original_row_id int64 8 2.03k | annotator_id int64 8 8 | Note stringlengths 1.86k 4.31k | Dialogue stringlengths 3.16k 7.1k | ICD10 stringlengths 3 7 | ICD10_desc stringlengths 8 109 |
|---|---|---|---|---|---|
8 | 8 | **1. Subjective:**
**Chief Complaint (CC):**
The patient, a 45-year-old Asian male, presents with severe abdominal pain, high fever, and confusion.
**History of Present Illness (HPI):**
The patient reports experiencing severe abdominal pain, high fever, jaundice, confusion, and weakness for the past 36 hours. He is c... | **[Doctor]** Hi there. How are you feeling today?
**[Patient]** Not good, doctor. I'm in a lot of pain.
**[Doctor]** I'm sorry to hear that. Can you tell me a bit more about what's been going on?
**[Patient]** Sure. I've been having really bad abdominal pain and a high fever for the last day and a half. I'm also fee... | A4189 | OTHER SPECIFIED SEPSIS |
18 | 8 | **Subjective:**
**Chief Complaint (CC):**
Itchy skin lesions on the trunk and arms.
**History of Present Illness (HPI):**
The patient is a 6-year-old African American male who presents today for an initial consultation regarding itchy skin lesions that have been present for the past 2 months. The lesions are describe... | [doctor] Hi there, I'm Dr. Smith. How are you doing today?
[patient] Hi, I'm okay. Just a little itchy.
[doctor] I see. So, you're here because of some itchy skin lesions on your trunk and arms. Could you tell me more about that?
[parent] Yes, he's had these itchy spots for about two months now. They started as smal... | B081 | MOLLUSCUM CONTAGIOSUM |
28 | 8 | #####
**1. Subjective**
**Chief Complaint (CC)**
Severe itching, scaling, and swelling of feet.
**History of Present Illness (HPI)**
A 60-year-old Hispanic male, Mr. Juan Martinez, presents via telemedicine for evaluation and management of severe itching, scaling, and swelling of the feet persisting for the past mont... | [doctor]: Good morning, how are you today?
[patient]: Good morning, doctor. I'm not doing too well, actually.
[doctor]: I'm sorry to hear that. What seems to be the problem?
[patient]: I've been having severe itching, scaling, and swelling on my feet for the past month. It's really bad.
[doctor]: Hmm, that sounds u... | B353 | TINEA PEDIS |
38 | 8 | **1. Subjective:**
**Chief Complaint (CC):**
Follow-up visit for severe respiratory symptoms, previously seen in the ER for the same.
**History of Present Illness (HPI):**
The patient is a 45-year-old African American female with a past medical history significant for asthma and obesity. She presents for follow-u... | [doctor] Hi, how are you today? What brings you in?
[patient] Hi, I'm not doing too well. I'm here for a follow-up visit. I was in the ER recently for some severe respiratory symptoms.
[doctor] I see. Can you tell me more about what's been going on?
[patient] Sure. I've had these symptoms for about 9 days now. I hav... | B961 | KLEBSIELLA PNEUMONIAE [K. PNEUMONIAE] AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE |
48 | 8 | #####
**1. Subjective:**
**Chief Complaint (CC):**
- Severe dysphagia with inability to swallow solids.
**History of Present Illness (HPI):**
- A 68-year-old Asian male presents with a 4-month history of progressive dysphagia, now severe, preventing him from swallowing solids. He reports frequent hematemesis, signifi... | [doctor]: Good morning. How are you feeling today?
[patient]: Good morning, doctor. I'm not feeling well. I've been having a lot of trouble swallowing.
[doctor]: Hmm, I'm sorry to hear that. Can you tell me more about your swallowing difficulties?
[patient]: Yes, it's been getting worse over the last four months. No... | C159 | MALIGNANT NEOPLASM OF ESOPHAGUS, UNSPECIFIED |
58 | 8 | **1. Subjective:**
**Chief Complaint (CC):**
Moderate to severe pain during bowel movements, rectal bleeding, and unintentional weight loss over the past 2 months.
**History of Present Illness (HPI):**
John Smith is a 58-year-old Caucasian male presenting with moderate to severe pain during bowel movements, which he ... | [doctor]: Hi John, how are you today?
[patient]: Hi, Doctor. I'm hanging in there, but it's been tough.
[doctor]: I understand. Let's go through your symptoms and concerns. Can you tell me a bit about what's been going on?
