qid int64 2.2M 5.29M | context stringlengths 327 2.78k | diagnosis stringlengths 6 49 | diagnosis_code stringlengths 7 7 |
|---|---|---|---|
4,635,107 | Patient Information:
Age: 29 years
Gender: Male
Chief Complaint: Left flank and abdominal pain for 9 hours.
Present Illness History: The patient experienced sudden onset of left and right flank and abdominal pain 9 hours ago without any obvious trigger. The pain is intermittent and colicky in nature, accompanied by dif... | Urolithiasis | N20.900 |
4,648,210 | **Medical Record Description:**
**Patient Information:**
- Age: 11 years 6 months
- Gender: Male
- Chief complaint: Chest tightness for half a day
**Present Illness History:**
The patient has recently experienced nasal congestion and rhinorrhea. Today, without any obvious trigger, he developed chest tightness. There ... | Acute tonsillitis | J03.900 |
4,671,793 | Patient information:
Age: 35 years
Gender: Female
Chief complaint: Episodes of loss of consciousness and limb convulsions for more than 4 months. Four months ago, while driving, the patient was unaware of the direction, turning left instead of right, and was switched out of the vehicle by family members. After returnin... | Epilepsy | G40.900 |
4,675,065 | **Medical Record Description:**
**Patient Information:**
- Age: 67 years
- Gender: Female
**Chief Complaint:**
- Throat discomfort and a sensation of a foreign body in the throat for 1 year, with intermittent hoarseness for over 6 months.
**Current Medical History:**
- No throat pain, no difficulty swallowing, no choki... | Chronic pharyngitis | J31.200 |
4,701,554 | Patient Information:
Age: 62 years
Gender: Male
Chief Complaints: Intermittent chest pain for 5 days, worsening for 4 hours.
Present Illness: The patient experienced discomfort behind the sternum 5 days ago without any obvious trigger, lasting about ten minutes and resolving on its own. Today, the patient reports that ... | Acute Coronary Syndrome (ACS) | I24.901 |
4,732,571 | Patient Information:
Age: 52 years
Gender: Female
Chief Complaint: Petechiae and ecchymosis all over the body accompanied by fatigue and poor appetite for 5 days.
Present Illness: The patient developed multiple petechiae and ecchymosis all over the body 5 days ago, accompanied by poor appetite and fatigue, without feve... | Thrombocytopenia | D69.600 |
4,768,827 | **Patient Information:**
- Age: 47 years
- Gender: Male
- Chief Complaint: Discovered intracranial cyst two months ago
**Present Illness History:**
The patient experienced dizziness and was found to have an intracranial cyst during an examination at an external hospital.
**Past Medical History:**
In the two weeks pri... | Arachnoid cyst | G93.001 |
4,813,651 | Patient Information:
Age: 72 years
Gender: Male
Chief Complaint: Shortness of breath and fatigue for 2 weeks.
Current Medical History: The patient developed shortness of breath 2 weeks ago without any apparent trigger, which worsened with activity. He also experienced symptoms of fatigue and difficulty breathing, which... | Heart failure | I50.900 |
4,822,653 | Patient Information:
Age: 6 years 1 month
Gender: Female
Chief Complaint: Short stature consultation.
Current Medical History: Born full-term via cesarean section, birth weight 3kg, birth length 50cm, no asphyxia or birth injuries at birth. Patient has had a gradually slower height growth, with height falling behind. A... | Short stature not elsewhere classified | E34.300 |
4,860,030 | **Medical Record Description:**
**Patient Information:**
- Age: 54 years
- Gender: Male
**Chief Complaint:**
Dizziness, chest tightness, nausea, and vomiting for 1 week.
**Present Illness History:**
Dizziness, chest tightness, nausea, and vomiting occurred suddenly last Monday without obvious triggers. After treatment ... | Coronary Atherosclerosis | I25.102 |
4,902,587 | Patient Information:
Age: 23 years
Gender: Male
Chief Complaint: Found to have a cyst in the cisterna magna for more than one month.
Present Illness: The patient presented one month ago with headaches and dizziness, and an MRI of the brain performed at another hospital revealed a cyst in the cisterna magna. He has come... | Arachnoid cyst | G93.001 |
4,950,489 | **Patient Information:**
- Age: 55 years
- Gender: Male
- Chief Complaint: Chest pain and tightness for 4 days.
**Present Illness History:**
The patient experienced chest pain behind the sternum 4 days ago after exertion, described as a pressure-like pain, accompanied by chest tightness and shortness of breath. There ... | Acute coronary syndrome | I24.901 |
4,971,573 | Medical Record Description:
Patient Information:
Age: 24 years
Gender: Female
Chief Complaint: Crooked teeth, requesting orthodontic treatment.
