original_row_id int64 9 2.03k | annotator_id int64 9 9 | Note stringlengths 1.33k 4.1k | Dialogue stringlengths 3.14k 6.49k | ICD10 stringlengths 3 7 | ICD10_desc stringlengths 8 114 |
|---|---|---|---|---|---|
9 | 9 | #####
**1. Subjective:**
**Chief Complaint:**
High fever, significant fatigue, nausea, decreased urine output, and abdominal pain for the last 3 days.
**History of Present Illness:**
The patient is a 45-year-old Hispanic male who presents with a severe high fever (102°F), significant fatigue, nausea, decreased urine... | [doctor]: Hi, good afternoon. How are you doing today?
[patient]: Hi, I'm not feeling well at all. I've had a high fever, I'm extremely tired, and I've been feeling nauseous.
[doctor]: Oh no, I'm sorry to hear that. How long have these symptoms been going on?
[patient]: It's been about three days now. The fever is r... | A419 | SEPSIS, UNSPECIFIED ORGANISM |
19 | 9 | **1. Subjective:**
**Chief Complaint (CC):**
Severe mouth pain and moderate fever for 2 days.
**History of Present Illness (HPI):**
A 4-year-old Caucasian male, named Ethan, presents with severe mouth pain and moderate fever for the past 2 days. His symptoms include a rash on his hands and feet accompan... | [doctor]: Good morning, how are you today?
[parent]: Good morning, doctor. We're doing alright, but my son has been having some severe mouth pain and a moderate fever for the past couple of days.
[doctor]: I'm sorry to hear that. Can you tell me more about his symptoms?
[parent]: Sure. He has a really bad pain in hi... | B084 | ENTEROVIRAL VESICULAR STOMATITIS WITH EXANTHEM |
29 | 9 | #####
**1. Subjective:**
**Chief Complaint (CC):**
Ring-shaped rash on the right forearm.
**History of Present Illness (HPI):**
A 35-year-old Asian male, named John Lee, presents with a complaint of an itchy, red, ring-shaped rash on his right forearm. The rash has been present for 3 weeks and has caused moderate itc... | [doctor]: Good morning, how are you today?
[patient]: Good morning, I'm doing okay. How about you?
[doctor]: I'm good, thank you. I see you're here about a rash on your right forearm. Can you tell me more about it?
[patient]: Sure, I've had this itchy, red, ring-shaped rash on my right forearm for about 3 weeks now.... | B354 | TINEA CORPORIS |
39 | 9 | **1. Subjective:**
**Chief Complaint (CC):**
Severe symptoms of high fever, chills, burning sensation during urination, and frequent urination persisting for 7 days.
**History of Present Illness (HPI):**
The patient, Maria Gonzalez, is a 45-year-old Hispanic female who presents with recurrent symptoms of severe urina... | **[doctor]** Hello, how are you feeling today?
**[patient]** Hi, doctor. I'm really not feeling well. I've been having some severe symptoms for the past week.
**[doctor]** I'm sorry to hear that. Can you tell me more about what you've been experiencing?
**[patient]** Sure. I've had a high fever and chills, and I fee... | B9620 | UNSPECIFIED ESCHERICHIA COLI [E. COLI] AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE |
49 | 9 | #####
**1. Subjective**
**Chief Complaint (CC):**
Persistent nausea, early satiety, occasional vomiting for the past 2 months.
**History of Present Illness (HPI):**
The patient is a 58-year-old Hispanic female with a history of COPD and osteoarthritis. She presents for a follow-up visit with persistent nausea, early ... | [doctor]: Good morning. How are you feeling today?
[patient]: Good morning, Doctor. I've been better, honestly. My primary care doctor referred me to you because of this persistent nausea and other symptoms I've been having.
[doctor]: I see. Can you describe the symptoms you've been experiencing?
[patient]: Sure. I'... | C160 | MALIGNANT NEOPLASM OF CARDIA |
59 | 9 | #####
1. Subjective:
- **Chief Complaint (CC):** Anal discomfort and itching.
- **History of Present Illness (HPI):**
The patient is a 50-year-old female with a significant medical history of irritable bowel syndrome (IBS) managed with diet and antispasmodics, presenting with mild discomfort and itchi... | [doctor]: Hi there, how are you today?
[patient]: I'm good, thank you. How are you?
