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**1. Subjective:** **Chief Complaint (CC):** Profuse watery diarrhea, severe abdominal pain, vomiting, and high fever for 2 days. **History of Present Illness (HPI):** The patient, a 34-year-old Caucasian male with a postgraduate education and a job as a full-time high school teacher, presents to the urgent care cent...
[doctor]: Hi there, how are you feeling today? [patient]: Hi, not so great, to be honest. I've been really sick the past couple of days. [doctor]: I'm sorry to hear that. What seems to be the problem? [patient]: I've had really bad diarrhea, severe abdominal pain, vomiting, and a high fever for the past two days. [...
A09
INFECTIOUS GASTROENTERITIS AND COLITIS, UNSPECIFIED
13
3
##### **1. Subjective:** **Chief Complaint (CC):** Recurrent outbreaks of herpes-like symptoms. **History of Present Illness (HPI):** The patient, a 38-year-old Caucasian female with a history of hypertension and recurrent UTIs, reports moderate herpes-like symptoms lasting for one week. Symptoms include swollen lymp...
[doctor]: Good morning! How are you doing today? [patient]: Good morning, doctor. I've been better. I'm having some issues that seem to keep coming back. [doctor]: Oh no, I'm sorry to hear that. Can you tell me more about what’s going on? [patient]: Sure. I've been having these herpes-like symptoms that come and go....
B009
HERPESVIRAL INFECTION, UNSPECIFIED
23
3
**1. Subjective:** **Chief Complaint (CC):** Moderate fatigue for the past 3 months. **History of Present Illness (HPI):** A 45-year-old Hispanic male, named Carlos Martinez, presents with a 3-month history of moderate fatigue. He reports associated symptoms of jaundice and nausea occurring daily, significantly impac...
[doctor]: Hi there, how are you today? [patient]: Hi, I'm okay. I've been really tired for the past few months, though. [doctor]: Hmm, I'm sorry to hear that. Can you tell me more about this fatigue? How long has it been going on? [patient]: It's been about three months now. It’s not just tiredness; I feel exhausted...
B1920
UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA
33
3
### Gastroenterologist Medical Note #### 1. Subjective: **Chief Complaint (CC):** Difficulty swallowing and persistent discomfort affecting sleep and eating habits due to chronic heartburn, regurgitation, and chest pain for the past 3 months. **History of Present Illness (HPI):** The patient is a 55-year-old Cauc...
**Doctor:** Hi there, how are you doing today? **Patient:** Hello, Doc. I'm hanging in there, but honestly, not too great. I've been having some issues lately. **Doctor:** I'm sorry to hear that. Can you tell me more about what’s been going on? **Patient:** Sure, I've been having a lot of trouble swallowing and this...
B3781
CANDIDAL ESOPHAGITIS
43
3
**1. Subjective:** **Chief Complaint (CC):** Severe symptoms including high fever, jaundice, dark urine, clay-colored stools, and enlarged liver and spleen for the past 2 weeks. **History of Present Illness (HPI):** The patient is a 47-year-old Asian male with a history of chronic Hepatitis B and hyperten...
[doctor]: Hello, how are you doing today? [patient]: Hi, doctor. I've been feeling really awful lately. [doctor]: I'm sorry to hear that. Can you tell me a bit more about what's been going on? [patient]: Sure. For the past two weeks, I've had a high fever, yellow skin, and dark urine. My stools are also clay-colored...
B9789
OTHER VIRAL AGENTS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE
53
3
### Subjective #### Chief Complaint (CC) Abdominal pain with additional concerning symptoms. #### History of Present Illness (HPI) Dr. Sophia Chen, a 45-year-old Asian female with a history of irritable bowel syndrome (IBS) and hypothyroidism, presents for evaluation of persistent moderate to severe abdominal pain rat...
[doctor]: Hi Dr. Chen, thank you for coming in today. I see that you're experiencing some abdominal pain along with other symptoms. Can you tell me a bit more about what's been going on? [patient]: Yes, I've been having pretty severe abdominal pain for about six weeks now. It’s been quite persistent and can get really...
