Note stringlengths 1.73k 4.93k | Dialogue stringlengths 2.83k 7.25k ⌀ | ICD10 stringlengths 3 7 | ICD10_desc stringlengths 6 159 |
|---|---|---|---|
**1. Subjective:**
**Chief Complaint (CC):**
Watery diarrhea and abdominal cramping.
**History of Present Illness (HPI):**
The patient, John Doe, is a 28-year-old male who presents via telemedicine consultation with a 2-day history of moderate watery diarrhea occurring approximately 4-5 times per day, accompanied by ... | [doctor]: Good morning, how are you today?
[patient]: Good morning, Doctor. I'm not feeling too well, actually.
[doctor]: I'm sorry to hear that. Can you tell me what's been going on?
[patient]: I've had watery diarrhea for the past two days, about 4-5 times a day, along with some abdominal cramping, mild fever, and... | A047 | ENTEROCOLITIS DUE TO CLOSTRIDIUM DIFFICILE |
**1. Subjective:**
**Chief Complaint (CC):**
Severe diarrhea and associated symptoms.
**History of Present Illness (HPI):**
Ms. Garcia is a 41-year-old African American female who presents today for an evaluation of severe diarrhea, which has persisted for 2 days. She reports having a high fever, chills, weakness, an... | [doctor]: Good morning, Ms. Garcia. I see you’re here today because of severe diarrhea. Can you tell me a bit more about what’s been going on?
[patient]: Good morning, doctor. Yes, I've been having really bad diarrhea for the past two days. It happens every 30 minutes, and it's been terrible.
[doctor]: That sounds ve... | A084 | VIRAL INTESTINAL INFECTION, UNSPECIFIED |
#####
**1. Subjective:**
**Chief Complaint (CC):**
Fatigue, joint pain, headache, and rash.
**History of Present Illness (HPI):**
The patient, Ms. Emily Johnson, is a 42-year-old Caucasian female with a history of hypertension, managed with Amlodipine 5 mg daily. She presents today with complaints of fatigue, joint p... | [doctor] Hi there, how are you feeling today?
[patient] Hi, I'm okay, but I've been feeling really tired and have some other symptoms.
[doctor] Hmm, okay. Let’s talk about what's been going on. What symptoms have you been experiencing?
[patient] I've been feeling fatigued, having joint pain, headaches, and I've also... | A4101 | SEPSIS DUE TO METHICILLIN SUSCEPTIBLE STAPHYLOCOCCUS AUREUS |
#####
**1. Subjective:**
**Chief Complaint (CC):**
Severe fever, hypotension, and newly developed palpitations.
**History of Present Illness (HPI):**
The patient is a 68-year-old Asian female with a history of congestive heart failure and atrial fibrillation who presents with a 48-hour history of severe fever (38.7°C... | [doctor] Hi, how are you feeling today?
[patient] Hi, doctor. Not so great, to be honest. I've been feeling really unwell.
[doctor] I'm sorry to hear that. Can you tell me more about what's been going on?
[patient] Well, I've had this severe fever for the past two days, and my heart has been racing. I also feel very... | A4151 | SEPSIS DUE TO ESCHERICHIA COLI [E. COLI] |
**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 |
**1. Subjective:**
**Chief Complaint (CC):**
The patient, Mr. John Davis, is a 45-year-old African American male presenting with intense itching and significant pain in the anogenital region.
**History of Present Illness (HPI):**
The patient reports that the symptoms started around 4 months ago and have progressively... | ```markdown
[doctor]: Good morning, how are you doing today?
[patient]: I've been better. My primary care doctor wanted me to see you because of this intense itching and significant pain in my anogenital region.
[doctor]: I'm sorry to hear that. Can you tell me when these symptoms started?
[patient]: It's been aroun... | A630 | ANOGENITAL (VENEREAL) WARTS |
**1. Subjective:**
**Chief Complaint (CC):**
Severe joint pain and swelling, primarily in the left knee, along with high fever, severe headaches, and profound fatigue for the past 5 weeks.
**History of Present Illness (HPI):**
The patient, a 58-year-old African-American female named Mrs. Angela Thompson, presents w... | [doctor]: Hello, how are you doing today?
[patient]: Hi, Doctor. Not great, to be honest. I've been dealing with severe joint pain and swelling in my left knee, and I've had a high fever, severe headaches, and just feeling extremely tired for the past 5 weeks.
[doctor]: I’m sorry to hear that. Can you tell me more ab... | A6920 | LYME DISEASE, UNSPECIFIED |
#####
**1. Subjective:**
**Chief Complaint (CC):**
Severe localized vesicular rash with burning and stabbing pain.
**History of Present Illness (HPI):**
The patient, Mr. James Thompson, is a 45-year-old African American male with a history of Type 2 Diabetes, presenting with a severe localized vesicular rash ass... | [doctor]: Hello, good to see you today. Can you tell me what brings you in?