Present Illness: The patient reports that her posterior teeth are not aligned properly, affecting both aesthetics and function, and has come to our department requesting correc... | Malocclusion | K07.302 |
4,979,132 | Patient Information:
Age: 4 years and 4 months
Gender: Female
Chief Complaint: Unclear speech in a 4-year-old.
Present Illness History: The child started making sounds about 9 months ago and currently has no significant communication barriers in daily life. However, certain sounds are unclear. Speech clarity has improv... | Speech and language development disorders | F80.900 |
4,996,793 | Patient Information:
Age: 49 years
Gender: Male
Chief Complaint: Epilepsy for 20 years.
Present Illness: First seizure occurred in 2003 during sleep at night, characterized by limb convulsions and foaming at the mouth. Since then, he has experienced recurrent seizures, sometimes with "petit mal" seizures, present... | Epilepsy | G40.900 |
5,020,759 | Medical Record Description:
Patient Information:
Age: 52 years
Gender: Male
Chief Complaint: Intracranial aneurysm discovered 1 week ago.
Present Illness History: An intracranial aneurysm was found at an outside hospital 1 week ago, and the patient has come to our hospital for further examination.
Physica... | Intracranial Aneurysm | I67.110 |
5,044,386 | Patient Information:
Age: 19 years old
Gender: Female
Chief Complaint: Rectal bleeding for 1 day.
Present Illness: The patient experienced bright red blood during defecation today, with a small amount. She came for further diagnosis and treatment.
Physical Examination:
- Rectal Examination: External hemorrhoids noted ... | Mixed hemorrhoids | I84.201 |
5,071,438 | **Medical Record Description:**
**Patient Information:**
- Age: 70 years
- Gender: Female
- Chief Complaint: Numbness in the right upper limb and face for six months.
**Present Illness History:**
The patient has experienced numbness in the right upper limb and around the right side of the mouth for six months. She was ... | Cerebral infarction | I63.900 |
5,206,569 | Patient Information:
Age: 3 years
Gender: Male
Chief Complaint: Fever for 1 day
Present Illness: The child has presented with a fever starting today, with an irregular fever pattern and a maximum temperature of 38.9°C. There are no chills, no seizures, but he has a cough. There is no wheezing, no hoarseness, no cyanosi... | Acute upper respiratory tract infection | J06.900 |
5,215,266 | **Medical Record Description:**
**Patient Information:**
- Age: 30 years
- Gender: Male
- Chief Complaints: Sore throat for 2 days
**Present Illness History:**
- The patient began experiencing sore throat and pain during swallowing 2 days ago and sought consultation in our outpatient department.
**Past Medical History:... | Acute Pharyngitis | J02.900 |
5,237,063 | Medical Record Description:
Patient Information:
Age: 30 years
Gender: Male
Chief Complaint: Fractured upper left posterior tooth for one day
Present Illness History: The patient reports that his upper left posterior tooth fractured one day ago, and he is now seeking treatment in our department.
Physical Examination: T... | Dental fracture | K02.400 |
5,271,856 | **Medical Record Description:**
**Patient Information:**
- Age: 31 years
- Gender: Female
**Chief Complaint:** Thyroid abnormalities detected during physical examination six months ago.
**Present Illness History:** Approximately six months ago, during a health check at a hospital in Badong County, the patient was infor... | Hashimoto's thyroiditis | E06.304 |
2,231,502 | Patient Information:
Age: 9 years 4 months
Gender: Male
Chief Complaint: Discovered a subarachnoid cyst 1 day ago
Present Illness: The patient underwent a cranial MRI 1 day ago for attention deficit hyperactivity disorder (ADHD), which indicated a left temporal lobe subarachnoid cyst. He has come for further treatment.... | Arachnoid cyst | G93.001 |
2,269,727 | Patient Information:
Age: 1 year
Gender: Male
Chief Complaint: Diarrhea for 1 month
Present Illness: The child experienced diarrhea 1 month ago, with yellow, watery stools, 2 times/day, without mucus, blood, fever, vomiting, or paroxysmal crying. The child is alert and eating normally. Urine output is adequate.