[doctor]: I'm doing well, thanks for asking. So, what brings you in today?
[patient]: I've been having some anal discomfort and itching for the last six weeks.
[doctor]: Hmm, I see. When did you first notice these symptoms?
[patien... | C210 | MALIGNANT NEOPLASM OF ANUS, UNSPECIFIED |
69 | 9 | **Subjective:**
**Chief Complaint (CC):**
Follow-up for malignant neoplasm of the lower lobe, left bronchus, or lung.
**History of Present Illness (HPI):**
The patient is a 55-year-old Asian male named Mr. Kenji Tanaka who returns for follow-up after being diagnosed with a malignant neoplasm of the lower lobe, left b... | [doctor] Hi there, how are you feeling today?
[patient] I'm doing okay, thank you. How are you?
[doctor] I'm well, thank you. So, you're here for a follow-up on your malignant neoplasm of the lower lobe, left bronchus, or lung. How have you been feeling since we last saw you?
[patient] Well, to be honest, it's been ... | C3432 | MALIGNANT NEOPLASM OF LOWER LOBE, LEFT BRONCHUS OR LUNG |
79 | 9 | **1. Subjective:**
**Chief Complaint (CC):**
- Mild to moderate irritation on scalp and neck with rough, scaly patches.
**History of Present Illness (HPI):**
- 64-year-old Caucasian male presents with rough, scaly patches on the scalp and neck. These lesions have been present for the last year and have worsened over ... | [doctor] Good morning, how are you doing today?
[patient] Good morning, doctor. I'm doing alright, but I've been having some issues with my scalp and neck.
[doctor] I see. Can you tell me more about what's been going on?
[patient] Sure, I've been dealing with these rough, scaly patches on my scalp and neck for the l... | C4442 | SQUAMOUS CELL CARCINOMA OF SKIN OF SCALP AND NECK |
89 | 9 | #####
**1. Subjective:**
**Chief Complaint (CC)**
Follow-up visit post initial biopsy for a lump in the left breast with severe pain.
**History of Present Illness (HPI)**
The patient, Maria Gonzalez, is a 45-year-old Hispanic female with a past medical history significant for type 2 diabetes mellitus and hypothyroidi... | ```plaintext
[doctor]: Hello! How are you doing today?
[patient]: Hi, Doctor. I'm alright, but I'm really worried about this pain in my breast.
[doctor]: I understand. I see here that you recently had a biopsy for a lump in your left breast. Can you tell me more about how you're feeling?
[patient]: Yes, I found a lu... | C50312 | MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF LEFT FEMALE BREAST |
99 | 9 | **1. Subjective:**
- **Chief Complaint (CC):**
Follow-up for recent diagnosis of malignant neoplasm of cervix uteri.
- **History of Present Illness (HPI):**
The patient, named Angela Thompson, is a 34-year-old African American female with a history of polycystic ovary syndrome (PCOS) who presents... | ```plaintext
[doctor] Hi, how are you doing today? I understand you’re here for a follow-up after your recent diagnosis.
[patient] Hi, yes, I'm here for the follow-up. It's been a tough few weeks.
[doctor] I'm sorry to hear that. Can you tell me more about how you've been feeling?
[patient] I've been having severe p... | C539 | MALIGNANT NEOPLASM OF CERVIX UTERI, UNSPECIFIED |
109 | 9 | **1. Subjective:**
**CHIEF COMPLAINT**
Painless hematuria and increased urinary frequency.
**HISTORY OF PRESENT ILLNESS**
The patient is a 32-year-old Asian female named Emily Chen who presents to the clinic for evaluation of painless hematuria and increased urinary frequency. She reports that these symptoms began ap... | [Doctor] Hi, how are you today?
[Patient] Hello, I'm doing okay. Thanks for seeing me.
[Doctor] Of course. I'm Dr. Smith. What brings you in today?
[Patient] I've been having some issues. I've noticed blood in my urine and I need to go to the bathroom frequently.
[Doctor] I see. How long have you been experiencing ... | C672 | MALIGNANT NEOPLASM OF LATERAL WALL OF BLADDER |
119 | 9 | **1. Subjective:**
**Chief Complaint (CC):**
Severe pain in the left axilla and upper limb.
**History of Present Illness (HPI):**
John Doe is a 65-year-old African American male with a significant past medical history of COPD and Type 2 Diabetes Mellitus, who presents with severe pain in the left axilla and upper lim... | [doctor]: Good morning, how are you today?