[patient]: Hi, Doc. I'm really worried about this rash I've developed. It's burning and stabbing, and it's been here for five days now.
[doctor]: I'm sorry to hear that. Can you tell me more about this rash?
[patient]: Sure, it's a localized... | B029 | ZOSTER WITHOUT COMPLICATIONS |
**1. Subjective:**
**Chief Complaint (CC):**
Painful plantar warts on both feet.
**History of Present Illness (HPI):**
James Robinson is a 45-year-old African American male who presents today with complaints of painful plantar warts on the soles of both feet. He states that these warts have been present for the past ... | [doctor] Hello, James. How are you doing today?
[patient] Hi, Doctor. I'm doing okay, but I've been having some trouble with my feet.
[doctor] Oh no, that doesn’t sound good. What seems to be the problem with your feet?
[patient] I've got these painful plantar warts on the soles of both feet. They've been there for ... | B078 | OTHER VIRAL WARTS |
**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 |
#####
**1. Subjective:**
**Chief Complaint (CC):**
Patient presents concerns about chronic viral hepatitis B with worsening symptoms.
**History of Present Illness (HPI):**
Mr. John Doe is a 30-year-old Caucasian male presenting for follow-up of chronic viral hepatitis B, initially diagnosed five years ago. Over the p... | [doctor]: Good morning, Mr. Doe. How are you doing today?
[patient]: Good morning, doctor. I'm not feeling very well, to be honest.
[doctor]: I'm sorry to hear that. What seems to be the problem?
[patient]: Well, I've been having a lot of issues with my chronic hepatitis B. The symptoms have gotten a lot worse over ... | B181 | CHRONIC VIRAL HEPATITIS B WITHOUT DELTA-AGENT |
#####
**1. SUBJECTIVE:**
**Chief Complaint (CC):**
Severe fatigue, anorexia, abdominal pain, dark urine, jaundice.
**History of Present Illness (HPI):**
Mr. John Smith is a 40-year-old Caucasian male construction worker who presents to the clinic today with a history of severe fatigue, anorexia, abdominal pain, dark ... | [doctor]: Hi Mr. Smith, how are you feeling today?
[patient]: Hi, doctor. Honestly, I've been feeling pretty awful.
[doctor]: I'm sorry to hear that. Can you tell me a bit about what's been going on?
[patient]: Sure. I've been extremely tired, I have no appetite, my abdomen hurts a lot, my urine is dark, and my skin... | B1910 | UNSPECIFIED VIRAL HEPATITIS B WITHOUT HEPATIC COMA |
**1. Subjective:**
**Chief Complaint (CC):**
The patient, a 33-year-old Caucasian male, presents with a chronic cough and shortness of breath.
**History of Present Illness (HPI):**
The patient has been experiencing a moderate chronic cough for the past 4 months, which has worsened in the last month. He has associated... | [doctor]: Hi there, how are you doing today?
[patient]: Hi, Doctor. I've been better. I've been having this chronic cough and shortness of breath that's really bothering me.
[doctor]: Hmm, I see. Can you tell me how long you've been experiencing these symptoms?
[patient]: It's been about 4 months now. The cough has ... | B20 | HUMAN IMMUNODEFICIENCY VIRUS [HIV] DISEASE |
#####
1. Subjective:
**Chief Complaint (CC):**
The patient presents with symptoms of sore throat, cough, mild fever, fatigue, and muscle aches for the past 7 days.
**History of Present Illness (HPI):**
The patient is a 28-year-old Hispanic female, working as an administrative assistant, who reports having symptoms... | [doctor] Hi there, how are you doing today?
[patient] Hi, I'm not feeling too well, actually.
[doctor] Oh, I'm sorry to hear that. Can you tell me what's been bothering you?
[patient] Sure, I've had a sore throat, cough, mild fever, fatigue, and muscle aches for the past 7 days.
[doctor] That sounds uncomfortable. ... | B349 | VIRAL INFECTION, UNSPECIFIED |
#####
**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 |
**1. Subjective:**
**CHIEF COMPLAINT**
White patches on tongue and inner cheeks, mild burning sensation, and slight difficulty swallowing for the past 3 weeks.
**HISTORY OF PRESENT ILLNESS**
The patient is a 68-year-old African American female presenting with mild to moderate symptoms of white patches on her tongue a... | [doctor] Hi there, how are you doing today?
[patient] Hello, I'm doing okay, thank you.
[doctor] I understand you're here because of some white patches on your tongue and inner cheeks, is that correct?
[patient] Yes, that's right. They've been there for about three weeks now.
[doctor] Hmm, I see. Could you tell me a bi... | B370 | CANDIDAL STOMATITIS |
#####
**1. Subjective:**
**Chief Complaint (CC):**
Severe vaginal itching, burning during urination, and cottage cheese-like discharge.