C184
MALIGNANT NEOPLASM OF TRANSVERSE COLON
63
3
##### **1. Subjective:** **Chief Complaint (CC)** Severe abdominal pain, radiating to the back, along with persistent nausea and vomiting. **History of Present Illness (HPI)** Mr. Juan Hernandez, a 67-year-old Hispanic male, presents for an initial oncology consultation. He reports severe, continuous abdominal pain r...
**Chief Complaint:** Severe abdominal pain, radiating to the back, along with persistent nausea and vomiting. --- **History of Present Illness:** [doctor]: Good morning, Mr. Hernandez. How are you feeling today? [patient]: Not good, doctor. I have severe abdominal pain that radiates to my back. It has been going o...
C251
MALIGNANT NEOPLASM OF BODY OF PANCREAS
73
3
**1. Subjective:** **Chief Complaint (CC):** Lesion on the lower back. **History of Present Illness (HPI):** 65-year-old Hispanic male, named Juan Martinez, presents with a lesion on the lower back. The lesion appeared 1 month ago and has rapidly increased in size, with recent episodes of bleeding and occasional pain...
[doctor] Hi, how are you today? [patient] Hello, I'm okay, thank you. How are you? [doctor] I'm doing well, thank you. I understand you have a lesion on your lower back. Can you tell me more about it? [patient] Yes, I noticed it about a month ago. It started as a small spot, but it's grown really fast and even start...
C4359
MALIGNANT MELANOMA OF OTHER PART OF TRUNK
83
3
**1. Subjective:** **Chief Complaint (CC):** Severe pain and noticeable mass in the right thigh. **History of Present Illness (HPI):** The patient is a 54-year-old African-American female who presents with a 6-month history of severe pain and an increasingly noticeable mass in her right thigh. She reports persistent...
[doctor]: Hi, I'm Dr. Thompson. How are you feeling today? [patient]: Hi, Doctor. Not great, to be honest. I've been having severe pain in my right thigh for the past six months, and I've noticed a mass there that's getting bigger. [doctor]: Hmm, I'm sorry to hear that. Can you tell me more about the pain and the mas...
C499
MALIGNANT NEOPLASM OF CONNECTIVE AND SOFT TISSUE, UNSPECIFIED
93
3
##### **1. Subjective:** **Chief Complaint (CC):** Moderate pain and noticeable lump in the left breast. **History of Present Illness (HPI):** The patient, a 38-year-old Hispanic female, presents with concerns of a lump in her left breast, which she first noticed three months ago. She reports moderate pain associated...
[doctor] Hello! How are you doing today? [patient] Hi, I'm alright, thank you. [doctor] I understand you have some concerns about a lump in your left breast. Can you tell me more about it? [patient] Yes, I first noticed the lump about three months ago. It’s been causing moderate pain, and there's also some skin dimp...
C50512
MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF LEFT FEMALE BREAST
103
3
--- **1. Subjective:** **Chief Complaint (CC):** Severe pelvic and lower abdominal pain, early satiety, significant weight loss, and a feeling of fullness. **History of Present Illness (HPI):** Ms. Yamamoto is a 67-year-old Asian female presenting for a pre-surgical consultation regarding a newly diagnosed malignan...
[doctor]: Good morning, Ms. Yamamoto. How are you feeling today? [patient]: Good morning, doctor. I'm not feeling too well, actually. I'm experiencing severe pelvic and lower abdominal pain. [doctor]: I'm sorry to hear that. How long have you been experiencing this pain? [patient]: It's been about four months now, a...
C562
MALIGNANT NEOPLASM OF LEFT OVARY
113
3
**1. Subjective:** **Chief Complaint (CC):** Moderate headaches and dizziness. **History of Present Illness (HPI):** The patient, Dr. Emily Carter, a 33-year-old female with a PhD in Environmental Science, presents with a one-month history of moderate headaches and dizziness. Headaches occur several times per week, a...