Past Me... | Pediatric Diarrhea | K52.919 |
2,299,827 | Medical Record Description:
Patient Information:
Age: 35 years
Gender: Female
Chief Complaint: Sore throat for 1 day
Present Illness: Sore throat developed after exposure to cold yesterday, no cough or phlegm production, temperature unknown
Past Medical History: No history of drug allergies
Physical Examination: Rednes... | Acute Pharyngitis | J02.900 |
2,302,718 | Patient Information:
Age: 44 years
Gender: Female
Chief Complaint: Fatty liver diagnosed 2 weeks ago
Present Illness: The patient was diagnosed with fatty liver during a routine health check 2 weeks ago. Liver function is normal, and she reports no fatigue, poor appetite, or aversion to greasy foods. There are no signi... | Fatty liver disease | K76.000 |
2,318,132 | Patient Information:
Age: 48 years
Gender: Male
Chief Complaint: Sudden headache for three hours
Present Illness: The patient experienced a sudden headache three hours ago with no obvious trigger, accompanied by nausea and vomiting. There are no visual disturbances, no chest tightness or pain, no fever, no abdominal pa... | Subarachnoid hemorrhage | I60.900 |
2,340,238 | **Patient Information:**
- Age: 1 year and 5 months
- Gender: Female
- Chief Complaint: Diarrhea for 5 days
**Present Illness History:**
The child developed diarrhea 5 days ago without obvious triggers, with stools described as yellow and watery, occurring 3-5 times per day. There is no mucus, pus, or blood in the stoo... | Diarrhea | K52.916 |
2,357,535 | Patient Information:
Age: 4 years and 7 months
Gender: Female
Chief Complaint: Fever for half a day
Present Illness: The child has developed a fever today, with irregular fever patterns, the highest temperature reaching 39.6℃. There are no chills, but she is experiencing headache and sore throat. There is no cough or r... | Acute tonsillitis | J03.900 |
2,361,191 | Patient Information:
Age: 45 years
Gender: Female
Chief Complaint: Uterine adenomyosis, currently undergoing treatment with Dienogest
Present Illness History: Vaginal bleeding for over ten days
Physical Examination: Blood pressure / mmHg, Pulse [rate] / min, Respiratory rate / min, Temperature / °C
Auxiliary Examinatio... | Endometriosis | N80.001 |
2,381,073 | Medical Record Description:
Patient Information:
Age: 33 years
Gender: Female
Chief Complaint: History of polycystic ovary syndrome
Present Illness: Oral treatment with Diane-35
Past Medical History: Normal delivery in October 2018
Auxiliary Examination: Serum Insulin Measurement: Luminol method, Test Result: Serum Ins... | Polycystic Ovary Syndrome (PCOS) | E28.200 |
2,396,392 | Medical Record Description:
Patient Information:
Age: 52 years
Gender: Female
Chief Complaint: Cervical polyp detected at an external hospital, 1 week ago
Present Illness History: Experiences post-coital vaginal bleeding. Claims that cervical cancer screening was normal (no report available).
Physical Examination: Vulv... | Cervical polyp | N84.100 |
2,434,266 | **Medical Record Description:**
**Patient Information:**
- Age: 37 years
- Gender: Female
- Chief Complaint: Slight vaginal bleeding for 4 days
**Current Medical History:**
The patient has a history of irregular menstruation, with cycles ranging from 1 to 4 months. The last menstrual period was on September 9. On Septe... | Endometrial polyp | N84.001 |
2,434,352 | Patient Information:
Age: 54 years
Gender: Female
Chief Complaint: Gastrointestinal endoscopy revealed gastric polyps, requesting endoscopic treatment.
Examination Report: Routine gastroscopy findings:
Esophagus: Mucosa smooth, vascular network clear.
Cardia: Good opening and closing, dentate line clear.
Gastric Fun... | Gastric polyp | K31.703 |
2,452,896 | Medical Record Description:
Patient Information:
Age: 63 years
Gender: Female
Chief Complaint: Bilateral eyelid twitching for 2 months
Present Illness: The patient experienced involuntary twitching of both eyelids without obvious triggers starting 2 months ago, with symptoms exacerbating during stress and fatigue. Ther... | Hemifacial spasm | G51.301 |
2,510,693 | Patient Information:
Age: 13 years 3 months
Gender: Female
Chief Complaint: Nosebleed for half a day
Present Illness: The nosebleed has lasted for half a day, with bleeding persisting for about 4 hours before stopping. The patient has a history of petechiae and has a previous diagnosis of thrombocytopenic purpura... | Thrombocytopenic purpura | D69.406 |
2,515,672 | Patient Information:
Age: 32 years
Gender: Female
Chief Complaint: History of chronic aplastic anemia for over 20 years, family member collects medication on her behalf.
Present Illness: History of chronic aplastic anemia for over 20 years, no family member has collected medication recently. Reports repeated blood tran... | Aplastic Anemia | D61.900 |
2,559,000 | **Medical Record Description:**
**Patient Information:**
- Age: 6 months and 12 days
- Gender: Male
**Chief Complaint:** Anemia for 1 day
**History of Present Illness:** The patient suddenly developed a decrease in hemoglobin 1 day ago without any obvious cause.