**History of Present Illness (HPI):**
The patient, named Mei Lin, is a 50-year-old Asian female presenting with severe vaginal itching and burning during urination for the past 10 da... | ```
[doctor] Hello! How are you doing today?
[patient] Not too well, Doctor. I've been having some severe vaginal itching and burning when I pee.
[doctor] I'm sorry to hear that. How long have these symptoms been going on?
[patient] It's been about 10 days now. It's really starting to mess with my sleep and work.
[doct... | B373 | CANDIDIASIS OF VULVA AND VAGINA |
**Subjective:**
**Chief Complaint (CC):**
Intense itching and burning sensation in the genital area.
**History of Present Illness (HPI):**
Ms. Li Wei, a 28-year-old Asian female, presents with severe symptoms of a recurrent yeast infection. She reports experiencing intense itching, burning sensation, and thick wh... | [doctor]: Hi Ms. Wei, how are you today?
[patient]: Hi doctor, I've been better. I'm here because I'm having some really intense itching and burning in my genital area.
[doctor]: Oh, I'm sorry to hear that. How long have you been experiencing these symptoms?
[patient]: It's been about a week and a half now. It's rea... | B379 | CANDIDIASIS, UNSPECIFIED |
**1. Subjective:**
**Chief Complaint (CC):**
Fatigue, fever, and new heart murmurs.
**History of Present Illness (HPI):**
Ms. Jane Liu is a 65-year-old Asian female who presents with moderate to severe generalized weakness and fatigue for the past 8 days. She reports a persistent fever of 101.5°F, night sweats, and r... | [doctor]: Good morning Ms. Liu, how are you today?
[patient]: Good morning, Doctor. I've been feeling quite terrible, to be honest. I'm very weak and tired.
[doctor]: Hmm, I see. Can you tell me more about your symptoms?
[patient]: I've been feeling this way for the past 8 days. I'm extremely fatigued and have a per... | B9561 | METHICILLIN SUSCEPTIBLE STAPHYLOCOCCUS AUREUS INFECTION AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE |
**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 |
### Initial Consultation Telemedicine Note
**1. Subjective:**
**Chief Complaint (CC):**
Severe abdominal pain, fever, and chills with decreased urine output over the past 5 days.
**History of Present Illness (HPI):**
The patient is a 35-year-old Asian male who presents with severe abdominal pain, fever, chills, and... | [Doctor]: Hi there, how are you doing today?
[Patient]: Hello, doctor. I'm not doing well. I've been having really severe abdominal pain, along with fever and chills for the past 5 days.
[Doctor]: I'm sorry to hear that. Let's go through your symptoms in more detail. You mentioned severe abdominal pain. Is it continu... | B965 | PSEUDOMONAS (AERUGINOSA) (MALLEI) (PSEUDOMALLEI) AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE |
**1. Subjective:**
**Chief Complaint (CC):**
Persistent cough, fever, and night sweats.
**History of Present Illness (HPI):**
The patient, a 47-year-old Asian male, presents with severe symptoms lasting for the past two weeks. He has a persistent cough, fever, night sweats, weight loss, and chest pain. The symptoms... | [doctor]: Hi there, how are you doing today? I see you're here because of a persistent cough, fever, and night sweats. Can you tell me more about what's been going on?
[patient]: Hi, doctor. Yeah, I've been feeling really terrible for the past two weeks. I have this cough that just won't go away, and I keep getting th... | B9689 | OTHER SPECIFIED BACTERIAL AGENTS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE |
**1. Subjective:**
- **Chief Complaint (CC):**
- Follow-up visit for worsening symptoms; moderate fever, chills, headache, fatigue, abdominal pain, and nausea.
- **History of Present Illness (HPI):**
- The patient is a 65-year-old African American female presenting for a follow-up visit. She has been experiencing... | [doctor]: Hello, how are you doing today?
[patient]: Hi, Doctor. I'm not feeling well. My symptoms have been getting worse.
[doctor]: I'm sorry to hear that. Can you tell me more about what's been going on?
[patient]: Sure. I've had a moderate fever, chills, a headache, fatigue, abdominal pain, and nausea. These sym... | B999 | UNSPECIFIED INFECTIOUS DISEASE |
#####
**1. Subjective:**
**Chief Complaint (CC):**
Severe throat pain and noticeable lump on the right side of the neck.
**History of Present Illness (HPI):**
Mary Johnson is a 68-year-old African American female with a past medical history of diabetes mellitus type 2 (treated with metformin), hyperlipidemia, and a f... | [doctor]: Hi Mary, how are you doing today?
[patient]: I've been better, doctor. I've been having this terrible throat pain, and I noticed a lump on the right side of my neck.
[doctor]: Oh, I'm sorry to hear that. How long have you been experiencing this throat pain?
[patient]: It's been going on for about three mon... | C099 | MALIGNANT NEOPLASM OF TONSIL, UNSPECIFIED |
#####
**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 |
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