[patient]: Good morning, Doctor. I've been better, honestly.
[doctor]: I'm sorry to hear that. What brings you in today?
[patient]: I've been having severe pain in my left armpit and upper arm. It's been going on for about three months now and it's just getting worse.
[doc... | C773 | SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF AXILLA AND UPPER LIMB LYMPH NODES |
129 | 9 | #####
**1. Subjective:**
**Chief Complaint (CC):**
Routine check-up with new-onset generalized bone pain, fatigue, and night sweats.
**History of Present Illness (HPI):**
The patient, Mr. John Smith, is a 51-year-old Caucasian male with a history of colon cancer treated 6 years ago and known hyperlipidemia presenting... | **Doctor:** Hi there, how are you doing today?
**Patient:** Hi doctor, I'm doing alright, just here for my routine check-up.
**Doctor:** Great, let's start with how you've been feeling lately. Any new symptoms or concerns?
**Patient:** Well, actually, yes. I've been having this generalized bone pain, feeling really ... | C799 | SECONDARY MALIGNANT NEOPLASM OF UNSPECIFIED SITE |
139 | 9 | **1. Subjective:**
**CHIEF COMPLAINT**
Follow-up for multiple myeloma management.
**HISTORY OF PRESENT ILLNESS**
Patient is a 58-year-old African American female diagnosed with multiple myeloma a year ago. She presents for her routine follow-up to discuss her current symptoms and ongoing treatment regimen. She repo... | [doctor]: Good morning! How are you feeling today?
[patient]: Good morning, doctor. I've been alright, but I have some bone pain in my hips and shoulders.
[doctor]: Oh, I'm sorry to hear that. Can you describe the bone pain for me?
[patient]: It's been moderate and mostly in my hips and shoulders. It comes and goes,... | C9000 | MULTIPLE MYELOMA NOT HAVING ACHIEVED REMISSION |
149 | 9 | **1. Subjective:**
**Chief Complaint (CC)**:
Routine screening mammogram detected abnormality in the right breast.
**History of Present Illness (HPI)**:
Maria Gonzalez, a 55-year-old Hispanic female, presents to the community health clinic for an initial consultation regarding an abnormality detected in her right bre... | [doctor]: Good morning, Maria. How are you today?
[patient]: Good morning, Doctor. I'm doing alright, thank you.
[doctor]: That's good to hear. I understand that you are here because of an abnormality detected in your right breast during a routine screening mammogram?
[patient]: Yes, that's correct. It was found abo... | D0511 | INTRADUCTAL CARCINOMA IN SITU OF RIGHT BREAST |
159 | 9 | #####
**1. Subjective:**
**Chief Complaint (CC):**
Patient presents with a lump in the lower back.
**History of Present Illness (HPI):**
Mr. John Lee, a 35-year-old Asian male, reports noticing a lump in his lower back approximately 3 months ago. He describes moderate discomfort, especially when sitting for long per... | [doctor]: Good morning, Mr. Lee. How are you today?
[patient]: Good morning, Doctor. I'm okay, thank you.
[doctor]: What brings you in today?
[patient]: Well, I've noticed a lump in my lower back, and it's been there for about three months now.
[doctor]: I see. Can you describe the lump for me?
[patient]: It's a s... | D171 | BENIGN LIPOMATOUS NEOPLASM OF SKIN AND SUBCUTANEOUS TISSUE OF TRUNK |
169 | 9 | **1. Subjective:**
**Chief Complaint (CC):**
Left breast lump with associated tenderness.
**History of Present Illness (HPI):**
Maria Gonzalez is a 60-year-old Hispanic female presenting for follow-up after an abnormal screening mammogram revealed a suspicious area in her left breast. She has been experiencing modera... | [doctor]: Hello Maria, how are you feeling today?
[patient]: Hello, Doctor. I’m alright, but I’m worried about this lump in my left breast.
[doctor]: I understand. Can you tell me a little more about the lump and how it’s been affecting you?
[patient]: Well, I first noticed it about six months ago. It’s been painful... | D242 | BENIGN NEOPLASM OF LEFT BREAST |
179 | 9 | #####
**1. Subjective:**
**Chief Complaint (CC):**
Frequent dizziness and headaches.