**Past Medical History:** None
**Physical Examination:**
... | Moderate Anemia | D64.902 |
2,576,736 | Patient information:
Age: 40 years
Gender: Male
Chief complaint: Dizziness and vomiting after drinking alcohol for 1 hour.
Present illness: The patient experienced vomiting of gastric contents (about 3 taels) after drinking white wine 1 hour ago, with over 10 episodes of vomiting, accompanied by unsteady gait and dizzi... | Acute alcohol intoxication | F10.001 |
2,589,915 | Patient Information:
Age: 74 years
Gender: Male
Chief Complaint: Blood routine examination indicates platelet count decreased to half in half a day
Present Illness History: The patient visited our hospital today for consultation in the relevant department, where a routine blood test showed a platelet count of 99 G/L. T... | Thrombocytopenia | D69.600 |
2,623,513 | Patient Information:
Age: 79 years
Gender: Male
Chief Complaint: Left facial pain for 2 years
Present Illness: The patient has experienced left facial pain for 2 years, which is more pronounced during eating, washing the face, and exposure to wind. The pain is paroxysmal, and there are no symptoms of dizziness or fever... | Trigeminal neuralgia | G50.000 |
2,658,514 | **Patient Information:**
- Age: 5 years 6 months
- Gender: Female
- Chief Complaint: Cough for 5 days
**Present Illness:**
The patient developed a cough 5 days ago without any obvious trigger. The cough is paroxysmal, primarily dry. At the onset, she had a fever for 2 days, with a highest temperature of 38.9℃. She also... | Acute Suppurative Tonsillitis | J03.901 |
2,671,431 | Patient Information:
Age: 32 years
Gender: Male
Chief Complaint: Hematospermia for 9 days
Present Illness History: The patient presented with hematospermia 9 days ago without any obvious inducement. significant
Physical Examination: Abdomen soft, no tenderness or rebound tenderness, no percussion pain in both kidney re... | Seminal vesiculitis | N49.001 |
2,685,591 | Patient Information:
Age: 29 years old
Gender: Female
Chief Complaint: 10 years post gastric polyp removal surgery
Present Illness: Planned to undergo painless gastroscopy examination.
Physical Examination: BP 118/79 mmHg, HR 93 beats/min, W 60 kg. Conscious, coherent responses. Mouth opening of 3 finger breadths, Mall... | Gastric polyp | K31.703 |
2,690,332 | Patient Information:
Age: 46 years
Gender: Female
Chief Complaint: Vomiting after drinking for 5 hours.
Present Illness: The patient consumed approximately 300ml of white liquor 5 hours ago and then started to vomit gastric contents, accompanied by unsteady gait, and was subsequently brought to our department by friend... | Acute alcohol intoxication | F10.001 |
2,696,162 | Patient Information:
Age: 43 years
Gender: Male
Chief Complaint: Drowsiness 1 hour after drinking alcohol.
Present Illness: The patient drank approximately 350ml of white liquor 1 hour ago and then became drowsy, unresponsive when called, without nausea or vomiting, and was brought to our department for treatment by fr... | Acute alcohol intoxication | F10.001 |
2,713,611 | **Medical Record Description:**
**Patient Information:**
- Age: 41 years
- Gender: Female
**Chief Complaint:**
- Head heaviness and insomnia for 1 month.
**Present Illness:**
- The patient began experiencing insomnia after excessive mental exertion, accompanied by head heaviness. She needs to take 4 tablets of Phen... | Neurasthenia | F48.000 |
2,722,054 | **Medical Record Description:**
**Patient Information:**
- Age: 6 years and 7 months
- Gender: Female
- Chief Complaint: Intermittent abdominal pain for 2 days
**Present Illness History:**
The child has experienced intermittent abdominal pain primarily around the navel for the past 2 days. The pain is colicky in natur... | Acute mesenteric lymphadenitis | I88.001 |
2,758,352 | **Medical Record Description:**
**Patient Information:**
- Age: 32 years
- Gender: Female
**Chief Complaint:** Headache for 4 years
**Present Illness:** The patient developed a headache 4 years ago without any obvious triggering factor. The headache presents as a bilateral temporal dull pain, with a pulsating quality, ... | Migraine | G43.900 |
2,760,970 | **Medical Record Description:**
**Patient Information:**
- Age: 8 years
- Gender: Male
**Chief Complaint:** Mouth breathing during sleep for 1 year.
**Present Illness:** Malocclusion.
**Past Medical History:** None.
**Physical Examination:** Nasal mucosa is congested, bilateral inferior turbinates are swollen, and a sm... | Adenoid hypertrophy | J35.200 |
2,761,179 | Patient Information:
Age: 28 years
Gender: Female
Chief Complaint: Abnormal thyroid found during physical examination.