[patient]: Sure. I've been having moderate to severe pain during bowel movements for the past ... | C20 | MALIGNANT NEOPLASM OF RECTUM |
68 | 8 | **1. Subjective:**
**Chief Complaint (CC):**
Persistent cough with blood-tinged sputum, night sweats, and increasing fatigue over the last 2 months.
**History of Present Illness (HPI):**
The patient is a 65-year-old Asian female, a retired teacher, who presents with a history of worsening cough, blood-tinged sputum, ... | ```markdown
[doctor] Good morning. How are you feeling today?
[patient] Good morning, doctor. I'm not feeling too great, to be honest.
[doctor] Hmm, I'm sorry to hear that. Can you tell me more about what's been going on?
[patient] Well, I've had this persistent cough for the past two months, and lately, I've been c... | C3431 | MALIGNANT NEOPLASM OF LOWER LOBE, RIGHT BRONCHUS OR LUNG |
78 | 8 | #####
**1. Subjective:**
- **Chief Complaint (CC):**
- The patient, Maria Gonzalez, is a 63-year-old Hispanic female presenting for evaluation of a scalp lesion noted to be expanding over the last 2 months.
- **History of Present Illness (HPI):**
- Lesion has been expanding for the past 2 months.
- Moderate ... | [doctor]: Good morning, how are you doing today?
[patient]: Good morning, doctor. I'm okay, but I've got this lesion on my scalp that's been worrying me.
[doctor]: I see. Can you tell me more about it?
[patient]: Sure, it's been there for about 2 months now and it seems to be getting bigger.
[doctor]: Hmm, I unders... | C4441 | BASAL CELL CARCINOMA OF SKIN OF SCALP AND NECK |
88 | 8 | #####
1. Subjective:
**Chief Complaint (CC):**
Mild pain in the right breast and a noticeable lump.
**History of Present Illness (HPI):**
Maria Sanchez, a 45-year-old Hispanic female and school teacher, presents for an initial consultation. She reports noticing mild pain in her right breast over the past 2 months. Sh... | [doctor]: Good morning, Maria. How are you doing today?
[patient]: Good morning, Doctor. I'm a bit anxious, to be honest.
[doctor]: Hmm, I understand. I see you're here because of some pain in your right breast and a lump you found. Can you tell me more about it?
[patient]: Yes, I've had mild pain in my right breast... | C50311 | MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF RIGHT FEMALE BREAST |
98 | 8 | ### Initial Consultation Note
#### 1. Subjective:
**Chief Complaint (CC):**
Severe breast pain, rated 8/10.
**History of Present Illness (HPI):**
María González, a 67-year-old Hispanic female, presents with severe breast pain in the right breast, rated 8/10, ongoing for the past 6 months. She also reports persistent... | [doctor]: Hi María, how are you doing today?
[patient]: Hola, doctor. I’m not feeling well. I have a lot of pain.
[doctor]: I’m sorry to hear that. Can you tell me more about your pain?
[patient]: Sí, it’s in my right breast. It’s very painful, like an 8 out of 10.
[doctor]: I see. How long have you been experienci... | C50919 | MALIGNANT NEOPLASM OF UNSPECIFIED SITE OF UNSPECIFIED FEMALE BREAST |
108 | 8 | ### Subjective
#### Chief Complaint (CC)
Follow-up visit for the management of newly diagnosed malignant neoplasm of unspecified kidney.
#### History of Present Illness (HPI)
The patient, named Mei Lin, is a 32-year-old Asian female who initially presented with intermittent hematuria and mild lower back pain for the ... | [doctor] Hi there, how are you today?
[patient] Hello, I'm doing alright, thank you. I'm here for my follow-up visit.
[doctor] Great, let's get started. Can you remind me what brought you in today?
[patient] Yes, it's for the management of my newly diagnosed kidney cancer.
[doctor] Right, I see. How have you been f... | C649 | MALIGNANT NEOPLASM OF UNSPECIFIED KIDNEY, EXCEPT RENAL PELVIS |
118 | 8 | ### **Medical Note**
**1. Subjective:**
**Chief Complaint (CC):**
Follow-up for evaluation and treatment of newly identified metastatic lymph nodes.
**History of Present Illness (HPI):**
Mr. Huang is a 68-year-old Asian male with a significant past medical history of stage II gastric cancer treated with gastrectomy ... | [doctor]: Good morning, Mr. Huang. How are you feeling today?
[patient]: Good morning, Doctor. I've been feeling a bit of pressure in my abdomen.
