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ICD10
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##### **1. Subjective:** **Chief Complaint (CC):** High-grade fever, lethargy, and severe joint pain. **History of Present Illness (HPI):** A 55-year-old Asian female with a history of Rheumatoid Arthritis and Chronic Hepatitis C presents with a 72-hour history of severe symptoms, including high-grade fever, rigors, ...
[doctor] Hi there, how are you feeling today? [patient] Hi, Doctor. I'm feeling really awful, to be honest. [doctor] I'm sorry to hear that. Can you tell me more about what's been going on? [patient] Sure. I've had a high-grade fever for the past three days, and I'm just so tired and in a lot of pain. My joints hurt...
A4102
SEPSIS DUE TO METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS
15
5
### Medical Note #### 1. Subjective: **Chief Complaint (CC):** Severe pain in the left foot. **History of Present Illness (HPI):** - **Onset:** 5 months ago. - **Location:** Left plantar surface of the foot. - **Duration:** Constant. - **Characteristics:** Severe pain, thickened skin, occasional itching. - **Aggravat...
```plaintext [doctor] Good afternoon. How are you today? [patient] Not so great, actually. I’ve been having a lot of pain in my left foot. [doctor] I'm sorry to hear that. Can you tell me more about this pain? [patient] It started about five months ago. The pain is on the bottom of my left foot, and it’s been consta...
B070
PLANTAR WART
25
5
**Subjective:** **Chief Complaint (CC):** Prolonged illness with high-grade fever, extreme fatigue, and severe sore throat. **History of Present Illness (HPI):** Maria Gonzalez is a 35-year-old Hispanic female with a past medical history significant for mild asthma and seasonal allergies, who presents today for an eme...
[doctor] Hi Maria, how are you feeling today? What brings you in? [patient] Hi, Doctor. I'm really not feeling well. I've had this high fever, extreme fatigue, and a really bad sore throat for about three weeks now. [doctor] Oh, I’m sorry to hear that. That sounds very uncomfortable. Have you noticed any other sympto...
B2790
INFECTIOUS MONONUCLEOSIS, UNSPECIFIED WITHOUT COMPLICATION
35
5
**1. Subjective:** - Chief Complaint (CC): - The patient presents with high fever, chills, sweating, body aches, and general fatigue for the past 4 days. - History of Present Illness (HPI): - A 65-year-old Hispanic male named Carlos Martinez with a previous medical history of Type 2 Diabetes Mellitus, Hyperte...
[doctor]: Good morning! How are you feeling today? [patient]: Good morning, doctor. Honestly, I’ve been feeling pretty awful for the past few days. [doctor]: I’m sorry to hear that. Can you tell me more about what’s been going on? [patient]: Sure. I’ve had a high fever, chills, sweating, body aches, and just overall...
B952
ENTEROCOCCUS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE
45
5
### Medical Note #### 1. Subjective: **Chief Complaint (CC):** Severe pain at the base of the tongue, worse with swallowing. **History of Present Illness (HPI):** The patient, a 50-year-old Asian female, presents with a 6-month history of severe pain at the base of her tongue, rated 9/10, exacerbated by swallowing. ...
#### 1. Subjective: **Chief Complaint (CC):** Severe pain at the base of the tongue, worse with swallowing. --- [doctor]: Hi there, how are you doing today? [patient]: Not too well, doctor. I've been experiencing severe pain at the base of my tongue, especially when I swallow. [doctor]: I'm sorry to hear that. How...
C01
MALIGNANT NEOPLASM OF BASE OF TONGUE
55
5
**1. Subjective:** **Chief Complaint (CC):** Persistent lower abdominal pain. **History of Present Illness (HPI):** The patient is a 62-year-old Hispanic male named Carlos Martinez who presents for follow-up after a recent diagnosis of malignant neoplasm of the sigmoid colon. He reports having moderate to severe lowe...
[Doctor] Hi, how are you doing today? [Patient] Hi, Doctor. I've been better, to be honest. The pain has been pretty bad. [Doctor] I'm sorry to hear that. Can you tell me more about the pain you're experiencing? [Patient] Sure. It's a persistent pain in my lower abdomen. It’s been going on for about four months now....