Present Illness: The patient underwent a physical examination where an ultrasound indicated "diffuse lesions of the thyroid." There is no neck pain or hoarseness, no fatigue, no palpitations, no edema,... | Autoimmune Thyroiditis | E06.300 |
2,776,910 | Patient Information:
Age: 36 years
Gender: Female
Chief Complaint: Pain in the lower left back tooth for over a year
Present Illness: The patient reports that a year ago, she experienced painful chewing in the lower left back tooth. She previously took anti-inflammatory medication on her own, but it did not alleviate h... | Periodontal abscess | K05.201 |
2,779,680 | Patient Information:
Age: 27 years old
Gender: Female
Chief Complaint: Infertility for one and a half years after marriage with no contraception
Present Illness: The patient has a regular menstrual cycle, with a 30-day cycle and a duration of 6 days, no dysmenorrhea, dark red menstrual flow, and moderate volume. The la... | Female infertility | N97.900 |
2,824,780 | Medical Record Description:
Patient Information:
Age: 23 years
Gender: Male
Chief Complaint: Post-operative changes after arachnoid cyst surgery
Present Illness History: -
Physical Examination: Conscious; pupils equal, round, 2.5mm in diameter, with normal light reflex; muscle strength and tone in all extremities are n... | Arachnoid cyst | G93.001 |
2,839,652 | Medical Record Description:
Patient Information:
Age: 56 years
Gender: Female
Chief Complaint: Thyroid nodule discovered during physical examination 1 week ago.
Present Illness History: The patient was found to have a thyroid nodule during a physical examination at another hospital one week ago. Ultrasound indicated “m... | Thyroid nodule | E04.101 |
2,852,132 | Patient Information:
Age: 38 years
Gender: Male
Chief complaint: Recurrent limb spasms and loss of consciousness for over 10 years.
Present illness: The patient started experiencing recurrent limb spasms and loss of consciousness over 10 years ago. He has been taking "LTG" since 2013, which has provided acceptable cont... | Epilepsy | G40.900 |
2,872,025 | Medical Record Description:
Patient Information:
Age: 20 years
Gender: Female
Chief Complaint: Amenorrhea for 52 days
Present Illness: Amenorrhea
Auxiliary Examination: Urine Pregnancy Test: Gold Standard Method, Test Result: HCG Qualitative Negative (-).
Examination Report: Ultrasound Color Doppler of Uterus and Adnex... | Amenorrhea | N91.200 |
2,895,814 | Medical Record Description:
Patient Information:
Age: 55 years
Gender: Female
Chief Complaint: Abnormality of the thyroid gland discovered during a physical examination
Present Illness History: Recently underwent an ultrasound at another hospital, which indicated uneven echogenicity of the thyroid gland. The patient no... | Autoimmune Thyroiditis | E06.300 |
2,907,971 | Patient Information:
Age: 46 years
Gender: Female
Chief Complaint: Menopausal symptoms including hot flashes, irritability, and mood disturbances.
Present Illness History: Epidemiological history: Denies any community residence or travel history related to COVID-19 cases within 14 days prior to onset; denies contact wi... | Menopausal Syndrome | N95.101 |
2,914,430 | **Medical Record Description:**
**Patient Information:**
- Age: 37 years old
- Gender: Female
**Chief Complaint:** Menstrual cessation for six months following medical abortion and curettage.
**Present Illness History:** The patient visited on November 11, receiving oral medication including Fenugreek and deer placenta... | Amenorrhea | N91.200 |
2,915,610 | Patient Information:
Age: 37 years
Gender: Male
Chief Complaint: Urinary frequency and urgency for 10 days
Present Illness: The patient experienced urinary frequency and urgency 10 days ago without any obvious cause.
Past Medical History: The patient has a history of urethritis.
Physical Examination: Abdomen is soft, n... | Urethritis, others | N34.200 |
2,967,324 | Medical Record Description:
Patient Information:
Age: 49 years
Gender: Male
Chief Complaint: Lip dryness for over a year.
Present Illness: The patient has experienced dryness and peeling of the lips for the past year without any treatment and has come seeking medical attention.
Past Medical History: The patient has had... | Cheilitis | K13.013 |
2,996,559 | Medical Record Description:
Patient Information:
Age: 52 years
Gender: Female
Chief Complaint: Paroxysmal lightning-like pain in the left submandibular area for 2 years.