**History of Present Illness (HPI):**
The patient, a 67-year-old Hispanic female named Maria Gonzalez, presents with severe dizziness and headaches, which she reports have been occurring almost daily for the past 8 months. Associate... | ```plaintext
[doctor]: Hello! How are you feeling today?
[patient]: Hi, Doctor. I’ve been feeling really dizzy and having severe headaches almost every day.
[doctor]: Hmm, I’m sorry to hear that. How long has this been happening?
[patient]: It’s been going on for about 8 months now.
[doctor]: That’s quite a while. Are ... | D45 | POLYCYTHEMIA VERA |
189 | 9 | ### Subjective:
**CHIEF COMPLAINT**
Extreme fatigue and dizziness.
**HISTORY OF PRESENT ILLNESS**
The patient, a 60-year-old Caucasian male with a past medical history of obesity and gastric bypass surgery 3 years ago, presents with severe fatigue, dizziness, memory loss, and depression for the past 6 months. He repo... | [doctor]: Hi there, how are you doing today?
[patient]: Hi, doctor. I've been feeling really tired and dizzy lately.
[doctor]: I'm sorry to hear that. Can you tell me more about what's been going on?
[patient]: Sure, it's been about 6 months now. I feel extremely fatigued all the time, and I get dizzy quite often. I... | D518 | OTHER VITAMIN B12 DEFICIENCY ANEMIAS |
199 | 9 | **1. Subjective:**
**Chief Complaint (CC):**
Severe fatigue and chest pain.
**History of Present Illness (HPI):**
The patient, named Mei Lin, is a 60-year-old Asian female with a known history of Crohn's Disease, osteoarthritis, hypertension, and hyperlipidemia who presents with complaints of severe fatigue and chest... | [doctor] Good morning, how are you today?
[patient] Good morning, Doctor. I'm not feeling well at all.
[doctor] I'm sorry to hear that. I see from my notes that you're experiencing severe fatigue and chest pain. Can you tell me more about that?
[patient] Yes, Doctor. I've been feeling extremely tired and my chest ha... | D638 | ANEMIA IN OTHER CHRONIC DISEASES CLASSIFIED ELSEWHERE |
209 | 9 | #### Hematology Consultation Note
**1. Subjective:**
**Chief Complaint (CC):**
Fatigue and pallor for the past 6 weeks.
**History of Present Illness (HPI):**
The patient, a 66-year-old African American female, presents with a 6-week history of fatigue, pallor, and shortness of breath on exertion. She reports tha... | [doctor] Hi there, how are you today?
[patient] I'm alright, just feeling very tired lately.
[doctor] Hmm, I'm sorry to hear that. I see you're here because of fatigue and pallor. How long have you been experiencing these symptoms?
[patient] It's been about six weeks now. It's slowly gotten worse over time.
[doctor... | D6959 | OTHER SECONDARY THROMBOCYTOPENIA |
219 | 9 | **1. Subjective:**
The patient, a 50-year-old Asian female named Mei Lin, presents with severe episodes of chronic diarrhea, abdominal pain, and frequent fevers. She has a history of chronic urinary tract infections and gastritis. Over the past 4 years, she has experienced persistent symptoms occurring bi-weekly, signi... | ```
[doctor] Hello! How are you feeling today?
[patient] Not great, to be honest. I've been having severe episodes of diarrhea, abdominal pain, and frequent fevers.
[doctor] I'm sorry to hear that. Can you tell me how long you've been experiencing these symptoms?
[patient] It’s been going on for about four years now... | D839 | COMMON VARIABLE IMMUNODEFICIENCY, UNSPECIFIED |
229 | 9 | ### **Emergency Visit Medical Note**
#### 1. Subjective
**Chief Complaint (CC)**:
- Significant neck swelling and difficulty breathing, particularly when lying down.
**History of Present Illness (HPI)**:
- A 28-year-old Caucasian female presents with severe neck swelling persisting for 1 year.
- Symptoms include dif... | [doctor]: Hi there, how are you today?
[patient]: Hello, I'm not doing so well, honestly. I've been having a lot of trouble with my neck and breathing.
[doctor]: I'm sorry to hear that. I understand you’re dealing with significant neck swelling and difficulty breathing, especially when lying down. Is that correct?
[... | E042 | NONTOXIC MULTINODULAR GOITER |
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