[doctor]: Good morning! How are you today? [patient]: Good morning, Doctor. I'm okay, but I've been having some issues lately. [doctor]: Hmm, I'm sorry to hear that. What brings you in today? [patient]: I've been having moderate headaches and dizziness for about a month now. [doctor]: Oh, I see. Can you tell me mor...
C719
MALIGNANT NEOPLASM OF BRAIN, UNSPECIFIED
123
3
**1. Subjective:** **Chief Complaint (CC):** Worsening respiratory symptoms and severe chest pain. **History of Present Illness (HPI):** The patient is a 75-year-old Caucasian male with a history of chronic obstructive pulmonary disease (COPD) and prior lymphoma, presenting with severe and progressively worsening dys...
[doctor]: Good morning, how are you feeling today? [patient]: Good morning, doctor. Not too well, to be honest. [doctor]: I'm sorry to hear that. Can you tell me more about what's been bothering you? [patient]: Well, I've been having a lot of trouble breathing lately. It feels like it's getting worse every day. I al...
C7802
SECONDARY MALIGNANT NEOPLASM OF LEFT LUNG
133
3
**1. Subjective:** **Chief Complaint (CC):** Severe chest pain and shortness of breath. **History of Present Illness (HPI):** The patient is a 34-year-old Hispanic male with a history of depression and asthma. He presents with a 4-month history of persistent fatigue, drenching night sweats, significant weight loss (~...
```plaintext [doctor] Hi, thanks for coming in. How are you feeling today? [patient] Not good, doctor. I've been having severe chest pain and shortness of breath. [doctor] I'm sorry to hear that. When did these symptoms start? [patient] It's been about four months now. The chest pain and shortness of breath have bee...
C8330
DIFFUSE LARGE B-CELL LYMPHOMA, UNSPECIFIED SITE
143
3
**1. Subjective:** **Chief Complaint (CC):** Follow-up for Acute Lymphoblastic Leukemia (ALL) and management of chronic conditions. **History of Present Illness (HPI):** Ms. Lee is a 45-year-old female with a history of Acute Lymphoblastic Leukemia (ALL), currently in remission for 12 months. She presents today for a...
[doctor]: Good morning, Ms. Lee. How are you doing today? [patient]: Good morning, doctor. I’ve been doing okay. Just here for my follow-up for my leukemia and to discuss some other health concerns. [doctor]: Alright, let's get started. How have you been feeling lately? Any new symptoms or concerns? [patient]: Well,...
C9101
ACUTE LYMPHOBLASTIC LEUKEMIA, IN REMISSION
153
3
##### **1. Subjective:** **Chief Complaint (CC):** Moderate pain in the abdomen lasting for 3 weeks, with associated blood in the stool and decreased appetite. **History of Present Illness (HPI):** Maria Lopez is a 45-year-old Hispanic female with a known history of type 2 diabetes, presenting for a follow-up visit a...
[doctor] Good morning, Maria. How are you feeling today? [patient] Good morning, Doctor. I've been better, honestly. [doctor] I see. The notes say you're here for a follow-up regarding your abdominal pain. Can you tell me more about what's been going on? [patient] Yes, so I've been having this moderate pain in my ab...
D122
BENIGN NEOPLASM OF ASCENDING COLON
163
3
**1. Subjective:** **Chief Complaint (CC):** Patient, John Smith, presents with a gradual increase in the number of melanocytic nevi on the trunk over the past year. **History of Present Illness (HPI):** - **Severity:** Asymptomatic, with some nevi slightly raised. - **Duration:** Noticed gradual increase in the numb...
[doctor]: Good morning! How are you today? [patient]: Morning, doc. I'm doing fine, thanks. [doctor]: Great to hear. So, what brings you in today? [patient]: I've noticed more moles popping up on my trunk over the past year. [doctor]: Hmm, I see. Are these moles causing you any pain or discomfort? [patient]: Nope,...
D225
MELANOCYTIC NEVI OF TRUNK
173
3
### 1. Subjective **Chief Complaint (CC)** Severe pelvic pain and dysmenorrhea. **History of Present Illness (HPI)** The patient, named Emily Johnson, is a 29-year-old Caucasian female who presents for follow-up regarding severe pelvic pain that has persisted for approximately 2 years. The pain is described as debili...