C187
MALIGNANT NEOPLASM OF SIGMOID COLON
65
5
##### **1. Subjective:** **Chief Complaint (CC):** Patient presents for a follow-up visit regarding management of diagnosed malignant neoplasm of the upper lobe, right bronchus or lung. **History of Present Illness (HPI):** - Severity: Symptoms described as mild to moderate. - Duration: Symptoms have been present for...
``` [doctor] Hello, how are you doing today? [patient] Hi doctor, I'm doing okay, just here for my follow-up. [doctor] Great, so I see we're here to discuss the management of your diagnosed malignant neoplasm in the upper lobe of your right bronchus or lung. How have you been feeling? [patient] Well, the symptoms ar...
C3411
MALIGNANT NEOPLASM OF UPPER LOBE, RIGHT BRONCHUS OR LUNG
75
5
**1. Subjective:** **Chief Complaint (CC):** Lesion on the nose with occasional pain and bleeding. **History of Present Illness (HPI):** Ms. Lee is a 45-year-old Asian female who presents for follow-up after an initial biopsy and outpatient evaluation of a lesion on her nose. The lesion has been present for approxima...
[doctor]: Hi Ms. Lee, it's nice to see you again. How have you been feeling since your last visit? [patient]: Hi, Doctor. I've been okay, but the lesion on my nose is still bothering me. It's been painful and occasionally bleeds. [doctor]: I'm sorry to hear that. Let's go over everything in detail. Can you tell me wh...
C44311
BASAL CELL CARCINOMA OF SKIN OF NOSE
85
5
##### **1. Subjective:** - **Chief Complaint (CC):** Severe pain in the left breast, noticeable lump, and associated redness and swelling, with occasional bloody nipple discharge. - **History of Present Illness (HPI):** Mariela Santos is a 52-year-old African American female who presents today for trea...
[doctor]: Good morning, Mariela. How are you feeling today? [patient]: Good morning, Doctor. I've been better. The pain in my left breast is just unbearable. [doctor]: I'm sorry to hear that. How long have you been experiencing this severe pain? [patient]: It's been about three weeks now. It's really affecting my da...
C50112
MALIGNANT NEOPLASM OF CENTRAL PORTION OF LEFT FEMALE BREAST
95
5
### Subjective: #### Chief Complaint (CC): Moderate pain in the left breast. #### History of Present Illness (HPI): The patient is a 65-year-old African American female presenting for an initial oncology consultation following a referral from her primary care physician due to a lump in her left breast. The patient no...
[doctor]: Good morning. How are you doing today? [patient]: Good morning, doctor. I'm okay, but I've been having some pain in my left breast. [doctor]: I see. Can you tell me more about this pain and when it started? [patient]: Sure. I first noticed a lump in my left breast about a month ago. The pain started two we...
C50812
MALIGNANT NEOPLASM OF OVERLAPPING SITES OF LEFT FEMALE BREAST
105
5
**1. Subjective:** **Chief Complaint (CC):** - Mild pelvic discomfort. **History of Present Illness (HPI):** - Patient is a 62-year-old Asian American male, retired professor, presenting with mild pelvic discomfort for the past 2 months. The discomfort is intermittent and has minimal impact on daily activities. He re...
[doctor]: Hi there, how are you today? [patient]: Hello, I'm doing alright. Nice to meet you. [doctor]: Nice to meet you too. I see you're here because of some mild pelvic discomfort. Can you tell me more about that? [patient]: Sure. I've been feeling this mild discomfort in my pelvic area for the past two months. I...
C61
MALIGNANT NEOPLASM OF PROSTATE
115
5
##### **1. Subjective:** **Chief Complaint (CC):** Persistent nasal congestion, occasional nosebleeds, and facial swelling. **History of Present Illness (HPI):** Mr. Miguel Hernandez is a 72-year-old Hispanic male presenting via telemedicine for a routine oncology check-up. He reports a 6-week history of mild but per...