Present Illness: Two years ago, without any obvious trigger, the patient began experiencing paroxysmal lightning-like, burning pain in the left subman... | Trigeminal neuralgia | G50.000 |
3,012,319 | **Medical Record Description:**
**Patient Information:**
- Age: 28 years
- Gender: Female
**Chief Complaint:** Headache for 3 years.
**Present Illness History:** The patient experiences bilateral temporal pulling pain and throbbing pain, occasionally accompanied by nausea and vomiting. Symptoms are somewhat relieved by... | Migraine | G43.900 |
3,034,265 | Patient Information:
Age: 48 years
Gender: Male
Chief Complaint: The patient has abnormal thyroid function and requests tests and medication.
Present Illness: The patient has a history of hypothyroidism but currently has no discomfort. He requests a test order.
Auxiliary Examinations: Free Thyroxine (FT4) measured by c... | Hypothyroidism | E03.900 |
3,040,753 | Patient Information:
Age: 53 years
Gender: Female
Chief Complaint: Headache for 3 months.
Present Illness: Pressure sensation on the top of the head, poor sleep at night, difficulty falling asleep.
Physical Examination: Conscious and alert, neurological signs negative (NS -).
Examination Report: Brain CT scan showed no... | Tension-type headache | G44.200 |
3,079,426 | Patient Information:
Age: 36 years
Gender: Female
Chief Complaint: Hoarseness of voice accompanied by sore throat for 3 days
Present Illness: The patient felt sore throat and hoarseness after being exposed to cold 3 days ago, with no other discomfort. She self-medicated, but her condition did not improve. She came to o... | Acute Pharyngitis | J02.900 |
3,079,673 | Patient Information:
Age: 28 years
Gender: Female
Chief Complaint: Thyroid abnormalities found during a physical examination one month ago.
Present Illness: One month ago, the patient discovered "diffuse thyroid enlargement with uneven echogenicity" during a physical examination at an external hospital. Thyroid functio... | Autoimmune Thyroiditis | E06.300 |
3,100,975 | Patient Information:
Age: 43 years
Gender: Male
Chief Complaint: Headache for 7 years
Medical History: The patient has experienced headaches for 7 years without obvious triggers. The headaches are episodic, characterized by bilateral temporal pressure-like pain that is pulsating, without nausea or vomiting.
Past Medica... | Migraine | G43.900 |
3,126,493 | Patient Information:
Age: 23 years
Gender: Male
Chief Complaint: Varicocele for 2 years
Present Illness: Planning to undergo surgical treatment.
Physical Examination: Bp 136/81 mmHg, HR 81 beats/min, W 71 kg. Patient is conscious and able to answer questions appropriately. Mouth opening is 3 finger breadths, Mallampati... | Varicocele | I86.101 |
3,133,406 | Here's the translation of the medical record into English:
**Patient Information:**
- Age: 27 years
- Gender: Male
**Chief Complaint:**
- Persistent hoarseness for over 1 year
**Present Illness:**
- No fever, no sore throat, feels a sensation of a foreign body in the throat, no swallowing obstruction
- No cough, no phl... | Vocal cord polyp | J38.102 |
3,184,885 | Patient Information:
Age: 25 years
Gender: Female
Chief Complaint: Anemia discovered during a medical examination for 2 years
History of Present Illness: For the past 2 years, the patient has experienced dizziness and fatigue; blood tests indicated anemia, prompting further investigations.
Past Medical History: Slightl... | Iron Deficiency Anemia | D50.900 |
3,208,868 | **Medical Record Description:**
**Patient Information:**
- Age: 74 years
- Gender: Female
- Chief Complaint: Gum bleeding in the upper right area for half a month
**Present Illness History:**
The patient reports a palpable mass on the palatal side of the upper right front teeth for the past half month. Licking the are... | Periodontal disease | K05.600 |
3,272,052 | Patient Information:
Age: 23 years
Gender: Male
Chief Complaint: Frequency, urgency, and pain during urination for 3 days
Present Illness: The patient developed urinary frequency, urgency, and urethral burning pain 3 days ago without any obvious trigger. There is no significant hematuria, and the patient does not have ... | Urethritis, others | N34.200 |
3,279,403 | Medical Record Description:
Patient Information:
Age: 9 years and 2 months
Gender: Female
Chief Complaint: Breast enlargement noticed for more than half a year.
Present Illness: The patient has noticed breast enlargement for over half a year, accompanied by a growth spurt in height. There are no reports of dizziness or... | Precocious puberty | E30.100 |
3,297,578 | Patient Information:
Age: 21 years old
Gender: Male
Chief Complaint: Sore throat for 3 days.