**Doctor:** Good morning. How are you feeling today? **Patient:** Not great, to be honest. The pain is still really bad. **Doctor:** I’m sorry to hear that. Can you remind me how long you’ve been experiencing this severe pelvic pain? **Patient:** It’s been about two years now. It’s really affecting my life. I can ba...
D259
LEIOMYOMA OF UTERUS, UNSPECIFIED
183
3
**1. Subjective:** **Chief Complaint (CC):** New skin lesion on the left forearm with persistent itching and occasional tenderness. **History of Present Illness (HPI):** The patient is a 38-year-old Asian female who presents with a new lesion on her left forearm. She discovered the lesion one week ago and...
[Doctor]: Hi there, how are you doing today? [Patient]: Hello, I'm alright, thank you. I have this new skin lesion on my left forearm that's been really bothering me. [Doctor]: I see. Can you tell me more about it? When did you first notice this lesion? [Patient]: I first noticed it about a week ago. It's been growi...
D485
NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN
193
3
##### **1. Subjective:** **CHIEF COMPLAINT** Severe pain episodes, fever, and difficulty breathing. **HISTORY OF PRESENT ILLNESS** The patient, named Jamal Thompson, is a 16-year-old African American male with a known history of sickle-cell disease and previous episodes of acute chest syndrome. He presents to the emer...
**[doctor]** Hi there, I'm Dr. Smith. How are you feeling today? **[patient]** Hi, Doctor. I'm not feeling too great. I've been having severe pain and some other issues. **[doctor]** I'm sorry to hear that. Can you tell me more about the pain you're experiencing? **[patient]** The pain is really bad. It happens twic...
D571
SICKLE-CELL DISEASE WITHOUT CRISIS
203
3
**1. Subjective:** **Chief Complaint (CC):** - Sudden onset chest pain **History of Present Illness (HPI):** - A 52-year-old African American male presents with a 1-week history of severe, intermittent chest pain exacerbated by exertion. The pain is associated with dyspnea, palpitations, and episodes of s...
[doctor]: Good morning, how are you feeling today? [patient]: I've been having a rough week, doctor. I'm experiencing severe chest pain. [doctor]: I’m sorry to hear that. Can you tell me more about this chest pain? When did it start? [patient]: It started about a week ago. The pain comes and goes, but it gets really...
D6851
ACTIVATED PROTEIN C RESISTANCE
213
3
**1. Subjective** **Chief Complaint (CC):** Fatigue and recurrent infections. **History of Present Illness (HPI):** The patient is a 35-year-old African American female with a known history of Systemic Lupus Erythematosus (SLE) who presents for follow-up due to persistent symptoms over the past two month...
[doctor]: Hi there, how are you doing today? [patient]: Hi, doctor. I’m really tired and worried about my health. [doctor]: Hmm, I see. What brings you in today? [patient]: I’ve been feeling very fatigued and have had recurrent infections over the past two months. [doctor]: I understand. Could you give me more deta...
D72819
DECREASED WHITE BLOOD CELL COUNT, UNSPECIFIED
223
3
**1. Subjective:** **Chief Complaint (CC):** - Joint stiffness, fatigue, skin rashes **History of Present Illness (HPI):** - The patient is a 60-year-old Asian female who presents for follow-up due to persistent autoimmune-related symptoms. She reports moderate joint stiffness and fatigue persisting for th...
[doctor]: Hi there, how are you doing today? [patient]: Hi, doctor. I'm doing okay, but I've been struggling with joint stiffness, fatigue, and skin rashes. [doctor]: Hmm, I'm sorry to hear that. Can you tell me more about the joint stiffness and fatigue? [patient]: Sure. The joint stiffness and fatigue have been pe...
D8989
OTHER SPECIFIED DISORDERS INVOLVING THE IMMUNE MECHANISM, NOT ELSEWHERE CLASSIFIED
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