[doctor]: Hmm, I see. Can you tell me more about this pressure?
[patient]: Yeah, it's been happening for about a month now. It comes and goes, maybe a few times a day.
[d... | C772 | SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRA-ABDOMINAL LYMPH NODES |
128 | 8 | #####
**1. Subjective:**
**Chief Complaint (CC):**
Severe lower back pain and significant weight loss.
**History of Present Illness (HPI):**
Mr. John Doe is a 68-year-old African American retired factory worker who presents to the emergency room with severe lower back pain, which has been persistent for the past mont... | [doctor] Hi Mr. Doe, how are you feeling today?
[patient] Oh, doctor, it's been tough. My lower back pain has been unbearable.
[doctor] I'm sorry to hear that. Can you tell me more about when this pain started?
[patient] It started about a month ago. It's been getting worse and is really affecting my ability to move... | C7989 | SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES |
138 | 8 | #####
**1. Subjective:**
**Chief Complaint (CC):**
Persistent headaches, dizziness, and peripheral neuropathy.
**History of Present Illness (HPI):**
Ms. Maria Gonzalez is a 72-year-old African American female presenting to the clinic for worsening symptoms of Waldenstrom macroglobulinemia. She reports that her sym... | [doctor]: Good morning, Ms. Gonzalez. How are you feeling today?
[patient]: Good morning, doctor. I'm not feeling so well, to be honest. I'm here because I've been having persistent headaches, dizziness, and my legs feel numb all the time.
[doctor]: Hmm, I'm sorry to hear that, Ms. Gonzalez. Can you tell me when thes... | C880 | WALDENSTROM MACROGLOBULINEMIA |
148 | 8 | ### MEDICAL NOTE
**1. Subjective:**
**Chief Complaint (CC):**
Moderate itching and slight bleeding on the right temple.
**History of Present Illness (HPI):**
The patient, a 72-year-old Hispanic male, presents with a lesion on his right temple. He reports moderate itching and slight bleeding from the lesion that has ... | ```plaintext
[doctor] Hello, Mr. Rodriguez. How are you doing today?
[patient] Hello, Doctor. I’m alright, but I’m here because of this problem on my right temple.
[doctor] I see. Can you tell me more about what’s been going on with your right temple?
[patient] Well, I’ve had this lesion here for about three months ... | D0439 | CARCINOMA IN SITU OF SKIN OF OTHER PARTS OF FACE |
158 | 8 | **1. Subjective:**
**Chief Complaint (CC):**
Mrs. Sylvia Johnson, a 64-year-old African American female, presents with concerns of dark blood in stool and occasional abdominal pain, persisting for the last two months.
**History of Present Illness (HPI):**
The patient reports experiencing moderate, persistent symptoms... | [doctor]: Hi Mrs. Johnson, how are you doing today?
[patient]: Hi doctor, not too great. I've been having some concerning symptoms.
[doctor]: Oh, I'm sorry to hear that. What seems to be the problem?
[patient]: I've noticed dark blood in my stool and some abdominal pain for the past two months.
[doctor]: Oh dear, t... | D128 | BENIGN NEOPLASM OF RECTUM |
168 | 8 | **1. Subjective:**
**Chief Complaint (CC):**
Right breast lump with moderate pain.
**History of Present Illness (HPI):**
The patient is a 58-year-old Asian female who presents for a pre-operative consultation for a benign neoplasm of the right breast. She has noticed a lump and associated pain for 4 mont... | [doctor]: Hello, how are you doing today?
[patient]: Hi, I'm doing alright, thank you.
[doctor]: I see you're here for a pre-operative consultation for a lump in your right breast. Can you tell me more about that?
[patient]: Yeah, I noticed a lump in my right breast about four months ago. It's been causing me some p... | D241 | BENIGN NEOPLASM OF RIGHT BREAST |
178 | 8 | **1. Subjective:**
**Chief Complaint (CC):** The patient reports experiencing visual disturbances, cold intolerance, fatigue, and decreased libido for the past 7 months.
**History of Present Illness (HPI):** The patient, a 55-year-old African American male, presents for a follow-up visit. He has been experiencing mod... | [doctor]: Hi there, thanks for coming in today. How have you been feeling?
[patient]: Hi, Doctor. I've been feeling pretty terrible, to be honest. I've been having visual disturbances, feeling cold all the time, really fatigued, and I have no interest in sex anymore. It's been going on for about 7 months now.