Present Illness: No fever, no difficulty breathing, no cough or sputum, no palpitations or chest tightness.
Past Medical History: Denies history of hypertension, diabetes, coronary heart disease, and drug allergies.
Physical Ex... | Acute Pharyngitis | J02.900 |
3,303,506 | Patient Information:
Age: 53 years
Gender: Female
Chief Complaint: Sudden palpitations for 2 hours.
Present Illness: The patient experienced palpitations and chest tightness without any obvious triggers 2 hours ago. There was no chest pain, back pain, no blackout or syncope, and no fever, cough, or sputum produ... | Arrhythmia | I49.900 |
3,303,933 | Patient Information:
Age: 52 years old
Gender: Female
Chief Complaint: Intoxication for more than 2 hours.
Present Illness: The patient experienced dizziness, accompanied by nausea and vomiting several times (reported by colleagues to have consumed approximately 125 ml of alcohol) 2 hours ago due to excessive drinking.... | Acute alcohol intoxication | F10.001 |
3,385,519 | Medical Record Description:
Patient Information:
Age: 46 years
Gender: Female
Chief Complaint: Abdominal pain for 5 hours
Present Illness: The patient experienced upper abdominal pain 5 hours ago without any obvious trigger, characterized by intermittent bloating abdominal pain, accompanied by nausea and vomiting (the ... | Acute Gastroenteritis | K52.905 |
3,393,103 | Medical Record Description:
Patient Information:
Age: 4 years and 9 months
Gender: Female
Chief Complaint: Diarrhea for 1 day
Present Illness: The child developed diarrhea 1 day ago without any obvious triggers, with stool described as yellow and watery, occurring 8 times a day, each time in small amounts, with no mucu... | Diarrhea | K52.916 |
3,432,406 | Patient Information:
Age: 4 years and 7 months
Gender: Female
Chief Complaint: Language Development Delay
Present Illness: The child started speaking at the age of 2 and can now speak in long sentences, although her pronunciation is unclear. There are no reports of vomiting or diarrhea, no rashes, and her spirit and ap... | Speech and language development disorders | F80.900 |
3,456,376 | Patient Information:
Age: 42 years old
Gender: Female
Chief Complaint: Fatigue for 1 month
Present Illness History: Fatigue for 1 month
Physical Examination: Appearance of anemia
Auxiliary Examinations: Serum vitamin testing via chemiluminescence method, test results: Serum ferritin 2.9 ng/ml (reference value 13~232); ... | Iron deficiency anemia | D50.900 |
3,477,223 | Patient Information:
Age: 31 years old
Gender: Female
Chief Complaint: Hyperthyroidism for 20 days
Present Illness: The patient was diagnosed with hyperthyroidism accompanied by "atrial fibrillation" 20 days ago in Suzhou following a visit due to complaints of "palpitations." She received treatment with "amiodarone" fo... | Hyperthyroidism | E05.901 |
3,483,410 | Medical Record Description:
Patient Information:
Age: 46 years
Gender: Male
Chief Complaint: Loss of consciousness with seizures and foaming at the mouth for 1 month
Present Illness History: One month ago, the patient suddenly experienced loss of consciousness and seizures without any obvious triggers. He foamed at the... | Epilepsy | G40.900 |
3,498,327 | **Medical Record Description:**
**Patient Information:**
- Age: 57 years
- Gender: Male
- Chief Complaint: Right side low back pain for 1 day
**Present Illness History:**
The patient developed right side low back pain 1 day ago without any obvious precipitating cause and came to our hospital for consultation today.
**... | Ureteral Calculi | N20.100 |
3,525,240 | **Medical Record Description:**
**Patient Information:**
- Age: 22 years
- Gender: Female
**Chief Complaint:**
Fracture of upper front tooth due to trauma one hour ago.
**Present Illness History:**
One hour ago, the patient accidentally collided with a wall, resulting in a fracture of the upper left front tooth. Th... | Dental fracture | K02.400 |
3,558,750 | Patient Information:
Age: 68 years
Gender: Male
Chief Complaint: Vomiting after drinking alcohol for over 1 hour.
Present Illness History: The patient consumed 4 doses of white wine 1 hour ago and subsequently experienced vomiting with a large amount of gastric contents, accompanied by unsteady gait and altered conscio... | Acute alcohol intoxication | F10.001 |
3,583,890 | Patient Information:
Age: 80 years
Gender: Male
Chief Complaint: Aphasia for 1 day.