[doctor]: Hi Mr. Hernandez, how are you doing today? [patient]: Hi doctor, I'm doing okay. Thank you. [doctor]: Great to hear. I understand you’re having some issues with nasal congestion, occasional nosebleeds, and some facial swelling. Can you tell me more about that? [patient]: Yes, it’s been about six weeks now....
C760
MALIGNANT NEOPLASM OF HEAD, FACE AND NECK
125
5
**1. Subjective:** **Chief Complaint (CC):** 45-year-old female presenting for initial consultation regarding symptoms of nausea, anorexia, and dark urine. **History of Present Illness (HPI):** The patient is a 45-year-old African American female with a past medical history of primary breast cancer treated 5 years ag...
[doctor] Hello, how are you doing today? [patient] Hi, Doctor. I'm not feeling very well, to be honest. [doctor] I'm sorry to hear that. I'm Dr. Hartman. Let's go over what brings you in today. I see in your notes that you've been experiencing nausea, anorexia, and dark urine. Can you tell me more about these symptom...
C787
SECONDARY MALIGNANT NEOPLASM OF LIVER AND INTRAHEPATIC BILE DUCT
135
5
##### **1. Subjective:** **Chief Complaint (CC):** Severe chest discomfort and bilateral leg swelling. **History of Present Illness (HPI):** The patient, Ms. Angela Thompson, is a 52-year-old African American female presenting with a 3-month history of severe chest discomfort and bilateral leg swelling. The patient a...
[doctor] Hi, it's good to see you today. What brings you in? [patient] Hi, Doctor. I've been having severe chest discomfort and my legs have been swelling a lot lately. [doctor] Oh, that sounds concerning. How long have you been experiencing these symptoms? [patient] It's been about three months now. The chest pain ...
C8339
DIFFUSE LARGE B-CELL LYMPHOMA, EXTRANODAL AND SOLID ORGAN SITES
145
5
### Medical Note #### 1. Subjective: **Chief Complaint (CC):** The patient, a 60-year-old Asian male, presents for a routine check-up with complaints of severe bone pain and shortness of breath. **History of Present Illness (HPI):** The patient was diagnosed with Acute Myeloblastic Leukemia (AML) six months ago and h...
[doctor]: Good morning, how are you feeling today? [patient]: Good morning, Doctor. I've been feeling quite terrible, actually. The bone pain is really severe, and I'm having trouble breathing. [doctor]: I'm sorry to hear that. Let's go through everything systematically. I see in your records that you were diagnosed ...
C9200
ACUTE MYELOBLASTIC LEUKEMIA, NOT HAVING ACHIEVED REMISSION
155
5
### Medical Note #### 1. Subjective: **CC:** Moderate discomfort and frequent constipation over the past 2 months. **HPI:** The patient, Ms. Johnson, is a 63-year-old African American female presenting for a follow-up visit concerning a benign neoplasm of the descending colon. She reports moderate discomfort, par...
[doctor]: Hello Ms. Johnson, it's great to see you again. How have you been feeling since your last visit? [patient]: Hi, doctor. I've been okay, but I've been having some moderate discomfort and frequent constipation over the past 2 months. [doctor]: Hmm, I see. Could you tell me more about the discomfort you're exp...
D124
BENIGN NEOPLASM OF DESCENDING COLON
165
5
#### MEDICAL NOTE **1. Subjective:** **Chief Complaint (CC):** The patient, a 55-year-old African American male, presents with a small, raised lesion on his face that he noticed 3 months ago. **History of Present Illness (HPI):** The patient reports that the lesion on his left cheek has been present for the past 3 m...
[doctor] Hello there, I’m Dr. Smith. What brings you in today? [patient] Hi, Doctor. I have this small, raised spot on my face. I noticed it about three months ago. [doctor] Hmm, alright. Can you tell me more about this spot? How did you first notice it, and has it changed in any way? [patient] Well, it's been on my...