[doctor... | D352 | BENIGN NEOPLASM OF PITUITARY GLAND |
188 | 8 | #####
**SUBJECTIVE:**
**Chief Complaint (CC):**
Profound fatigue and dizziness.
**History of Present Illness (HPI):**
The patient, Mr. James Carter, a 65-year-old African American male, presents with severe fatigue and dizziness that have persisted over the past three months. He describes daily episodes of shortness ... | [doctor]: Good morning, how are you today?
[patient]: Good morning, doctor. I've been better, to be honest.
[doctor]: I'm sorry to hear that. Can you tell me more about what's been bothering you?
[patient]: Sure. I've been feeling really tired and dizzy for the past three months. It's been getting worse, and now I f... | D510 | VITAMIN B12 DEFICIENCY ANEMIA DUE TO INTRINSIC FACTOR DEFICIENCY |
198 | 8 | **1. Subjective:**
**Chief Complaint (CC):**
The patient reports mild fatigue and occasional dizziness for the past month.
**History of Present Illness (HPI):**
A 45-year-old Asian female with a history of Chronic Kidney Disease (Stage 3) and Hypertension presents for a routine check-up and to address her recent symp... | [doctor]: Hi, it's good to see you. How have you been feeling?
[patient]: Hi, Doctor. I've been feeling a bit off lately—mild fatigue and occasional dizziness for the past month.
[doctor]: Hmm, I see. Can you tell me more about these symptoms? How often do they occur and how severe are they?
[patient]: They happen a... | D631 | ANEMIA IN CHRONIC KIDNEY DISEASE |
208 | 8 | #####
**1. Subjective:**
**Chief Complaint (CC):**
Severe joint pain and petechiae.
**History of Present Illness (HPI):**
Mr. Lee, a 52-year-old Asian male, presents to the community health center for a follow-up visit regarding his ongoing severe joint pain and the appearance of petechiae over the past month. He re... | [doctor] Hi Mr. Lee, how are you doing today?
[patient] Hi, doctor. I've been better. The joint pain and these little red spots, they're really getting to me.
[doctor] I see. Can you tell me more about the joint pain and the petechiae?
[patient] Sure. The joint pain is really severe, especially in my right knee. It'... | D693 | IMMUNE THROMBOCYTOPENIC PURPURA |
218 | 8 | **1. Subjective:**
**CHIEF COMPLAINT**
Recurrent infections and failure to thrive.
**HISTORY OF PRESENT ILLNESS**
Juan Martinez is a 5-year-old Hispanic male who presents for an initial consultation due to recurrent infections and failure to thrive, symptoms ongoing for the past 3 months. The patient has experienced ... | [doctor]: Good morning! How are you today?
[patient's parent]: Good morning, doctor. We're doing okay, but we've been quite worried about Juan.
[doctor]: I understand. I see that Juan has been having quite a tough time with recurrent infections and failure to thrive. Could you tell me more about what’s been going on?... | D819 | COMBINED IMMUNODEFICIENCY, UNSPECIFIED |
228 | 8 | #####
**1. Subjective:**
**Chief Complaint (CC):**
Mild neck swelling and intermittent discomfort.
**History of Present Illness (HPI):**
The patient is a 60-year-old Hispanic female with a known history of type 2 diabetes and GERD, who presents for an initial consultation regarding a thyroid nodule noticed approximat... | [doctor]: Hi there! How are you doing today?
[patient]: I'm doing okay, thank you.
[doctor]: Great to hear. So, what brings you in today?
[patient]: I've noticed some mild swelling in my neck and feel a bit of discomfort sometimes.
[doctor]: I see. How long have you been experiencing this?
[patient]: It started ab... | E041 | NONTOXIC SINGLE THYROID NODULE |
238 | 8 | #####
**1. Subjective:**
**Chief Complaint (CC):**
38-year-old female presenting for management of Type 1 diabetes mellitus with recent hypoglycemia episodes.
**History of Present Illness (HPI):**
The patient, a 38-year-old Asian female PhD in Biochemistry and university professor, reports experiencing hypoglycemia e... | [doctor]: Hello, good to see you today. How are you feeling?
[patient]: Hi, I'm doing okay, thanks. I'm here to discuss my diabetes management.
[doctor]: Alright, let's get started. Can you tell me a bit about what's been going on with your diabetes lately?
[patient]: Sure. I've been having episodes of hypoglycemia,... | E10649 | TYPE 1 DIABETES MELLITUS WITH HYPOGLYCEMIA WITHOUT COMA |
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