Present Illness: According to the family, the patient suddenly developed aphasia around 8 AM yesterday without any obvious trigger. There was no limb weakness, no facial drooping, and no dizziness or headache. He visited Changbanpo Hosp... | Cerebral infarction | I63.900 |
3,592,351 | Patient Information:
Age: 52 years
Gender: Female
Chief Complaint: Intermittent stabbing pain in the right upper quadrant for 10 years, with recurrence for 1 day.
Present Illness History: Ten years ago, the patient experienced intermittent stabbing pain in the right upper quadrant without any obvious trigger, with each... | Intercostal neuralgia | G58.001 |
3,608,158 | Medical Record Description:
Patient Information:
Age: 36 years
Gender: Female
Chief Complaint: Request for cervical polyp removal
Present Illness History: On July 18, 2018, the patient underwent a cervical cone biopsy at Yidu City Maternal and Child Health Hospital due to cervical HSIL. Postoperative follow-up TCT and ... | Cervical polyp | N84.100 |
3,651,913 | Patient Information:
Age: 28 years
Gender: Female
Chief Complaint: History of PCOS and attempting to conceive for nearly one year with no success; amenorrhea for 50 days.
Current Illness History: Usually has a menstrual cycle of 6-7/21-60 days; flow is normal, no dysmenorrhea. Last menstrual period (LMP): September 1, ... | Polycystic Ovary Syndrome (PCOS) | E28.200 |
3,727,564 | Patient Information:
Age: 18 years old
Gender: Female
Chief Complaint: Irregular menstruation for several years, frequent menstruation for half a year
Examination Report: Pelvic color Doppler ultrasound examination: Findings show that the uterus measures approximately 4.0 x 3.8 x 2.4 cm, with normal size and shape. End... | Polycystic Ovary Syndrome (PCOS) | E28.200 |
3,739,624 | Patient Information:
Age: 27 years
Gender: Female
Chief Complaint: Routine examination indicated microcytic hypochromic anemia
Present Medical History: Routine examination indicated microcytic hypochromic anemia
Auxiliary Examination: Serum vitamin assessment by chemiluminescence method, test results: Folate 9.22 ng/ml... | Microcytic hypochromic anemia | D50.801 |
3,745,479 | Medical Record Description:
Patient Information:
Age: 46 years
Gender: Female
Chief Complaint: Yellow urine, fatigue for more than 1 month
Present Illness: The patient developed yellow urine and fatigue for more than 1 month without obvious inducement, accompanied by skin jaundice and palpitations. She consulted Enshi ... | Hemolytic anemia | D58.901 |
3,748,610 | Patient Information:
Age: 48 years
Gender: Female
Chief Complaint: Headache for over 20 years, numbness in the left thigh for 1 month
Present Illness: The patient has experienced headaches for over 20 years without any obvious triggers, characterized by a throbbing pain in the left temporal region, which becomes severe... | Migraine | G43.900 |
3,779,672 | Patient Information:
Age: 32 years old
Gender: Female
Chief Complaint: Headache for more than 3 days
Present Illness: The patient experienced a sudden severe headache at the top of the head without any obvious trigger 3 days ago. She also accompanied it with nausea. Symptoms slightly improved yesterday. No fever.... | Migraine | G43.900 |
3,857,778 | Patient Information:
Age: 5 years and 1 month
Gender: Male
Chief Complaint: A 5-year-old boy who cannot speak
Present Illness: The patient began to make sounds around 9 months of age, could call others around 1 year old, but after the age of 2 showed little interest in interacting with people. Currently, he can only sp... | Pediatric Autism Spectrum Disorder | F84.000 |
3,864,177 | Medical Record Description:
Patient Information:
Age: 12 years and 4 months
Gender: Male
Chief Complaint: Vomiting for half a day
Present Illness: The child began vomiting about half a day ago without any obvious trigger, approximately 5 times. The vomit was non-projectile and contained gastric contents, without coffee... | Acute Gastroenteritis | K52.905 |
3,866,509 | **Patient Information:**
- Age: 1 year and 1 month
- Gender: Male
**Chief Complaint:** History as before
**Current Illness History:** The child has been experiencing vomiting and diarrhea for 2 days. Today, the vomit has a coffee-ground appearance and is in small amounts, occurring 5 times in total. The stools are gray... | Infantile enteritis | K52.918 |
3,867,126 | Medical Record Description:
Patient Information:
Age: 1 month 29 days
Gender: Male
Chief Complaint: Constipation for 3 days.
Present Illness: The infant developed constipation 3 days ago without any obvious trigger, with no bowel movements, and no cough, convulsions, vomiting, diarrhea, abdominal pain, or ras... | Constipation | K59.000 |
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