D2339
OTHER BENIGN NEOPLASM OF SKIN OF OTHER PARTS OF FACE
175
5
#### MEDICAL NOTE **1. Subjective:** **Chief Complaint (CC):** Persistent left-sided pelvic pain. **History of Present Illness (HPI):** Ms. Luisa Martinez is a 45-year-old Latina female who presents today for a follow-up visit regarding her persistent left-sided pelvic pain. She reports that the pain has been se...
[doctor]: Hi Ms. Martinez, how are you doing today? [patient]: Hi, Doctor. Honestly, I'm struggling. The pain is just not getting any better. [doctor]: I'm sorry to hear that. Let's talk about your pain first. How long have you been experiencing this left-sided pelvic pain? [patient]: It's been about 6 months now. I...
D271
BENIGN NEOPLASM OF LEFT OVARY
185
5
**1. Subjective:** - **Chief Complaint (CC):** Unresolved fatigue and weakness despite initial treatment. - **History of Present Illness (HPI):** - The patient, a 68-year-old Asian female, presents for a follow-up visit to address ongoing fatigue and weakness. Despite initial treatments, symptoms have persisted fo...
[doctor] Hi there, how are you feeling today? [patient] Hi doctor. I'm still feeling quite fatigued and weak. [doctor] Hmm, I'm sorry to hear that. Can you tell me more about your symptoms? [patient] Sure. I've been experiencing this fatigue and weakness for the past six months. It's moderate to severe, and it just ...
D500
IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC)
195
5
**1. Subjective:** **Chief Complaint (CC):** Patient presents with generalized fatigue, frequent infections, bleeding gums, and shortness of breath. **History of Present Illness (HPI):** The 28-year-old female of Asian ethnicity reports experiencing moderate fatigue, frequent infections, bleeding gums, and shortness ...
**[doctor]** Hello, it's good to see you today. So, I understand you've been having some health issues lately. Can you tell me a bit more about what's been going on? **[patient]** Hi, yes. For the past two months, I've been feeling really tired all the time. I've also been getting infections frequently, my gums are bl...
D61818
OTHER PANCYTOPENIA
205
5
**1. Subjective:** **Chief Complaint (CC):** Swelling in the left leg. **History of Present Illness (HPI):** The patient, Mr. James Carter, is a 55-year-old African American male presenting for a follow-up visit regarding recent diagnosis and management of Antiphospholipid Syndrome (APS). Symptoms have persisted for...
[doctor]: Good morning! How are you doing today? [patient]: Morning, Doctor. Not too well, honestly. My left leg is still swollen, and it’s been like this for two weeks now. [doctor]: I see. Can you tell me more about the swelling and any other symptoms you've been experiencing? [patient]: Sure. The swelling in my l...
D6861
ANTIPHOSPHOLIPID SYNDROME
215
5
#### Subjective: **CHIEF COMPLAINT** Fatigue and frequent nosebleeds. **HISTORY OF PRESENT ILLNESS** The patient, named Mei Lin, is a 65-year-old Asian female who presents with moderate severity symptoms persisting for the past 4 months. She reports frequent nosebleeds, fatigue, and pruritus after hot baths, occu...
[doctor] Hi, it's nice to see you today. What brings you in? [patient] Hi, Doctor. I've been feeling really tired and I've been getting a lot of nosebleeds lately. [doctor] I'm sorry to hear that. How long have you been experiencing these symptoms? [patient] It's been about 4 months now. The nosebleeds happen quite...
D751
SECONDARY POLYCYTHEMIA
225
5
**1. Subjective:** **Chief Complaint (CC):** Frequent urination, excessive thirst, weight loss, and blurred vision. **History of Present Illness (HPI):** The patient, a 17-year-old Asian male, presents with a two-month history of severe polyuria, polydipsia, unexplained weight loss, and blurred vision. These symptoms...
**Doctor:** Hi there, how are you doing today? **Patient:** Hi, I’m alright. I’ve been having some issues lately, though. **Doctor:** Hmm, I see. Can you tell me more about what’s been going on? **Patient:** Sure. I’ve been experiencing frequent urination and excessive thirst for the past two months. I’ve also lost ...
E034
ATROPHY OF THYROID (ACQUIRED)
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