAL HISTORY
Patient reports history of asthma.
SURGICAL HISTORY
Patient reports history of tonsillectomy.
SOCIAL HISTORY
Patient reports she is a student and enjoys playing water polo as well as being active with aerobics and running.
ALLERGIES
Patient reports history of seasonal allergies.
MEDICATIONS
Patient reports using an albuterol inhaler, 2 puffs as needed.
REVIEW OF SYSTEMS
Constitutional: Reports fatigue.
Respiratory: Reports shortness of breath....
virtassist
D2N011
[doctor] hi , roger . how are you ?
[patient] hey . good to see you .
[doctor] good to see you . are you ready to get started ?
[patient] yes , i am .
[doctor] roger is a 62 year old male here for emergency room follow-up for some chest pain . so , roger , i heard you went to the er for some chest discomfort .
[patient] yeah . we were doing a bunch of yard work and it was really hot over the weekend and i was short of breath and i felt a little chest pain for probably about an hour or so . so , ...
HISTORY OF PRESENT ILLNESS
Roger Nelson is a 62-year-old male who presents for emergency room follow-up for chest pain. The patient was doing yard work over the weekend when he began to feel short of breath and a full chest pain for approximately hour. He denies a history of chest pain. The patient notes that after he finished he felt fine. He has not had any other symptoms since that time. He denies a family history of heart disease.
The patient underwent right knee surgery a couple of months...
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D2N023
[doctor] next patient is paul edwards , date of birth is january 15th 1962 . so he's a 59 year old hiv positive gentleman here for hypogonadism . patient was last seen on november 24th 2020 . his notable things are number one , he is on 1 milliliter every 10 days , uh , his levels were less than 300 to begin with . he's on finasteride currently . he also takes cialis daily so he takes all his pills just from me . um , patient's other area of concern is gynecomastia which is ... which we will dis...
CHIEF COMPLAINT
Hypogonadism.
HISTORY OF PRESENT ILLNESS
Mr. Paul Edwards is a 59-year-old male, an established patient, who presents to the clinic today for hypogonadism. He was last seen on 11/24/2020. The patient’s history includes positive for HIV, and today he is concerned with gynecomastia.
The patient is doing well, overall, and feels the testosterone is helping. He reports weight stability, feels lively, good, more vigorous, and he is sleeping well. He also thinks the testosterone is...
virtassist
D2N019
[doctor] hi ms. hernandez , dr. fisher , how are you ?
[patient] hi dr. fisher . i'm doing okay except for my elbow here .
[doctor] all right . so it's your right elbow ?
[patient] it's my right elbow , yes .
[doctor] okay . hey dragon , ms. hernandez is a 48-year-old female here for a right elbow . so , tell me what happened .
[patient] well , i was , um , moving to a new home-
[doctor] okay .
[patient] and i was , um , moving boxes from the truck into the house and i lifted a box up and then i...
CC:
Right elbow pain.
HPI:
Ms. Hernandez is a 48-year-old female who presents today for an evaluation of right elbow pain. She states she was moving boxes from the truck into the house yesterday and felt a pop in her elbow. She has tried applying ice and taking Ibuprofen, but it does not help. She has a history of anaphylaxis and has an EpiPen. Her past surgical history is significant for neck surgery.
EXAM
Examination of the right elbow shows tenderness over the lateral epicondyle. Swellin...
aci
D2N058
[doctor] russell ramirez is a 45 -year-old male with past medical history significant for cad status post prior status post prior rca stent in twenty eighteen hypertension and diabetes mellitus who presents for hospital follow-up after an anterior stemi now status post drug-eluting stent and lad and newly reduced ejection fraction ejection fraction thirty five percent and moderate mitral regurgitation alright russell hi how are you doing today
[patient] hey document i i do n't know i'm doing alr...
CHIEF COMPLAINT
Hospital follow-up after an anterior STEMI.
MEDICAL HISTORY
Patient reports history of CAD status post prior RCA stent in 2018, hypertension, and diabetes mellitus.
SURGICAL HISTORY
Patient reports history of RCA stent in 2018 and most recently underwent drug-eluting stent placement in the LAD.
SOCIAL HISTORY
Patient reports enjoying walking outside, gardening, and nature photography.
MEDICATIONS
Patient reports taking aspirin 81 mg daily, Brilinta 90 mg twice a day, Lip...
aci
D2N039
[doctor] hi virginia how are you today what brings you in
[patient] i'm doing alright i started seeing this new pcp last year and you know she has been doing a lot of changes to my medication and making sure everything is up to date and she my noticed that my blood pressure has been quite high so she added to medications but and but i you know i've been taking them i've been really good and i i before i was n't but now i am and we're still having a hard time controlling my blood pressure so she ...
CHIEF COMPLAINT
High blood pressure.
SOCIAL HISTORY
Patient reports drinking a couple of beers during the week and approximately 1 to 2 on the weekend. She is employed.
FAMILY HISTORY
Patient reports both of her parents have hypertension and one also had kidney disease.
MEDICATIONS
Patient reports taking Norvasc 10 mg daily and carvedilol 25 mg twice daily. She occasionally takes anti-inflammatories.
REVIEW OF SYSTEMS
Cardiovascular: Denies chest pain or dyspnea on exertion.
Respiratory...
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D2N021
[doctor] next patient is christine hernandez , uh , date of birth is january 13th , 1982 .
[doctor] hey , miss christine , how are you doing today ?
[patient] i'm good , thanks . how are you ?
[doctor] i'm pretty good . so it looks like you've completed the covid vaccine , that's great .
[patient] yes , i did .
[doctor] anything new since your last visit ?
[patient] no , i did all the tests that you had recommended me to take . i have n't been able to take the thyroid medicine , the one that you...
CHIEF COMPLAINT
Hypothyroidism.
Abnormal liver enzymes.
Abnormal weight gain.
Acne vulgaris.
HISTORY OF PRESENT ILLNESS
Christine Hernandez is a 39-year-old female who presents today for evaluation and management of abnormal liver enzymes and hypothyroidism.
When the patient was last seen, her thyroid medicine was changed to Unithroid, but due to the cost of $75, she has not yet started the new medicine and continues taking her previous thyroid medicine. She denies utilizing the coupon that ...
aci
D2N061
[doctor] hi virginia how're you today
[patient] i'm good thanks how are you
[doctor] good so you know you got that knee x-ray when you first came in but tell me a little bit about what happened
[patient] i was playing basketball and jerry ran into me and the inside of my knee hurts
[doctor] okay did you fall to the ground or did you just kinda plant and he pushed and you went one way and your knee did n't
[patient] i did fall to the ground
[doctor] you did fall to the ground okay and did you lan...
CHIEF COMPLAINT
Right knee pain.
HISTORY OF PRESENT ILLNESS
Virginia Phillips is a pleasant 53-year-old female who presents to the clinic today for the evaluation of right knee pain. The onset of her pain began 7 days ago, when she was playing basketball and another player ran into her. She states that she fell to the ground and landed on her side. She denies hearing or feeling a pop at the time of the injury. The patient localizes her pain to the medial aspect of her knee. She used ice and a...
virtassist
D2N015
[doctor] thanks , rachel . nice , nice to meet you .
[patient] yeah .
[doctor] um , as my nurse told you , we're using dax . so i'm just gon na tell dax a little bit about you .
[patient] mm-hmm .
[doctor] so rachel is a 48-year-old female here for shortness of breath . she has a history of depression , smoking , and chronic back pain . so tell me about this shortness of breath .
[patient] okay . so there are times when i'm either doing very , very mild exercises or just walking , even if i'm ju...
CHIEF COMPLAINT
Shortness of breath.
HISTORY OF PRESENT ILLNESS
The patient is a 48-year-old female who presents for shortness of breath. She has a history of depression, smoking and chronic back pain.
The patient reports shortness of breath with mild exercise and walking. She also notes some palpitations at times. She is not sure if it is due to her back pain or not. The patient states she has been exercising more. She continues to smoke but has decreased from two packs a day down to a coup...
aci
D2N052
[doctor] so anna good to see you today so reading here in your appointment notes you were you were diagnosed with kidney stones from your your pcp and you currently have one and so they they had you come in so can you tell me what happened how's all that going for you
[patient] sure i've been having some back pain on my right side it's been lasting for about a week now
[doctor] okay
[patient] and i also started to see some blood in my urine
[doctor] okay so on the right side so does that pain do...
HISTORY OF PRESENT ILLNESS
Anna Diaz is a pleasant 29-year-old female who presents to the clinic today for the evaluation of right-sided back pain.
For approximately 1 week, the patient has been experiencing constant right-sided back pain that radiates down to her lower right side, as well as hematuria and nausea. Her primary care physician was concerned for possible kidney stones and subsequently referred her here for further evaluation. She denies any pain with urination or vomiting, but adm...
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